The respiratory year in review: 2014
As the year draws to an end, we look back on some of the recent developments in respiratory care and indulge in some crystal ball gazing for the year ahead
Medical knowledge evolves at what seems to be an ever-increasing pace. Keeping up to date is essential, but in our increasingly pressured health service, this can be challenging. This article gives an overview of some of the major publications, advances and changes in our approach to respiratory patients that have happened this year – together with some ideas about future changes and a ‘wishlist’ that could improve patient care in the future.
ASTHMA DEATHS
‘The National Review of Asthma Deaths: why asthma still kills’ (NRAD), undertaken to discover why people with asthma had died from a condition that is eminently treatable, was published in May.1 It made for sobering reading.
The review highlighted complacency, in both health care professionals and patients themselves, as one of the most important factors leading to preventable exacerbations of asthma and made recommendations as to how we should address this. The report (and the deaths) delivered a timely and important reminder that asthma is a potential killer. Those who died had often not been prescribed (or had not taken) inhaled steroids and, as a result, had not been able to control the inflammation that is the most significant element of the pathophysiology of asthma.
Some individuals had been given 30 or more reliever inhalers in the year before their death. In people with well-controlled asthma, where short acting bronchodilators are used no more than twice a week, a salbutamol metered dose inhaler with 200 puffs should last almost a year. In too many cases worsening asthma control went unrecognised and untreated, with fatal results. This huge discrepancy between best practice and real life care is an important reminder of why the education of people with asthma (and a suitably educated workforce able to provide the necessary information) is central to effective asthma care.
There were four key recommendations for primary care from this report:
1. Every GP practice should have a named clinician for asthma care
2. There needs to be better monitoring of asthma control; where loss of control is identified, immediate action is required to address it
3. Better education is needed for doctors, nurses, patients and carers, to make them aware of the risks of poor control, and to enable them to recognise the warning signs and know what to do
4. All patients should be provided with a personal asthma action plan (PAAP), to help them identify if their asthma is worsening and which tells them how and when to seek help.
THE BTS/SIGN ASTHMA GUIDELINE UPDATE
Bearing in mind the findings from NRAD, it is quite serendipitous that the latest guidelines from the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) for the management of asthma were published in October this year.2 This is one of the biggest overhauls of the guidelines in recent years.
The 2014 update includes advice on implementing the new guidance and points to key recommendations, such as the newly revised sections on supported self-management and the fully overhauled section on non-pharmacological management. The strong focus on patient centred care was underlined by the positioning of self-management at the beginning of the guideline rather than towards the end, where the impression may have been that the provision of self-management education and PAAPs was a ‘nice to do’ rather than a ‘need to do’ aspect of asthma care. Moving self-management plans to this position really emphasises the importance of upskilling people to self-manage, and reflects one of the key messages from NRAD.
The importance of using simple, personalised and written asthma action plans cannot be over-emphasised. It behoves all of us in general practice to think about what we are providing and whether all of the team is taking the same approach.
EMERGENCY INHALERS IN SCHOOLS
Also in October, the Department of Health (DH) issued guidance on the emergency use of reliever inhalers in schools. The school inhaler project had been running since the beginning of the decade. It is gratifying to see recommendations being brought into force as a result of this project which will help school staff recognise and treat acute exacerbations of asthma.3
A ‘spin off’ from the school inhaler project has been the realisation, in many areas, that more training is needed for staff who find themselves dealing with children having an acute attack. For some time now the BTS/SIGN guidelines have been advocates of general practice clinicians and health care professionals from schools working together to improve asthma care. Evidence that this is being implemented, however, is thin on the ground. Clinical Commissioning Groups (CCGs) should be thinking about this element as well as implementing the new guidance. The publication of the updated BTS/SIGN guidelines and the DH guidance on managing acute asthma in schools opens up the opportunity to have these conversations with schools in your area again.
COPD AND THE MISSING MILLIONS
This year wasn’t all about asthma. Chronic obstructive pulmonary disease (COPD) was in the headlines when a study by Rupert Jones identified that many people with COPD were not being diagnosed when they presented in general practice with typical symptoms, such as chronic cough, breathlessness and chest infections.4
This study found that:
- 85% of patients had visited their doctor or a clinic at least once with respiratory symptoms in the 5 years before diagnosis
- 58% first reported symptoms 6-10 years before diagnosis, and
- 42% had had symptoms for 11-15 years before diagnosis.
This study highlights that many people diagnosed with COPD could have benefited from earlier diagnosis and treatment, with consequent improvements in long term morbidity and mortality.
Once again, this brings us back to the importance of education, so that health care professionals seeing people with these symptoms have an increased index of suspicion and remember to ask pertinent questions about smoking history and occupation.
THE LATEST ON E-CIGARETTES
Giving advice and support about smoking cessation is one of the most important interventions that anyone can carry out, particularly in regard to COPD. Stopping smoking is linked to overall reductions in both the incidence and severity of a wide range of conditions, such as respiratory and cardiovascular disease, and cancer.
A report from the Smoking in England group this year showed that the use of NRT is decreasing at the same time as the use of e-cigarettes is increasing.5 The debate continues to rage as to whether e-cigarettes are useful or harmful in the battle to stop people smoking. Some people have suggested that e-cigarettes may be a ‘gateway’ to smoking normal cigarettes. The concern is that they could be particularly attractive to schoolchildren as they may be vulnerable to the marketing techniques employed by the manufacturers. However, an updated information sheet from Action on Smoking and Health (ASH) this year refutes this and gives a broad insight into the advantages and disadvantages of e-cigarette use.6 Research into these products continues and licensing will come into effect in 2016.
- See e-cigarettes: a Practice Nurse guide, Practice Nurse October 2014;44(10):14-18
SPIROMETRY
It wouldn’t be possible to discuss COPD without mentioning spirometry. Although history taking is the most important element of making a diagnosis of COPD, post-bronchodilator spirometry provides objective evidence of irreversible airflow obstruction – the cherry on the diagnostic cake.
It is almost 10 years since the publication of a booklet from the BTS COPD Consortium, emphasising the need for people to be trained in carrying out spirometry.7 Yet this training is still not mandatory. Compare this with smear test training, where clinicians need to be trained, assessed and show evidence of ongoing competency to be allowed to carry out the test.
Discussions about who should be carrying out diagnostic spirometry and the training they need to do this have been going on for years, but this year we have been waiting for final confirmation of the standards required. Following last year’s publication of the guide to performing quality assured diagnostic spirometry (QADS),8 there is a rumour that NHS England will imminently announce plans to ensure that anyone carrying out diagnostic spirometry has the Association for Respiratory Technology and Physiology (ARTP) qualification which accredits them to do so. The rumour suggests that there will be a long run-in period before this is obligatory, so that people have time to produce a portfolio and complete the necessary requirements. This rumour has been around for some time, however, so it will be good to see some clarity around the issue before long. In the meantime, the QADS document gives some guidance to inform practice for now and, for those who want to get ahead of the game, accredited training is already available (see resources).
NEW APPROACHES TO TREATING COPD
There has been a range of new drugs and devices to treat both asthma and COPD launched this year but perhaps the biggest sea change of the year has been the move away from NICE guidance on treating COPD,9 towards an approach which focuses more on the ABCD approach of the Global Obstructive Lung Disease (GOLD) guidelines.10 Although neither guideline provides a ‘one size fits all approach’ (not surprisingly, as there is very little chance of one size ever fitting all) there has been growing debate over the use of inhaled corticosteroid/long acting beta2 agonist (ICS/LABA) combinations in some of the categories that NICE suggests, especially when high dose inhaled steroids are being used.11,12
The GOLD categories suggest careful consideration on a case by case basis to identify those most at risk of exacerbations and most likely to benefit from ICS/LABA combinations as compared with those who will benefit more from bronchodilation using a LABA, a long acting muscarinic antagonists (LAMA) or even both. This has led to even more debate about when and how to step people who may not need it off ICS/LABA combinations.13 The London Respiratory Network developed an inhaled steroid safety card for people on high doses of ICS (>1000mcg total daily dose of standard ICS) to carry (see resources). However, an equally important aim of the project was to ensure that those on high dose ICS were reviewed and plans put in place to step them down onto lower doses where appropriate.
NEW DRUGS AND DEVICES
There was a sudden influx of new drugs and devices onto the respiratory market in 2014. The electronic medicines compendium website (https://www.medicines.org.uk/emc) has information on these new products marketed under brand names such as:
- Anoro Ellipta
- Duoresp Spiromax
- Fostair Nexthaler
- Incruse Ellipta
- Relvar Ellipta, and
- Striverdi Respimat.
Some drugs and devices are licensed for both asthma and COPD, some are for one or the other and all have different doses and age indications. Health care professionals should ensure that they are familiar with these devices as recommended by NICE.9 Formularies may simplify choice, but you should be mindful that most guidelines have a rider that states that they do not replace clinical decision making. The old motto that the ‘most expensive device is the one that is not used’ still holds true today and patient choice, preference and ability should be considered at all times.
CRYSTAL BALL GAZING
Looking to the future, we should be seeing more dual bronchodilator drugs on the market and triple therapy in one device will not be far behind – inhalers that include an ICS, LAMA and LABA are already close to coming to market.
More trials will be carried out in real world populations to see what happens when patients take treatments in real world settings, as opposed to the so-called gold standard randomised controlled trials (RCTs) where most of the people you might use the drugs on in real life are left out as a result of strict inclusion and exclusion criteria. Although there are pros and cons to real life studies too, more and more researchers are considering the value of these trials versus RCTs. Expect to see more trials reporting real world data in the future.
A RESPIRATORY WISHLIST
It would be interesting to compile a wish-list of future developments in respiratory disease. One opportunity has perhaps been missed: the chance to remove step 1 (prn bronchodilators only) as a credible option for treating asthma. Asthma is an inflammatory condition and it will always be hard to get people to recognise that bronchodilators do not ‘treat’ asthma when they remain at step one of the treatment algorithm.
The issue of free prescriptions for respiratory patients continues to elude us in England, yet it would surely be very simple and effective to make all inhaled steroids free for people with asthma, at the very least. Another easy win would be to fully recognise the value of pulmonary rehabilitation by ensuring that it is a central part of COPD management, similar to programmes like DESMOND and XPERT for type 2 diabetes.
THE COST OF IGNORANCE
Ultimately, effective, evidence-based respiratory care comes down to (as someone once said) ‘education, education, education’. Education of health care professionals in order to facilitate education of the public – patients, parents, teachers, carers and the like – has to be made a key priority for the next government. In these times of financial constraints, education is often the first sacrifice to cutbacks. However, as the American lawyer and educator Derek Bok once said – ‘If you think education is expensive, try ignorance’.
REFERENCES
1. Royal College of Physicians. National Review of Asthma Deaths: why asthma still kills. 2014 https://www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf
2. BTS/SIGN asthma guidelines, 2014 https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
3. Department of Health. Guidance on the use of emergency salbutamol inhalers in schools, 2014 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/360585/guidance_on_use_of_emergency_inhalers_in_schools_October_2014.pdf
4. Jones RCM. Price D, Ryan D, et al. Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort. The Lancet Respiratory Medicine 2014; 2(4): 267-76 www.thelancet.com/journals/lanres/article/PIIS2213-2600(14)70008-6/abstract
5. Smoking in England Group. E-cigarettes: what we know, 2014 http://www.smokinginengland.info/reports/
6. ASH. Electronic cigarettes, 2014 http://www.ash.org.uk/files/documents/ASH_715.pdf
7. BTS COPD Consortium. Spirometry in practice, 2005 https://www.brit-thoracic.org.uk/document-library/delivery-of-respiratory-care/spirometry/spirometry-in-practice/
8. Primary Care Commissioning. A guide to performing Quality Assured Diagnostic Spirometry. 2013 http://www.pcc-cic.org.uk/article/guide-quality-assured-diagnostic-spirometry
9. NICE CG101. Management of chronic obstructive pulmonary disease in adults in primary and secondary care, 2010 https://www.nice.org.uk/guidance/cg101
10. GOLD. Pocket guide to COPD diagnosis, management and prevention, 2014 http://www.goldcopd.org/guidelines-pocket-guide-to-copd-diagnosis.html
11. Bostock-Cox B. Masterclass: using combination inhalers in COPD. Practice Nurse July 2014;44(07):13-18
12. Hurst JR, Vestbo J, Anzueto A, et al for the Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points (ECLIPSE) investigators. Susceptibility to Exacerbation in Chronic Obstructive Pulmonary Disease. New England Journal of Medicine 2010; 363:1128-1138
13. Magnussen H, Disse B, Rodriguez-Roisin R. et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD New England Journal of Medicine 2014; 371(14):1285-94
