GP focus with Dr Pat Haslam

Our GPs are an important part of Bay Health Care Partners and here our GPs and primary care colleagues have the opportunity to talk about issues and specialties that they are working on or interested in.

This month Dr Pat Haslam, a local GP and Clinical Lead for Morecambe Bay Respiratory Network, goes through top tips for winter for colleagues treating people with respiratory conditions. You can download a PDF version of the top tips here.

Five top tips for Preparing for winter

1. Prioritise reviews for high-risk patients

The Morecambe Bay Respiratory Network (MBRN) has developed searches to help identify those patients on Chronic Obstructive Pulmonary Disease (COPD) and Asthma registers who are at high risk of deterioration. You can find the search on the PRIMIS section of population health reporting in EMIS under ‘MBRN High-Risk Respiratory’.

2. Self-care support

It’s never been more important to encourage good self-care for patients. Key messages should include:

·         check out the British Lung Foundation https://www.blf.org.uk/ and Asthma UK websites https://www.asthma.org.uk/ which have brilliant advice

·         avoid triggers

·         ensure action plans are reviewed and relevant

·         good hydration and nutrition are essential.

3. Encourage vaccinations

This is such an easy win. It’s really important to encourage flu and Pneumococcal vaccines in adults and flu vaccines in children 12 and over with chronic conditions such as Asthma.

4. Rescue Packs

When Rescue Packs are used appropriately and in the right patient are very useful. It doesn’t mean the patient shouldn’t come in for review. Rescue Packs are not suitable for patients with Asthma and in COPD not everyone needs steroids (see below for more information)

5. Inhaler technique

This is a perennial problem and evidence shows most patients, most of the time have critical errors in technique. Evidence also shows that technique gets worse four weeks after being taught. The Asthma UK website has some excellent videos which could be shared with patients https://www.asthma.org.uk/advice/inhaler-videos/

Five top tips for treating exacerbations:

1. Bronchiectasis Exacerbations

Patients with Bronchiectasis require 10-14 days of antibiotics (not just five to seven days). Sputum microscopy, culture and susceptibility (MC&S) is essential and it can help patients to have a supply of yellow top pots at home.

2. Sputum, sputum, sputum

Patients with Bronchiectasis, Asthma and COPD can all have symptoms and increased infection risk due to mucous plugging. Good hydration is essential as cilia function is reduced in the dehydrated state. Carbocisteine and hypertonic saline (via respiratory nurses) is helpful.

3. Increasing Inhaled Corticosteroids (ICS) in Asthma

Patients who double (or more) their usual ICS prevent dose at the onset of symptoms can avoid further deterioration and requirement for oral steroids. More and more evidence is emerging to support this strategy.

4. Chronic Obstructive Pulmonary Disease (COPD) exacerbations

Most exacerbations are triggered by viruses. Early antibiotics (as per guidelines) are important where bacterial infection is suspected. Not all patients require, or benefit, from oral steroids. Consider in those with previous asthma or atopy, good prior response to steroids or on ICS inhaler.

5. Follow up

The most important tip. Exacerbations are key events that should be followed up. Follow up is an opportunity to do the annual review, address the issues which led to the exacerbation and look to escalate treatment when indicated.

Three top tips for Respiratory Syncytial Virus and Bronchiolitis in Infants:

1. Don’t pass the baby around

This can be a difficult conversation but it is a key message paediatricians are trying to get out. Reducing the risk of transmission of viral respiratory infections is essential. Passing the baby around multiple family members can increase the risk of RVS transmission.

2. NICE traffic light guidance

Such a great resource to risk-stratify patients. Green and amber patients can be safely managed in the community with support and early review. NICE guidance can be found here.

3. Supportive care

Inhaled therapy, oral steroids and antibiotics are not indicated in the vast majority of patients. Supportive care with fluids, review and safety netting is key.