A cough that produces sputum, symptoms only after an upper respiratory tract infection, and peripheral pins and needles are all factors that make a diagnosis of asthma less likely.

When considering asthma, it is important to take into account recurrent episodes of symptoms that may be triggered by viral infections, exposure to allergens, NSAIDs/beta-blockers, and exacerbated by exercise, cold air, and emotions/laughter in children. It is also important to note recorded observations of wheezing, which should be documented by a clinician due to varying use of language. Symptom variability is another factor to consider, as asthma is typically worse at night or early in the morning. A personal history of atopy, such as eczema or allergic rhinitis, should also be taken into account. Additionally, the absence of symptoms of alternative diagnoses, such as COPD, dysfunctional breathing, or obesity, should be considered. Finally, a historical record of variable peak flows or FEV1 can also be helpful in diagnosing asthma.

Asthma diagnosis has been updated by NICE guidelines in 2017, which emphasizes the use of objective tests rather than subjective/clinical judgments. The guidance recommends the use of fractional exhaled nitric oxide (FeNO) test, which measures the level of nitric oxide produced by inflammatory cells, particularly eosinophils. Other established objective tests such as spirometry and peak flow variability are still important. All patients aged five and above should have objective tests to confirm the diagnosis. For patients aged 17 and above, spirometry with a bronchodilator reversibility (BDR) test and FeNO test should be performed. For children aged 5-16, spirometry with a BDR test and FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative BDR test. For patients under five years old, diagnosis should be made based on clinical judgment. The specific points about the tests include a FeNO level of >= 40 ppb for adults and >= 35 ppb for children considered positive, and a FEV1/FVC ratio less than 70% or below the lower limit of normal considered obstructive for spirometry. A positive reversibility test is indicated by an improvement in FEV1 of 12% or more and an increase in volume of 200 ml or more for adults, and an improvement in FEV1 of 12% or more for children.

Cautionary Measures for β2-Adrenergic Agonist Treatment

β2-adrenergic agonist treatment may lead to potentially serious hypokalaemia, especially in severe asthma cases. This effect can be intensified by theophylline, corticosteroids, diuretics, and hypoxia. Therefore, it is crucial to monitor plasma-potassium concentration in severe asthma patients. People with diabetes should also exercise caution when using β2 agonists, particularly when given intravenously, as it may increase the risk of ketoacidosis. These cautionary measures are necessary to ensure the safe and effective use of β2-adrenergic agonist treatment.

Step-Up Treatment for COPD Patients

When a patient with COPD is only taking salbutamol inhalers and their FEV1 is less than 50%, it may be necessary to step up their treatment. One option is to add a LABA+ICS, which can help improve lung function and reduce symptoms. However, it’s important to note that a LAMA should not be used in combination with an ICS. While adding a regular ICS may be considered in asthma treatment, it is not typically part of the step-up approach for COPD. Additionally, a SAMA can be an alternative to salbutamol inhalers, but it is not intended as a step-up treatment. By carefully considering the best options for each patient, healthcare providers can help manage COPD symptoms and improve quality of life.

As per the NICE 2017 guidelines, if a patient with asthma is not effectively managed with a SABA + ICS, their treatment plan should include the addition of a LTRA instead of a LABA. In this case, since the patient is already taking a short-acting beta-agonist and a low-dose inhaled corticosteroid, the recommended course of action would be to offer them an oral leukotriene receptor antagonist. This is in contrast to the previous BTS guidance which would have suggested the use of a long-acting beta-agonist in such a scenario.

The management of asthma in adults has been updated by NICE in 2017, following the 2016 British Thoracic Society (BTS) guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist, not a LABA. NICE doesn’t follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. It should be noted that NICE doesn’t recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance.

The steps for managing asthma in adults are as follows: for newly-diagnosed asthma, a short-acting beta agonist (SABA) is recommended. If the patient is not controlled on the previous step or has symptoms >= 3/week or night-time waking, a SABA + low-dose inhaled corticosteroid (ICS) is recommended. For step 3, a SABA + low-dose ICS + leukotriene receptor antagonist (LTRA) is recommended. Step 4 involves a SABA + low-dose ICS + long-acting beta agonist (LABA), and LTRA should be continued depending on the patient’s response. Step 5 involves a SABA +/- LTRA, and switching ICS/LABA for a maintenance and reliever therapy (MART) that includes a low-dose ICS. Step 6 involves a SABA +/- LTRA + medium-dose ICS MART, or changing back to a fixed-dose of a moderate-dose ICS and a separate LABA. Step 7 involves a SABA +/- LTRA + one of the following options: increasing ICS to high-dose (only as part of a fixed-dose regime, not as a MART), a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline), or seeking advice from a healthcare professional with expertise in asthma.

It is important to note that the definitions of what constitutes a low, moderate, or high-dose ICS have changed. For adults, <= 400 micrograms budesonide or equivalent is considered a low dose, 400 micrograms - 800 micrograms budesonide or equivalent is a moderate dose, and > 800 micrograms budes

BTS Guidance on Low Dose ICS and LABA Treatment

According to the 2016 BTS guidance, if a patient taking a low dose ICS doesn’t respond to the addition of a LABA, the LABA should be discontinued. Instead, healthcare providers should consider increasing the dose of ICS. It is important to note that options suggesting only an increase in ICS dose without stopping the LABA are incorrect.

This guidance emphasizes the importance of individualized treatment plans for patients with respiratory conditions. By carefully monitoring patient response to medication and adjusting treatment as needed, healthcare providers can help improve patient outcomes and quality of life. Proper medication management can also help reduce the risk of adverse effects and complications associated with respiratory conditions.

Management of COPD with Persistent Breathlessness

Patients with COPD who experience persistent breathlessness despite regular SABA use require additional inhaled treatment to improve symptom control and prevent exacerbations. Spirometry results confirming an obstructive picture, frequent exacerbations, and an FEV1 of less than 50% are useful in determining the next step in management.

The two options for add-on inhaled treatment are a LABA+ICS combination inhaler or a LAMA. The choice depends on the presence of asthmatic features, such as a previous diagnosis of asthma or atopy, a higher eosinophil count, substantial variation on FEV1 over time, or a substantial diurnal variation in peak flow. If asthmatic features are present, a LABA & ICS combination inhaler is preferred.

Adding a regular ICS on its own has no role in the COPD treatment ladder, while a regular SAMA can be used instead of a SABA but is not an option for add-in treatment. Adding a LABA may improve symptoms, but the combination of ICS/LABA is more beneficial for patients with a history of frequent exacerbations.

In addition to inhaled treatment, it may be necessary to issue an emergency supply of antibiotics and oral steroids for patients with persistent breathlessness and frequent exacerbations. For more information on managing stable COPD, refer to the NICE Visual Summary guide and NICE NG115 guidelines.

Overall, the management of COPD with persistent breathlessness requires a tailored approach based on individual patient characteristics and the presence of asthmatic features.

Acute exacerbations of COPD are a common reason for hospitalization in developed countries. The most common causes of these exacerbations are bacterial infections, such as Haemophilus influenza, Streptococcus pneumoniae, and Moraxella catarrhalis, as well as respiratory viruses, with human rhinovirus being the most important pathogen. Symptoms of an exacerbation include an increase in dyspnea, cough, and wheezing, as well as hypoxia and acute confusion in some cases.

NICE guidelines recommend increasing the frequency of bronchodilator use and giving prednisolone for five days. Antibiotics should only be given if sputum is purulent or there are clinical signs of pneumonia. Admission to the hospital is recommended for patients with severe breathlessness, acute confusion or impaired consciousness, cyanosis, oxygen saturation less than 90%, social reasons, or significant comorbidity.

For severe exacerbations requiring secondary care, oxygen therapy should be used with an initial saturation target of 88-92%. Nebulized bronchodilators, such as beta adrenergic agonists and muscarinic antagonists, should also be used. Steroid therapy and IV theophylline may be considered, and non-invasive ventilation may be used for patients with type 2 respiratory failure. BiPAP is typically used with initial settings of EPAP at 4-5 cm H2O and IPAP at 10-15 cm H2O.

Therapies for Smoking Cessation

There are various therapies available for smoking cessation, including newer drugs that have been specifically developed for this purpose. One such drug is Varenicline, which is a non-nicotine drug that acts as a partial agonist of the alpha-4 beta-2 nicotinic receptor.

Nicotine is a stimulant that releases dopamine in the brain, leading to addictive effects of smoking. However, nicotine replacement therapy can help replace these effects and reduce addiction to cigarette smoking. Bupropion (Zyban) is another drug that reduces the neuronal uptake of dopamine, serotonin, and norepinephrine.

Clonidine is a second-line agent due to its side effects, but it is an a2-noradrenergic agonist that suppresses sympathetic activity. Nortriptyline, a tricyclic antidepressant with mostly noradrenergic properties, is also an effective agent for smoking cessation.

Overall, there are many options available for those looking to quit smoking, and it is important to work with a healthcare provider to determine the best approach for each individual.

The prescription for oxygen is now done through the Home Oxygen Order Form instead of the FP10. Private companies are now responsible for providing the oxygen supply instead of the local pharmacy.

Long-Term Oxygen Therapy for COPD Patients

Long-term oxygen therapy (LTOT) is recommended for patients with chronic obstructive pulmonary disease (COPD) who have severe or very severe airflow obstruction, cyanosis, polycythaemia, peripheral oedema, raised jugular venous pressure, or oxygen saturations less than or equal to 92% on room air. LTOT involves breathing supplementary oxygen for at least 15 hours a day using oxygen concentrators.

To assess patients for LTOT, arterial blood gases are measured on two occasions at least three weeks apart in patients with stable COPD on optimal management. Patients with a pO2 of less than 7.3 kPa or those with a pO2 of 7.3-8 kPa and secondary polycythaemia, peripheral oedema, or pulmonary hypertension should be offered LTOT. However, LTOT should not be offered to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services.

Before offering LTOT, a structured risk assessment should be carried out to evaluate the risks of falls from tripping over the equipment, the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e-cigarettes).

Overall, LTOT is an important treatment option for COPD patients with severe or very severe airflow obstruction or other related symptoms.

Diagnosis and Treatment of Asthma in Adults

In adults, the diagnosis of asthma can be challenging, especially when there is diagnostic uncertainty or when both asthma and chronic obstructive pulmonary disease (COPD) are present. The British Thoracic Society recommends a 6-8 week treatment trial of inhaled beclomethasone (or equivalent) twice daily for patients with significant airflow obstruction. However, in patients with suspected inhaled corticosteroid resistance, a two-week treatment trial of oral prednisolone 30 mg daily is preferred.

To help identify asthma, clinicians should assess FEV1 (or PEF) and/or symptoms before and after 400mcg inhaled salbutamol. A >400ml improvement in FEV1 to either b2 agonists or corticosteroid treatment strongly suggests underlying asthma. Serial peak flow measurements showing 20% or greater diurnal or day-to-day variability can also be used to help diagnose asthma.

NICE NG115 further clarifies that a large response to bronchodilators or oral prednisolone (over 400 ml) can also help identify asthma. Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy. In cases of diagnostic uncertainty, a combination of these findings can be used to help diagnose asthma and guide treatment decisions.