Breathlessness in the Older Adult: Is It Asthma?
22
September

By Adem Lewis / in , , /


Hello, I’m Norman Swan. Welcome to this program
on breathlessness in the older adult, asking the question, ‘Is it asthma?’ We’re coming to you live
across Australia through the Rural Health Education
Foundation’s satellite network. Some older people think that breathlessness is
a natural consequence of ageing, unaware that’s not the case, even though the prevalence of asthma and chronic obstructive
pulmonary disease, COPD, both increase with age. In this program, we’ll talk about the differential
diagnosis of breathlessness, with special reference
to asthma and COPD. The distinction between asthma
and COPD is important, even when they coexist,
as there are significant differences in the care of people
with each condition. As always,
we have a number of useful resources on the Rural Health Education
Foundation’s website – As usual, the broadcast is interactive, and we want your phone calls and faxes
when you want to ask a question. You can even drop us an email. We’ve already had one question in
ahead of time. We look forward to yours. The numbers to call in on are – Fax numbers – Or you can drop us an email, and somebody will be hanging
on the computer, waiting for it – Now let’s meet our panel. Christine McDonald is Deputy Director
of the Austin Hospital’s Department of Respiratory and Sleep Medicine, and a director of the Institute
for Breathing and Sleep Medicine at the same institution. – Welcome, Christine.
– Thanks very much. As a clinician/researcher, Christine’s
special research interests include airways diseases, asthma, COPD
and lung cancer. She’s a member of the Australian
Lung Foundation’s COPD Executive. Gary Kilov
is a solo general practitioner, currently practising in Clarinda,
in Melbourne, with over 25 years’ experience in both
metropolitan and regional practice. – Welcome, Gary.
– Thank you. Toni Riley is a community pharmacist
with 30 years’ experience, currently practising
in Bendigo, Victoria. A Victorian evening this evening. – Welcome, Toni.
– Thank you. Toni has a major focus in her pharmacy as a provision of pharmacy services
to residential care facilities, and is also on the National Asthma
Council Pharmacist Asthma Group. Last but not least, Vanessa McDonald, who’s a respiratory and sleep-medicine
clinical nurse/consultant with Hunter New England Health
in Newcastle in New South Wales and has 15 years’ experience
in asthma and respiratory education. – Welcome, Vanessa.
– Thanks, Norman. Vanessa’s current PhD studies are in obstructive-airways disease
in older people. Sounds like her special interests
tonight are in Mastermind. We’ll sit back and have a spotlight
going on you all. Welcome to you all. What are the major issues from a general practice point of view,
Gary? We see a number of patients who may
present with shortness of breath or some respiratory symptom. The issue is really to try and tease out
the potential causes, the differential diagnosis, and then to stratify those in terms of potential seriousness
and potential urgency. – A common walk-in, though, isn’t it?
– It is indeed. It may often be even
an incidental finding, when somebody
presents with something else. They may present with
an upper respiratory tract infection, and when one delves a bit deeper
into the history, they may explain that they routinely
need several courses of antibiotics, they get more frequent infections
than other people. It’s something
that we can then explore further. Do you ever get a surprise diagnosis
when you go through the differential? We do. We do indeed. And I think,
particularly with the older patient, because the existence often of multiple
diagnosis, multiple pathology, even if one is fairly certain about
one’s diagnosis, one has to be vigilant not to miss something else. By the time you get to
the back of the pharmacy, a few must be breathless, Toni? You’re probably correct. NORMAN: Your head’s buried in the
computer screen. You wouldn’t know. No, not at all. The reality is we do get the odd
breathless patient in the pharmacy that perhaps hasn’t been to the doctor
at that stage. It would be our normal procedure to endeavour to make sure that person
was seen by the doctor. We might even ring the doctor first
and ensure that that was facilitated. If it was urgent, obviously,
we’d be calling an ambulance… What are the common medication issues? As in drug interaction-type things,
you’re thinking along the lines? We need to be very careful about
beta-blockers and people with asthma – not only beta-blockers treating
cardiovascular conditions but beta-blockers
they’re using in eye drops. Oftentimes, ophthalmologists don’t
get to know the rest of their condition. They may not know this is
a contraindication for this person. There is another part of the body
than the eye. There is, yes, yes. Vanessa, you’d imagine these days,
when smoking rates, particularly in the over-50s,
are incredibly low, that the problems of COPD, et cetera
and asthma must be disappearing. We’re certainly seeing a decreasing
trend in asthma admissions into the acute setting. However, we’re not seeing
the same trend with COPD admissions. The prevalence of asthma and COPD
in this country and internationally is in fact increasing. – Really?
– Mm-hm. Christine,
why aren’t the rates going down? In COPD, we’re seeing people
in the older age group who started off as a cohort
who might have been smokers. We’re still seeing the effects
of the smoking down the track. In terms of asthma and COPD
in the older age group, as we’re here to talk about tonight, it can be difficult to tease out
one from the other, particularly if they have been smokers. Although smoking rates are going down,
smoking rates among asthmatics are not dissimilar
from the rest of the community. It’s still around 17% to 20%. That’s why we’re still seeing people
admitted to hospital with COPD, and asthma in the older age group – because, probably,
many of them have coexistent disease. I understand that asthma deaths
these days are in the older age group? Yes, they are. Again, part of that may be
that they’re COPD patients, partly to do with the fact that we’re underdiagnosing asthma
in the elderly population. Why is that? Possibly not thinking of it as much. In fact, there’s data to suggest that – that patients who are older
may not be tested, or diagnosis may not be thought of
as much as in a younger person. There’s also male-female discrepancy. If you see a woman presenting with
breathlessness, you’re more likely to think of asthma. If you see an older man,
you’re more likely to think of COPD. Whereas that doesn’t always follow. There’s a burden
of undiagnosed COPD? Undoubtedly there is, yes. Have people done the epidemiology
of a mixed picture, even if you add in
coronary heart disease? Not very well, Norman. That hasn’t been done very well. A lot of the epidemiology, the asthma
prevalence and the COPD prevalence, there’s probably an interaction
between the two. There have been papers
looking at the number of patients who are co-diagnosed
with both asthma and COPD. This is quite high. Patients themselves will say,
‘One doctor told me I had asthma, the other one said I had emphysema.
What have I got?’ Often it is difficult to tease that out.
They may have both. Is there an inordinate focus on the
heart, being a respiratory condition? Yes, I do think so. As hospital specialists, of course,
we see the patients, they’ve normally had the investigations
for the cardiac disease. So they’ve had their echocardiogram,
they’ve had their ECG. Then someone thinks, maybe
they should have a breathing test. And the penny drops. Do you find that as well, Vanessa? Yes. In fact, the prevalence
of this overlap and this mixed disease is being increasingly recognised. There was a paper this month in Thorax
from a group in New Zealand that studied a large group of people
with airways disease. They found that only 19% could be
definitively defined as COPD alone. The rest of the population
had some kind of overlap, whether it be asthma and COPD or whether that be chronic bronchitis,
emphysema or some other mix. Which, Gary,
must complicate management? Absolutely.
I know this is a respiratory evening, but as a GP, I am perhaps defending
the cardiac perspective a little bit. We’re holistic here. We can cope. Cardiovascular death still – despite
all the advances that have occurred – it still takes the lion’s share
of mortality. There is a mindset among GPs that if there is a possibility
of this being cardiac, that’s going to be the focus. To some extent, as you mentioned,
we don’t think about COPD enough. The risk factors, or the pathogenesis,
of some of these conditions overlap. Once the GP has perhaps excluded
what they perceive might be a cause of sudden death
or of much greater urgency, sometimes the drive to continue
to explore the causes is lessened. Hopefully this evening,
we can change that a little bit. Let’s try. We’ve got a few case studies.
Let’s take a look at our first one. Max is a 65-year-old man,
new to your surgery, Gary. He comes in complaining of increasing
breathlessness with some activities. He’s finding it harder
going to the shops, climbing stairs, walking any distance. He’s not too worried. He says
he’s not as young as he used to be. What’s your approach to Max? This is a fairly common scenario – a patient who presents
new to the practice. They may have moved into the area
or their GP may have retired. They’ll often minimise the symptoms because they’ve been coming on over…
sometimes decades. They’ll attribute it to ageing,
to perhaps putting on a little weight or giving up the golf. Because it’s insidious, people are able to adjust remarkably
well to their declining lung function. From the GP’s perspective,
you have undifferentiated disease. We’re looking broadly, I suppose, at
cardiac causes, respiratory causes, and of course
there’s an overlap of both. Then of course there are the
non-cardiac, non-respiratory causes, such as perhaps anaemia, even anxiety. We are seeing more of our patients
becoming obese and deconditioned. It can be difficult to tease out on the basis of the limited information
we have at present. Anything to add to
the differential diagnosis, Christine? Just thinking of thyroid disease.
There’s a bit of a differential. In terms of respiratory diseases, there are other respiratory diseases,
such as pulmonary fibrosis. I mean, much rarer. But, again, in terms of your
differential with cardiac diseases – with crackles, for example. If you go into Max’s history, he’s had a run of
upper respiratory infections, but he tells you
he was always a chesty child. He does talk about
wheezing and coughing, particularly on exercise
first thing in the morning. He is mildly obese, with a BMI of 30. He’s taking half an aspirin a day
on the advice of his last doctor and atorvastatin, 20mg daily. Between the ages of 17 and 50
he smoked a pack a day, and he says
that he’s now an ex-smoker. He tells you that his last doctor
did an ultrasound of his heart, but he’s never had a lung test. What are you going to do for him now? This focuses our attention now more
on the respiratory side. He’s had some
of the cardiological investigations, though there’s certainly room for more. The previous GP would have
excluded things like heart failure, but there could still be
silent ischaemia. We would like to do other investigations
looking at anaemia and we would like to do spirometry. Anybody who presents
with any respiratory symptom should have spirometry. Max would be a candidate for that. And a chest X-ray looking for a tumour? Yes, a chest X-ray as well. Is it going to take much else
other than a tumour, Christine, a reason for an X-ray
in a man like this? If you see a major degree
of hyperinflation, you could be thinking asthma or COPD. You’d be looking for cardiac signs,
as you say. But tumour, and pulmonary fibrosis, but on examination
you would have found some crackles. This is presuming we would have skipped
over examination. – You have laid a hand on him, Gary?
– Absolutely. Assuming there’s not much to find. Gary, what’s your view of the role
of spirometry in general practice? I think spirometry is very important. In a situation like this, it can give us
an enormous amount of information, and can possibly obviate the need for more complicated and expensive
investigations. It’s an effective way
of picking up obstructive lung disease. We can also pick up restriction, which,
as Christine said, is less common. It will also help us in terms of
defining the severity of the disease, if there is any. It’s a good baseline to determine
the response of medication. If there’s an improvement, we can also track the progression
of the disease as well. Spirometry
is an absolutely essential part of any respiratory history
and examination. An essential part of general practice. Some people have argued that if you’ve
got a stethoscope in general practice, you should have a spirometer. Diagnosing respiratory disease
without doing it with spirometry is a bit like managing diabetes
without looking at the blood sugar as far as I’m concerned,
but I am a respiratory physician. We need to be doing it more
in general practice. What are you looking for
on the spirometry, Christine, to differentiate between asthma
or COPD in someone like Max? We’re looking for airflow obstruction
to diagnose either of them. In asthma there’s variability and
reversibility of airflow obstruction. In most patients,
that reversibility is complete. Post-bronchodilator,
you’ll get normal spirometry. In COPD, by its definition, you have an irreversible or poorly
reversible degree of airflow obstruction and post-bronchodilator spirometry will still show
a persisting obstructive defect. Vanessa, what would be the issues,
if you’re thinking ahead and dealing with Max, in terms of
self-management and other things, you’d want to be preparing
yourself or him for? With Max, despite whether
this might be asthma or COPD, it will be a new diagnosis. He’s going to need to understand
the process of the disease and how it’s managed in terms of
the actions of these medications, the side effects that might happen
and how they’re delivered – most likely
they’ll be inhaled medications. That would be the first things
to deal with with Max. He has been a past smoker,
so we’d need to revisit whether or not he is currently smoking
or has been smoking recently. Just because someone
gave up previously doesn’t mean
they’re still a current smoker. Whether Max is diagnosed with asthma
or COPD, we’d need to look at whether or not he needs
exercise rehabilitation. As Gary said, he’s deconditioned,
he’s overweight. That would be an effective form
of treatment for him with his decreased lung function, that’s if he has decreased lung
function, after we do the spirometry. The final thing would be developing
some kind of management plan with him so that he knows what to do
should his symptoms deteriorate. Christine, is there any evidence
that reducing weight improves respiratory symptoms
in asthma or COPD? There is limited evidence, Norman,
that that is the case, yes. But it’s very difficult
to get people to lose weight, so the studies are difficult to do. We know from the sleep apnoea world,
whenever we try and do such studies, the majority of patients
don’t lose the weight. But I would agree
that an exercise program and a weight-reduction program would be an important part
of this man’s management. Although often with COPD,
you’re thin rather than fat. TONI: Oftentimes. That used to be the case, although we’re finding now,
with the obesity epidemic… You’re getting the same paradox
you get with heart failure – you’re more likely to get heart failure
if you’re obese, but once you’re obese,
you’re more likely to survive it. Certainly in COPD
there is that obesity paradox, in that if you’re obese
you’re protected against mortality. Many studies have shown that. It’s difficult to know what to do
in that situation, I suppose. Is there much difference in
symptomatology between, say, somebody in their 30s or 40s
versus Max, in his late 60s? – In terms of…
– Asthma. COPD, you’re not going to expect
in the younger person. But asthma? If the person is younger, it’s usually more clear-cut
that they have asthma. But the symptoms will be the same. In this instance, the patient’s
main symptom is breathlessness. In the younger age group, certainly
teens and children and younger adults, we’ll probably see wheeze
more frequently rather than the insidious onset
of breathlessness. It’s the older patient who
attributes this to the ageing process that we see commonly, whereas younger people
would be usually more energetic, doing more exercise,
and this is not normal, so they’ll go along perhaps earlier. Gary, let’s assume for a moment
that Max is pure COPD, the 1 in 5, the 20% who have got COPD
rather than the mixed picture. How would you manage him? It would be important to quantify
the degree of obstruction. That would determine
the choice of medication. Say if he had mild COPD,
we may find that simple PRN use of a short-acting bronchodilator
may be enough. Even if there’s not much reversibility? Yes. It has been shown to improve
exercise tolerance and quality of life. If he was a little more severe, we might
add a long-acting bronchodilator such as tiotropium. If it was getting into the more moderate
to severe level, we might then add inhaled steroids and perhaps a long-acting beta-agonist
combination. And the role of antibiotics? The role of antibiotics is important
in intercurrent infection. It can be difficult though
to differentiate between… NORMAN: An acute exacerbation.
– Yeah, and also viral versus bacterial. Even with a viral infection,
they may cough up discoloured sputum. We do know that
untreated intercurrent infection does in fact further damage the lungs. So early and aggressive
appropriate management is important with antibiotics. Anything to add or change, Christine? On the antibiotic question, depending on
how much sputum this man has, another differential
we haven’t discussed is bronchiectasis. Quite a large number of patients
with COPD, when you go to do HRCTs,
may have bronchiectasis. That’s muddying the water, but
we haven’t mentioned it, and we should. NORMAN: If it was bronchiectasis,
a chest physio? Chest physiotherapy would be posturing
and flutter valves and, again, prompt use of antibiotics
for infections. Would you change anything
to Gary’s management? No, I don’t think so. Vanessa has mentioned
the pulmonary rehabilitation, but I think that’s really important
to emphasise. In this man
and in all patients with COPD, pulmonary rehabilitation
is level-1 evidence to support its use in terms of improvement in
exercise capacity and quality of life, and potentially also some reduction
in hospital admissions. As far as my understanding
through the Lung Foundation’s work, about 2% of patients with COPD
in Australia has access to pulmonary rehab,
so it’s really inadequate. And I guess the message should be that there’s a toolkit available on
the Australia Lung Foundation website. People who are interested
can go to that. In the rural community, we need to be
thinking about setting up groups to assist these patients, as well as… It’s easy in Melbourne or Sydney. Vanessa? Absolutely. I agree. The access that people have to rehab
is appalling, really, when you look at the population. Is this the sort of stuff a local physio
or OT could get involved with? It’s not complicated,
it’s just doing it. Absolutely. Pulmonary rehabilitation
programs that combine exercise together with self-management are those that have been shown
to be the most effective. Doing that in the local community centre
is easy enough to do if you’ve got the resources. Adherence is pretty important, Toni? Absolutely.
From the pharmacist’s perspective, understanding what disease this patient
actually has is important. Oftentimes we’re not privy
with that diagnosis. That makes it difficult for pharmacists. Going through the adherence program
with the patient, making sure they know
how to use their devices, and understanding why and
what they’re doing is really important. We probably see them
more than anyone else does, so it’s an opportunity. A question from a general practitioner
in rural Victoria to you, Gary – what would be the recommended antibiotic
for acute exacerbations? I’d probably look at a combination
of amoxicillin and clavulanic acid. We know that there’s an increasing
incidence of atypical organisms, so one may consider macrolide as well
if the initial response isn’t adequate, or sometimes in combination. Do you agree with that, Toni? It’s certainly what we see in practice. NORMAN: That’s a diplomatic answer. It’s an honest answer. The thing we see a lot in practice
with older patients being put on those groups of antibiotics
is the resultant diarrhoea, which is a bit of an issue. You’ve got the compliance problem,
so what happens next? Maybe they stop taking the antibiotics
and don’t tell anybody, or maybe they do stop taking the
antibiotics and get something else. That is an issue
we see quite frequently. Christine, the antibiotic question? I suspect Gary’s thinking about that
they may have a patch of pneumonia. That combination of therapy would be
very appropriate in that situation. If it’s a simple bronchitic illness, some Rulide or some amoxicillin
might be enough. A question from a GP in Queensland asks, how often would you repeat respirometry in somebody with, say, COPD to look at whether or not
you’re maintaining or declining? There’s no level-1 evidence for that. This is really level 4. NORMAN: In your opinion. Expert opinion, yes. I would be repeating it firstly
in terms of a trial of medication in someone that I might suspect
has coexistent asthma, where I’m expecting to see
a significant improvement. Otherwise, probably if the patient
is not doing well and the breathlessness is deteriorating
despite my best attempts, to see whether there’s any significant
change in spirometric indices. In fact though,
spirometry doesn’t correlate very well with level of dyspnoea
in COPD in general. Oftentimes,
an MRC breathlessness score or a quality-of-life score might be
more useful to monitor the patient. A GP in South Australia asks – you think there’s coexisting
coronary heart disease. You want to do a stress test to see if
you can elicit significant ischaemia, but there’s COPD as well. How do you get through all that
to not muddy the stress test? You’re often using
a dobutamine stress test or something, because you can’t exercise the patient
enough. What we do in our hospital is a combined
cardio-pulmonary exercise test, where we use a cycle ergometer. We’ve got cardiac response,
we’re looking at ECG, we can also look at
what’s happening to ventilation. That can give a nice picture
of the lungs and heart. – It’s a specialist thing?
– Yeah. In terms of a stress test, dobutamine
stress tests are the way to go if the patient cannot exert themselves. Do you want to comment, Gary? I agree, absolutely. Let’s go to our next case study,
and keep those questions coming in. Andrew is 55 years old.
He presents with breathlessness. There’s no history of asthma, but
he’s been a smoker for 41 pack years. Let’s have a look at his baseline pulmonary function test. Do you want to walk us through these? CHRISTINE: Sure. Firstly, on the left-hand side – I’m sure many of you are familiar with spirometric indices, but just to go through them – the forced expiratory volume in one second. The forced vital capacity – the amount of air you can take in and fully breathe out. The vital capacity, done not as a forced manoeuvre but a slow manoeuvre. The forced expiratory ratio – the ratio of the forced expiratory volume over vital capacity. In this case, we’ve also got a measure of gas-exchange capacity, the TLCO, or carbon monoxide-diffusing capacity. He’s got severe airflow obstruction. He’s got an FEV1 of less than a litre, 25% I think it is, of predicted. There’s an improvement post-bronchodilator, so it’s post-MDI, probably salbutamol, I imagine. He’s left with a significant, persisting, obstructive ventilatory defect, even post-bronchodilator. So looking like COPD, particularly with that gas-exchange abnormality, but still could be asthma. There’s a 27% improvement in FEV1 post-bronchodilator – only a couple of hundred mils, right on the borderline. You’d be thinking about COPD. What would you do for him, Gary? As Christine has mentioned, you’re trying to tease out
whether this is COPD or asthma or probably a combination of both, given that there has been
a reasonable amount of reversibility. I would look at a steroid challenge,
either oral steroid, perhaps prednisolone,
25mg a day for four weeks, or inhaled steroids. To some extent,
the choice would depend on how symptomatic the patient is. I would then repeat the spirometry and see whether we were able to achieve
significant improvement. What would you do, Christine? Exactly the same thing. Oral steroids or inhaled? You know what? I know this patient. I know that I gave him oral steroids. This patient was really quite unwell. I take Gary’s point
that in a particularly unwell person, probably oral,
to get that response quickly. Let’s see what his pulmonary function
tests were after three weeks. Christine? I’m delighted to say that there’s been a significant improvement in the FEV1. Remembering that it was under a litre in the previous table,
and now 2.4 litres, which is 68% of predicted normal. So a significant improvement
in baseline ventilatory function, with a forced-expiratory ratio
post-bronchodilator now of 66%. He still has a persisting degree of airflow obstruction,
but really an asthmatic-type response, I would say,
to this course of prednisolone. NORMAN: It’s a mixed picture? It’s a mixed picture
in that he still has a persisting degree
of airflow obstruction even after our maximum treatment. Gary, how are you going to manage him,
going forward? He’s on oral steroids.
You got a good response. He’s ready to run a marathon –
a very limited one, given his COPD. I would certainly look to transfer him
onto inhaled steroids, probably in combination
with a long-acting beta-agonist. This fella has quite significant asthma. He’s probably got either remodelling
from undertreated or untreated asthma, but he’s also of course a smoker,
so he’s got the double whammy. NORMAN: How are you going to
get him off his smoking? Oh, I wish I knew the answer. One of the things that I find works is really to show him the result
of his spirometry. I find that quite powerful because you can show the patient
what they achieved – this is the best that you could do,
this is what you should be doing, this is as a result of your smoking. There’s randomised
control-trial evidence to suggest that telling them their lung age
makes a difference to motivating them. Quite a number of spirometers now
include that as an option in the print-out. NORMAN: You’ve got
85-year-old lungs, Andrew. Yes. This is one of the rare situations
where we can wind time backwards. We can get your lungs younger. We can’t often offer that. Toni, what are the PBS issues here
in terms of Andrew moving forward, given this transition? Given the transition, initially,
Andrew’s going to need to try a plain, inhaled steroid
before he can go on. That needs to be successful before the beta-agonist can be added in
to a combination. Initially he could be having
two inhalers. NORMAN: A short-acting reliever? Plus steroid.
You know, your inhaled steroid. And the dose of steroid? It would probably be the 250mcg-type
dose, I should think, I would imagine. I’d have to defer to my
respiratory physician and GP, of course. Well, probably he’d be starting higher
at that stage, wouldn’t he, because he’s been on his oral. So it does depend a bit
on what the physicians are feeling. From the pharmacist’s perspective,
there’s a lot of other issues around compliance
and understanding the disease stage and the willingness to treat. Especially in a younger person, the willingness to treat
and accept that that’s essential is often the challenge that we’re faced, and I should imagine people
like Vanessa deal with every single day. What about the dosage
of corticosteroids, because we’re still going too high. It’s high. It’s difficult, isn’t it? If he’s purely got asthma, we’ve certainly moved away
from those very high doses that were used to be used
sort of a decade or so ago. On the other hand,
if we think he has COPD and we know he’s got some
irreversible airflow obstruction… It’s a moot point, isn’t it, whether
it’s the remodelling you talked about or whether it truly is the COPD. You’ll be aware that the studies
that have been done on COPD have used higher doses,
fixed doses of inhaled corticosteroid and long-acting beta-agonist
of 1,000mcg in the large studies, such as the TORCH Study, and
800mcg of budesonide in studies by… That might have been engineered by the pharmaceutical company
to flog more drugs. Indeed so, but the trouble is,
we have those studies and we don’t have the studies
of the lower doses in COPD. In asthma, we know we can use quite low
doses of inhaled corticosteroids and that there’s a plateau effect. NORMAN: Are you hamstrung by the PBS
rules if you’ve got COPD and asthma? – Um…
TONI: Not necessarily. No. So, but the temptation… I’m trying to
get the picture of the mixed picture and how that changes your management. With titration of dose, following
the national asthma guidelines, the asthma action plans and so on, it’s fairly straightforward
how you teeter up, teeter down. But with COPD, teetering down, titrating
down, might be more of an issue. That’s right.
Thinking about this particular man, I’d be treating him fairly aggressively
for his asthma and I’d probably be wanting
to back-titrate. If, however, he was a different patient,
with severe COPD, having recurrent exacerbations, I’d probably be sticking him on
combination therapy, leaving him on that, and getting benefit
in terms of quality of life and hopefully reductions
in exacerbation. Those are the differences. You don’t back-titrate with COPD if you’re aiming at reducing hospital
admissions in that severe group. This man… He started off severe,
but we’ve converted him to moderate. Would you expect that spirometry
to change much in a month’s time? Well, not if he’s got COPD. If he’s truly got asthma, we may see
some further benefit, I suppose. As I know the patient, I should
know that, but I can’t remember. I think his airflow obstruction
stayed fairly fixed, so I truly did believe
he had two diseases. What would you do for him, Vanessa? There’s a range of different things
that Andrew needs. Firstly, one of the best treatments for someone with COPD,
or asthma for that matter, is to get him to stop smoking. We need to build a partnership with him in terms of getting him
to see the things that he needs to do in order to change his behaviour. In terms of his smoking cessation,
we’d need to do counselling, but also offer some pharmacotherapy, either using
nicotine-replacement therapy or some varenicline if necessary, and make a commitment
to continue to see him in terms of his smoking cessation
to provide some support. And do referrals to other support lines,
such as the Quitline, et cetera. But again, with Andrew,
this is a new diagnosis. He’s come in. He’s got a new diagnosis.
He’s been told to stop smoking. He’s been given
a couple of new devices. He needs to make some
substantial changes to his behaviour. He needs to understand why, and how these treatments
are going to work for him and what he will get out of it. We talked briefly about ways of getting
him to consider stopping smoking. But he’s only 55. If he can see the advances
he’ll get from stopping smoking now, then that might give him some keys
to change his smoking behaviour. The Fletcher-Peto chart
is always very useful when you’re trying to get people
to stop, because they can see the damage that
they don’t do to their lung function by stopping at an earlier age. But it’s never too late. So that’s his smoking cessation. Again, if he’s got COPD
and his TLCO is reduced, he would also benefit
from some pulmonary rehabilitation. But he does have that element
of asthma, so a written action plan for him
would be effective in terms of avoiding exacerbations,
et cetera. Finally, we need to just make sure
he’s using his inhalers correctly. A question from Tasmania
asks to explain more fully what a pack year is. A pack year is smoking 20 cigarettes
per day for one year. NORMAN: As simple as that?
Intuitively, that’s what it is. A question from Cairns – ‘Is there any truth in the need
to change the Spiriva machine yearly? – Six-monthly.
– Six-monthly, OK. Let’s go to our next case study. Denise is 63, and has lived with asthma
for most of her adult life. She also has seasonal rhinitis
and gastro-oesophageal reflux. She’s on budesonide, 100mcg, and eformoterol, 6mcg
on the SMART regime. Tell us what the SMART regime is,
Christine. – Are we allowed to use drug names?
– We are. We have to in this case. It’s Symbicort used as maintenance
and reliever therapy. The patient would take
twice-daily Symbicort, then use that as their reliever as well
through the day. – Instead of a short-acting?
– Correct. Don’t you risk
getting an overdose of steroids on that? Work has been done – the steroid load
seems to be lower in the patient group when SMART was compared
to a regular BD plus short-acting
bronchodilator regimen. You’re effectively treating
mini attacks, I suppose, exacerbations of asthma
through the day, by nipping them in the bud
with the inhaled steroid as well as the bronchodilator. Denise has come in
with increased breathlessness. What are you going to do for her? The idea, of course, is
to try and ascertain the cause of that. Does she have
an intercurrent infection? Does she have another diagnosis? Is she using her medication correctly,
or at all? We often find patients
discontinue medications because of something they may have seen
on a current affair program. So it’s a matter of teasing out
what’s changed for the patient. If we assume
that all remains much the same, then you may need to then look at
other possible confounding factors. We’ve spoken about some of the things
that might aggravate asthma – reflux, rhinitis. These issues can make the control
of the asthma more difficult. NORMAN:
What are you going to do for her reflux? A fairly standard treatment now is
to introduce a proton pump inhibitor. They work quickly,
they work effectively. NORMAN: Does it have to be asthma?
– Unfortunately, not always. It can. Reflux can in itself cause respiratory
symptoms that can cause a cough. It may cause aspiration. There are a number of mechanisms
by which reflux can cause respiratory symptoms. You can still have fluid coming up,
it’s just not as acidic with the PPI. That’s right. If it’s volume reflux,
you may have a problem with that. You may need to add a prokinetic agent. But we know that patients may develop
a cough even if they’re not aspirating, from reflux effects. The question then is,
‘Are these symptoms in fact asthma?’ If it is asthma, and this is again
where spirometry is so useful, if you have serial spirometry, whilst it’s useful
to compare patients’ spirometry results against predicted levels
or against lower limits of normal, it’s nowhere near as useful as comparing it against their own
performance, against themselves. And so, if you find that the spirometry
has not declined, you may be more inclined
to seek other causes. On the other hand, if there’s been
a definite increase in the obstruction, a deterioration in lung function, you’re going to be shifting towards concentrating on
the respiratory medicine. What about rhinitis?
That could make the asthma worse. Absolutely. We know that 80% of people
with asthma do have rhinitis. We also know that uncontrolled rhinitis does make it more difficult
to control the asthma. So we would certainly be inclined
to treat both. What about the steroid dose if
you’re starting to treat the rhinitis? If you’re thinking about the dose,
it’s relatively small – 32mcg or 64mcg, compared to what we’re talking here,
in hundreds of micrograms. It’s relatively small,
but yes, you have to think about that. As Gary said,
it’s important to treat the nose because of the improvement
in the asthma. What you do with Denise is,
you treat the reflux, you give her nasal steroids
for her rhinitis. A month later, she’s still complaining
of increasing breathlessness. What are you going to do now? If we’ve excluded other causes – and we spoke in the case of Max
about cardiac pathology and other non-cardiac
and non-respiratory pathology – if we’ve excluded those, then the important thing
would be to look at what’s changed, what’s causing this deterioration. It may be something as simple as the patient not using their medication
correctly, losing some coordination. So what you decide to do
is try and increase the dose, because you can’t really find anything. But she comes back, and Toni,
she’s just not taking the medication because she’s getting thrush. She complains to you. She doesn’t like to upset Dr Kilov,
’cause he’s trying so hard. Look, sometimes that is a reality. The other reality is too,
with the nasal steroids, they’re not covered by the PBS. Ultimately, the person has to
wear the cost of that medication. Commonly we find our elderly patients aren’t all that happy about
paying a significant amount of money, or just don’t have spare money to pay
for that, so choose not to use it. Of course, they don’t want
to bother the doctor with that, because the doctor
wants them to have it. They just assume
that everything will go on. Oral thrush is a significant problem, and is quite commonly told to us
in the pharmacy. It’s about technique,
about treating that for them. We would usually let the doctor know
that this person has had that problem, this is what we’ve done
because it’s over the counter, and recommended the proper way
of using their steroid inhaler – make sure they’ve rinsed their mouth and spit out the water
after they’ve rinsed. What about drug interactions? You alluded to beta-blocker drops
earlier. What other drug interactions
do you need to be wary of? Especially in older patients, oftentimes they’re taking medication
for arthritis or rheumatism. They may be well be taking
a nonsteroidal anti-inflammatory. In a select group of people, that will
cause an exacerbation of their asthma. They’re probably
our biggest group of drugs, so we really need to be mindful
of the eye drops, we need to be mindful of the aches
and pains that people suffer, we need to be mindful
of the beta-blockers that they may well be using
for their cardiovascular problems. The other thing with an older person,
we need to think about osteoporosis. That’s not in your direction, but it’s
something else we need to think about. Not our place to prescribe, obviously,
but it’s certainly our place… If somebody was doing a home-medicines
review for this patient… Would you do a baseline DEXA
on somebody like this, Gary? Again, coming back to the issue of cost, it’s not PBS-reimbursed
unless they’ve had a fracture. That can be a problem. The other problem is that once you’ve determined,
assuming they do have osteoporosis, again the medication
is not PBS-reimbursed unless they’ve had
a minimal-trauma fracture. Unless you’re sure
that you can act on that, it’s probably not worth pursuing. The other alternative is, there is evidence for using calcium
and vitamin D. GARY: I think we should be doing that
anyway. I know this is not,
perhaps, the forum for this, but there is an epidemic
of vitamin-D deficiency. They should all be tested for it, then
hopefully put on calcium and vitamin D. Taking a therapeutic dose, too. Improving mobility to reduce falls. There’s a good point. NORMAN: Vanessa?
– With Denise, we mentioned earlier that older people may not be able to use
Turbuhalers as effectively as younger people.
This is the device… NORMAN: Denise isn’t crumbling here.
She’s only 63. I have no answer to that. She may not be able to inspire deep
enough to activate the Turbuhaler. If we had established that
the problem was adherence, that would be a consideration for her. In terms of the adherence
due to side effects, you’d also want
to think about the device, and think about converting her
to maybe a puffer and a spacer, where she’s more likely
to get oropharyngeal deposition and therefore less likely
to get oral thrush. NORMAN: Christine? CHRISTINE:
Can I just make a comment? Going back to the point
about doing her spirometry and maybe not seeing much of a change,
and wondering, ‘Is it worsening of her asthma
or something else?’ We’ve determined that
there are adherence issues. We can,
perhaps not so much in rural areas, but if you do have
a lung-function laboratory nearby, they can do a methacholine challenge
and some sort of challenge test to determine
the bronchial hyper-responsiveness that may be still present
in this person. Perhaps of interest to people
would be other tests that are a bit experimental, but we hope we’ll bring into
regular clinical practice, such as exhaled nitric oxide
as a measure of inflammation and also sputum eosinophils,
again as a measure of inflammation, can be helpful in patients
where you’re trying to determine, is it flaring of their asthma – the lung
function is not changing very much – or is it something else, for example,
vocal-cord dysfunction? We’ve got problems
with oropharyngeal candidiasis. That can also mimic asthma. – What about influenza vaccination?
CHRISTINE: In this lady? We would be recommending it,
and the guidelines recommend it. Let’s go to our next case study. Irene is an 85-year-old woman
with a confirmed diagnosis of asthma. She’s pretty stable on salmeterol 50mcg and fluticasone 250mcg bd, short-acting, and salbutamol as required. She lives independently near her
daughter and her daughter’s family. Her mobility is limited,
and she has mild macular degeneration. Vanessa, take us through
what you think… She’s come back for a routine check-up.
There’s nothing changed. What are the issues here for someone
we could justifiably call elderly? VANESSA: The first thing to note is that
she seems to have adequate control on the treatment that she’s taking,
which is pleasing to see. But the other things that can be
highlighted in terms of her management is that she’s got
mild macular degeneration. That will have an effect on her ability
to use the different inhaler devices in terms of loading medications
and loading the spacer, et cetera. And the other thing
is her decreased mobility, and that may have some effect
on her strength as well and her ability
to activate the different devices. So those things would need to be
reviewed and considered. The other thing to think about
with Irene is she is an older person
with some macular degeneration. In terms of her management,
or self-management, for example, we’d need to consider things
a little bit differently. We did mention earlier in the program that the mortality rates
among older people are increasing. We’ve very effectively been able
to reduce mortality in Australia over the last 20 years. That highlights that maybe there are
things we need to do differently as people age. Our approach may not be working
as effectively. Action plans are a major component
of treatment for people with asthma. She may not be able to read it. Right. With macular degeneration, a written action plan
might be ineffective for her. The size of the font
that people are given action plans for is a problem in older people. Some groups have developed
written action plans using large fonts to try and avoid that problem. With her, we would need to involve her
family members in her management. She does have a daughter nearby who may be involved
in regular follow-up with her and assessment of how she’s going. So I would want to involve her
in her action plan and simplify the plan
as much as possible. I’d also want to assess Irene’s needs
and see what the biggest problem is for her
in terms of her breathing disability, and see how we could effectively
improve her management based on achieving
a better outcome for her and really making it
a person-centred approach. Gary, in your practice,
who gives the patient education? I do. I would almost invariably involve
an asthma educator. It’s virtually impossible
to manage any chronic disease, be it asthma, diabetes, COPD, without the involvement
of allied health-care professionals, the pharmacist. It is a team approach.
It needs to be a team approach. It needs to be an ongoing,
regularly reviewed program. It’s not a set-and-forget. Whilst I might educate the patient, they will get more information, they’ll
get reinforcement of the information, say, from an asthma educator. We know that retention rates
in a consultation are very low. We’re talking about
of the order of 10%, 20%. Much of the information does need to be
reinforced, does need to be repeated. In a country town, presumably,
you just find whoever you can – whoever’s available
in terms of professionals… Yes. And I would imagine
in most country towns, at the least you’ll have the GP
and the pharmacist working together. Christine, what’s the role of spirometry
and, say, pulmonary rehabilitation in someone like Irene? I was just wondering that myself,
Norman. Depending on how disabled she is…
But, as you were suggesting, Vanessa, she seems to be
reasonably well-managed. I would like to see all patients
with either COPD or asthma having at least had some spirometry at some point
in their management process so that we know where we are. Depending on her access
to a pulmonary rehabilitation program, if her daughter is able to take her, I know it would improve her quality
of life and her exercise capacity. so I’d certainly strongly be
recommending both of those things. A question
from rural New South Wales – ‘What’s the current thinking
on the amount of marijuana smoking needed to cause COPD?’ How many bong years
are we talking about here? I don’t know how many bong years. – It’s a good question.
– No, it is. I think it must be from the north coast
of New South Wales, actually. We’re seeing more and more patients
presenting with COPD who have really nasty
cystic lung disease. NORMAN: The ageing hippies
are coming home to roost? It really is very severe. The chest X-rays and CT scans
are really quite characteristic. As you know, it’s quite difficult
for these patients to stop using. Often the marijuana
is mixed with nicotine. It’s a difficult management situation. We are seeing quite a lot of it. Rhinitis – treating the nose
with Nasonex to help the asthma? – Yes.
– What is Nasonex? Mometasone. It’s another nasal corticosteroid. Are there COPD plans,
like asthma plans? Yes, there are. Looking at
the Australian Lung Foundation website, there are plans available. Cochrane meta-analysis suggests
that the use of these plans isn’t quite as helpful as they have been
in asthma, but I suspect that we just don’t have
the evidence about them. Talking about a holistic approach
and a self-management approach to management of either
of these disease, it makes common sense to have a patient
understanding and using a plan, for example,
for flare-ups of their COPD. What are your take-home messages?
Vanessa? One of the take-home messages is that the needs of older people
are quite different, that we do need to define
an integrated approach to the management of older people
with either asthma or COPD, and changing our approach
to be more holistic. – Toni?
– I have to agree with that. I particularly think it’s very important
in a rural area. The limited number of health
professionals there are in that area need to work together. For pharmacists, it’s really important that you get to know
who else is in your area. The other thing is that
pharmacists, I think, have a huge role in medication compliance
and adherence. We probably have
a more complete record. Potentially, in country areas, where there may only be one pharmacy
in a town, they’ll know everything
that person is taking. There needs to be open communication
with the prescribers. Gary? Errors in medicine are generally
because of not looking rather than not knowing. We would certainly want to encourage
greater use of spirometry, particularly in rural settings, where you may not have access
to tertiary institutions. Performing office spirometry
can be very effective in helping to tease out
what’s going on with these patients. The other thing that’s been mentioned,
and I’d like to reinforce, is the team-based approach. This is an ideal situation for the use
of a GP management plan and team-care arrangement. GPs are often pressed for time. Where you do a GP management plan
and team-care arrangement, you are getting adequately remunerated
for the time and effort spent, and you’re involving the necessary
allied health professionals, pharmacists and so on. – Christine?
– They’ve said everything, haven’t they? I really would suggest that people
have a look at the COPD-X guidelines. They’re very useful. The first step in those guidelines
is to confirm the diagnosis, so, reiterating the importance
of doing spirometry. It’s hard to treat someone properly
if you don’t know what you’re treating. It may be mixed disease,
but it’s important to know that, and educate the patient. Thank you all very much. I hope you’ve enjoyed tonight’s program
on breathlessness and the older adult. If you’re interested in obtaining more
information about the issues raised, there are a number of resource available on the Rural Health Education
Foundation’s website – Don’t forget to complete and send in
your evaluation forms, and please register for CPD points by completing the attendance sheet. Our thanks to the National
Asthma Council of Australia for making the program possible, with funding from the Government’s
Department of Health and Ageing. Thanks to you for taking the time
to attend and contribute. I’m Norman Swan.
From all of us, bye for now. Captions by
Captioning & Subtitling International Funded by the Australian Government
Department of Families, Housing, Community Services
and Indigenous Affairs�


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