Mark:
Please give us a little background on yourself, your education, experience and your current responsibilities.
Dermot:
My name is Dermot Ryan I qualified at University College Dublin back in 1977 and did my primary care training in Ireland. I travelled around a little bit and eventually ended up in England in a partnership as a General Practitioner in 1984. I developed an interest in asthma around 1985 which has been one of the central things of my professional career. I’ve always been a General Practitioner, I’m not an academic just a real-life GP or primary care physician or family physician, its name changes from country to country. In the UK, GPs look after people from the minute they are born, to the minute they die. We look after children, adults and the elderly as well. Currently, I retired from General Practice a couple of years ago, but I came back to work because of the COVID epidemic. My work now is in the vaccination centres.
Mark:
Why don’t you tell us about the Respiratory Effectiveness Group and who makes up this group?
Dermot:
This group is a group set up by a bunch of interested permissions who work around the world. It’s a global not-for-profit organization. It is a collaboration of Clinicians, Scientists and Epidemiologists working together to identify and fulfil real-life research needs in respiratory medicine and advocating for change to drive and improve patient management. Real life differs from the fantasy world (I use those words advisedly) of guidelines which are drawn from highly controlled clinical trials and the findings may not always be applicable in ordinary everyday practice. They do of course become the foundation of our guidelines and are a very important part of the evidence base. We need to translate the evidence base into the environment in which we work.
Primary care patients are considerably different to those seen in secondary care and very much different from those who are seen by clinicians in tertiary care. Although we will have people from all those groups within primary care. For example, guidelines really meet the needs of people who fall in the middle. If you look at a bell-shaped population curve, they’d meet the needs of the people falling between 45 and 55% of the median. However, the vast majority of people fall outside of that. It’s about trying to use the true meaning of evidence-based medicine using the guidelines to meet the needs of the individual patient using your clinical expertise and the resources available to you, as I said there are people from around the world from the States, from Canada, from Asia, from Europe working together to try and achieve this.
We have done some very good stuff. We have identified a core data state for asthma / COPD studies that are known as ‘Torpedo’. We looked at the match plasma childhood real-life comparative studies to the addition of antibiotics. They imagined asthma exacerbations in primary care by looking at the point of care, biomarkers and asset management. Which of course is quite important, particularly in the tertiary care environment. We made a manifesto concerning the use of real-life evidence in guidelines which is published in the European Respiratory Journal a couple of years ago.
Janson:
I know that you are part of the International Primary Care Respiratory Group. Can you give me more information about that?
Dermot:
With pleasure. The International Primary Care Respiratory Group was founded at the annual scientific meeting of the Primary Care and Respiratory Society in Cambridge in 2000. It held its first international meeting in Amsterdam in 2002. It has a scientific meeting every two years and a research meeting in the years which you take those two years.
It’s made up of Primary Care Respiratory interest groups from about 35 nations across the world. From wealthy nations and from lower and middle-income countries. It reaches about 150,000 physicians and it shares its journal with the Primary Care Respiratory Society, the Primary Care Respiratory Medicine is published by MPJ.
The MPJ was at the primary care respiratory medicine was founded to publish evidence generated within primary care. This is an area which doesn’t necessarily appear very often is in specialist journals like the Blue Journal or the Journal of Allergy and Clinical Immunology or the European Respiratory Journal Thorax. It was very important to have a showcase for the research done within primary care to meet the needs of those patients and doctors who work and who attend primary care.
Janson:
What are their goals and how have they effectively improved patient care?
Dermot:
The goals are to improve patient care (this is the IPCRG) and there have been some very active programs in low- and middle-income countries to help improve care. Particularly programs looking at reducing domestic smoke within the house.
In many countries in the world, fuels are used within the home, for example not used with a hole in the roof or a chimney. Even something as basic as a hole, so mothers and children are not breathing in fumes the whole time, it impairs their respiratory function. It started off in Uganda and is now being rolled out in other countries.
We have also looked at ways of trying to improve respiratory function tests in lower-middle countries. We have looked at sourcing less expensive Spirometry. Even some simple things like peak flow meters and try to moderate guidelines as they currently stand to meet the needs of the population. Working in those countries, some people might say is dumbing down but on the other hand, it’s better to have something on the ground which makes for a more accurate diagnosis and therefore, more direct treatment than having no guidance or no idea of how to proceed at all.
Janson:
I agree 100% on that. Especially in making sure that we get almost every patient out there or potential patient out there seen. A lot of times in third-world countries you don’t have the means to even do a basic assessment. Having a peak flow meter at least gives you a quick snapshot or a monitor to exacerbate or move them on to doing a spirometry slash full pulmonary function testing.
Dermot:
Of course, we also recognize very clearly that the respiratory needs of the primary care physician vary enormously from country to country. In the United Kingdom, we don’t have much tuberculosis. I would have seen in practice one new case a year. That’s an awful lot more than most GPs, but I live in an area with a high number of immigrants.
I was talking about this with some colleagues from Pakistan and they said we see two or three new cases of TB every day.
Their needs are considerably different. Their viewpoint is skewed compared to ours because their needs are so very different. Of course, community-acquired pneumonia is also very common in low-income countries. Particularly amongst children and it’s real killer disease.
Janson:
It is amazing we don’t see anything like that here. A lot of healthcare workers do the annual TB testing. Seeing one a year is a lot in our eyes but then seeing one or two a day I can’t even imagine the risk associated with it alone. Moving on, what are some of the problems with the diagnosis of asthma within primary care?
Dermot:
I think the biggest problem with making a diagnosis of asthma in primary care is the feeling that you must make a diagnosis straight away. Of course, is not the case. Diagnosis needs to be made over a period of maybe over three or four consultations. Sometimes it’s obvious when a patient comes in that the diagnosis is asthma but really the diagnosis needs to be considered a professional diagnosis until you’ve proved it. One of the problems with asthma is there is no complete picture of what somebody with asthma looks like. If you think about a picture and break it up into little pieces like a jigsaw, then you must put together those pieces of the jigsaw in order to try and get a fair idea of what the big picture is. Central to that is the need to demonstrate in my opinion. Either airway variability or reversibility.
One of the big problems is that, oftentimes tests are done on patients when they are asymptomatic or clinically stable. In which case, unless you’re doing provocation testing the tests will be negative giving a misleading reassurance there is nothing going on here. We need to look at the picture, we need to look at the actual symptoms the patient has at the time, when they come to see you, how long they’ve lasted, how they vary, what brings them on and so forth. We need to think about the family history and whether there’s anything relevant in that first degree. Relatives with asthma or a personal history of eczema for example; need to think about occupational factors. About 10% of adults have occupational asthma and some people have akin to occupational asthma hobbies that reduce asthma. When you think about what they are doing in their personal life which might be causing these symptoms. We need to think about what medications are taking in case they are causing the problem. We need to think about comorbidities they may have and in particular, rhinitis. Be it allergic or nonallergic rhinitis, because both impact asthma makes it more likely the patient has got asthma. Having rhinitis doesn’t mean you’re going to have asthma and we need to think about what biomarkers are available to help put together the picture. Having how high a synovial count is not for example a biomarker for asthma. If you have a higher accentual count in the presence of other features suggesting asthma. Then it may very well be helpful.
We need to think also in terms of what is found in clinical examination. One of the things which I find very distressing, and I have observed it very frequently, is the number of times a clinician examines a patient with their clothes on. They are listening to the chest through a shirt or through a blouse, which means they’re not really listening to the chest. They are pretending to do something. They are going through the motions so the examination which should include pulse rate, which should include respiratory rate, which should include examination of the chest and if possible, at least at peak flow reading needs to be done properly. I think many examinations are not done properly. We know that in primary care spirometry is a problem. Successive studies from the United Kingdom and the Netherlands had demonstrated that only about 30% of primary care clinics do spirometry to a decent standard. As opposed to 60 to 70% of the hospital setting. Even in hospitals spirometry is always of a high standard and that can be very misleading. Whether you talk about asthma or COPD so it’s not just about having the equipment it’s knowing how to use it. It is knowing how to do the test properly and it’s known how to interpret the test when it is done.
Janson:
At the very beginning of that portion and you talked about always needing a diagnosis first time meeting with the patient. Here in the States, somebody goes to the doctor because they are sick, and they want to know why, right now. That is just kind of the US eccentric way of life. You need to know the answers right now but as we know in our field it can take weeks of testing just to verify something. Whether it’s oncology or whether it’s with respiratory, that’s why I feel like trending data is fantastic for a patient that is just recently diagnosed with asthma. Your trend that data the next 30, 60, 90 days, how they are doing with their inhaler, which leads me on to you know why is asthma over-diagnosed?
That is huge. I think it’s one of those big things. The markers check and I can’t uncheck them. I’m just going to go ahead and say you have asthma – in your mind why do you think asthma is overdiagnosed?
Dermot:
One of the big culprits is cough. Certainly, we’re seeing it in many practices in the United Kingdom. Somebody comes in with a chronic cough and is diagnosed as having asthma just because of it. No wheezing, no other symptoms just cough. Of course, Gastroenterologists see this as well. Patients with cough and put it down to reflux and patients are given PPI. That doesn’t particularly benefit them either.
Cough, in isolation is rarely an indicator of asthma. Cough however in association with shortness of breath on exertion or night cough or night cough with wheezing or cough with a tight chest. When you add those things into the mix you increase the probability of the person having asthma. Again, that can’t be confirmed unless you demonstrate airway variability or reversibility.
Another big factor is dysfunctional breathing. We’ve all probably suffered from dysfunctional breathing at some time. You’re driving along a motorway and you might be a little bit above the speed limit for example and you see some blue lights in your rearview mirror and your chest goes tight and you feel a bit short of breath. Well, that’s not asthma, clearly, that’s you worried in case you’re going to get a speeding fine. There are times when we are all a bit provoked, and we may feel a bit short of breath or a bit tight chest, or feel our heart beating a bit more quickly, but this is due to momentary anxiety.
Similarly, there are many people working in jobs which cause them to speak rapidly, and loudly over a protracted period, maybe under time pressure, and they often feel short of breath. The big thing is you ask them what did they mean when they felt short of breath. Is the difficulty getting the air in or getting the air out? Invariably they answered that the problem is breathing in and that’s partly because they hold themselves in, in the degree of hyper expansion. They find it difficult to get air in as would somebody with an acute severe asthma attack. Observing the patient in the consultation, looking at how they talk, looking at how they breathe during the consultation, observing their neck muscles and looking at their other behavior. These are all clues that can be employed to determine whether the patient is more likely got some form of dysfunctional breathing or whether they’re really this really is symptomatic of asthma.
Of course, the problem is the two things can coexist. As always in medicine, nothing is 100% and that’s why you need to look at the whole jigsaw of what’s going on rather than one single thing in isolation.
Janson:
Why are there so many people being over diagnosed with asthma?
Dermot:
That’s a very big question. It is not just primary care it’s people in secondary care practice and tertiary care practice as well. If we look at the tertiary care, paper published by Liam Heaney in The Lancet in the early part of this century.
Liam runs a tertiary clinic in Belfast. 2/3 of his referrals come from secondary care clinicians. Very few get in directly through their primary care physician. It is a tertiary referral center. 30% of the patients referred don’t have asthma so they appear to have uncontrolled last night. They have got uncontrolled problems which people mistake as being asthma, but they haven’t got asthma. Again, this is where the overdiagnosis comes into place. Many people with uncontrolled asthma haven’t got asthma.
There was a paper by Sean Aaron and his colleagues from British Columbia in Canada reviewing people who had a diagnosis in the last few years. It was found that about 30% of those didn’t have asthma, and many of them had just simple rhinitis. Equally many of them had no pathology at all. Overdiagnosis is very important.
The second big thing I think is the inhaler technique. Most doctors and nurses, and there are a multitude of studies from across the globe which demonstrate this, don’t know how to use an inhaler. If they don’t know how to use an inhaler properly, they can neither teach the patient how to use it nor check the inhaler technique. They don’t know the steps which are involved and point out where the fault is. When you have patients coming in, having seen another physician, and you ask them to show you how to use their inhaler. They stick the inhaler in their mouth with the caps still on you know you have got a fundamental problem. A further factor is that many patients are on a mixture of dry powder inhalers and metered dose inhalers. These are two different types of an inhaler with fundamentally different inhaler techniques. The patients have difficulty, as healthcare professionals do, in recognizing which technique is for which device. They haven’t been properly taught and so they may be using their inhalers regularly but getting little or no benefit from the use. Certainly, may not be getting anywhere near the intended dose for the patient. That in itself means the patient finds that the medication doesn’t work, and they stop using the inhaler.
Adherence is a problem partly because they think it doesn’t work. There are other reasons behind faulty adherence and that’s a failure of the clinicians to educate the patients and the benefit of the treatment that they have been prescribed and the importance of taking it every day or nearly every day. Some people clearly with seasonal allergic asthma. They only need to take their medication for maybe six weeks or three months during a year and can have medication holidays at the times when the pollens which are causing their problems aren’t around. By and large, the patient needs to understand and feel that they should take their medication every day if possible. Patient beliefs clearly enter this as well.
Beliefs are things which sometimes can be found difficult to change. With a careful caring, rational explanation you can win most patients around, most of the time. Those are some of the reasons why patients remain uncontrolled.
Janson:
Here at Vitalograph, we preach the educational side of aerosol inhalation monitoring. We have a product called the ‘Aim’. It basically trains the patient how to utilize either MDI, DPI or a spacer. Ensuring they are accurately getting the proper medication that they need. I have been all around the States preaching and teaching effective use. Utilizing 50% of the medication is not designed to make sure that those patients are getting everything that they need when they need it.
Moving on to primary care, for those patients that you have diagnosed with asthma or any other respiratory lung disease or ailment, referring those over to specialty care, what is your process? How can we increase those referrals?
Dermot:
There aren’t really any guidelines or statements which tell us when we need to refer. If there is diagnostic doubt, the patient should be referred for a second opinion to see what is going on. A GP doesn’t know everything about everything, we’d like to think we do but the reality is that we do not. If you are unable to make a diagnosis, there is no shame in asking a specialist for help in getting to make that diagnosis. What we see is patients being uncontrolled and judged by either continuation of symptoms. Somebody has symptoms most days of the week, are using their reliever inhaler most days of the week and are patients who are waking at night or whose social life is impaired because of their respiratory symptoms. One of the things we do tend to do is to escalate the dose of their medication. We give more and more medication without checking first that the diagnosis is correct.
We are not going to get it right all the time. However, checking if the diagnosis is correct is very important because inhaled corticosteroids do not really work for dysfunctional breathing. Check if the diagnosis is correct and check if the inhalation technique is correct. People say this takes time and it does take a bit of time. It also gives quite a bit of amusement to the day because some of the things that people do with their inhalation inhalers are just phenomenal. From spraying your medication onto your sandwiches to take to work so you get your afternoon dose, to putting the whole inhaler in your mouth and trying to actuate it. It is worth watching people do it because there is often so much to correct. It will give you a great batch of stories to tell when you’re talking to other people about the inhaler technique. The inhaler technique is critical. Check the patient’s understanding of what they are doing and why they’re doing it. Check their motivation, check they are not smoking still, try and adjust other things. For example, many people think their asthma is out of control because they’re short of breath and they may well be short of breath on exertion. However, there may also be completely deconditioned, and it would be normal for somebody who is deconditioned to be short of breath if they’re obese that’s going to have an impact on their asthma control.
We see in study after study after study that people whose asthma is uncontrolled the heavier, they are, the less likely they are to gain control over their asthma. What I’m saying is, look at other things in their life and lifestyle. Their life may be contributing to their symptomatology as opposed to their asthma. We know that for many people taking more than 800 micrograms of budesonide or beclomethasone, or 500 micrograms of fluticasone doesn’t generally cause any great improvement in their symptoms. You are reaching the top of the dose-response curve so escalating patients up to 1600 micrograms or 2000 micrograms or 1000 micrograms of fluticasone a day probably isn’t in the patient’s best interests. You have done everything that you need to do in terms of checking their smoking, their inhaler technique, their adherence to medication, their coexisting factors like rhinitis and controlling those. You have done everything you can do after a series of reviews. If you cannot get the patient under control well then maybe that is a time to send somebody off to see a specialist for further evaluation, they have got all sorts of gizmos and gadgets that we have not got. It can take an expert view of what is going on rather than the relatively amateur view that we might have in primary care.
Mark:
Switching gears what are your concerns about the new COVID variants, and what’s happening over in the UK? We see a lot higher levels of testing and people getting this variance that has now reared its ugly head.
Dermot:
The numbers have certainly gone up in the UK and have done in many other European countries. I am looking at the app here, and it reckons there are four and a half million active cases today, by ZOE Health Study App, which is quite a large number. However, in the last week hospitalizations for COVID is falling. Most people that I know now have had COVID at least once, if not more than once, and for most people who have been vaccinated or have had a previous attack of COVID, it is a relatively minor inconvenience. People are feeling unwell for a day or two and then feeling fine. After five or six days getting on with their lives, which I think is probably the right thing to do. However, there are people I believe who are taking great risks in not having their vaccinations. Of course, there are 101 reasons behind that. There is a massive anti-vax lobby, and this is built around beliefs. Unlike asthma, where you can change some of those beliefs, the people who believe that the vaccines are poisonous and are putting mic-bots into your bloodstream and tracking you from space and trying to alter those beliefs with rational conversation is very difficult. It is not until they get a severe infection that they start thinking I wish I had that vaccine after all. Most of the people who are going to hospitals in the United Kingdom currently remain those people who have been unvaccinated or who are otherwise at high risk. There are of course some people who have been vaccinated and who end up going to the hospital but it may be that they are the immunocompromised people who have escaped the beneficial effects of the vaccine.
We know that the new viruses appeared to escape some of the antibodies created by the vaccines but the impact that’s having on us now is really very small. I hope it stays that way.
Mark:
Dermot this has been a very fascinating and good insight into what’s happening over in the UK with the diagnosis of asthma and how primary care works in the UK. Is there anything else you would like to add to or say to our audience?
Dermot:
I would really like people to listen carefully to what I said about demonstrating airway variability or airway reversibility. I do not think we should be doing challenge tests in primary care. We probably haven’t got the expertise although there are safe challenge tests which can be done in primary care. For example, the mannitol challenge test but that’s very time consuming and in the context of many primary care clinicians in the world is not particularly helpful. However, serial peak flow readings can be very helpful in finding out what’s going on. Particularly if someone’s having night symptoms or you suspect an occupational reason. Asking people to do their peak flows at night, if they’re woken up, with coughing or wheezing can be very revealing. People with occupational asthma will have relief of their symptoms if they’re not going to work, for holidays for example or often just a release of symptoms over the weekends or over a bank holiday weekend when they’re no longer exposed to the allergen that’s causing that problem. Reversibility and variability are the key factors which I would urge people to look for when making the diagnosis of asthma. Once you have got that you can fairly well confirm it and probably won’t need to doubt the diagnosis. Again, even a diagnosis of asthma is not 100% we’ve all made mistakes including my colleagues in secondary care, because for a variety of reasons. Particularly things which are very unusual and so you need to be prepared not to worry about yourself making those mistakes. As long as you’ve demonstrated that you have done everything you possibly can do in order to try and ensure that those mistakes aren’t made or that the diagnosis is correct.
Mark:
Dermot this has been great good information and a different perspective from what you guys are dealing with over there in the UK. I really appreciate you being on our program today.
Dermot:
Thank you very much for asking me, I hope that your listeners find it helpful. If you’re in primary care, you can look at the International Primary Care Respiratory Group website and if you are interested in real-life evidence then the Respiratory Effectiveness Group website is perhaps somewhere you would like to look at as well.
