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5029200-93345RESPIRATORY MANAGED CLINICAL NETWORKLead Clinician – Dave AndersonDavid.Anderson@ggc.scot.nhs.ukMCN Co-ordinator – Alan FosterAlan.foster@ggc.scot.nhs.co.ukRespiratory MCN website :-?NHSGGC : Respiratory MCNRespiratory MCN twitter:- NHSGGC Respiratory MCN @respiratorymcn Respiratory MCN instructions in relation to COVID pandemic April 2020Guidance for community management of acute asthma exacerbationsBackground: For the majority of asthmatics there is no evidence that they are at higher risk of contracting COVID19 disease nor that the severity of disease is likely to be worse. That is, usually asthma does not predict severity of COVID disease. However all asthmatics are at risk from viral respiratory infections and can experience more prolonged viral courses and deterioration of normal asthma control with viral infections. Priority for asthmatics in the community is to restrict exposure to COVID19 while managing exacerbations promptly and safely, recognising when hospital referral is necessary. Most patients who die of asthma have chronically severe asthma however for a minority thefatal attack occurred suddenly in a patient with mild or moderately severe background disease. The main lessons of a series of national and regional reviews of asthma deaths are that failure to:Recognise severity by patients and health care workers Use objective evidence in assessment of asthma (Resp Rate, Peak flow, O2 Sat, Pulse Rate, BP)Manage exacerbations and deteriorating asthma with corticosteroids Prevent over-use of short acting beta-agonists Lead to increased asthma deaths. Patients with severe asthma are likely to be at higher risk of COVID19 and they need to be treated with extra-caution. We would define those as those patients: on advanced asthma therapies – high dose inhaled corticosteroid (see below) and biological therapies; those with greater than 2 courses of supplemental corticosteroid over the course of the previous 12 months and anyone admitted to hospital for their asthma in the previous 12 months. These patients are at particular risk and a low bar for early intervention and referral to hospital is appropriate. Principles Managing Acute Asthma In the community During the COVID epidemic:Assess the patient’s risk status – high risk or normal risk, using the severity indicators listed aboveAssess the symptoms: Is this a presentation of COVID19 – particularly fever, headache, dry cough (more than 2 days)Is this an exacerbation of asthma – worsening wheeze, breathlessness, exercise intoleranceAssess severity of asthma using objective measurements:Peak flow – ask the patient to measure peak flow in a separate room or at a distance. Peak flow measurement is not an aerosol generating procedure, but in some patients with bronchospasm it will induce coughing.Pulse rate, respiratory rate and BPDecide on disposal – If COVID in asthma patient follow COVID pathwayIf Asthma exacerbation – mild – moderate asthma in normal risk patient – home or referral to Community Respiratory Response TeamMild asthma in severe asthma – home with worsening advice or referral to Community Respiratory Response TeamModerate asthma in severe asthma – consider referral to hospitalSevere asthma in normal or high risk – refer to hospitalIndicators of severity of asthma Peak flow ≤ 50% recent bestHeart rate ≥ 110Respiratory Rate ≥ 25High Dose Inhaled Corticosteroid dose1,200 micrograms per day or higher beclamethasone 600 micrograms per day or higher fluticasone 1,000 micrograms per day or higher Beclamethasone diporprionateIe:Clenil 200 x 3 puffs BDBudesonide (symbicort) 400 x 2 puffs BDSEretide 250 x 2 puffs BDRelvar – 184 doseFostair – 200 x 2 puffs BDAdvanced asthma therapiesAny biological therapy (Bendralizumab, omalizumab or mepolizumab)Regular (daily) Oral corticosteroid (prednisolone or hydrocortisone)Immunosuppressive therapy – methotrexate, azothioprine, Dr David AndersonRespiratory ConsultantRespiratory MCN lead clinician ................
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