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IPCRG 2nd World Conference
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Program Highlights - Day 4
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Keynote 8
Whealing and dealing in asthma: the deal is the
wheal!
Isobel Martin
Department of General Practice,
Dunedin School of Medicine,
New Zealand
The role of allergy in both the aetiology and
symptomatology of asthma remains controversial.
A brief overview of the history of this debate will
be given.
Many factors are implicated in the cause of
asthma, including both individual and environmental
factors and subsequent interactions. So too the
control and management of allergic asthma in primary
care is multifactorial.
Factors involved include not only biological
mechanisms, such as bronchial hyperresponsiveness,
but also psychosocial, medical, environmental and
self management issues. Problems surrounding the
identification of allergic asthma will be discussed.
Management options such as medication,
desensitisation and/or environmental control will be
described. The implications and effect of each of
these choices on health professional and patient
interaction and subsequent patient behaviour will
also be addressed.
Keynote 9
Home Medicines Review (HMR) - A Vital Tool In Patient Management
Gowan JA1 , Charlton 12,
Hogan L3
1. Northern & Northeast Valley Divisions of General
Practice;
2. General Practitioner NSW;
3. Consultant Pharmacist and Asthma Educator,
Sunbury Victoria
Home Medicines Review (HMR) is a service to patients living at home in the community. The goal of an HMR is to maximise an individual patient’s benefit from their medication regimen, and prevent medication-related problems through a team approach, involving the patient’s GP and preferred community pharmacy, with the patient as the central focus. It may also involve other relevant members of the healthcare team, such as nurses in community practice or carers. The HMR process utilises the specific knowledge and expertise of each of the health care professionals involved. In collaboration with the GP, a pharmacist comprehensively reviews the patient’s medication regimen in a home visit. After discussion of the visit findings and report with the pharmacist, the GP and patient agree on a medication management plan. The patient is central in the development and implementation of this plan with their GP. The objectives of an HMR are to:
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achieve safe, effective, and appropriate use of medications by detecting and addressing medication-related problem/s that interfere with desired patient outcomes;
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improve the patient’s quality of life and health outcomes using a best practice approach, that involves a collaborative effort between the GP, pharmacist, other relevant health professionals and the patient (and where appropriate, their carer);
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improve the patient’s, and health professionals’, knowledge and understanding about medications, and
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facilitate cooperative working relationships between members of the health care team, in the interests of patient health and well being.
The program was introduced in October 2001. At the end of October 2003, nearly 36,000 HMRs had been completed and $5M remuneration claimed by pharmacists and general practitioners from the Federal government.
After an introduction about the process Assoc Prof Ian Charlton, General Practitioner, Mrs Luisa Hogan, Consultant pharmacist and asthma educator, and Dr Jenny Gowan, Consultant pharmacist and HMR Facilitator will discuss the success of this new Australian initiative using case studies.
Workshop 19 - Cough of All Ages
Cough and Breathlessness in Adults
P.W. Holmes and C.M. Mellis
Monash Medical Centre, Clayton, Victoria and
Bond University, Gold Coast, Queensland
The management of significant cough in adults is often dictated by the duration of symptoms and whether or not sputum is produced. Dry cough of less than six weeks’ duration usually follows a viral respiratory tract infection and may be troublesome due to heightened cough receptor sensitivity. It usually settles with time. Psychogenic cough in adults on the other hand is uncommon, but anxiety associated with frequent and disabling cough is very common.
Cough is said to become ‘chronic’ after six weeks’ duration. It is usually a complaint of non-smokers and occurs more frequently in females. The differential diagnosis then includes asthma, particularly where the cough is associated with breathlessness, wheeze and chest tightness, past hay fever, eczema, or a family history of atopy. Other causes include gastro-oesophageal reflux, which may or may not be symptomatic, and upper respiratory tract symptoms, particularly of post-nasal drip, sometimes in the absence of nasal obstruction. Infections such as adult whooping cough, mycoplasma pneumoniae and tuberculosis can also cause protracted cough in adults. Finally, some drugs initiate cough, such as ACE inhibitors, and other drugs that promote gastro-oesophageal reflux can also act as a cough-inducing agent.
History is an important component of management of troublesome cough in adults, particularly in noting the presence of sputum production, response to previous bronchodilator therapy, occurrence at night and wakefulness from sleep. Dry cough at night can suggest asthma, adult whooping cough, ACE inhibitor cough or occasionally gastro-oesophageal reflux. Breathlessness is often associated with cough and often follows a coughing bout due to inadequate inspiration after numerous coughing spasms. It is also seen in asthma and infective exacerbations of COPD. In adults, the physical examination is often unhelpful. Spirometry on the other hand may demonstrate the presence of airflow obstruction, but often milder increases in airway hyper-responsiveness require a formal bronchial provocation test
Cough of longer duration in adults needs to be investigated further, usually with a fibreoptic bronchoscopy to exclude a foreign body, or a previously unsuspected endobronchial tumour. Disappointingly, however, the diagnostic yield form bronchoscopy in chronic cough is usually low.
Cough and Breathlessness in Children
CM Mellis (1) and Peter Holmes (2)
Bond University, Gold Coast, Queensland (1);
Monash Medical Centre, Clayton, Victoria (2)
Cough is one of the commonest symptoms in
childhood and in most instances is due to an acute
infection which subsides spontaneously in 7-10 days
[ie, acute viral bronchitis]. There is general
consensus that a ‘chronic’ cough be defined as cough
persisting for 4-6 weeks. Infective causes of
chronic cough include specific infections such as:
Viral influenza, Pertussis (whooping cough),
Mycoplasma pneumoniae, and rarely, Mycobacterium
tuberculosis. Children with a chronic productive
cough should be suspected of chronic suppurative
lung disease (eg, retained foreign body inhalation,
bronchiectasis, Cystic Fibrosis). A classical cause
of a chronic, bizarre cough in older children is
psychogenic cough. Children with structural
malformations of the major airways [eg, primary or
secondary tracheomalacia] will also have an unusual
sounding, ‘honking’ cough. As distinct from adults,
gastro-oesophageal reflux, post-nasal drip/chronic
sinusitis, and chronic bronchitis are rare causes of
cough in childhood.
The combination of recurrent or persistent cough
and breathlessness (usually with audible wheeze) is
very common in childhood, and is generally due to
asthma. Thus, while cough, wheeze, and
breathlessness represent the classical triad of
symptoms of childhood asthma, cough in the absence
of wheeze and breathlessness is generally not due to
asthma. In a substantial number of young children,
bouts of ‘cough alone’ will be frequent, recurrent
and disturbing for both the child and the parents (ie,
recurrent viral bronchitis). With acquisition of
immunity to the common respiratory viruses with
increasing age, the child will have progressively
fewer bouts of ‘cough alone’, and the episodes will
become less troublesome. An important concept is the
distinction between Airways Hyper-Responsiveness (AHR)
which equates with bronchoconstriction/asthma; and
heightened Cough Receptor Sensitivity (CRS) which
equates with a predisposition to ‘cough alone’- but
not asthma. The pathways for bronchoconstriction and
cough are quite separate, with different laboratory
based provoking agents and different blocking
agents.
By far the most important distinguishing feature
is the clinical history and physical
examination.
In summary, recurrent cough and breathlessness in
children is due to asthma. ‘Cough alone’ is usually
not due to asthma, but is more likely to be due to
acute or recurrent viral bronchitis, although other
less common conditions need to be considered. While
the differentiation of asthma from viral bronchitis
is clinical, simple lung function testing can detect
reversible airflow obstruction in older (school age)
children. If uncertain, a therapeutic trial of
asthma medications may be appropriate. However, the
possibility of a placebo effect, and the favourable
natural history of recurrent viral bronchitis may
falsely suggest a response to therapy. Thus, the
trial should be of relatively short duration, with
critical review of any response. Trials using
progressively higher doses of inhaled
corticosteroids are not indicated in the child with
‘cough alone’.
Professor Craig Mellis
Foundation Head of Medicine
School of Health Sciences
Bond University, Queensland 4229
Telephone: + 61 7 5595 5499
Fax: +61 7 5595 4122
Email: craig_mellis@bond.edu.au
Closing Ceremony
Dr Ron Tomlins
Chairman of the National Asthma Council and Chairman of the IPCRG Conference Organising Committee
There are many people who worked
tirelessly in making the IPCRG 2nd World Conference
of the IPCRG such a success.
Thanks to
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Keynote Speakers and Chairs
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Oral papers and poster presenters
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The Conference Organising Committee and Scientific Members
especially Professor Justin Beilby, Chairman of the Organising Committee
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IPCRG Secretariat, UK: Sam Knowles and Sian Williams
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Porter Novelli for Media and Public Relations, Caroline James
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Impagination for the conference website and the conference slide design, Suzanne and Jeff Grainger and
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Asthma Victoria for all their help with the conference.
Very special thanks go to Kathy Hope, National Asthma Council and Garry Irving, Asthma Victoria.
We look forward to the IPCRG 3rd World Conference in 2006 in Norway.
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More conference photos to follow soon.
Farewell from Melbourne.
©IPCRG Melbourne 2004