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An asthma plan

2021; Elsevier BV; Volume: 9; Issue: 1 Linguagem: Inglês

10.1016/s2213-2600(20)30564-6

2213-2619

Mark Wilson,

Child and Adolescent Health

I was first diagnosed with asthma in 1988; back then, I was a typical outgoing, sports-mad teenager. My asthma wasn’t too bad at first, and like many people I was prescribed 2 inhalers: a “brown preventer” and a “blue reliever”. They both helped, and my life continued as normal and without any concerns of how my asthma would impact upon my quality of life as I got older. I reached my 30s before my asthma became a real problem. Whereas previously I had only had a few visits to the emergency department (ED) and no hospital admissions, things started to become more serious, with more frequent ED visits, which turned into hospital admissions, and all of sudden my asthma was a significant part of my life. I wouldn’t say that I had carefree attitude towards my asthma up until this stage, but I probably didn’t always take it as seriously as I should. I was determined that my asthma would not affect my life too much; even if I wasn’t well, I would always try to carry on as normal, still going to work, still travelling the length of the country on a cold December evening to watch my beloved Scunthorpe United football team play. I was always compliant with my medication but in hindsight, making a 500-mile round trip in subzero temperatures to stand on a cold open terrace watching football when I was struggling to breathe probably wasn’t the most sensible thing to do. I needed to take to step back and re-assess my life and the seriousness of my condition. The first step was my referral to a respiratory consultant at the hospital. My asthma didn’t really improve but at least there was a plan put in place. I tried different types of treatment (with varying degrees of success), and it suddenly felt as though we had a plan as to how to deal with my deteriorating health. I developed a great relationship with my consultant and nurses; at times we argued about how things were going. I wanted immediate results, but my consultant was looking at both the short-term and long-term plan. More often than not, she was right in what she said and did—one of the key things for me, though, is that she involved me in the decision making and the plans that she had. She always discussed things thoroughly and it really did feel like we were a team. If ever I asked her a question (eg, asking if I could try a different drug, which I had read about), she would explain things clearly and highlighted the pros and cons. The relationship and the ever-important trust remained strong. I became the model patient; I never missed my medication, I monitored my condition, checking my peak flows and SpO2, I followed my Asthma Action Plan, and I would listen to my body (eventually learning that at times the asthma would win and I would have do things slightly differently, even if that meant me missing going to the football). January, 2012, saw a major event in my life. I was in the middle of yet another admission and I had just transferred from intensive care to the high dependency unit when I began to feel even more unwell. I was really struggling to breathe, I had severe chest tightness and pain, and my observations were dropping alarmingly. It was a staff shift change, and the oncoming nurse wasn’t too worried and put my current condition down to my asthma and possibly some anxiety; the nurse who was going off shift disagreed and had a hunch that I might have a pulmonary embolism. She managed to get in touch with my consultant who agreed that it was a possibility. It turned out that it was indeed a pulmonary embolism. I was later told that it was serious, and had it not been spotted at that time, it could’ve killed me. The nurse who spotted it still works in the same high dependency unit now, and we still see each other regularly and talk about that day. Over the next few years, my health didn’t particularly improve. My admissions were longer and more frequent, I was spending most of the winter months in hospital and things weren’t great. At times, my life was on complete hold. Despite this, I did feel more knowledgeable about my condition. I felt confident that we had a plan to deal with things and we were always looking at alternatives to my treatment. I was referred to a professor in Sheffield for a second opinion and to see if there was any other treatment available; he was great, and between the professor, my consultant, and myself, we continued to explore ways of improving my asthma. I had more tests done and was told that my asthma was “very brittle” and “severe”. I began a biological treatment called Xolair (omalizumab) which is sometimes prescribed for severe asthmatics and often helps where there is an allergic response to an asthma trigger. I was given a non-invasive ventilator to use at home and despite everything I was happy with the support that I was receiving. Along with the non-invasive ventilator and the biological injections, I was prescribed a nebuliser at home. I was also taking three different inhalers, long-term steroids (which led to weight gain and steroid-induced diabetes), and a cocktail of tablets, which often exceeded 50 per day. Things changed for me a couple of years ago. My consultant suddenly left her position at the hospital as did a couple of other members of the respiratory team. Since then, I feel that my treatment and support is not where it should be. I have had nine hospital admissions in the past 2 years and my health has deteriorated. I have had to stop my biological treatment due to suffering some pretty bad side effects, such as serum sickness, which is basically an allergic reaction, and in my case resulted in dizziness, violent headaches, and shortness of breath. I have had only one outpatient appointment in that time and seven further appointments cancelled. I couldn’t even tell you who my consultant is anymore. My positivity about dealing with my health has declined and having no real plan going forward is not helping matters. I don’t intend to be critical of the National Health Service or of my care, after all it can’t be easy when half of a respiratory department leave virtually overnight, and then within a few months are dealing with the COVID-19 pandemic. Whenever I have spoken to the respiratory nurses, they have been very supportive and my care and treatment during admissions has remained at a high standard. I feel that, from a confidence and a mental perspective, it is crucial to have a good relationship with your consultant. Hopefully, once things get back to normal, I can build that relationship with my new consultant. I should have an opportunity to do this over the coming weeks, as I now have an outpatient appointment booked. The fact that I had such a good relationship with my previous consultant has definitely helped, and even though things aren’t quite perfect for me at the minute, I do feel as though I have enough understanding of my condition and what I need to do to at least keep going. We worked together as a team—it was a two-way street, and we both worked hard to develop my understanding of my asthma. As she often told me, I am the real expert when it comes to my asthma. I know how I feel, and I usually know when to seek medical advice. This is important, as you can’t always rely on your consultant. Yes, there is always emergency support available, but if you are in the middle of an asthma flare up, it is important to know what to do and what works for you. That is why I always carry that information with me, including my medication details, general health details, and what works for me in the middle of an attack. The information, which is printed on a small laminated card, also gives information on my symptoms and my usual peak flow and SpO2 levels. On many occasions, having this information has been really helpful and has saved time when in the ED, especially when I am struggling to talk. If I could give one bit of advice to any asthmatic, it would be to work closely with their health-care professionals to learn about their asthma, to understand it, and to develop a plan. A lot of that requires a good respiratory team, but ultimately it needs commitment from the patient as well. More options for managing severe asthma in adultsPersonalised medicine for various diseases including asthma has been advocated for decades. Although the initial focus on β2-adrenoceptor genotypes proved to be impractical and largely failed,1 the focus on type-2 (T2) airway inflammation biomarkers has had more success, particularly with high-cost biologics (eg, interleukin[IL]-4, IL-5, and IL-13 inhibitors); however, many questions remain.2 Two novel, well-conducted, randomised controlled trials3,4 have assessed whether incorporation of T2 biomarkers might provide clinicians with more options when managing adults with uncontrolled or severe asthma without the use of biologics. Full-Text PDF Open AccessInhaled corticosteroids and COVID-19-related mortality: confounding or clarifying?Inhaled corticosteroids (ICSs) are the mainstay of anti-inflammatory therapy for asthma and chronic obstructive pulmonary disease (COPD).1,2 Studies have shown worse outcomes in patients with COVID-19 who have been admitted to hospital and have comorbidities including chronic lung diseases.3–5 Whether ICSs protect against COVID-19 or contribute to worse outcomes from COVID-19 has been debated.6,7 ICS use might reduce antiviral immunity and increase the frequency of pneumonia in patients with COPD. Full-Text PDF Open AccessProstaglandin D2: the end of a story or just the beginning?Tremendous progress has been made in the treatment of asthma over the past decade. The development of monoclonal antibodies against IgE, interleukin-5 (IL-5) or its receptor, or the IL-4 receptor in particular has been a game changer, for a selected group of patients. These biologics all target the allergic or type 2 side of the spectrum of asthma, but even within the severe allergic or type 2 high asthma population these drugs do not completely prevent exacerbations, reducing their frequency by around 40–60%. Full-Text PDF Reflecting on World Asthma Day in the era of COVID-19On May 2, 2020, World Asthma Day will again focus on the needs of people with asthma across the globe. Previous themes have included managing asthma and living with the disease. These themes resonate more than ever this year, as any discussions are likely to be dominated by current debates in relation to the coronavirus disease 2019 (COVID-19) pandemic and its effects on asthma care and management. Full-Text PDF Risk of COVID-19-related death among patients with chronic obstructive pulmonary disease or asthma prescribed inhaled corticosteroids: an observational cohort study using the OpenSAFELY platformOur results do not support a major role for regular ICS use in protecting against COVID-19-related death among people with asthma or COPD. Observed increased risks of COVID-19-related death can be plausibly explained by unmeasured confounding due to disease severity. Full-Text PDF Open Access