Diagnosing and Treating Asthma in Humber and North Yorkshire
There are more than 100,000 people living with asthma across Humber and North Yorkshire (HNY). Asthma is an inflammatory disease that affects the airways in the lung, leading sufferers to experience symptoms such as breathlessness, cough and wheeze that typically vary over time.
The HNY Respiratory Network and HNY Children and Young People’s (CYP) Asthma Taskforce are passionate about ensuring that everyone with asthma across the region can access high quality and sustainable asthma care.
It is well established that over-use of short-acting beta agonist (SABA) inhalers and under-use of steroid containing inhalers (ICS) in asthma is associated with increased risk of asthma attacks and asthma related deaths. Humber and North Yorkshire (HNY) has historically had high levels of SABA-use. The HNY Respiratory Network and HNY CYP Asthma Taskforce have worked with asthma clinicians and patients from across the region to develop a unified approach to managing asthma across all ages. These guidelines recognise the importance of identifying and addressing SABA over-use in asthma and ensuring people with asthma receive the anti-inflammatory (steroid containing) inhalers that they need to control their asthma. Please follow the links to view the 2023 HNY Asthma Guidelines.
The following asthma guidelines are intended for use by clinicians working in Humber and North Yorkshire. These guidelines have been developed to inform treatment decisions for:
- People with suspected asthma that are awaiting objective diagnostic testing
- People with newly diagnosed asthma
- People with uncontrolled asthma considered by their clinician to require a change in treatment
- People considered by their clinician to require a change in asthma treatment for another reason
through shared decision making.
Supporting guideline implementation resources
Having a guideline that supports evidence-based, sustainable asthma care is not enough. To improve the care for asthma sufferers across the region, it is essential that guideline recommended care is implemented into practice. For this reason, the HNY Respiratory Network and HNY CYP Asthma Taskforce have developed a range of resources and educational materials to support practice change.
Please use the links below to access these resources:
Launch Webinar on 24th October 2023 Recordings:
Frequently asked questions
How many puffs of ICS-fometorol is a patient allowed in acute exacerbations?
Different combinations have different licenced maximum doses. Budesonide-Fometorol combinations (DPI) are generally up to a maximum of 12 inhalations in 24 hours. Bethlomethasone-formetorol combinations are generally up to a maximum of 8 inhalations in 24 hours.
Asthma and Lung UK have recently added a MART asthma action plan to their website and it has guidance for what to do in an asthma attack. It recommends taking 1 puff every 1-3 minutes up to 6 puffs and calling an ambulance if feeling worse or not feeling any better. Following this, it suggests repeating 1 inhalation every 1 to 3 minutes up to 6 puffs, and if not improving and the ambulance hasn’t arrived, contacting 999 again immediately. (A+L UK PAAP: https://cdn.shopify.com/s/files/1/0221/4446/files/MART_action_plan_editable_full_colour_V4.pdf?v=1694507849)
Do patients often report changes in side effects type/frequency when switching to MART ICS/LABA treatment from SABA/ICS or SABA only treatment?
Generally not in my experience. The same advice goes for AIR/MART inhalers as any other steroid containing inhaler where patients are advised to rinse their mouth out where possible after use, although I appreciate this isn’t always convenient when used for relief during the day, but is more manageable for maintenance doses in MART.
I also want to make clear that nobody with a confirmed diagnosis of asthma should be on SABA only treatment. It is worthwhile carrying out a search within practices to find these patients and bring them in for review.
Enerzair is now available in 2 strengths. Would we start patients on the higher strength to start if working towards biologics? 150/50/160?
Enerzair is currently only available in one strength in the UK (114/46/136). This is equivalent to high dose ICS and is suitable for the use in managing patients with severe asthma. If the lower dose preparation is licenced, dosing details will be added to the relevant page of the guideline.
A lot of our patients are on fostair (not fostair nexthaler) and doing mart. Can we keep them on this or do they need swapping to fostair nexthaler?
If someone is on therapy and is controlled and it is felt they are on the right inhaler for them, we do not advocate changing their therapy. However, lots of people on pMDI inahlers don’t use them effectively and may be better suited to dry powder inhalers. Many patients will be able to use both a pMDI and DPI. If patients have good technique with their pMDI they can still be offered a choice of a lower carbon dry powder inhaler, which can be the Fostair Nexthaler, and assessed to make sure they can use this. The reason that Fostair pMDI doesn’t feature on the guideline specifically is because lufrobec is an alternative beclomethasone-formoterol pMDI (and is lower cost). Fostair pMDI is still on the formulary patients already on this that are suited to it and are well controlled, can remain on this.
Is there any risk of a patient developing as a fixed airway further down the track?
Long term data isn’t available as yet for AIR Therapy, however, we know that the majority of people prescribed regular ICS with SABA reliever for mild-moderate asthma are not adherent with their regular preventer therapy, meaning that they are effectively receiving SABA only therapy, which is not a safe way to manage asthma. As such, AIR Therapy offers a much safer alternative to this. For people with severe asthma on biologics, a recent study suggested that weaning their inhaled steroids to ‘as-needed’ AIR Therapy without maintenance doses was associated with an increase in FeNO and some lung function decline. However, this is a severe asthma cohort, which is not the same as mild asthma. AIR is a safe and effective approach to asthma management and prevents exacerbations. If you are concerned about persistent airway inflammation with AIR Therapy (e.g. they have a raised feno on AIR Therapy), you can escalate them to a MART regime, giving the regular maintenance doses but still using the same ICS-formoterol combination to relieve symptoms.
At what point when a patient is using MART with regular reliever doses would you consider stepping up inhaler strength or adding in additional therapy?
The general recommendation would be if requiring more than 7 reliever doses per week of AIR (3 or more uses of SABA if on a SABA containing regime), treatment should be reviewed and assuming adherence and inhaler technique are satisfactory and it is felt that asthma is the cause of their symptoms, a step-up in therapy should be considered. In addition to this, persistent symptoms (daytime and or night time) should prompt review. Therapy should also be reviewed following an exacerbation in order to consider whether a change in treatment is indicated to reduce risk of future exacerbation.
If a combination inhaler has been started when asthma suspected – should it be stopped before testing, spiro or feno – and for how long if stopped?
If there will not be a delay for objective testing and it is safe to do so, it is preferable to undertake testing prior to commencing therapy. However, if there will be delay in objective testing and/or there is felt to be a need for immediate treatment, it is advised to commence AIR Therapy and arrange diagnostic testing as soon as possible. Prior to undertaking spirometry with reversibility, treatment should be omitted prior to the test and advice depends on the treatment. We will endeavour to share guidance on this on the website when it is available.
During an exacerbation how do we advise patients to take their MART inhaler if they no longer have a SABA?
Information about use of AIR either just as needed or as part of a MART regime is detailed on the last page of the adult asthma guideline. Guidance is also provided in the A+L UK MART asthma action plan if using this. Essentially, patients use 1 puff of their ICS-formoterol inhaler to relieve symptoms in addition to their maintenance dose, this means they will receive higher doses of ICS during their exacerbation, targeting airway inflammation.
Are there any patient leaflets / asthma care plans to help support patients with AIR and/or MART?
Asthma and Lung UK provide good patient facing resources. I believe they are working on an anti-inflammatory reliever therapy action plan for mild asthma but, in the meantime, you could use their MART action plan and put 0 in boxes for regular morning and evening doses and just recommend required doses. Guidelines are recommending that where people are needing to use more than 7 inhalations per week of ‘as-needed’ AIR Therapy or as part of MART, they should seek advice from a healthcare professional and potentially step-up treatment accordingly. We are looking to produce some local action plans, but these are still a work in progress. These will go onto our website as soon as available.
Is there a plan in place or would you consider devising asthma action plans for patients which include some of the detail supplied within the new guidelines?
We are looking to produce some local action plans, but these are still work in progress. These will go onto our website as soon as available. In the meantime, Asthma + Lung UK have created a MART action plan (https://cdn.shopify.com/s/files/1/0221/4446/files/MART_action_plan_editable_full_colour_V4.pdf?v=1694507849)
Should we blanket switch our patients?
We are very clear that we do not support or endorse blanket switching of inhaled therapy. All of the asthma guidelines that have been produced have a coversheet that stipulates, ‘These guidelines are not intended to and should not be used to support or justify a switch in asthma therapy that is not clinically indicated. All change in treatment should be made through shared decision making between a patient and their clinician.’
Is the rightbreathe website good to use to show inhaler technique to patients?
Asthma and Lung UK and Rightbreathe both provide on-line inhaler videos. A+L UK include more spoken instruction in my experience but worth taking a look at both and seeing what fits best with how you wish to use them in practice.
Are we allowed to use the incheck again, we were advised to stop after covid because the filters we had were inspirate filters?
We have been advised for in check devices that the filters are safe for multi patient use. For peak flow meters, one way to do it is for practices to have a meter for demonstration only and patients should use their own peak flow meter.
Why does spiriva respimat not feature in these guidelines?
Spiriva Respimat is licenced to CYP from 6 years. This does not feature on the guideline though, as a LAMA would not routinely be prescribed in the treatment steps represented in this guideline. If asthma is not controlled by the treatment steps identified on these guidelines, and after checking the principals of good asthma care (Adherence, inhaler technique etc), then a referral to secondary care would be advised. There would be several other treatment steps to work through before the addition of a LAMA and this should be done under the supervision of a paediatrician with specialist interest in CYP asthma and in some cases only in tertiary care.
Inhaled Corticosteroids are the most important drug for the management of asthma and adding a LABA in the form of a combination inhaler (ICS/LABA) would be the preferred add on, over adding a LAMA. There are no combined ICS/LAMA’s licenced and LAMA’s used alone without co-prescribed ICS is also associated with increased risk of severe exacerbations. There is insufficient evidence to support ICS-LAMA over low-medium dose ICS/LABA.
We have only included in the guidelines medications that are licenced for the childrens age group
How are others managing SABA requests for schools and how many are they giving at a time/over the year?
Schools can purchase up to 5 SABA inhalers and spacers from a pharmacy, with a letter signed by the headteacher. Schools can follow guidance within the ’emergency asthma inhalers for use in schools’. This guidance is not statutory and schools may choose not to buy spare inhalers.
Legislation states that person prescribing for chronic conditions must ensure everyone around the child understand the diagnosis and how to treat, this includes schools. Recommend clinicians ensure CYP get an asthma action plan in their asthma reviews and share this with schools via secure email or by asking the parents to share it.
Re. Salbutamol in school – Health and Safety insurance legislation requires there to be an inhaler in school for emergencies. Will have to prescribe them one for school but limit it to being in date and just for school. Encourage them not to open it and just keep it for school. Hoping for clearer guidance in the future from Dept of Health and Dept of Education.
Asthma friendly schools scheme in place across Humber and North Yorkshire linked to from Healthier Together website.
The guidelines suggest 3 SABA a year for children – can we still give children a spare inhaler if they need one?
If issuing spare inhalers and spacers for different locations a child may visit, it is important to document the reason for the extra prescriptions on the system. This will help when assessing for SABA overuse. It needs to be recognised that CYP do spend a large amount of time outside the family home and whilst in an ideal world they would transport their inhaler/spacers on their person, this is not always possible and we have to ensure safety and schools need to be equipped to keep a CYP safe, with access to emergency treatment when it is needed. Due to the requirement of schools to purchase their own spare inhalers, out of their own budgets, not all schools will be able to or wish to follow this guidance.
If a child over 12 has MART dosing should they still have blue inhaler for school prescribed?
At this time, yes. Schools asthma education and school wide emergency plans direct them to administer the blue inhaler and spacer in an emergency. However, when giving education to the CYP and family around MART, ensure they know their MART PAAP and how to manage increased symptoms and when to seek emergency support. In young people 12+ we should be encouraging self management skills and recognising that they are more independent at high school, so should know how to increase their ICS/LABA in response to increased symptoms.
Trial of ICS treatment for 6 weeks for children. What dose would you recommend per age group? Starting at first step on the children’s guideline. In the younger guide (6-11) this would be very low dose ICS – e.g. clenil modulite/soprobec 100mcg BD. In the 12-17 guideline start with low dose ICS e.g. Pulmicort 200mcg BD.
The boxes on each treatment step on the guideline’s give clinicians all the device options in that step and each have equivalent ICS potency.
If a 13 or 14yr old only uses SABA once a month or even less, usually during periods of chest illness would you leave him with that or still switch to AIR?
Yes I would consider AIR. SABA only treatments are no longer recommended. Although inhaled SABA are highly effective for quick relief of symptoms, patients whose asthma is treated with SABA alone, are at higher risk for asthma related deaths (GINA 2023). In this instance where asthma is well controlled outside of chest illnesses, adherence to a fixed regime will likely be poor, there for AIR may be a good alternative. It would also be essential to consider diagnosis, is there objective evidence of asthma, or is SABA being used with no evidence of wheeze, SOB, chest tightness?
Where do we stand with infection control rules for use of peak flow meters and in check devices now?
We have been advised for in check devices that the filters are safe for multi patient use. For peak flow meters, one way to do it is for practices to have a meter for demonstration only and ask patients to use their own to practice on.
Spirometry waiting lists are lengthy. Would you advise diagnosing and coding with PEF diary, FeNO and excellent history taking?
Excellent history taking is key. Yes, we must be pragmatic and if can demonstrate variable air flow limitation with significant variability in peak flow plus air way inflammation with feno and got a consistent history then that is consistent. Where you are not sure spirometry is useful.
We have had several reports of pharmacies unable to source luforbec. How does the enhanced service stand if there are shortages?
These will be looked into to ensure supply is available. Not aware of any specific shortages.
With regards the lower cost inhalers – where do we stand here with the license – these would be used off license for AIR? Also Luforbec is currently unavailable from pharmacies – will this be considered when we’re not achieving?
We have had several reports of pharmacies unable to source luforbec. How does the enhanced service stand if there are shortages?
We have not be made aware of actual shortages of Luforbec but will monitor. It was suggested that Fobumix was also not available but the does not seem to be the case. But please liaise with local pharmacies on timing and numbers to allow them to plan for stock holding.
We have a lot of patients whose care has been transformed by using Fostair Nexthalers. So starting Luforbec pMDI would be a massive step backwards, and Fobumix DPI is a different agent and might unsettle things.
If a patient’s asthma is well controlled with a low carbon dry powder inhaler, there is no need to change their treatment. The cost-saving element of the scheme requires only relatively low use of Fobumix and Luforbec. These combination inhaler choices can be considered where they are a good fit for the patient. Luforbec should only be considered if the patient cannot use a low carbon ICS/Formoterol inhaler.