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Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE

18 Dec, 17 | by BMJ

John White, James Paton, Robert Niven, Hilary Pinnock
On behalf of the British Thoracic Society

The British Thoracic Society first produced a guideline on asthma and its management in 1990. The first collaborative guideline with the Scottish Intercollegiate Guideline Network (SIGN) using evidence-based medicine methodology was published in 2003 (1). It has since become a mainstay of asthma management across the UK and beyond, with updates published regularly every 18 to 24 months. The latest BTS/SIGN guideline for the management of asthma was published in 2016 (2).  Both BTS and SIGN are committed to continuing updates with the next update planned for publication in 2019.

Following publication of NICE Guidelines for diagnosis and monitoring, and for management of asthma (3, 4, 5) there are now two if not three national guidelines, for England at least, with some (apparently) striking differences. This statement considers the similarities and differences to assist clinical colleagues in the care of people with asthma.

The evidence base considered by the BTS/SIGN and NICE guideline development groups is broadly the same for each guideline, but the methodology used to produce recommendations is significantly different:

  • SIGN methodology is a multidisciplinary clinically-led process which employs robust critical appraisal of the literature, coupled with consideration of pragmatic studies to ensure that guidelines provide clinically-relevant recommendations;
  • NICE methodology overlays critical appraisal of the literature with health economic modelling, with interpretation supported by advice from a multidisciplinary Guideline Development Group.

These different processes have resulted in some discrepancies in recommendations made by BTS/SIGN and NICE.  This article seeks to provide some context to these differences in the key areas of:

  1. Diagnosis
  2. Pharmacological management
    • Treatment at diagnosis
    • The introduction of leukotriene receptor antagonists (LTRA) after low dose inhaled corticosteroids (ICS)
    • Maintenance and reliever therapy (MART)
    • Treatment beyond combined inhaler therapy
    • Some other issues in managing asthma in children

The BTS/SIGN guideline also provides recommendations for important aspects of asthma management that are not addressed within NICE guidelines. These include guidance on inhaler devices, the management of acute asthma attacks in both adults and children, the management of difficult asthma, guidance on asthma in adolescents, in pregnant women and on occupational factors.

Read the full article here.

This article is currently in press. It may subject to minor content and format changes before publication in the February 2018 issue of Thorax.

Nivolumab Data Presented

30 May, 15 | by BMJ

More to follow, no doubt. And there might *just* be a bit of journalistic hyperbole in there, but might this be some hope for lung cancer patients?

Guessing Tubes

26 May, 15 | by BMJ

I broke my stethoscope this week. I was listening to a chest, on a ward round, as you do, and the ear-pieces just went all wonky. The metal spring hidden in the rubber tubing had snapped.

My stethoscope is like Trigger’s broom – I’ve had the same stethoscope since 4th year of medical school; I’ve only replaced the diaphragm twice, the bell rubber three times, and the tubing once. The metal bit – the business end – is the original, shonkily engraved with my name.

I borrowed my registrar’s guessing tubes for the rest of the ward round. I think I used them once.

I’ve found a place that will sell me a replacement tube/earpiece thing. Last time it broke, in 2001, I think, I went to a medical supply store, and picked out the replacements. This time it’s the internet to the rescue, of course.

I was very excited about getting my first stethoscope. 1997, 4th year of medical school, and the Littmann reps came to the students’ mess with a range of excitingly coloured stethoscopes, and boxes of complimentary fish and chips, I recall. The decision of colour was simple – hunter green, obviously – but the mode of transport was perhaps more important: over the shoulders, round the neck, in a pocket?

Fast forward 5 years and I was using (mostly) the same stethoscope sitting my PACES exams. No longer guessing with my tubes, I was dedicated to the fine art of differentiating a murmur of aortic stenosis from that of mitral regurgitation. Fortunately the murmur in my exam was aortic regurgitation, and I didn’t have too much trouble.

I was regaling my registrar with this tale of exam pressure in 2002, when she asked me “But what’s the point, though? You’re going to get an echo regardless, aren’t you?” Yes, that’s as maybe, but they’re really important for listening to lungs, say I. “But aren’t you going to get a CT?” Sigh.

She makes an interesting point though.

10 years ago, when I started my respiratory registrar post, we had access to an ultrasound machine. It was the size of a top-loading washing machine (remember those?), and weight about 20 metric tons. We didn’t use it very much. Now we have a number of portable USS machines, all the size of a chunky laptops, and every chest SpR has to be trained to ‘level 1’ before they can get their CCT. Is there a pleural effusion, is it consolidation, is it an elevated diaphragm? We don’t listen, we don’t percuss any more, we get the ultrasound machine out and we know.

Should we be training up all our doctors to use the same ultrasound machines to look for valve abnormalities? I’m no cardiologist, so I have no idea how long it must take to train up to be able to look at valves, but the cardiology trainees manage.

In days of yore the fine details of murmur analysis were critically important. When to refer for an aortic valve replacement? When the second heart sound disappears, of course. Who would refer for an AVR without a valve area, or pressure gradient? W don’t put in a chest drain without doing an ultrasound of the thorax immediately beforehand, would we?

So should I get those replacement parts for my stethoscope? It’s going to cost me over £100 after all. Or would I be better off putting that money towards an echo course?

Are you asleep yet?

12 May, 15 | by BMJ

I don’t do a lot of sleep medicine. It’s never appealed to me. But I work in a relatively small department, so it’s inevitable that I will see people with sleep apnoea, and have to deal with it. In all senses.

We have a relatively small population to serve – about 450,000 across the whole of Tayside, but a prevalence of 4% means a lot of patients with sleep apnoea. The prevalence of ‘tiredness’ must trend towards 100%, so referrals into the system are numerous. Myriad. Legion. Over 100 a week, so I’ll go with legion.

Everyone gets limited polysomnography now. Overnight oximetry seems to diagnose the problem in a small few, but essentially everyone went on to get limited PSG anyway, so we just do that now. The test takes a long time to report. The computer does a lot of the work, but the technicians have to go through it, and highlight apnoeas. A long, tedious process, I’m sure.

Anyone with a normal study is dispatched at a virtual clinic review. Everyone else comes up to clinic, is seen by a consultant, and gets another appointment to come back and get a CPAP machine, and off they go.

Surely there’s a more straightforward way to deal with this large burden of investigation, reporting, clinic appointments? As a ‘non-enthusiast’, I wonder why we don’t just give everyone a trial of treatment? The outcome we’re chasing is decrease in daytime somnolence, so rather than go through the laborious process of limited PSG, reporting, and clinic review, why don’t we just give everyone who’s somnolent a CPAP machine to trial for a week? My sleep interested colleagues tell me that the response to CPAP is dramatic, so patients would know very quickly if it works. I also see how uncomfortable it must be, so anyone in whom it doesn’t work, would quickly hand it back, I think.

That shortens the pathway, doesn’t it? Patient falls asleep in the daytime. Gets CPAP machine in the post. It either works and they keep the machine, or it doesn’t and they hand it back.

I’m sure I’m over-simplifying a very complex and fascinating sub-speciality area. But it does seem to occupy a lot of our time, and anything that speeds up the process has to be worth a thought?

The other problem I don’t have an answer for is what to do with people who have sleep disordered breathing, but no daytime somnolence. Stopping breathing overnight is clearly a common occurrence, and we can obliterate that, but are we only treating the partner’s anxiety, rather than an actual disease? I floated this on sister site Doc2Doc a year or so ago – it was a very polarising question. There were sleep enthusiasts who told me very firmly that anyone with a raised AHI should, nay MUST, get a CPAP machine, and be treated aggressively. They couldn’t tell me why, as the outcome measure of somnolence is hard to monitor when the patient it not sleepy in the first place. Others asked the question of why bother to do the test, a view with which I clearly hold much sympathy.

As I write this, a colleague is poring over limited PSG reports, many of which are normal, but the majority will get a review appointment, and a trial of treatment for their equivocal limited PSG. I look over and my heart sinks. But I suspect he feels the same when he sees me leave to go to adolescent asthma clinic…

Decisions, Decisions

1 Apr, 15 | by BMJ

How many decisions do you make in a day? How many could you? Or should you?

Last weekend I moved house. A weekend full of decisions. Not massively meaningful decisions you might think, but you’ve probably not met my wife. What should we take first? Where should we put the sofas? Where should we put that box of things? Should we take that box of things to the skip? Or recycling? Or the charity shop? Or put it next to the other boxes in the hallway? After hours of deciding where to put stuff, I ran out.

Ran out of decisions.

“Where does that box need to go?” “Erm… Ah… I got nothing”

Recently there was a program on TV about decision making. Horizon, or some such. The program’s thesis went along the lines of this: the brain does not differentiate between a big decision, and small decision. Every decision takes the same ‘effort’, and we only have a certain amount of ‘effort’ to last each day. The implication was that we can only make a fixed number of decisions before we ‘run out’. The experiment shown in the program involved asking two matched groups of volunteers to make decisions in a test environment. One group were let into the room, and asked to sit the test. The other group were asked to make a number of ‘meaningless’ decisions prior to taking the test: which side of the room did they want to sit on, which way did they want their chairs to face, did they want a pen or a pencil, a blue or black pen, did they want coffee or tea after the test, with a biscuit or an apple. Those who were given fewer decisions to make prior to the test scored more highly.

Running out of decisions on the day I moved house wasn’t a big deal. We just put everything in the big room at the back of the house, and we’ll sort it sometime….

But what if I run out of decisions at work?

We make a lot of important decisions every day. Treatment choices. Decisions to keep a patient in hospital, or discharge them. Review in clinic, discharge to GP. Escalate therapy, or make a ceiling of treatment; palliate, withdraw therapy, or sit tight, and wait another day.

Who makes the decisions these days? Increasingly the decision making process has moved up the ladder; increasingly I see written in the notes: “Discuss with senior”, “Leave decision to day team” “Ask consultant about resus decision” “Discuss treatment options with consultant”. Our doctors in training seem to be less and less inclined to make treatment decisions. I suspect this is because the training we provide them re-enforces safety as the priory – and so it should, as we have a clear duty of care to do no harm to our patients. But not making a decision is not the same as being safe. Often the safest thing is to act, as making no action puts our patients in danger.

I get phoned a lot to make the same sort of decisions I used to make as a PRHO (remember those?). Can Mrs Miggins’ catheter come out? Can we change Mr Bloggs’ antibiotics from IV to oral? (does everyone else have the neo-verb “IVOST” now? “Can we IVOST Mr Bloggs?” Verbification of an acronym, the world has finally gone mad) Mrs Bloggs usually takes her aspirin at night with her supper, can it be re-written to be at 10pm? Mr Miggins has a headache, can he have some paracetamol? As consultants we can either sigh at this seemingly endless tide of decisions to make, and just make the changes as it’s easier than finding an FY-X doctor somewhere in a corridor, running around with a clipboard of jobs to do; or tell the nurses “No, I’m not making those decisions, find a doctor in training”, and appear as if we can’t be bothered to help.

I tend to do everything asked of me – even re-writing the treatment chart that’s run out, or writing up fluids that haven’t been prescribed, as well as making the decisions on the aforementioned paracetamol. One of my colleagues refuses to make these decisions, will not do jobs that he feels are clearly appropriate for doctors in training, and not to consultants, and often asks me why I capitulate, and do those jobs. I’ve always answered by saying that it takes little time, and is of no consequence to me, in the grand scheme of things; what harm could come of it?

But perhaps he’s right. Perhaps we should be storing up our decision making ‘effort’ for those more difficult decisions, those that require the additional training, experience, and expertise that we’ve acquired over the years? Perhaps making those smaller decisions is using up valuable ‘brain effort’. Perhaps we jeopardise more important decisions later in the day, by making these ‘Less important’ decisions?

Or maybe it’s bunkum. Perhaps I was just tired last weekend, just too tired to care about where we put the next box of books, or the bag of Summer clothes we’ll not need until the 24th July (the only day of Summer in the frozen North). Perhaps making those decisions for my junior colleagues frees them up to make more difficult decisions later on in the day? What if they can only make n decisions per day, but I can make 2n, or 3n? Maybe I’m just frustrated at making the same decisions now as I did 15 years ago when I was a house officer.

Whichever way I think about it, I still have to decide where we put that rug we used to have in the kids’ bedroom.

Exercise, but exercise restraint?

18 Feb, 15 | by BMJ

I wrote last time about the ongoing problem of breathlessness in our patients, with no organic cause beyond obesity. My usual response is to encourage weight loss by increased exercise – seems to be a winner, as exercise not only leads to weight loss, but it’s really good for us, right? And those patients who are breathless because they are simply unfit?

But how much exercise is the right amount of exercise to ‘prescribe’?

The government has guidance, so that’s a good place to start. 2.5 hours a week of moderate activity, in periods of at least 10 minutes. Or 30 minutes a day, 5 times a week.

NHS Choices agrees, of course, and gives more detail on what is moderate exercise, and what is vigorous exercise.

But last week the Beeb reported on a paper in the Journal of the American College of Cardiologists that too much exercise is as bad as none at all. Healthy joggers, and non joggers were followed up for 12 years. The conclusion was that 2.5 hours was the maximum that we should do, and if we are to run, we should run at a maximum of 8 kph. That’s 7:30 mins/km, or 12 minute miles. My 12 year old runs 5km in under 25 mins – that’s 5:00 mins/km, way to quick to remain ‘healthy’, according to the Danish study.

This isn’t the only study to support exercise being bad for us – Andrew Marr blamed his stroke on taking up rowing in 2013. And this week there’s a publication in Circulation looking at women in England and Scotland, their exercise regimens, and their cardiovascular risk. 4-6 sessions of mild exercise a week, or 2-3 sessions of strenuous exercise per week were deemed ideal. And anything more than that was deemed harmful.

I do a lot of exercise – I’m in a cycling club, I’m president of my Triathlon Club (not sure how that happened, I think I put my hand up at the wrong moment at the AGM), and I do about 8 hours of what these studies would call ‘strenuous’ exercise a week. All the people in the cycling club, and the tri club seem happy, healthy individuals to me, the occasional musculoskeletal injury notwithstanding. And I encourage my kids to be as active as possible.

But the data suggests moderation.

More to follow, I suspect.

Doom Dome

11 Feb, 15 | by BMJ

We manage our ward work differently these days. Different from when I was a lad. We do blocks of time on the ward, looking after all the patients in the ward for those two weeks. It makes for a high intensity fortnight, not least because we look after all the patients in the high dependency unit.

We have a disproportionately high number of patients in the HDU, compared with other specialities. Even if patients go in there under a different speciality, they often develop respiratory complications, become our responsibility, and leave HDU under our care. I’m sure this is the case in lots of HDUs around the country, certainly those not looked after by the intensivists.

We have more to offer our patients with respiratory these days – high flow nasal oxygen, NIV and CPAP are used frequently. But their use leads to difficult decisions – what to do when a patient becomes dependent on CPAP.

CPAP masks are uncomfortable, patients don’t like wearing them, and often refuse to wear then again, making the decision to continue a straightforward one. But the CPAP hood, the dome that fits over the whole of the patient’s head, is far more comfortable, and better tolerated. So well tolerated that patients are happy to sit with the hood on all day. It’s now commonplace to be faced with the situation where a patient sits happily on the hood, but once it’s removed, even briefly, their saturations plummet, and the hood is put back on.

The hood-dependent patient is not easy to manage.

Before anyone is put on NIV a decision is made on ceiling of treatment, duration of treatment, criteria for withdrawal of ventilation. But CPAP is often nurse initiated, the decision to use it made by doctors in training, and does not come, perhaps, with the same thought as NIV. Faced with a hyperaemic patient overnight, the decision to put on the CPAP hood is easy for the overnight team – our ICU won’t usually come to see a patient until CPAP has been trialled, and failed, and for a patient who is ‘not for ICU’, CPAP can keep the patients well saturated until the morning ward round.

On my last couple of weeks on the ward, like most weeks looking after HDU, I had patients who had been put on the hood overnight. The registrar looked despondent. “No-one who goes on the hood ever gets better”, she said. She was right about the patients that week. The other registrars agreed – patients who go on the “Doom Dome” do not do well. But CPAP works, does’t it?

In 2004, as a research fellow, I went to the American Thoracic Society Conference in Orlando. One of the talks I went to was about the utility of CPAP in respiratory failure. The speaker showed very clearly that CPAP works. For pulmonary oedema. But for any other indication CPAP was of little use, or a holding measure prior to intubation and ventilation.

CPAP gets used a lot for management of respiratory failure associated with CAP. This study suggests the use of CPAP in CAP, but it’s only 3 patients! This more recent study, with 123 patients, shows that although patients receiving CPAP had better SaO2 readings, their outcome was no different. The BTS guidelines for management of pneumonia state that CPAP is not routinely indicated for management of respiratory failure due to CAP – evidence level A-. But we still do it. It’s nice when the numbers get better – we feel like we’re doing something. But we’re only treating the numbers.

So we’re left with those patients who are dependent on the hood, but with no realistic expectation that they’ll get better, and a difficult decision to make. We have the evidence, but do we ignore it? Or do we hope we can make it work on a case by case basis?

I suspect this is a problem that’s not going away.


28 Jan, 15 | by BMJ

I teach the first year medical students about breathlessness. I also teach the FY docs, ST docs, nurses, physios, and anyone who’ll listen, about breathlessness.

I’m a stickler for minutiae, so I spend at least one slide, usually a couple, teaching, then reminding, that breathlessness is a symptom, not a sign. One cannot tell if someone *feels* breathless, just by looking at them. I can be certain that someone is using their accessory muscles of respiration, or they are tachypnoeic, or they have respiratory distress, but only the person can tell me if they’re breathless.

But we often say that people look breathless, don’t we? I’m being ludicrously pedantic, obviously. But I do it to demonstrate that breathlessness is completely subjective. I went for a run tonight – it’s pretty cold out, and my training plan asked for 6 x 1km intervals at under 4 min/km pace, with 2 mins recovery between the intervals. During each of these intervals I was tachypnoeic, using pretty much every accessory muscle I coul recruit, I increased my tidal volume by about 10-fold, and by the end, I had fairly noisy breathing. But I wouldn’t say I was particularly *breathless* until the last interval. Ok, the second last.

But my expectation is that to train hard I will have to breathe hard, so the physiological responses to exercise – increased RR, increased Vt, increased work of breathing – are no surprise to me, so I don’t perceive them as abnormal. In fact, I think it’s very normal to feel like that when I exercise.

I see a lot of breathless patients. It’s not particularly my area of interest, or specialist expertise, but general medicine clinic has its share of breathless patients. I don’t mean to generalise here (I have the data to back me up), but it’s rare to see a “breathless query cause” patient with a BMI of under 30. A bit of physics reminds us that work is force times distance, and the force required to move anything is proportional to its mass – any engine can move a certain load before it becomes overwhelmed. So the most likely diagnosis is always one of obesity, and lack of fitness.

At the ERS a couple of years ago I went to a presentation on the phenomenon of “Fat but fit”. There are certainly patients who are obese, sometimes orbidly so, but are very well conditioned, and have a sufficiently large ‘engine’ to carry the load. But I don’t see that very often, if ever.

But morbidly obese patients can have lung pathology too. A number of years ago a colleague saw a patient who was morbidly obese, normal CXR, normal-ish lung function, breathless on minimal exertion, and clearly unfit. He told her she was overweight and should lose weight, and discharged her.

She returned a year later, no lighter, but more breathless. Her CXR showed her lungs to be strikingly smaller than the previous year. She was referred for a biopsy, but the surgeon felt she was too high risk. She became house bound, then bed bound, then hospital bound. We eventually discovered that she had Shrinking Lung Syndrome, a very rare entity indeed.

But for every zebra there are ninety-nine horses. So is it reasonable to stop at the simple tests (CXR, spirometry) and discharge stating that the cause if obesity? 99 times out of 100 we’ll probably be right. Or should be pursue a diagnosis in every one? HRCT, V/Q, CPET…

An A&E adage is: You’re only dead once you’re warm and dead.

Should we adopt: You’re only breathless once you’re thin and breathless?

Probably not. Because we’re always looking for the zebra.

NEJM Images in Medicine This Week

22 Jan, 15 | by BMJ

A nice image in medicine in the NEJM this week – not something we see a lot, but my radiology colleagues are always telling us to look under the diaphragm, behind the heart, and behind the clavicles. Nice example of why they’re right. Sometimes.

Coiled and ready.

23 Nov, 14 | by BMJ

A couple of years ago I went on the advanced bronchoscopy course Palav Shah runs at the Brompton. I walked away with ideas of starting up a cryotherapy service, and excited about trying out some of the new lung volume reduction coils. I had a tinker with a cryotherapy machine, and hope to have another go with it at some point. The coils are a different issue – only available in the study, and only in London, initially.

After a couple of months I saw a patient I thought might be suitable for coils. It’s a long way down to London from up here, but the patient was keen to go, and wend down for the study. 18 coils later, he came back to clinic a completely changed man. He left for London in a wheelchair, he walked back into my clinic after his procedure. A dramatic response to therapy, for sure. How long would it last? A year, it turned out. After 12 months he was essentially back to square 1, back in his wheelchair, and back in clinic asking if he could have another referral back to London for more coils. He went back down, but the study was over so no more coils.

My n=1 experience made me interested in the end result of the study, and it’s now in this month’s Thorax. The average result seems to follow my n=1 result – about a year of improvement.

I had thought the best patients for this study would have been those with homogenous disease, rather than those with heterogenous disease who might do better with targeted valve therapy – but the results seem to show similarly good results with homogenous, and heterogenous lung disease.

It works. So should we all be offering it? We do all the normal bronch things, including EBUS, much as everyone will be doing all over the country, I’m sure. We haven’t managed to persuade the bean counters to let us do valves yet, but the complexity of looking for collateral airflow does make it a complicated procedure. Could we manage to get coils into the service? It’s not cheap, but it works, and in some patients it works really well. But can we predict which of those patients will do best? The paper couldn’t really identify which patients would respond best.

The COPD treatment landscape is currently very interesting. Moving away from steroids, a push towards dual bronchodilator therapy, the new technology is gaining an evidence base, the focus on phenotypic medicine can only gain momentum. And not to mention the eCigarette debate. Interesting times.

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