By Rachel Pugh
New respiratory guidelines are imminent which will clarify inconsistencies between the existing different approaches towards diagnosis and treatment of asthma.
In their respiratory update at the RCGP Conference in Liverpool, PCRS Education lead Steve Holmes and Stockport GP Stephen Gaduzo, provided key clinical tips to improve the care of people with respiratory problems based on the GOLD and NICE Chronic Obstructive Pulmonary Disorder (COPD) guidelines and the NICE and SIGN/BTS guidance on asthma. They also explained how to manage the differences between approaches in clinical practice.
* NICE, BTS and SIGN are jointly producing new guidelines and an asthma pathway to give a broader approach and materials for the diagnosis and management of asthma though an individual’s lifetime
* An update of the early progress on the proposed guideline and pathway will be at the BTS winter meeting in London, December 4-6, 2019
* New GOLD and NICE guidelines were produced for COPD in 2019 (1) (2).
COPD kills around 30,000 people a year in the UK ( www.bilf.org.uk/world-copd-day ) Around 900,000 people in the UK are diagnosed with COPD and an estimated two million undiagnosed. Respiratory disease (particularly COPD) is responsible for a significant number of hospital admissions and therefore is given due attention in the NHS Plan. Patients are more likely to die of COPD than a heart attack.
Despite this, little progress has been made in recent decades in improving diagnosis. Holmes recommended that GP colleagues consider COPD diagnosis in the case of patients:
* Aged over 35
* AND smokers or ex-smokers
* AND with any of the following symptoms - exertion breathlessness, chronic cough, regular sputum production, frequent winter bronchitis wheezing
NICE recommends diagnosis should be accompanied by a chest X-ray, but Holmes does not consider this useful in COPD patients.
He proposes the following steps at every COPD review:
* Offer smoking cessation advice and treatment
* Pneumococcal and influenza vaccines
* Offer pulmonary rehabilitation if indicated
* Co-develop a personalised self-management plan
* Optimise treatment of comorbidities - such as coronary heart disease, heart failure and osteoporosis.
In dealing with asthma, Dr Gaduzo - a past chair of the PCRS - acknowledged the complexities for GP colleagues by referring to two sets of guidelines - NICE and BTS/SIGN. BTS/SIGN is built on evidence-based systematic review of literature and translation of knowledge into action, whereas NICE is focused on improved quality of care and cost effectiveness.
Using an asthma case study, he demonstrated the differences between the two approaches for reviewing patients. His recommended the use of the PCRS Consensus (3) until the production of the new NICE, BTS and SIGN guidelines:
* Use the BTS/SIGN predictors of high probability such as atopy, variability and documented wheeze
* Try to gain objective evidence of reversible airways obstruction or variability, using spirometry with LLN to calculate the ratio and peak flow variation
* If in doubt seek evidence of airways inflammation (FENO).
He recommended the development of good self-management plans for patients, given limitations on the face-to-face contact between GP and asthma patients.