Asthma reset - what's changed for adults and kids

Good evening everyone and welcome to the Good GP. My name is Dr. Rami Rahman and I'm speaking to you from Perth today. And I'd like to acknowledge the traditional owners of the lands upon which we are here today and also acknowledge the lands upon which everyone else is listening to us this evening. So today we're talking about asthma reset. What's changed for adults and kids? We're talking about the recent shifts that we've seen in asthma care in many years.

So as many of us know, there has been an update to the Australian Asthma Handbook and now it's reframed how we approach asthma across all our consultations in all age groups, all the way from adults through to young children. And more importantly, how we think about risk and not just symptoms. So today to walk us through this and explain this, I'm joined by Dr. Stephen Ooo, Pediatric Respiratory Physician who works at Pert Children's Hospital, Fiona Stanley Hospital, and Respiratory Care WA.

and Steve's going to walk us through some of these updates and more importantly what it means in real-world general practice. So let's structure this so it makes it a little bit easier for our listeners. So welcome Steve. Thank you.

So let's start with adults and adolescents. So if there's one key message from the updated asthma guidelines that GPs should take into their next consult, what is it for adults and adolescents? It's a very good question. I think most of the guidelines and there's a few European and Gina, which is the international one, and the Asthma Handbook are all pretty aligned.

And I think if there's one message it's instead of using your blue puffer or self-in models, your reliever, they want all the patients to be really instead using what is now called AIR or the acronym stands for anti inflammatory reliever therapy. It's not a new concept. It's been around for almost a decade, but effectively it's using a combination

inhaler preventer, which has inhaled steroid as well as for motorole and using that as a reliever. So effectively when I talk to patients, it'll be use a red puffer instead of your blue puffer. whenever you would have normally used your blue puffer. Just to explain why that works. For motor roll as a long acting beta acronymus or a larva, it keeps working for twelve hours. But what's different about it is it's really short acting, so I can

work as quick as I'll be in a mole in three to four minutes. So patients will feel that same effect that they would have from tradition using Sabra or Sabin Mole. It used to be just Symbical that we used this for, but I think There's another manufacturer's who made similar medications which use for motorole as well. So there's a few others which I won't go through all of them. There's a list in Aspen Council websites.

And there are really good just to point out, there are really good asthma plans. that are on the National Alstomer Council websites where which delineates how many you can use in one day in terms of dosage. So I encourage people to use those. It's a really good option that's available and that's the real push that we've come across in the last Like a couple of guidelines now.

And so Steve, can you just unpack that a little bit more to say for the new guidelines and we're still talking about adults and adolescents, why has there been such a strong move away from the SABA only treatments, so the cell butamols? It's because this is much safer.

I think there's isn't anything intrinsically wrong with SABA, but the thing that everyone worries about in the Aspen community is SABA overuse. There are a number of patients that over rely on their subunimal'cause it feels like it works so well that effectively

It's not actually dealing with the core problem announcement, which is the airways inflammation. And this switch is so that when they're using their reliever, they're actually addressing the information at the same time. So it makes much more physiological sense.

That being said, in experience, it's a really uncomfortable shift moving from the blue puffer to the red puffer. You're not using as many doses and there's such long standing habits that it requires a lot of support and reassurance that this is the better way to go.

But we know over the decades it prevents severe exacerbations. And for those patients that don't use their regular preventer because they're quite mild and don't feel like they need it, it adds a little bit more autonomy into being able to Dose up, dose down, and it gives them a lot more patient control as well. So it's really good management if we can push that more and more.

Yeah. And so for our adults and adolescents, then I can see this happening in my consultation and probably many GP consultations as well. What should we be now starting and talking to a patient with a newly diagnosed asthma or mild asthma? Like what is the starting point for that discussion in an adult or an adolescent with the new guidelines?

I think it all comes down to how unwell you think they are, and that can be how frequent they're having symptoms, how severe their exacerbations are, how times they've been to hospital, how many times they've used oral steroids. If you're ticking lots of those boxes and it's really high, you should be thinking about regular maintenance preventer for those. I think even those that are milder asthmatics, generally in the studies that bore out all the evidence for this sort of air treatment.

They all have better symptoms scores when they were taking maintenance preventers. So the take home is always that if they can be on a regular preventer, most of the time it's better where the air shines through is when they have hardly any symptoms, it's very hard to justify regular preventer.

Or then just never gonna take it. And there can be lots of reasons why patients may struggle to take the regular preventer. And this is a better option for them. But I think If you are looking at a patient that's more symptomatic, you should really be encouraging them to take more and more regular preventer if they can. So the rest of the asthma escalation pathway is the same. You move through and health steroids and then further and further up to ICS lava and beyond.

Okay. All right. That's really helpful. So really the shift here is from treating symptoms to treating the underlying inflammation from the outset for you know I don't Absolutely. I think the other thing to take away is also for those that are using cyber only, when they have severe exacerbations, they often will come to their primary care physicians, probably the listeners out there.

who feel a bit hamstrung as to what else to do. So oral steros are usually the default option. Just to make people aware, there's a lot of emerging evidence now that quite dangerous for your bone health with A recent publication suggesting that a cumulative dose of a thousand milligrams of pernisoline sets you up for higher risks of osteoporosis. But in the pediatric literature, I think if you've had four to five courses of oral steroids, you triple your fracture risk.

I think that's to keep in mind as well that this is an alternative web. we should be considering out given the long term harm, that's not reversible basically with horal steroids.

Yeah, great. That's really helpful. Now I think we'll move on to the next age group, if that's okay. So children aged between six to twelve years. So these are school aged children. How do the guidelines differ here compared to adults? I think the guy likes defer because there isn't good evidence in the kids for using the air treatments or

Smart therapy. When I say smart therapy, that's was simbacter therapy. They renamed that to single maintenance and reliever therapies basically using Yeah, basically, but you add on maintenance reliever and then either side of it. So for the kids. It's frustrating. So there was a study published in New Zealand last year which said that you could use Cymbacort as a reliever. And we thought, finally, it's here. We can get going. We can use this in this age group and we desperately need it.

And they did SubmaCourt with the dosage, lost dosage you can find, which was fifty on three. And since that study got published, it's been discontinued. Oh yeah. Okay. So we're still stuck. There's there's a difference in guidelines between Gino, which is the international one, and the Australian Asphalt Handbook. And basically that's just in the lowest tier. So they instead of advocating for air, they're advocating for chasing salbutamol within hot steroids. So say for example, someone

your kid use four puffs of self unamol, you would use one to two puffs of the lowest dose of plixatite, for example, chasing anytime you use it. So it's sort of like air, but with two puffers. And then there's two big US studies that supported that, which are more than 10, 15 years ago. So that's a valid way to go. But effectively, I think again, that would apply for those that are very mild with no symptoms, the majority of patients.

The Aspra Habbook strategy of go with a regular in how low dose steroid is a good place to start is But we would advocate for the vast majority. Yeah. Okay. In this age group, so we're talking about the six to twelve year old age group, are we seeing the same move away from the Saba only in this age group?

It's harder to advocate for that unless you're doing that chasing Saba with inhaled steroid and that Not in the asthma handbook, but it's a valid strategy, but it's harder to explain to patients like how much can I use and all the other stuff unless you create your own sort of patient handout. I do that a bit, but I have to make my own patient hand down and print it off and hand it to them. So I can accept that's very difficult.

Basically it's almost the same practice as previous in health steroids use SABA as a reliever. But just to put out there that there is a valid strategy around that. But I think for those not on maintenance preventers, so Otherwise I think we're still like regular low dice in house stories for the majority. Okay.

So I think in the six to twelve year old age group, we're saying that the principles are very similar to the current guidelines. There's still the application is a little bit more nuanced in this group, depending on the circumstance. Yeah, absolutely. Not much has changed, I think, in that space. There is an emphasis on more lung function testing. Again, I'm

Don't know how useful that is in primary care because long function testing is very difficult to access. You could refer into the hospitals. Probably is a shameless plug, at least in WA at respiratory care WA, we do bulb Bill. service basically, so bog build lung function out of the communities. So we're one of the few places I think where you have community pediatric lung function services.

And we've been advocating for that to be more nationally and maybe people need to make more noise about that because it's in the guidelines. But I think I would support it, but I understand that access is very limited. Yeah. I think it depends on the circumstances of the patient as well. I think as a practicing GP, certainly spirometry is something that we do in our clinical practice. But I think the location of the patient does make a difference. But it's a really good point that you raise.

No, I'd encourage yeah, sorry. I encourage GPs to do this for M Tree, accepting that in the younger kids it's really difficult. I think for the adults it can be difficult, but in the younger kids I feel like that's one of the things that particularly difficult to do. I do think it needs more services, particularly around that. Yeah, certainly. No, and it's a really fair point. I agree. The age group is challenging and getting an effective spirometry process is also equally hard. So

Yeah. Let's move on to the next age group in terms of these guidelines. So we're talking about children less than six years of age. And often some of the most challenging group because it's sometimes very challenging to make the diagnosis. So how should we be thinking about asthma or wheeze in this age group with the updated guidelines? Oh. I don't know if the updated guidelines actually make things easier, to be honest with you. I think they give you an approach which is good.

So I think that's the change. There's a lot of nuance, there's a lot of grey in that. And so even if you followed the guidelines, I think you would still get stuck with the odd patient thinking, is this asthma or is this something else? Is this viral easier? This group is particularly challenging because testing is really difficult, often not available at all. I think you can do specialized tests in four years and above, which we do in the respiratory centres.

But I think what often happens is you have vague histories and they have overlying pathologies. So you get a lot of wet cough involved in that and in this age group there's an entity which exists called protractor bacterial bronchitis which responds r exquisitely well to antibiotics. So you have to consider that some of the patients

have high compliance in their airways because their cartilage isn't as well formed, particularly in the very younger groups, and that's called bronchomylasia, and they wheeze because of that. And often they're some kids are just very susceptible to getting severe viral infections. And those kids sometimes, despite getting quite severe and going to hospital all the time, they'll grow in the end. So trying to delineate which one of these is asthma proper.

is who will outgrow and who won't outgrow is really difficult. And I think a lot of the studies are born out that with a clinical assessment, we're still really not sure. So clinical assessment's not that reliable. So I think. The pragmatic approach is the way to go, I think, and that's what's in the guidelines. So how do you work that out? So if you've got interval symptoms and they behave like a classical asthma.

When I say into all symptoms, they've got symptoms outside of virus, are you talking symptoms with exercise, symptoms with cold air or nighttime and they're well, then you would say, Oh, they fit more of an asthma. And then I think we often use treatment as our delineator. So we talk about trial of treatment where you would use the steroids inhalt steroids for say a trial of six to eight weeks. and then reassess at the end of that whether they're much better as a result.

The evidence is most kids will have repeated viral attacks during that time. So if they're completely symptom free through that and they've had other viruses and running noses, then you've probably got reasonable evidence that it has probably worked. And then you would talk about do we stop it in summer and say and clearly if they get sick in summer again then you think, Oh no, you should probably just stay on it. And I think that's effectively where you end up and then

I think if the treatment is unclear to work, then you're a bit stuck again. So I think that's where you might need help, maybe a referral on or you try something else along the lines of try the antibiotics if there's more let cough and things like that. So It's a really difficult group. Yeah, uh and I'm just gonna unpack that a little bit more because this is actually quite a very uh common presentation in our consort rooms of the child less than six years of age and

the suspicion that it it might be asthma. So when should we be considering starting a preventive therapy? If you can just walk us through the symptoms. Okay. If they've got a background of like high A to B, like they've got eczema and allergic rhinitis, like that might contribute to it as well, but increases the chances of having asthma. So there are some risk factors.

that they've got a family history, particularly in a direct parent of asthma, and increases the chances as well. So if there's those two things, it's not absolute, but I'd start considering a bit more. And then if they've got those interval symptoms, then I think that would be a slam dunk. They probably need to try asthma treatment. And then it would be then how to steroids. And this is probably where education comes into it, into the bigger piece in terms of how do we talk about this, I think.

And when we're delineating between the viral wheezes and the asthmatics will always have some underlying airways information. That's in my head the delineating. How we discern that there's no good test really in that age group. We have force osmometry testing, which is a type of lung function, which could be done for and above. So most of the major pediatric centers have that. So you can refer in for that and that might help you. But often that's not an option in the community. So

you're looking at those factors and then and you absolutely can diagnose asthma in under sixes. I hear that a lot, but that's not the truth. Like you can diagnose it. It's that response to treatment and how close they are to having more classic asthma. And the viral wheezes are the ones that only get it with viruses and they tend to outgrow, but some of those will respond to asthma treatment as well. And so if they're having more severe exacerbations, like going to hospital all the time.

or very severe exacerbations were in the hospital for a number of days, then you would say, Look, enough's enough. You should probably try in house steroids. So I think those We're fast moving away from viral wheeze as a label because it's so unclear and just calling them all asthmatics'cause they respond to subunor. So I think that's more helpful for families in the end. Just calling them asthma, it's simpler.

Yeah, certainly. And I think you're right. It is that move towards trying to put a diagnosis on there, but also for the families to be able to initiate treatment and medical care when it's needed as well.

No, I'm going to also just want to discuss about one of the biggest challenges. It isn't about prescribing. It's actually what happens once the patient leaves our rooms. We're talking about education adherence. And an understanding about asthma. And Steve, I think we'd really appreciate it if you can sort of walk us through what you talk through with your patients in relation to improving adherence, educating about asthma. And I think that'll really wrap up the session quite nicely for us today.

Oh brilliant. I've raised you through exactly what I'd say to a regular patient. This may be a bit different for some of the adults, but it works quite well for the older kids as well. you would ask them what they know about asthma and then elaborate. And I think for a lot of patients you find that they don't know that much. And some know a lot, but I think most they've got confused with the bare basics. So you talk through I often show them a picture of the respiratory tree.

And say, look, it's upside down tree and where asthma affects is the branches and it can be the small branches, it can be the big branches. And then when we talk about that, I usually show them a picture which you can Google or get from an asthma Australia flip chart. showing inflammation in one of the airways and then what a normal airway looks like. And I think this is where language is key. When I talk about inflammation, I talk about the airways being sore and that's the key word.

And then let's say imagine that you got a scratch from your arm, for example. But initially it might not hurt that much, but when it gets red, when it's healing, or maybe it's affected, it gets red. And then that's sore. And I often say to them, Look, if I go to poke that, what are you gonna do?

And they go, Oh, I'm gonna move my arm away. You go, No, you're not. You're gonna really react. You're gonna go, ah, and then run away from me. Clearly your airways can't do something quite that dramatically. They aren't jump out of your chest and run away. But what they do in response to that

sort of poking is they clamp shut. So you can't poke them anymore. And that's what the arm muscle does. And so you then say, look, things that might poke your airway would be the exercise, cold air, viruses. And what your ventilin does is it just relaxes the muscle. It hasn't done anything about treating the inflammation, that soreness that was there. So once we get rid of that redness and it's not sore anymore.

You can poke it all you like and there's no reaction. So that's where I start. And I say, okay, at this point I start to make it a little bit more complicated. Just bear with me. I used to think this was too complicated for patients, but I think it it explains why you need to take your medications more frequently. So say you I would often draw them in picture and then maybe I can link a picture to it on your website somewhere, but I think

I draw one big tube connected to two small tubes and I block one of the tubes partially. And then I say Asthma, much like a sick tree, like not all the branches are equally affected. So you now have a plumbing problem. You've got to breathe down from the big tube down to the smaller tubes. If you've got one branch that's blocked and the other tube's completely open, where does your medication go?

And I think most of the patients will say, Well, it's gonna go into the open tube, isn't it? It's not blocked. And I say, Yeah, that's the whole problem in asthma, we're inhaling all of these medications. And for them to work they have to get into the tube that's most effective. But the more blocked it is, you're playing catch up already.

So I think that's really important because we never really have that conversation of why do you have to take it regularly? Why taking it every second day is so terrible? And it's that. It's just we're delivering medication into the wrong tube.

And that makes a lot of sense to people that really if you're playing catch-up, it's about chipping one of that tube and then as soon as it's open, then you can probably drop the dice here, prevent it, but until it's there, you have to be really on top of it.

And I think that's why the air therapy works quite well as well,'cause it's got that long acting and fast acting bronchodilator that then allows the steroid to get where it needs to when you're in critical. But even better strategy is to keep the tubes open in the first place. And that sort of crystallizes for me like

Ventilation, like the whole concept of this is ventilation heterogeneity or inhomogeneity. Like I think it's a well known concept in Asphab, but we don't talk about it enough. And that I actually educate patients around that's why I adherent is really important. And for some patients that makes a big difference. Others it

one factor and like the other factors are all to do with busyness of life and other things that get in the way. But I think at least they understand why they can't just drop off doses and why that's not all right. And I think that something we should consider, like how do we educate better? And I think I keep evolving the way I talk to my patients and I think any other strategies that people want to share and I'm always open to as well.

I think that's really helpful, Steve, because it puts perspective from a patient point of view and we all know that adherence and patient education is so important. Now I really liked your analogy as well. So I think it's been really helpful talking about the new guideline changes in asthma, a little bit of a recap in relation to asthma care and adults.

children aged between six to twelve and also children below the age of six years, as well as the complexity of educating patients for adherence of medication. So And I think general practice, that's where we make the biggest difference with early, consistent and connected care, that preventative care and education plays a role. So thank you so much for joining us this evening. We really appreciate having you on the Good G P. And we hope that we'll be able to catch up soon.

Thank you very much for having me. Thank you. Thank you, Steve. Thanks for listening to the video. Send an email. The content of this podcast represents the opinions of the good GP, hosts and guests of the show. The content is aimed at general practitioners working in the Australian context and is not intended to represent medical. Any listeners? We make every effort to ensure that the information shared is accurate and up to the first time.

The content of this podcast nature and does not refer to specific patients. recommend all health professionals, review local and up to date guidance. Prior to any clinical decision.