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The
9 Ds of Asthma Prof
Richard Lewis, Consultant in General and Respiratory Medicine Worcestershire
Royal Hospital |
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Most of us are faced with patients whose asthma is not well controlled either in an asthma clinic or in the surgery. The temptation is simply to add an additional layer of medication, or increase levels of current medication and ask the patient to return to see the effect. Over the last 18 years I have used the following simple check list which usually solves the problem without recourse to more asthma medication. Diagnosis Drug Dose Delivery Dirty Air Diet Depression Deprivation Downright difficult Diagnosis:
Is the problem asthma? The most important first move is to consider that breathlessness may be caused by a different problem. A simple to remember checklist for this is: A is for Allergic bronchopulmonary aspergillosis B is for Bronchitis C is for COPD D is for Diffuse lung disease E is for Embolus F is for Failure G is for GORD H is for Hyperventilation I is for Inhaled foreign body Drug Consider drugs which may be inducing asthma including beta blockers (do not forget the beta blocking eye drops which can be very potent), and NSAIAs. In treatment ensure that patients are using an inhaled steroid, and consider add on therapy (including long acting beta agonists, or leukotriene inhibitors or theophyllines rather that increasing the dose of inhaled steroid. Dose Non-concordance or non-compliance is the most important consideration. In a recent study we found around 50% of patients (even those recently admitted with asthma) take less or very much less than the prescribed dose of inhaled steroid. Therefore increasing the dose prescribed may be simply increasing the gap between reality gap. Delivery One of the most important causes of poor asthma control is failure to use an MDI correctly. It is safe to assume that the device is not being used correctly until proved otherwise, especially in the elderly. Dirty
air Active or passive smoking: I never cease to be amazed how my most difficult to control asthma patients are often covert smokers. Occupational asthma: (eg isocyanates, solder flux fumes, and other occupational asthma such as in bakery workers, industrial workers etc). Allergens: Avoidance may make a difference to control. Skin testing may detect pet, dust mite, and pollen allergy. Air pollutants I find the 5 Ds above the most important although on occasions consider Diet Some subjects may recognise dietary triggers and therefore may avoid them. Consider benzoates (E210-219), suphites (E220-228), cows milk, cereals, eggs, nuts, certain fermented products including wines, beers and cheeses. Depression This may be associated with non-compliance, poor help seeking behaviour, upper airway dysfunction mimicking asthma, smoking, and altered perception of the effect of asthma symptoms on lifestyle. Deprivation For a variety of reasons there is a strong relationship between asthma severity, asthma admission and indices of deprivation. Then when all of the above possibilities have been considered, it is just possible that your patient is running into difficulties because their asthma is simply Downright
Difficult And these are the patients who require referral to your local respiratory physician. |