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vivir no sabe, y morir no quiere "Imagina la vida como un juego en el que ests malabareando cinco pelotas en el aire. Estas son: Tu Trabajo,- Tu Familia,- Tu Salud,- Tus Amigos y - Tu Vida Espiritual, Y t las mantienes todas stas en el aire. Pronto te dars cuenta que el Trabajo es como una pelota de goma. Si la dejas caer, rebotar y regresar. Pero las otras cuatro pelotas: Familia, Salud, Amigos y Espritu son frgiles, como de cristal. Si dejas caer una de estas, irrevocablemente saldr astillada, marcada, mellada, daada e incluso rota. Nunca volver a ser lo mismo. Debes entender esto: apreciar y esforzarte por conseguir y cuidar lo ms valioso. Trabaja Eficientemente en el horario regular de oficina y deja el trabajo a tiempo. Dale el tiempo requerido a tu familia y a tus amigos. Haz ejercicio, come y descansa adecuadamente. Y sobre todo.....crece en vida interior, en lo espiritual, que es lo ms trascendental, porque es eterno.
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Most screened were not taking their medication or did not have asthma! JACI 2008; 122: 1138-44
Case Study 1
Dr Cara Bossley Paediatric Respiratory SpR Royal Brompton Hospital
3.
4. 5.
The productive cough, poor response to steroids and absence of bronchodilator reversibility are pointers that the diagnosis could be incorrect
Investigations
CT scan
Bronchial wall thickening, no frank bronchiectasis
Immunoglobulins
Normal total IgG/A/M
RASTs
All negative (total IgE 7) - Non-atopic
Sweat test
Negative (chloride 6)
3.
4. 5.
Due to the poor lung function and severity of inflammation and infection seen on bronchoscopy a 2 week course of IV antibiotics was given
Nasal nitric oxide testing can be performed as a screening test for primary ciliary dyskinesia which can be a cause of chronic productive cough and rhinitis
Ciliary studies
Normal cilia
Progress
Did very well after intravenous antibiotics Regular physiotherapy Stopped theophylline Halved flixotide dose (500 to 250mcg/d)
Summary
Ongoing poorly controlled symptoms despite high dose inhaled corticosteroids and add-on therapy Chronic productive cough
Non-atopic
Low lung function, with no evidence of bronchodilator reversibility or steroid responsiveness
Vascular ring
Co-morbidities
Immune abnormality 10/74 (14%) 5/12 non-atopic patients vs 5/62 atopic children (p=0.04) 41/55 (75%) gastro-oesphageal reflux disease 4/99 (4%) airway malacia
Enlarged adenoids
Stage 1 assessment
Definitions-1
Problematic Severe Asthma =
A new concept in the literature Presentation label Symptoms >3 times per week despite high dose ICS (>800 mcg BDP equivalent), LABAs, LTRAs & Theophyllines (?) Multiple severe exacerbations or a single PICU admission Brittle (chronically chaotic peak flow Type 1, catastrophic exacerbations out of the blue Type 2) Daily or alternate day prednisolone Persistent airflow limitation
Definitions-2
Difficult to treat asthma =
becomes easier when the basics are got right (adherence, environment, etc.) NOT candidates for novel therapies
Intramuscular Triamcinolone
Visit one: MDT Assessment Drug delivery device Assess symptoms, use of rescue medication Spirometry & reversibility Induced sputum, eNO Home visit: environment School visit: bullying? Assess compliance Psychological assessment
1-2 months
Visit two: FOB Assess symptoms, use of rescue medication Spirometry & reversibility Induced sputum, eNO FOB, BAL, biopsy
4 weeks
The Protocol
Assess symptoms, diary card, use of rescue medication Spirometry & reversibility Induced sputum, eNO Develop treatment plan
Adherence
Smoking
Allergens
Case Study 2
Pippa Hall Childrens Respiratory Nurse Royal Brompton Hospital
Child B - History
16 year old female Referred from local Paediatrician Ongoing persistent symptoms despite beyond guideline treatment Psychological issues 9 hospital admissions in past 12 months
including an admission to PICU
Treatment at Referral
Regular Medication Symbicort Montelukast Uniphylline Omalizumab Triamcinolone
400/12mcg (x3 puffs)
10mg 400mg 300mg 80mg (i/m)
BD
OD BD 2 weekly monthly
Rescue Medication 11 courses of high dose oral steroids in last year Short acting beta agonist (SABA) use >3 times daily
Investigation Results
FEV1: BDR: FeNO50:
73% predicted 26% 16ppb
3. 4. 5.
3.
4.
5.
Checked GP and hospital prescriptions Checked in the home for availability of in date medications
Shouted at everyone until a confession was made
4. <25%
Interventions
Patient education
Importance of regular inhaled medication discussed
Investigations Continued
Adherence
Poor understanding of Turbohaler use GP prescription uptake <25% No parental supervision of medication
Psychology
Referred to psychologist Psychological issues not thought to be contributing to poor adherence
FEV1:
ACT: No hospital admissions
75% predicted
20/25
Conclusion
Poor adherence to treatment was the main contributor to ongoing poorly controlled symptoms
In our cohort of difficult asthmatics1:
Prescription uptake was <50% expected in 19/59 23% did not have a complete set of in date medications available at the home visit Medication issues contributed to poor symptom control in 48%
1Thorax
Nos. %
Prescription Records
Case Study 3
Pippa Hall Childrens Respiratory Nurse Specialist Royal Brompton Hospital
Child A - History
15yr old boy Symptoms from 1 year of age Recent referral from local paediatrician Seretide 250mcg BD Using short acting bronchodilator (SABA) >3 daily School attendance 83% 12 courses of steroids / hospital admissions in past year
How should the child be assessed for sensitivity to allergens? 1. Skin prick testing
2. 3. Histamine challenge Total serum IgE
Investigation Results
FEV1: BDR: FeNO50:
61% predicted 48% 120ppb
Home Visit
Adherence Chaotic medication regimen noted in the home Smoke Exposure Step father smokes outside (no evidence of smoke inside) Allergen Exposure 4 cats at home
FEV1:
BDR:
85% predicted
15%
FeNO50:
ACT:
68ppb
16/25
Conclusions
Removing allergens in the home and simplifying medication regimen improved patient outcomes
Allergen avoidance?
HDM n=31 sensitised
Avoidance:
5 (16%) reasonable 15 (48%) some 11 (36%) none
Persistent Asthmatics
Dose-response curves for inhibition of PHA stimulation. White = no IL-2 or 4; Black = IL-2 & IL-4 IL-2 & IL-4 decrease sensitivity to the anti-proliferative effects of dexamethasone
A: Because the wrong question has been asked in the wrong population!
Unsuitable candidates
Not all had clinical allergy Demanding intervention did they have a problem?
Should have adjusted for season/ virus infections in small trials How many really severe asthmatics?
P<0.0001
OR (mv)
+ -
Ask the key question: What makes this asthma difficult? Consider environmental causes of steroid resistance