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Background: Inhaled medications are central to treating asthma and chronic obstructive pulmonary disease (COPD), yet critical inhaler technique errors are made by up to 90% of patients. In the clinical research setting, recruitment of subjects with poor inhaler technique may give a false impression of both the benefits and the necessity of add-on treatments such as biologic therapies.Objective: To assess the frequency with which inhaler technique is assessed and reliably optimized before and during patient enrollment into randomized controlled trials (RCTs) addressing the efficacy of topical therapy, and the escalation of therapy for asthma and COPD.Methods: Systematic searches were conducted of PubMed and Embase for RCTs published in the past 10 years involving patients with a diagnosis of asthma or COPD undergoing escalation of baseline inhaled therapy (stepping up, changing, adding, switching, increasing, etc) or the introduction of biologic agents.Results: Searches highlighted 1,014 studies, 118 of which were eligible after the removal of duplicates as well as screening and full text review. Of these, only 14 (11.9%) included accessible information in the methods section or referred to such information in online supplements or protocols concerning assessment of participants’ inhaler technique. We therefore developed the proposed Best Practice Inhaler Technique Assessment and Reporting Checklist.Conclusions: Our study identifies a concerning lack of checking and correcting inhaler technique, or at least reporting that this was undertaken, before enrollment in asthma and COPD RCTs, which may affect the conclusions drawn. Mandating the use of a standardized checklist in RCT protocols and ensuring all published RCTs report checking and correcting inhaler technique before enrollment are important next steps.

Funder: Global Initiative for Asthma, The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting β2 -agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function, and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, "MART") in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting β2 -agonist (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment, and review remain essential to optimize asthma outcomes.

The UK is the sick man of Europe in terms of the management of asthma in children and young people (CYP). Only one of the 28 CYP deaths assessed in the National Review of Asthma Deaths was adequately managed. Clearly, we are incapable of following established, evidence-based guidelines (https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills). Unfortunately, the response appears to be not to follow what works, but to switch to poorly evidenced strategies. One example is the use of very high, unlicenced dose ‘salbutamol weaning plans’ where children are prescribed 10 puffs (1000 μg) of salbutamol every 4 hours in reducing doses for up to 5 days (ie, up to 6000 μg salbutamol a day) after hospital or emergency department discharge. This wholly non-evidenced-based practice, which may mask the need for systemic corticosteroids, has come in by the back door despite clear-cut evidence of harm from excessive doses of β-2 agonist and evidence from adult studies detailed in the Global Initiative on Asthma (GINA) that as-needed bronchodilator shortens hospital stay for an acute attack compared with regular administration.1 More recently, some UK paediatric departments are now discharging CYP after acute treatment for asthma/wheezing attacks with a single predischarge dose of dexamethasone instead of guideline-directed advice of daily prednisolone for 3 or more days (https://www.sign.ac.uk). The rationale is that dexamethasone carries a lower risk of vomiting, and is cheaper and more convenient. However, this new practice has only a weak evidence base and is justified on heterogeneous studies of low or very low quality in meta-analyses. Keeney …

Introduction During the first wave of the COVID-19 pandemic in the UK there was a reduction in AEdriven by COVID-19 1 We investigated whether hospital admissions due to asthma were reduced in April 2020 compared to the previous five years and if this was accompanied by an increase in asthma deaths Methods Five-year data were obtained from Public Health Scotland from the time period January 2015 to June 2020 Hospital admission data was sourced from Public Health Scotland's Scottish Morbidity Records, death certificate data from National Records of Scotland and AEan excess of 2731 from previous 5-year mean In 130 deaths asthma was recorded on the death certificate as either the underlying or the contributory cause, giving rise to around 100 apparent excess deaths versus the previous 5-year mean of 27 5 (figure 1b) Asthma was recorded as the underlying cause of death in 7 cases, comparable with the previous 5 year mean of 9 2 deaths (figure 1c) The age distribution of those with asthma on the death certificate was: 97-65, 27 aged 45-65, 6 aged 18-44 and 0

Background: The North West London (NWL) Whole Systems Integrated Care(WSIC) dataset from primary and secondary care provides: i) up-to-date asthma clinical risk registers (dashboards);& ii) a research facility (Discover) of de-identified data for > 2.2 million patients. We aimed to describe the burden of asthma and risk of poor outcomes in Children and Young People (CYP:aged ≤18 years) in this population. Methods: Data was extracted from Discover on CYP coded with asthma diagnosis by General Practices (GPs) for 12 months from April 2018. Ethics approval by the NWL Data Research Access Group. Results: 14405/482029 (3%) CYP (40% female) in 329 GP practices were coded with asthma. Median prevalence 2.88% (Q1,3: 2.52%,3.38%); i.e. below national prevalence. An unknown number of CYP were treated without being coded with asthma. Exacerbations: i) 749 CYP had 797 hospital admissions (32 had 2-6): ii) 910 were coded by GPs with 1168 asthma attacks (170 had 2-12);iii)1485 had 2123 prescriptions for courses of oral corticosteroids(OCS) (408 had 2-12). 12332 CYP were prescribed SABAs: 43%, 11% and 1% had more than 3, 6 and 12 inhalers. 4328(30%) CYP were not prescribed inhaled corticosteroids(ICS); only 49% of authorized ICS prescriptions were requested by patient’s, 51% requested Asthma Control Test: 6% scored ≤19. 63% and 57% CYP were provided with personal asthma action plans and annual reviews respectivly. Conclusions: Over 10% of this population face potential life threatening asthma attacks. Improved utilisation of dynamic clinical risk registers could easily facilitate recognition of risk with optimisation of care for CYP with asthma. Study supported by AstraZeneca UK

Aims and Objectives: Chronic cough (CC) is a debilitating respiratory symptom, now increasingly recognized as a discrete disease entity. This study evaluated the burden of CC in a primary care setting. Methodology: This cross-sectional, retrospective cohort study used de-identified data from the Whole Systems Integrated Care (Discover) dataset, which includes >350 North West London (NWL) primary care practices, linking coded data from primary and secondary care. Data were extracted for individuals ≥18 years with a CC read code, cough (persisting ≥8 weeks) or cough remedy prescription (suppressant/expectorant/demulcent/mucolytic), between Jan 2015 - Sep 2019. The study was approved by the NWL Data Research Access Group. Results: Data extracted from 2,109,430 patients identified a cohort of 43,453 with CC. Median (IQR) age was 64 years (41-87), 22% were current and 22% previous smokers. Among the cohort, 26% had been given a diagnosis of asthma, 17% COPD, 12% rhinitis, 15% reflux, and 1% stress incontinence; 31% had no recorded comorbidities. Overall CC prevalence was 2%. Prevalence was greater in women (57%) than men (43%) and highest in the 65–74 age range (Figure). Conclusion: Data from routine clinical practice indicate 2% of the NWL adult population has CC and more women are affected than men. Appraisal of linked primary-care databases may enable earlier detection of CC patients, for specialist clinic referral and targeted treatment.

Over the last decade, there is increasing evidence that the small airways, i. e. airways

Few would deny that an asthma attack (not an ‘exacerbation’, an utterly feeble and inadequate word1) can be a really serious life-event. The strongest predictor of a severe or fatal asthma attack is a previous bad attack. Asthma attacks are associated with impaired trajectories of airway development and growth. Despite a positive Tsunami of guidelines, working parties, bundles, initiatives and many thousands of words, children still die of asthma in 21st century Britain;2 the challenge is to turn good intentions (and writing) into good practice, and in that we have largely failed. Preventable asthma attacks have been described as ‘never events’,1 a really serious failure of management which should provoke a focused response to prevent a potentially fatal recurrence. The postattack review (preferably within 48 hours of discharge from hospital or at the end of a course of steroids for attacks managed in the community), which is hardly ever performed (only 127/333 (

© 2020 The Authors. Published by Elsevier Inc. on behalf of the American Academy of Allergy, Asthma & Immunology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/), Spacers are pressurized metered-dose inhaler (pMDI) accessory devices developed to reduce problems of poor inhaler technique with pMDIs. Spacers that feature a 1-way inspiratory valve are termed valved holding chambers (VHCs); they act as aerosol reservoirs, allowing the user to actuate the pMDI device and then inhale the medication in a 2-step process that helps users overcome challenges in coordinating pMDI actuation with inhalation. Both spacers and VHCs have been shown to increase fine particle delivery to the lungs, decrease oropharyngeal deposition, and reduce corticosteroid-related side effects such as throat irritation, dysphonia, and oral candidiasis commonly seen with the use of pMDIs alone. Spacers and VHCs are not all the same, and also are not interchangeable: the performance may vary according to their size, shape, material of manufacture and propensity to become electrostatically charged, their mode of interface with the patient, and the presence or otherwise of valves and feedback devices. Thus, pairing of a pMDI plus a spacer or a VHC should be considered as a unique delivery system. In this Rostrum we discuss the risk potential for a patient getting switched to a spacer or VHC that delivers a reduced dose medication.

What is already known? ### What this study adds? Outcomes for children with asthma in the UK continue to lag behind other European countries. Mortality remains unacceptably high and in contrast to adults with asthma, most deaths occur in the 1 in 20 children with asthma who have severe asthma. Despite evidence that children with asthma have better outcomes with subspecialist care, many children with severe asthma are not referred onwards and barriers exist at every level of the UK healthcare system. The National Review of Asthma Deaths (NRAD) recommended that specialist review should be requested if there had been three or more courses of oral steroids, two or more visits to accident and emergency or an admission to hospital. This review reports the results of a recent interview study of 126 healthcare professionals. More than half of general practitioners (n=49) reported adopting a higher threshold than this. General paediatricians (n=47) set a higher bar still. Their median thresholds for referral to a subspecialist asthma clinic were 4 courses of oral steroids, 3 hospital admissions and 30 days off school in the previous year. This review offers a simple working definition of severe asthma based on current national and international guidelines and provides an example of the recently adopted referral criteria to …

Asthma is a complex chronic disease, characterised by intermittent respiratory symptoms, airway inflammation and reversible airflow obstruction, without the availability of a single confirmatory diagnostic test. Management of this disease involves many challenges for primary care physicians. These include diagnosis, monitoring, identifying risk and chronic as well as acute management; furthermore, it is challenging to maintain up to date knowledge of asthma to facilitate good quality patient education. Primary care clinicians with their limited availability of routine appointments, plus the vast spectrum of medical conditions they manage, are generalists and cannot be experts in every clinical condition. Although these health professionals develop skills in quickly assessing patients and making decisions for urgent or delayed management, the initial challenge is to accurately diagnose chronic diseases and second having the confidence and knowledge to manage these complex diseases in the community. In the case of asthma, diagnosis and monitoring are frequently based on reporting of symptoms, which are limited by their lack of specificity and patient recall. Considerable controversy1 2 surrounds the recent UK recommendations3 that primary care physicians should include spirometry and fractional exhaled nitric oxide (FeNO) in diagnosing asthma in the UK. Neither quality assured spirometry nor FeNO is widely available in primary care. This is further complicated because asthma patients may have normal spirometry when tested and this would potentially need to be repeated on a number of occasions to demonstrate reversible airflow obstruction, which is totally impractical in primary (or secondary) care settings. Peak flow diaries are a practical alternative in these cases.4 5 In their prospective …

The National Review of Asthma Deaths (NRAD) report entitled Why Asthma Still Kills ,1 published on World Asthma Day in May 2014, concluded that only one of the 28 children and young people (CYP) who died had been adequately managed by health professionals. Of the 19 NRAD recommendations only one has been initiated nationally in the UK, namely setting up a National Asthma Audit, which has yet to report after nearly 5 years. Care for children with asthma in the UK is mainly provided in primary care, and is often limited to the few tasks set out in the Quality and Outcomes Framework (QOF)2 to provide data to qualify for payments. Currently the QOF requires a recorded asthma diagnosis confirmed by measures of airflow reversibility, smoking status, and evidence of an asthma review in the preceding 12 months that includes an assessment of asthma control using the Royal College of Physicians’ three questions (RCP 3 Questions); the latter are not validated and nor are they recommended for children aged

Inhalable medications for patients with asthma and chronic obstructive pulmonary disease (COPD) can be confusing even for health care professionals because of the multitude of available devices each with different operating principles. Dry powder inhalers (DPI) are a valuable option for almost all of the patients with asthma or COPD. Based on recorded patient inspiratory profiles, the peak inspiratory flow requirement of 30 L min−1 of high-resistance devices does not usually pose any practical limitations for the patients. Suboptimal adherence and errors in device handling are common and require continuous checking and patient education in order to avoid these pitfalls of all inhalation therapy. The aim of this opinion paper is to describe the working principles of DPIs and to summarise their key properties in order to help prescribing the correct inhaler for each patient. Funding: Orion Pharma.

The United Kingdom (UK) National Review of Asthma Deaths (NRAD) (2011–2014) identified a number of contributory risk factors which had not previously been recognized by those caring for people with asthma. Only one of the 19 NRAD recommendations has so far been implemented nationally, and that only partially, and as yet systems are not in place to identify patients at risk of attacks and dying from asthma. In 2015/2016 Bedfordshire Clinical Commissioning Group (CCG) in England, UK, initiated a quality asthma audit of people with asthma to identify some of the risk factors identified in the NRAD report with the aim of optimizing patient care. Fifty (89%) of the General Practices caring for 415,152 patients (27,587 diagnosed with asthma (prevalence 7%; range 4–12%)), participated and the results identified a wide variation in process of care and presence of risk factors including: excess short acting reliever and insufficient preventer prescriptions, failure to issue personal asthma action plans, and to perform annual reviews or check inhaler technique. Identification of these patients involved high-intensity input by trained asthma nurses using sophisticated data extraction software. GP computer systems used in primary care currently do not have the functionally, without the need for manual audit, to implement the NRAD recommendations, starting with the identification of patients at risk. Modifications to existing systems within both primary and secondary care are required in order to prevent unnecessary deaths related to asthma. There is a pressing need to move towards a more pro-active model of care., Asthma: Encouraging proactive care Pro-active disease management for patients with asthma is crucial and could be vastly improved with an overhaul of computer systems in primary care. Following the UK National Review of Asthma Deaths (NRAD) in 2011–2014, multiple mortality risk factors were identified that have yet to be factored into asthma care. The NHS Bedfordshire Clinical Commissioning Group, with support from NSHI and Dr Mark L Levy (Harrow CCG), conducted a manual audit of 50 Bedfordshire doctors’ surgeries to identify relevant NRAD recommendations to optimize patient care. Levy’s team found marked variations in asthma care between the surgeries. Risk factors present included excessive short-acting reliever inhaler prescriptions and inadequate prescribing of preventer inhalers, together with limited implementation of personal asthma plans and annual reviews. The researchers highlight the limitations of existing computer systems for these purposes and recommend an overhaul of asthma tracking and automated alerts.

An asthma attack or exacerbation signals treatment failure. Most attacks are preventable and failure to recognize risk of asthma attacks are well recognized as risk factors for future attacks and even death. Of the 19 recommendations made by the United Kingdom National Review of Asthma Deaths (NRAD) (1) only one has been partially implemented—a National Asthma Audit; however, this hasn’t reported yet. The Harrow Clinical Commissioning Group (CCG) in London implemented a clinical asthma audit on 291 children and young people aged under 19 years (CYP) who had been treated for asthma attacks in 2016. This was funded as a Local Incentive Scheme (LIS) aimed at improving quality health care delivery. Two years after the publication of the NRAD report it is surprising that risks for future attacks were not recognized, that few patients were assessed objectively during attacks and only 10% of attacks were followed up within 2 days. However, it is encouraging that CYP hospital admissions following the audit were reduced by 16%, with clear benefit for patients, their families and the local health economy. This audit has provided an example of how clinicians can focus learning on patients who have had asthma attacks and utilize these events as a catalyst for active reflection in particular on modifiable risk factors. Through identification of these risks and active optimization of management, preventable asthma attacks could become ‘never events’., Asthma attacks: learning from experience Encouraging self-reflection and best practice can help doctors improve patient care following asthma attacks. A recent UK national review uncovered multiple shortfalls in asthma management. Mark Levy at Harrow Clinical Commissioning Group in London and co-workers conducted a clinical asthma audit to assess the after-care of 291 patients under the age of 19 who had been treated for an asthma attack in Harrow during 2016. Analysis of patient records showed that risks of future attacks were not routinely highlighted during follow-up consultations. Only a third of patients had a personal asthma action plan and only 10 per cent of attacks were followed up within two days. During the audit, doctors from each surgery attended focus groups aimed at encouraging best practice. Following the audit, patient hospital admissions from these surgeries dropped by 16 per cent.

Contains fulltext : 193643.pdf (Publisher’s version ) (Open Access) We present an extensive review of the literature to date pertaining to the rationale for using a spacer/valved holding chamber (VHC) to deliver inhaled therapy from a pressurised, metered-dose inhaler, a discussion of how the properties of individual devices may vary according to their physical characteristics and materials of manufacture, the potential risks and benefits of ancillaries such as valves, and the evidence that they contribute tangibly to the delivery of therapy. We also reiterate practical recommendations for the correct usage and maintenance of spacers/VHCs, which we trust offer practical help and advice to patients and healthcare professionals alike.

This review discusses issues related to managing problematic severe asthma in children and young people. A small minority of children have genuinely severe asthma symptoms which are difficult to control. Children with genuinely severe asthma need investigations and treatments beyond those described within conventional guidelines. However, the majority of children with poor symptom control despite high-intensity treatment achieve improvement in their asthma control once attention has been paid to the basics of asthma management. Basic asthma management requires optimisation of inhaler technique and treatment adherence, avoidance of environmental triggers and self-management education. It is also important that clinicians recognise risk factors that predispose patients to asthma exacerbations and potentially life-threatening attacks. These correctable issues need to be tackled in partnership with children and young people and their families. This requires a coordinated approach between professionals across healthcare settings. Establishing appropriate infrastructure for coordinated asthma care benefits not only those with problematic severe asthma, but also the wider asthma population as similar correctable issues exist for children with asthma of all severities. Investigation and management of genuine severe asthma requires specialist multidisciplinary expertise and a systematic approach to characterising patients’ asthma phenotypes and delivering individualised care. While inhaled corticosteroids continue to play a leading role in asthma therapy, new treatments on the horizon might further support phenotype-specific therapy.

GINA no longer recommends treating adults/adolescents with asthma with short-acting bronchodilators alone. Instead, they should receive symptom-driven (in mild asthma) or a daily corticosteroid-containing inhaler, to reduce risk of severe exacerbations.http://bit.ly/310LLzE

Background: In practice it is logical that inhalers are prescribed only after patients have received training and demonstrated their ability to use the device. However, many patients are unable to use their pressurised metered-dose inhaler devices (pMDIs) correctly. We assessed the relationship between asthma control and patients' ability to use their prescribed pMDIs. Methods: Evaluation of 3,981 (46% male) primary care asthma patient reviews, which included inhaler technique and asthma control, by specialist nurses in primary care in 2009. The paper focuses on people currently prescribed pMDI devices. Results: Accurate data on reliever and preventer inhaler prescriptions were available for 3,686 and 2,887 patients, respectively. In patients prescribed reliever inhalers, 2,375 (64%) and 525 (14%) were on pMDI alone or pMDI plus spacer, respectively. For those prescribed preventers, 1,976 (68%) and 171 (6%) were using a pMDI without and with a spacer, respectively. Asthma was controlled in 50% of patients reviewed. The majority of patients (60% of 3,686) were using reliever pMDIs, 13% with spacers. Incorrect pMDI use was associated with poor asthma control (p

SummaryThis brief overview of the factors determining lung deposition of aerosols provides background information required by health care providers when instructing patients to use their prescribed inhalers. We discuss differences in the optimal inhalation manoeuvres for each type of aerosol generator and the difficulties patients face. Provision of short, clear instructions with demonstration of critical steps and checking technique during later clinical visits are necessary if these aerosolised medications are to be fully beneficial.

> ‘I’m commonly consulted by children, whose parents report they were “coughing and wheezing all night”. These kids often appear well and their lung function may be normal.’ Asthma is a chronic respiratory disease characterised by fluctuating respiratory symptoms and reversible airflow obstruction.1,2 Confirmation of the diagnosis hinges on demonstrating airflow obstruction varying over time. Patients with undiagnosed asthma who consult repeatedly with symptoms ranging in severity3 may demonstrate perfectly normal spirometry. As there is no single ‘gold standard’ test, clinical asthma diagnosis is based on evidence of recurrent respiratory symptoms; reversibility with anti-asthma treatment; and variable airflow obstruction. Demonstrating any, or all three, of these features in a clinical setting is challenging: the disease fluctuates. The diagnosis is clear cut if spirometry in a patient with a history suggestive of asthma demonstrates airflow obstruction with reversibility. …

BACKGROUND: Most patients with chronic obstructive pulmonary disease (COPD) in Europe are treated in primary care, but perceptions on what guides primary care physicians (PCPs) in managing patients are lacking. AIMS: To describe factors associated with the assessment by PCPs of COPD severity and those associated with impaired health status, as assessed by patient-reported outcomes. METHODS: This cross-sectional study evaluated health-related quality of life (HRQL) in 2,294 COPD patients from five European countries. The severity of COPD was clinically judged by the PCPs and GOLD stage severity was calculated using spirometry data. RESULTS: PCPs' categories of severity reflected a wider range of HRQL scores (St George's Respiratory Questionnaire (SGRQ) total score: mild 30.3; moderate 41.7; severe 55.0; very severe 66.1) than GOLD severity grading (Stage I 38.2; Stage II 41.1; Stage III 49.9; Stage IV 58.5). Multiple ordinal logistic regression models showed that factors most closely related to PCP-rated COPD severity were Medical Research Council (MRC) dyspnoea grade, forced expiratory volume in 1 second (FEV(1)) percent predicted, HRQL score (either SGRQ or COPD Assessment Test (CAT)), and previous hospitalisations (model generalised R(2)=0.45 or 0.44 (SQRQ or CAT in model, respectively); all factors p

Background We sought to understand the barriers and facilitators to participation in research from the perspectives of South Asian people with asthma. Methods Eight focus groups were conducted in the preferred language of participants. Sampling was purposeful to ensure inclusion of males and females from differing ethnic, linguistic and religious backgrounds. Results The forming of trusting relationships was described as pivotal to the successful recruitment of minority ethnic groups into research; personalized approaches were likely to be better received than more impersonal written approaches. Notable barriers to participation included: the stigma of being labelled with asthma; concerns surrounding participation in pharmaceutical trials; major time or travel commitments and a failure to show respect by not making information available in minority ethnic languages. Flexibility, in terms of timing, location and respecting of cultural and religious sensitivities around gender segregation, together with the offer of incentives, were highlighted as key factors to promote participation. Conclusions The barriers to recruitment are largely surmountable, but these will necessitate the use of resource intensive and more personalized approaches than are commonly employed for the White European origin population. Our proposed model to enhance recruitment is likely to have transferability beyond the field of asthma.

A short, easy-to-use health status questionnaire is needed in the multidimensional assessment of chronic obstructive pulmonary disease (COPD) in routine practice. The performance of the eight-item COPD assessment test (CAT) was analysed in 1,817 patients from primary care in seven European countries. The CAT has a scoring range of 0-40 (high score representing poor health status). Mean CAT scores indicated significant health status impairment that was related to severity of airway obstruction, but within each Global Initiative for Obstructive Lung Disease stage (I to IV) there was a wide range of scores (I: 16.2 ± 8.8; II: 16.3 ± 7.9; III: 19.3 ± 8.2; and IV: 22.3 ± 8.7; I versus II, p = 0.88; II versus III, p

We have developed a winter forecasting service to predict when patients with COPD are at higher risk of an exacerbation and alert them via an automated telephone call. To assess the effect of the service and its ability to predict periods of increased risk. A 4-month prospective randomised controlled trial using clinical criteria and the EXACT PRO questionnaire to identify exacerbations. Patients were randomly allocated to receive alert calls. All patients completed a diary including the EXACT PRO questionnaire on a BlackBerry Smartphone each day. They were contacted and assessed if they appeared to be exacerbating. 79 patients participated, 40 received alert calls. The exacerbation frequency per patient per week was significantly greater during periods of predicted high risk (0.086±0.010 v 0.055±0.010). The exacerbation frequency (± standard error of the mean, SEM) in patients receiving alert calls was lower (0.95±0.27 v 1.17±0.29) but this was not statistically significant. Fewer patients receiving alert calls had one or more EXACT event compared to the controls (34% v 53%, p=0.11), their duration was shorter (8.2±2.0 v10.1±1.9 days, p=0.481) and they were less severe (AUC 65±21 v 115±22, p=0.118). There were no significant differences in the mean change (±SEM) in SGRQ scores between the groups. The ability of the forecast to predict high risk periods was confirmed unequivocally. Alert calls appeared to reduce the frequency and severity of exacerbations but these effects did not reach statistical significance, perhaps because of the number of participants, lower than expected exacerbation rates, and the fact that there was contact with patients in both groups whenever they appeared to be exacerbating.

Pan-European data on health-related quality of life (HRQL) in chronic obstructive pulmonary disease (COPD) are lacking.This cross-sectional epidemiological study evaluated health status in 1817 COPD patients from an 'all-comers' primary care population in seven European countries (87% stable disease; 13% with current exacerbation) using: St George's Respiratory Questionnaire-COPD specific (SGRQ-C), the short form health survey (SF-12) and the Functional Assessment of Chronic Illness Therapy (FACIT) Fatigue scale.Mean total score for SGRQ was 44.7 +/- 19.4 showing marked impairment of HRQL. Scores differed little between countries (range 39.2-50.1). Impairment was associated with the severity of airway obstruction, but within each GOLD stage the variation (SD) was wide [Stage I: 38.5 +/- 19.3 (n = 223); Stage II: 40.4 +/- 18.1 (n = 868); Stage III: 50.2 +/- 18.6 (n = 551); Stage IV: 58.6 +/- 17.7 (n = 144)]. Patients suffering an exacerbation had a worse SGRQ score (54.9 +/- 19.3) than those with stable disease (43.3 +/- 19.0). The presence of >= 3 co-morbidities (CM) was also associated with a significantly worse score (49.9 +/- 19.1) vs. 1-2 CM (42.1 +/- 19.1) or no CM (42.3 +/- 18.6). Findings with the SF-12 and FACIT-F results were consistent with those from the SGRQ-C.This large observational primary care study shows that health status is significantly impaired in COPD patients of all severities, even in those with mild airway obstruction. Within each GOLD stage of severity there is considerable heterogeneity in HRQL impairment among patients. (Study number: 111749). (C) 2010 Elsevier Ltd. All rights reserved.

Introduction: The UK National Health Service (NHS) is essentially publicly funded through general taxation. Challenges facing the NHS include the rise in prevalence of long-term conditions and financial pressures.National policy trends: Political devolution within the UK has led to variations in the way services are organised and delivered between the four nations.Primary care respiratory services in the UK: Primary care is the first point of contact with services. Most respiratory conditions are managed here, including prevention, diagnosis, treatment and palliative care.Epidemiology: Respiratory disease accounts for more primary care consultations than any other type of illness, with 24 million consultations annually.Access to care: Equitable access to care is an ongoing challenge: telehealthcare is being tried as a possible solution for monitoring of asthma and COPD.Referral and access to specialist care: Referrals for specialist advice are usually to a secondary care respiratory physician, though respiratory General Practitioners with a Special Interest (GPwSIs) are an option in some localities.Conclusions: Prevalence of asthma and COPD is high. Asthma services are predominantly nurse-led. Self-management strategies are widely promoted but poorly implemented. COPD is high on the policy agenda with a shift in focus to preventive lung health and long-term condition management. (C) 2011 Primary Care Respiratory Society UK. All rights reserved. Q Zhang et al. Prim Care Respir J 2011; 20(1): 97-101 doi:10.4104/pcrj.2010.00061

Inhaled medications are the preferred therapies for patients with asthma and COPD, but their effectiveness is limited by the patient's ability to use the device properly, an issue often neglected when these medications are prescribed. Correct inhaler technique must be taught and learnt, and requires educational and motivational programs aimed at patients and healthcare providers alike. Written instructions alone are manifestly insufficient: education must include practical demonstration and periodic re-assessment and reeducation, since correct technique and motivation usually deteriorate with time. Several devices are available on the market, the purpose of which is to train patients to use inhalers correctly. They are often directed at particular devices or groups of devices and/or particular critical aspects of technique. This paper reviews the devices currently available for training patients in the correct use of both pressurised metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs).

Objectives: The UK Meteorological Office (Met Office) has developed a health forecasting service for chronic obstructive pulmonary disease (COPD) patients, combining a rule-based model predicting risk based on environmental conditions with an anticipatory care intervention providing information on self-management and warnings via an interactive telephone call. Our aim was to explore the acceptability and utility of such a service to patients with COPD and its perceived impact on their behaviour and disease management. Methods: A cross-sectional questionnaire survey of service users drawn from 189 general practices in England, Scotland and Wales at the end of the winter of 2007/8. Results: Completed questionnaires were received from 3288 COPD patients, representing a response rate of 40%. Eighty-five percent of those returning a questionnaire reported at least one exacerbation during the study period and 8% had been admitted to hospital on one occasion or more. The majority of respondents deemed the information pack (comprising a booklet and thermometers) useful while the automated calls were generally said to be convenient, easy to understand and reassuring. Those less satisfied with the service felt they were already sufficiently aware of the prevailing weather conditions or felt more detailed information was needed. Most benefit was reported by those patients who were willing to be pro-active in the management of their condition, with the service encouraging 36% of respondents to seek a repeat prescription, 28% to reread their information pack and 12% to consult their GP for worsening of symptoms. Conclusions: Patients found the automated interactive calling, combined with a health risk forecast, both viable and useful, welcoming the information and tools it offered. In many cases, it added to patients’ understanding of their illness and promoted better self-management. Future research should focus on the potential impact of the service in terms of health outcomes and cost-effectiveness.

INTRODUCTION: The identification and management of adults presenting with pneumonia is a major challenge for primary care health professionals. This paper summarises the key recommendations of the British Thoracic Society (BTS) Guidelines for the management of Community Acquired Pneumonia (CAP) in adults. METHOD: Systematic electronic database searches were conducted in order to identify potentially relevant studies that might inform guideline recommendations. Generic study appraisal checklists and an evidence grading from A+ to D were used to indicate the strength of the evidence upon which recommendations were made. CONCLUSIONS: This paper provides definitions, key messages, and recommendations for handling the uncertainty surrounding the clinical diagnosis, assessing severity, management, and follow-up of patients with CAP in the community setting. Diagnosis and decision on hospital referral in primary care is based on clinical judgement and the CRB-65 score. Unlike some other respiratory infections (e.g. acute bronchitis) an antibiotic is always indicated when a clinical diagnosis of pneumonia is made. Timing of initial review will be determined by disease severity. When there is a delay in symptom or radiographic resolution beyond six weeks, the main concern is whether the CAP was a complication of an underlying condition such as lung cancer.

Primary care spirometry services can be provided by trained primary care staff, peripatetic specialist services, or through referral to hospital-based or laboratory spirometry. The first of these options is the focus of this Standards Document. It aims to provide detailed information for clinicians, managers and healthcare commissioners on the key areas of quality required for diagnostic spirometry in primary care — including training requirements and quality assurance. These proposals and recommendations are designed to raise the standard of spirometry and respiratory diagnosis in primary care and to provide the impetus for debate, improvement and maintenance of quality for diagnostic (rather than screening) spirometry performed in primary care. This document should therefore challenge current performance and should constitute an aspirational guide for delivery of this service.

Introduction Allergic diseases are common, increasing, and associated with significant morbidity and occasional, but potentially avoidable, mortality. There is widespread public, professional and government agreement about the poor quality of care received by many patients with allergic diseases in the UK. Many remain undiagnosed, few have access to specialist services, and the majority of primary care health professionals have no allergy training. We report an evaluation of a novel, UK NHS-funded primary care-based allergy service in North West London. Methods The clinic was run by a specialist allergy nurse and a general practitioner (GP) with a special interest in respiratory disease and allergy. Referrals from local GPs were made on dedicated proformas and handled according to developed and agreed community care pathways. Results 141/151 (93%) of those referred attended the clinic. On average, patients waited 15.7 (SD 15.67) days from referral to an offer of an appointment and were seen 18.11 (SD18.07) days from the date of referral. The majority of patients were referred for hives or wheals (61;40%), suspected food allergy (28;40%), multiple reasons, (19;12%) or rhinitis (19;12%). Skin prick and specific-IgE tests were performed on 69 (49%) and 19 (14%) patients respectively, with 4 (0.3%) patients having both. We estimated an overall saving of at least pound13,580 to the local health economy - through reduced secondary care referrals - during the nine months' duration of the clinic. Assessed using a validated patient satisfaction questionnaire, most patients rated their satisfaction with the service with an overall median score of 75% (IQR 65.64-82.32). Conclusions A primary care allergy service provided by appropriately trained personnel can cater adequately for the majority of primary care referrals. This model provides a pathway of care that supports self-directed care, reduces inappropriate referrals, and encourages care in the local community. The model is one that could easily be developed further into a clinical assessment service for allergy including respiratory based (asthma) problems. This would expand the scope and ensure value for money as well as responding to a clinical need with significant incidence locally. The UK Department of Health should consider rolling out this primary care-based model nationally.

Aerosol inhalation is considered the optimal route for administering the majority of drugs for the treatment of obstructive airways diseases. A number of Pressurised Metered-Dose and Dry Powder Inhalers are available for this purpose. However, inhalation of therapeutic aerosols is not without difficulty; it requires precise instructions on the inhalation manoeuvre, which is different from spontaneous normal breathing. Also, the characteristics of the inhaler device have to be suitable for the user. Available data indicate a frequent lack of knowledge demonstrated by health professionals and patients on the inhalation manoeuvre and handling of inhalers, resulting in a reduction of therapeutic benefit. This paper reviews the literature concerning the fundamental aspects of inhaler devices, inhalation manoeuvre and device selection, in an attempt to increase the knowledge of, and to optimise the clinical use of, therapeutic inhalers.

The 2008 BTS/SIGN British Guideline on the management of asthma provides comprehensive updated evidence-based guidance on asthma management for healthcare professionals. This primary care-focussed summary has been produced to aid dissemination and implementation of the key guideline messages into primary care. The section on diagnosis emphasises the new integrated symptom-based approach with clinicians using their deductive skills to determine the probability that the patient has asthma. The various tools used for monitoring asthma are discussed. There are sections on both non-pharmacological and pharmacological management of chronic asthma in adults and children. Treatment options for children are subdivided into the under-5s and children aged 5-12 years. Poor asthma control is manifested by exacerbations and acute asthma. Personalised asthma action plans for guided self management should be provided and used when levels of asthma control change. There are sections on difficult asthma and the treatment of exacerbations and acute severe asthma. Various outcome measures for auditing the quality of asthma care are discussed.

This article covers some of the models of care utilized in general practice or the primary care setting, and the process of management of patients with asthma in this setting. General principles are used to illustrate the types of problems and solutions for managing patients in this-challenging setting. The reader is advised to refer to more detailed texts, including national and international guidelines, for further information.