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Rapid Responses: Rapid Responses published:
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Importance of involving senior medical staff in management of severe asthma.
- B. Ronan O'Driscoll (17 February 2003)
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Why not disseminate them now?
- Stephen C Hastings (19 February 2003)
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Are the BTS guidelines misleading or misunderstood
- George Strube, RH11 8AX (24 February 2003)
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BTS and SIGN asthma guidelines
- Nicholas Chanarin (24 February 2003)
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B. Ronan O'Driscoll, Consultant Respiratory Physician Hope Hospital, Salford, M6 8HD
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Dr Rees has drawn attention to the importance and usefulness of the new asthma guidelines but he questioned the necessity of adding the authors' view that senior medical staff should be consulted in a situation where there is clear evidence of benefit (use of intravenous magnesium for severe asthma). As a member of BTS-SIGN Guideline Development Group for Management of Acute Asthma, I would like to clarify the reason for including this advice in the guidelines. A weakness of the previous BTS guidelines was the absence of clear advice concerning the involvement of senior staff in the care of high risk patients. It was common for junior staff to manage severely ill patients and to administer treatments such as aminophylline which could cause serious side-effects without discussing the patient with senior staff. Intravenous magnesium has been shown to be beneficial and safe in the management of severe asthma. The guidelines recommend that it should be given to patients with life-threatening asthma, near-fatal asthma or those with acute severe asthma who have not responded well to initial therapy. The Guideline Development Group felt that it was important to involve senior medical staff (or ICU staff) in the care of this small group of high-risk patients. The use of IV magnesium was seen as a useful trigger to identify these high-risk patients or non-responding patients who clearly require discussion with senior medical staff. Competing interests: Member of BTS-SIGN Guideline Development Group for Management of Acute Asthma |
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Stephen C Hastings, GP principal Wilmslow Road Medical Centre, Handforth,Cheshire,SK9 3LF
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It seems odd that this editorial provides no link to the actual guidlines, do we need to wait for a paper copy? Competing interests: None declared |
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George Strube, General Practioner 33, Goffs Park Road, Crawley, RH11 8AX
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The latest BTS guidelines (1) are disappointing as they still advise the use of short-acting B-agonists as the first step in treating newly diagnosed asthmatic patients. This ignores the evidence that asthma is caused by inflammation of the bronchial mucosa(2) causing bronchial hyper -reactivity, bronchospasm, bronchial obstruction due to mucosal oedema and increased mucus secretion. This can be treated effectively only by anti- inflammatory agents of which steroids are the most effective. Although B-agonists paralyse bronchial constriction for a short time giving temporary relief, the symptoms soon return and may even be worse, requiring ever more B-agonist inhalation. Proper control is never achieved as these drugs do not affect the underlying inflammatory process. Many patients struggle to control their asthma without anti-inflammatory treatment: optimum lung function is never reached, chronic disability continues and long-term lung damage develops. Numerous surveys and audits confirm widespread dependence on B-agonists(3), a result of the BTS guidelines which are either misleading or misunderstood. A completely fresh approach to the treatment of asthma is required. Steroids should be recognised as the correct treatment and used as soon as the diagnosis has been confirmed. A large dose is used initially to achieve control of symptoms and then gradually reduced to a level where the minimum dose is used to maintain control. Short acting B-agonists are reserved for break-through wheezing. They are not given initially except in emergency. Those subject to acute attacks carry their own supply of oral steroids and know how to take them in time to stop an attack. The evidence in favour of this approach has been shown by work in Finland and has been used successfully to achieve a revolution in asthma care(4). Since the inroduction of their programme in 1994, hospital admission has been reduced by 75%(5) The British guidelines would do well to follow this example. Some GPs (and nurses) in the UK alredy use this method but at present they are swimming against the tide of popular opinion generated by the BTS guidelines. References: 1. BMJ Editorial 2003;326:346-7 2. Walters E. et al., Airway inflammation, basement membrane thickening and bronchial response in asthma. Thorax 2002; 57:309-316. 3. Price D, Ryan D, Pearce L, Bride F. The AIR Study: asthma in real life. Asthma journal 1999;4:74-78 4. Haahtela T, Klaukka T, Koskela K et al. Asthma programme in Finland: a community problem needs community solutions. Thorax 2002;56:806 -814 5. Haahtela T: personal communication 14.12.2001 Competing interests: None declared |
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Nicholas Chanarin, Consultant Chest Physician Colchester General Hospital, CO4 5JL
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Dear Sir I would like you to consider a clinical problem. Imagine a young lady with difficult asthma. This lady presents to her doctor having found that she is pregnant. She asks for advice on how to prevent her unborn child developing asthma which has been such an ordeal for her. As a concientious practitionner you could refer to the new British Guideline on the Management of asthma (1). The guidelines are confusing. The guidelines have a promising section on "Non- pharmacological management and primary prophylaxsis". This section makes one grade A recommendation and that is to breast feed. The evidence sited for this is not consistent with the recommendation. The authors site two main pieces of evidence: The first is a systematic review and a meta-analysis involving 8183 subjects followed for 4 years which apparently revealed a significant protective effect of breast feeding against the development of asthma. The second study is in 1246 patients and found that there was a reduction in early life wheeze but an increase in asthma at six years. If the question is does breast feeding protect against the subsequent development of asthma then the answer on the given evidence is clearly undecided so why give a grade A recommendation to breast feed? What advice should be given to my hypothetical patient? I am further dissappointed and concerned by the removal of IV aminophylline from the regular management of acute severe asthma. The evidence for it's inclusion has never been good as the studies are old, underpowered and poorly designed. Surely there is room in the evidence based guidelines for common sense and good clinical practise based on experience. Most doctors who have used IV aminophylline can recall anecdotal examples of often dramatic responses. The same can not be said for IV magnesium. Yours sincerely Dr Nicholas Chanarin 1. British Guideline on the Management of Asthma. Thorax February 2003 Vol 58 Supplement 1 Competing interests: None declared |
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