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Gold, incentives and meh

Key learning points

Key questions on asthma:

• When diagnosing adult-onset asthma, always ask whether this is truly a new illness or a recurrence of an old one.

• Lifetime prevalence of asthma has increased between 2001 and 2005 in adults by 23%, 28% and 22% in people aged 15-44, 45-64 and over 65 years respectively.

• Older agents such as sodium cromoglicate and necrodomil may have a place in the management of adult patients who cannot or will not take steroids

• But there is no evidence to support their use in the management of asthma in children under 5

• Exacerbations during pregnancy increase the risk of foetal mortaility and preganancy often threatens previously good control of asthma

• Antenatal checks are a good opportunity to assess asthma control, adjust medication where necessary and provide or reinforce a personal asthma action plan.

• 30% of adults with asthma are prone to aspirin- or NSAID-induced exacerbations.

• High doses of inhaled steroids – over 1,000µg in adults or 400µg beclomethasone or equivalent in children – have the potential for reducing bone mineral density.

• If patients use a metered dose inhaler without a dose counter as a reliever they must always have a spare

• Methods for assessing control include validated questionnaires - such as the Asthma Control Test or Asthma Control Questionnaire.

• Asthma should be considered in any child with a history of intermittent wheezing, coughing or shortness of breath induced or triggered by any factor including viral illness, exercise, laughing, foods, exposure to fumes and perfumes.

• It's helpful to include a two to four hourly peak flow chart at and away from work with a any referral for suspected occupational asthma.

Ten top tips for coughing in children:

• In most children, cough is due to a simple URTI and will not need any investigations.

• Failure to gain weight, finger clubbing or chest deformity suggests an underlying chronic lung disease.

• Symptomatic cough can occur between seven and 10 times per year in school-age children.

• A chronic cough lasting longer than eight weeks requires a specific diagnosis.

• An inhaled steroid at 200µg twice a day with a bronchodilator can be trialled for ‘cough-variant asthma'.

• Psychogenic cough usually affects older children

• In this case, there is a fine line between doing investigations to rule out a possible underlying disease and overtesting, which can reinforce the problem.

• Parental smoking history should be addressed during the consultation

• Cough associated with feeding is a red flag symptom.

Challenges in COPD:

• Inhaled steroids are recommended for patients with frequent exacerbations when the FEV1 is less than 50% predicted

• As a general rule, oxygen therapy should only be provided where hypoxaemia can be demonstrated.

• When flying, COPD patients are at risk of to hypoxia and possible respiratory failure.

• Those who are already using oxygen at sea level or have SpO2 less than 92% will definitely need in-flight oxygen.

• Clinical pointers towards asthma rather than COPD include - early age of onset, family history, atopy, lack of smoking, variable nature of symptoms.

• Asthma may present later in life, in smokers who have had a significant occupational exposure or received ß-blockers or NSAIDs.

• Rehabilitation is very popular with patients and one of the most effective treatments available for COPD and other chronic respiratory diseases.

• But, pragmatically only those with more significant exercise limitation – scoring 3 to 5 on the MRC Dyspnoea Scale – hypersecretion of mucus should be referred for formal rehabilitation.

• The risk of death has been as high as 15% in patients admitted with a COPD exacerbation.

• Poor nutritional status – BMI less than 19- is a pointer to poor prognosis

• People admitted to hospital with respiratory failure have only a 50% chance of surviving two years.

A new paradigm for adult cough:

• Chronic cough is defined as cough lasting greater than eight weeks.

• 12% of the population complained of a chronic cough on a daily or weekly basis.

• Fainting while coughing – cough syncope – is thought by the DVLA to be responsible for a number of road fatalities per year.

• A change in atmosphere, such as going from a warm to a cold room, and minute quantities of environmental stimulants are trigger factors for patients with chronic cough.

• Most patients who present with a history of non- or minimally productive chronic cough with a normal chest X-ray will have airway reflux.

• Normal people score an average of 4 out of 70 on The Hull Airways Reflux Questionnaire (HARQ).

• Proton-pump inhibitors (PPI) are not a treatment for cough hypersensitivity caused by reflux.

• Low-dose morphine – not its prodrug codeine – helps one-third of intractable cases of cough.

• Patients with cystic fibrosis and bronchiectasis frequently have exacerbations that are characteristic of reflux and aspiration episodes.

Bronchiectasis: a GP guide:

• Bronchiectasis is defined by the presence of one or more abnormally and permanently dilated bronchi.

• Asthma, COPD and bronchiectasis are all associated with airflow obstruction on spirometry so there is no single definitive test.

• Up to 20% of cases may have Pseudomonas aeruginosa infections.

• Negative sputum cultures do not exclude an infective exacerbation.

• In patients with hypersecretion of mucus, specialist chest physiotherapists should be involved to tailor sputum clearance techniques.

• In a selected group of patients with focal bronchiectasis that is unresponsive despite maximal medical therapy, surgical intervention may be considered.

• Chronic macrolide therapy should not be started until mycobacterial infection is excluded and is generally felt best monitored by specialists.

• Pneumonia and influenza are probably over-represented in patients with bronchiectasis.

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