Severe asthma experts are advocating for a change in OCS treatment norms for patients with more severe forms of the condition.

Oral corticosteroids (OCS) are anti-inflammatory medicines used to treat a range of conditions including asthma. Most people with asthma manage their symptoms with inhalers. Severe asthma is a condition that is inadequately controlled by inhalers, so regular courses of OCS tablets are often used to treat a severe asthma attack.   

Dr Andrew Whittamore, GP with a respiratory interest, explains:

Consequences of OCS treatment for asthma 

Increasingly, specialists are questioning the wide use of OCS in patients with severe asthma. A report called ‘Do No Harm’ by Asthma and Lung UK, a charity fighting to transform lung health, states: “These tablets can stop the symptoms, but they have devastating side effects in the short and long term on physical and mental health — from suicidal thoughts and insomnia to diabetes and kidney damage.”  

An additional study suggests that people on regular OCS treatment are three times more likely to suffer from osteoporosis/osteoporotic fractures; more than twice as likely to suffer from pneumonia; and have a 1.34-fold greater risk of death. 

5–10% of the UK asthma population is estimated to have severe asthma — equivalent to approximately 200,000 children and adults. However, the cost of treating these patients is four times higher than general asthma patients, driven by the cost of treating the side effects of OCS.

Listening to the patient experience 

Patients say that the cumulative negative outcomes of long-term OCS use are rarely discussed, and healthcare professionals often prescribe a course of OCS to manage an acute asthma attack without an objective, in-person review.

Val, a patient who shared their firsthand experience at a recent GSK summit on OCS use, says: “No GP or hospital physician ever informed me I would get debilitating side effects from OCS use. I was hesitant to ask questions of my healthcare professionals and eventually found out myself from other people in the community, my work with Asthma and Lung UK and self-education from podcasts. I wish I had known.” 

How can we improve treatment for patients? 

There needs to be a two-pronged approach. Firstly, identification and referral to specialist centres need to improve. Dr Katherine Hickman, GP and Executive Chair of the Primary Care Respiratory Society, believes that patients who have had an acute asthma attack which resulted in OCS being prescribed should routinely be followed up with a GP review to assess the cause of the asthma attack and if any further management is needed.  

Current guidelines indicate that patients with suspected severe asthma, or those requiring two or more courses of OCS within 12 months, should be referred to a specialist centre for assessment — but experts acknowledge this rarely happens.  

Secondly, specialists agree that better education among healthcare professionals about the side effects of inappropriate OCS use is needed. This can be coupled with patient education about the side effects of OCS to empower patients to self-advocate. 

Focusing on alternative treatments for severe asthma 

Prof Liam Heaney, Professor of Respiratory Medicine, concludes:

NP-GB-ASU-OGM-230002 I June 2023

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Cystic fibrosis (CF) is an inherited genetic condition that affects over 10,900 people in the UK. The condition is caused by a faulty gene which controls the movement of salt and water in and out of your cells.

Cystic fibrosis affects many organs and tissues within the body including the lungs, which become clogged with thick, sticky mucus, making it hard to breathe and clear away infection-causing bugs and particulates in the air.

People with cystic fibrosis are extremely vulnerable to lung infections, which can be hard to treat, hard to detect and resistant to antimicrobial medicines. These infections can be picked up from the environment or by coming into contact with other people with the condition. While these infection-causing bugs are usually harmless to people who don’t have CF, they can cause permanent lung damage for those who do.

Living with long-term lung infections

The bacterium Pseudomonas aeruginosa (P. aeruginosa) causes serious, long-term infections in the lungs of some people with CF. The bacterium is found in many natural and domestic environments including plants, soils and surface water — especially warm, moist environments. Environments such as hydrotherapy pools and jacuzzis have been reported as a risk for people with cystic fibrosis.

Within the lungs of people with CF, P.aeruginosa infection can sometimes be kept under control by antibiotics. However, if it takes root, it can become resistant to antibiotics and cause serious problems.

People with cystic fibrosis are extremely vulnerable to lung infections, which can be hard to treat, hard to detect and resistant to antimicrobial medicines.

Candice King, involvement manager at Cystic Fibrosis Trust, shares her thoughts and experience living with the condition: “Having chronic pseudomonas lung infections means that, over the years, I’ve exhausted a number of antibiotics. Despite advances being made with modulator drugs — meaning many people with CF are living healthier lives — there are still plenty of people who can’t benefit from these, and lung infections can still cause serious lung damage. It’s important that research continues to make new advances and ensures everyone with CF can live a life unlimited.”

What are we doing about it?

Cystic Fibrosis Trustis funding several multidisciplinary research programmes to investigate how P. aeruginosa becomes so well adapted to live in the lungs of people with CF. With this knowledge, we hope researchers in the future will be able to develop better ways to detect and treat it. Research also is taking place to investigate the impact of pollution and air quality on the lungs of people with cystic fibrosis and their risk of infection.

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This year’s Clean Air Day theme — ‘Clean up our air to look after your mind’ — highlights the growing evidence that air pollution can impact mental and brain health.

Air pollution is the biggest environmental threat to our health, no matter who you are or where you live. Air pollution affects you from your first breath to your last, as the damage to our health can start in the womb and carry on through into old age.

Air pollution damages overall health

There is no safe level of air pollution, and the health effects of air pollution are complex. It increases the risk of many health conditions and makes some existing health problems worse. Individuals with heart and lung disease, children and the elderly are particularly vulnerable. 

The relationship between air pollution and our health has been studied for decades. While the physical health impacts of air pollution — such as asthma, heart disease and cancers — are well documented, more researchers are beginning to understand how air pollution can affect the brain and the mind. 

The Government and industries need to make
decisions that improve air quality for everyone

Link between air pollution and cognitive conditions 

People who breathe polluted air are more likely to develop mental health and brain problems than those who breathe clean air. Research shows that there is an association between air pollution and conditions including schizophrenia, depression, anxiety and mood disorders. It also leads to a more rapid decline in cognitive function, including an increased risk of developing dementia. 

One of the main culprits is particulate matter (PM). They are tiny pieces of solid or liquid substances that are inhaled as people breathe. When we breathe polluted air, these small pollution particles can enter through our lungs, into our bloodstream and reach the brain. It can cause inflammation and change the chemistry of our brain, negatively impacting our mental health. 

Taking steps to clear the air

By taking clean air actions, like driving less, we not only protect our mental and brain health but also benefit our wider physical health and the environment around us. However, we can’t do it alone — the Government and industries need to make decisions that improve air quality for everyone. We must use our voices to fight for cleaner air.

This Clean Air Day, we can all take simple steps to build a clean air future together — to protect our mental, physical and planet’s health. Any reductions in air pollution that we make can benefit our health and the local community.

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A significant proportion of respiratory care and diagnosis is undertaken by qualified specialist nurses and other healthcare professionals. This allows for more streamlined care management.

Respiratory conditions account for the majority of appointments in general practice and a high proportion of hospital appointments.¹ A high level of further education and training allows specialist nurses and other healthcare professionals to investigate, diagnose and treat these conditions and discharge people from hospitals.²

Importance of diagnosis in respiratory care

Effective management starts with the correct diagnosis. We are seeing greater investment in supporting general practice to carry out the tests which have been shown to support the diagnostic process. 

Taking a robust history is key to making any diagnosis, but examination and tests can help to confirm whether the person with respiratory symptoms (cough, wheezing, breathlessness, sputum production) has asthma, chronic obstructive pulmonary disease (COPD) or another condition. 

These tests can include spirometry — which can identify abnormalities in airflow through the lungs — and fractional exhaled nitric oxide (FeNO) testing — which can demonstrate the presence of inflammation in the airways. Blood tests, X-rays and scans can also help to confirm or refute a suspected diagnosis.

Effective management starts
with the correct diagnosis.

Better diagnostic process with respiratory tests

Anyone carrying out diagnostic tests will have had specific training on how to carry out the test and/or interpret the result. The skill is to put together all the information — history, examination and objective tests — so that the clinician is confident that the diagnosis is correct. 

The pandemic led to the cessation of many of these tests as there was a risk of spreading airborne infections. However, the situation is gradually returning to normal, and many practices are offering these routinely once more. Information about the tests can be found from sources such as the Asthma + Lung UK website or through discussion with the clinical staff in the practice or hospital.

[1] GBD Chronic Respiratory Disease Collaborators (2020). Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. Respiratory medicine, 8(6), 585–596. https://doi.org/10.1016/S2213-2600(20)30105-3
[2] Patel I. (2021). Integrated respiratory care. Clinics in Integrated Care, 6, 100053. https://doi.org/10.1016/j.intcar.2021.100053

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One in five people in the UK will need treatment for a lung condition in their lifetime. Lung disease varies from asthma, one of the most prevalent medical conditions, to lung cancer, the biggest cancer killer.

Lung disease is associated consistently with breathlessness, a frightening and debilitating symptom, and is strongly linked to health inequality and deprivation, meaning the most deprived and vulnerable communities are most affected.

Healthcare for people with lung conditions in the UK

The British Thoracic Society (BTS) is an organisation of respiratory professionals who, throughout the four UK nations, are committed to improving the lives of people with lung disease. For years, respiratory specialists have published groundbreaking research and been at the forefront of innovation and improvement.

Lack of access to respiratory diagnostic tests is a key issue which prevents people from receiving an accurate, early diagnosis while the current extreme and intense pressure on primary care limits access further.

Respiratory specialists are already under
pressure to deliver new services.

Nationwide access to respiratory specialists

If a person with a lung condition is treated by a respiratory specialist, they are more likely to have the correct diagnosis, receive the right treatment and experience fewer symptoms. They are also less likely to need hospital admission.

To deliver this, we need to train people to fill vacant posts and then grow the respiratory workforce. Respiratory teams are multidisciplinary and include doctors (consultants and specialty trainees), nurses, allied health professionals and healthcare scientists. There are shortages in all these professions.

Furthermore, respiratory specialists are already under pressure to deliver new services. They increasingly work in integrated care teams to deliver ‘hospital at home’ care and support primary care. They are setting up and working in new virtual wards to enhance acute respiratory care at home.

Respiratory professionals are also managing the extended workload of the new Targeted Lung Health Checks, which screen high-risk people for early lung disease. All these initiatives will lead to better lung care. However, they have to be properly resourced, or they risk staff burning out and leaving the NHS.

Addressing the workforce shortage

In our 2022 Report, A Respiratory Workforce for the Future, BTS focuses on respiratory workforce shortage as our main challenge, and we work with organisations like Asthma + Lung UK and the Primary Care Respiratory Society to highlight this. Everyone has the right to live a normal life, free from the debilitating effects of lung disease. The only way to ensure this is to provide high-quality respiratory care underpinned by a planned and sustainable specialist workforce.

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The scale is dramatic: the health impacts of air pollution, such as breathlessness, can be devastating to people’s everyday lives.

Air pollution’s deadly toll on the nation’s health is illustrated in Professor Chris Whitty’s recent report, showing it contributes to up to 43,000 premature deaths in the UK a year.

Air pollution can cause life-threatening conditions

Toxic air causes new lung conditions and can also worsen the symptoms of those who already live with them. It can inflame the airways, causing coughing and the terrifying feeling of breathlessness as well as life-threatening flare-ups of conditions like asthma and chronic obstructive pulmonary disease (COPD).

In the most extreme circumstances, such as the case of Ella Adoo Kissi Debrah, exposure to high levels of dirty air can cause early death for people with lung conditions.

As one concerned London parent put it to me recently: “Dirty air is really affecting our family’s health — in particular, my daughter, whose asthma has been made worse by air pollution. There are days when the high levels of toxic air near her school mean she can’t do sports or play with her friends. It’s hard to explain to a child that the reason she can’t play outside is something as intrinsic to life as the air you breathe.”    

This is unacceptable. That’s why we at Asthma + Lung UK are calling for urgent and bold government action to clean up the air and tackle this public health emergency head-on.

It’s hard to explain to a child that the reason
she can’t play outside is something as
intrinsic to life as the air you breathe.

Government investment can promote clean air

Tackling a problem as fundamental as the air we breathe requires the kind of bold government action that, so far, has been lacking. Transport is key in the fight for clean air, and our new plan sets out the steps that must be taken to ensure we win that fight.

The Government must help the poorest communities and those living with health conditions — whose lives are often most blighted by dirty air — to switch to cleaner means of transport. This is about helping the most vulnerable in society to switch to cleaner modes of transport, including less-polluting cars and active travel options like walking and cycling.

More government investment will help give people the financial incentives to make that switch. With more awareness, government action and the right targeted investment, we can apply the emergency brake on air pollution and save countless lives.

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It is estimated that 2 million people are currently living with undiagnosed COPD in the UK. It is also the fifth leading cause of death in the UK and accounts for 30,000 deaths every year.

COPD is a chronic lung condition that can cause symptoms of cough, sputum, breathlessness and leads to reduced mobility. Unfortunately, COPD can remain undiagnosed for many years.  

Early diagnosis is crucial  

Getting a diagnosis as early as possible is essential, as this will have a direct impact on how the disease progresses and future health. It is important that we encourage people experiencing respiratory symptoms to seek advice from healthcare services and not to assume that the cardinal symptoms are to be expected, due to possible history of smoking, pollution exposure or aging.  

Health care professionals must remain vigilant and suspect COPD as a possible cause for respiratory symptoms and ask about associated risk factors for COPD. The National Institute Clinical Excellence (2019) and Global Initiative for Chronic Disease (2021) guidelines provide clarification.  

It is important that we encourage people experiencing respiratory symptoms to seek advice from healthcare services.

Increased investment needed  

COPD remains a poor relation to other conditions in reference to national recognition and prioritisation and that the need for early diagnosis and greater investment into prevention and management is crucial (NHS RightCare Pathway COPD).   

The National COPD Policy Action Plan was launched to coincide with World COPD Day in November 21. The document sets out specific actions to improve outcomes for people living with COPD in the UK, developed by specialists and leaders in COPD.  

There are three key ambitions for change:  

1: Accelerated early and accurate diagnosis 

2: Reduce clinical inertia and focus on prevention 

3: Minimise health inequality and variation in care 

The document invites health care professionals to unite to impact policy at national level by approaching Integrated Care Boards to impact policy at local level and work with colleagues to implement change at grass roots level. This approach aligns with the NHS Long Term Plan and is supported by Respiratory Taskforce groups. 

Tips for good management 

Once the patient has a diagnosis of COPD, it is important to discuss how to manage the condition and take proactive steps to prevent worsening symptoms. Here are some tips:  

• Take medication as it has been prescribed 
• Get inhaler technique checked by health care professional 
• Keep vaccinations up to date 

• Understanding what a good COPD day looks like, to enable recognition of a change in symptoms 
• Following agreed action plan 
• Eat well balanced and healthy meals 
• Stay active  
• Seek help to stop smoking if appropriate 

• Seek advice if worried or concerned about respiratory symptoms 

Recommended links

Overview | Chronic obstructive pulmonary disease in over 16s: diagnosis and management | Guidance | NICE 

Global Initiative for Chronic Obstructive Lung Disease – Global Initiative for Chronic Obstructive Lung Disease – GOLD (goldcopd.org) 

Asthma + Lung UK (blf.org.uk) 

National-COPD-Policy-Action-Plan.pdf (pcrs-uk.org) 

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Chronic respiratory diseases present a huge burden on society but advancing technology can help patients to better manage their condition with the help of their healthcare professionals.

Chronic respiratory diseases (CRD) such as asthma or chronic obstructive pulmonary disease (COPD) impact over half a billion people globally, with COPD alone accounting for 3.2 million deaths worldwide in 2019. In the UK, the total annual cost of managing respiratory conditions is £11 billion, of which almost £5 billion relates to COPD and asthma.

Driven by harmful environmental, occupational and behavioural exposures, these numbers will continue to increase if measures to improve respiratory health are not implemented. In parallel, giving patients and care teams tools to better control disease and disease progression is paramount to reducing the CRD impact on quality of life, and improving clinical and medico-economic outcomes.

In the UK, the total annual cost of managing respiratory conditions is £11 billion, of which almost £5 billion relates to COPD and asthma.

Despite the availability of inexpensive inhaled therapeutics for CRD, poor disease control is currently commonplace, notably for asthma.

With this in mind, Aptar Pharma has launched HeroTracker® Sense, a novel smart device that transforms a standard metered dose inhaler into a smart connected healthcare device. The device provides feedback to help patients use medications as intended by prescribing healthcare providers (HCPs). By supporting inhalation technique and adherence, it can improve disease control and patient outcomes.

Empowering patients

HeroTracker® Sense is a patient-centric product that aligns trusted inhalers with modern lifestyles. It utilises sensors to support the coordination of inspiration with actuation, and to monitor flow rate and inhalation duration. The BreatheSmart® mobile app stores this data and also features date and time stamps to indicate when the patient should take their medication, environmental monitoring alerts on temperature and humidity issues.

Facilitate care delivery

This kind of technology is an innovation with parallel potential to reduce the burden that CRD imposes on HCPs and nurse practitioners. By providing valuable analytics, the device delivers insights into patient training, onboarding and performance. Teams can also better understand real-life situations and use and adapt treatment plans accordingly.

Build the future of care

Via systematic acquisitions and partnerships, the company is now working towards solutions for end-to-end integrated healthcare that efficiently combine therapies, drug delivery devices and digital services.
As summarised by Marcus Bates, Vice President of Digital Healthcare Business Development at Aptar Pharma: “Our ultimate goal is to leverage digital solutions to give patients more control over their disease and to cost-efficiently improve health outcomes.”

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Prof Ioannis Vogiatzis

Professor of Rehabilitation Sciences, Department of Sport, Exercise and Rehabilitation, Northumbria University 

Leading scientists are developing pioneering solutions to help diagnose those with respiratory disease and reduce the costs of treating and rehabilitating sufferers.

Since the start of the COVID-19 pandemic, respiratory diseases have gained increased focus, highlighting the importance of early diagnosis, correct treatment and patient rehabilitation.

Northumbria University is undertaking ground-breaking work for patients with a variety of lung diseases, including chronic obstructive pulmonary disease (COPD) and asthma.

Diagnosing lung conditions from breath

Dr Sterghios Moschos, Associate Professor, Department of Applied Sciences and his team have developed a device to collect a breath sample which can then be analysed for disease. It has been used during the pandemic to understand how the COVID virus transmits and he hopes soon to be able to share the understanding and knowledge gained from this work.

However, the non-invasive device is also set to play an instrumental role in the diagnosis of lung conditions, particularly in the over 65s and young children.

A third of all children under the age of three will present to GPs and A&E at some point with a wheeze. They use up 75% of all childhood NHS appointments, a total of 217,000 visits per year.

Before the pandemic, more than 120,000 patients over the age of 65 were admitted to UK hospitals with a respiratory condition every year and were likely treated with antibiotics and steroids without confirming the cause of infection, with the hope this would resolve the problem.

Our innovation can sample breath exclusively from the deep lung, entirely non-invasively.

Dr Sterghios Moschos

Correct treatment and management

Moschos says: “Our innovation can sample breath exclusively from the deep lung, entirely non-invasively and without anaesthesia to detect bacteria, viruses and fungi, as well as materials from the body that could be tell-tale signs of other diseases, like lung cancers and lung fibrosis.

“It will provide an effective diagnosis giving doctors specific, effective treatment options; if you have patients not coming back with recurring problems or unresolved disease, then the cost to the NHS could be massively reduced.”

Taking this innovative technology to market, Dr Moschos has worked with Northumbria’s IP Commercialisation team to launch the medtech spinout company PulmoBioMed Ltd. The process of taking the technology from academic research to a spinout company was facilitated with support from the Innovate UK NxNW ICURe program and Northern Accelerator, a collaboration between Northumbria, Durham, Newcastle, Sunderland and Teesside Universities to commercialise research and boost the region’s economy.

Providing the right exercise programme

Professor Ioannis Vogiatzis, Professor of Rehabilitation Sciences, Department of Sport, Exercise and Rehabilitation brings his 25 years of expertise in rehabilitation innovations mostly for COPD but has also worked with people who have cystic fibrosis, asthma and pulmonary hypertension.

Interval or intermittent exercise — a style of training which prescribes very short, intense, bursts of exercise followed by the same amount of rest before repeating — has grown in popularity with elite athletes worldwide. Professor Vogiatzis used this approach to devise an adapted exercise routine for people with lung disease.

“My work has informed the American, European and British Thoracic Societies’ pulmonary rehabilitation guidelines and has proven to work well with those who suffer from lung diseases. For those who are already breathless, doing long continuous exercise activity is not helpful,” Vogiatzis explains.

“There is good evidence now that this type of exercising works well for COPD and other lung disease sufferers.”

His exercise programme is now delivered by physiotherapists in hospital and community-based rehabilitation centres across the UK and around the world.

He concludes: “Patients who undertake this kind of programme may have a higher quality of life and are less anxious or depressed. They require fewer GP visits, less medication and hospital admissions decrease.”

Northumbria University has recently gained reinforcement of its already outstanding reputation for excellence in research, having been ranked 5th in the UK for research power in sport and exercise sciences, and ranked 8th in the UK for research power for professions allied to health, such as biomedical science, in the latest Research Excellence Framework (REF2021).

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Many respiratory conditions such as asthma or chronic obstructive pulmonary disease require inhaled therapy.

Inhalers are convenient and enable the medicine to be delivered exactly where it needs to go. But research suggests that up to 90% of people don’t use their inhalers correctly.

This can be due to a number of factors such as the design of the inhaler, how well the patient is able to physically handle the inhaler and whether they are able to coordinate inhaling at the same time as operating the inhaler.

Good inhaler technique is vital to ensure that as much of the medicine as possible is delivered to the lungs. Less than optimal technique can lead to poor disease control and quality of life, increased potential for side effects, more hospital admissions and increased costs of healthcare treatment.

Different inhalers require different techniques

There are many types of inhalers available. These mainly fall into two categories: aerosol metered dose inhalers (MDI) or dry powder inhalers (DPI). The technique required varies for different devices.

MDIs are commonly prescribed and they require slow, steady inhalation. But many patients aren’t taught how to use the device properly, or they struggle to use it (although this is improved by using a spacer device). This means that the medicine can’t reach where it needs to work and is therefore ineffective.

Good inhaler technique is vital to ensure that as much of the medicine as possible is delivered to the lungs.

Conversely, DPIs require a fast, deep inhalation. They also don’t contain propellant gases (which contribute to global warming) and may be a more suitable option. However, it is important to discuss with the patient and prescribe the device which is most suitable.

Training from healthcare professionals

Patients may not have been instructed on correct inhaler use or, despite this, may still be unable to use them. Almost everyone can learn good technique with adequate training and practice. Training from healthcare professionals (HCPs) should be repeated regularly to ensure that the patient continues to use the inhaler correctly in order to remain well.

Support and resources are available to help with this. Technique can be checked by asking the patient to demonstrate at treatment initiation and as part of their regular review.

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