Clinical Management

Role

Within the Clinical Management Group, Dr Helen Reddel conducts research focused on a better understanding of the mechanisms and outcomes of asthma treatment, mostly through investigator-initiated clinical trials, supported through independent grants or industry funding.

Research

The main areas of research in the Clinical Management Group are in the assessment of asthma control, the assessment and management of asthma exacerbations, the appropriate use of asthma medications, and attitudes, beliefs and needs of patients
with asthma.

ASSESSMENT OF ASTHMA CONTROL AND ASTHMA EXACERBATIONS
a. International Task Force
Dr Helen Reddel, together with Professor Robin Taylor of Dunedin, NZ, is co-chair of an international Task Force funded by the European Respiratory Society and the American Thoracic Society to provide recommendations about the assessment of asthma control and exacerbations, primarily for clinical trials but also for clinical practice. This Task Force, which has membership of 25 international asthma experts, has almost completed its research and is currently writing up its recommendations. Dr Reddel is also responsible for leading the Task Force working group on ambulatory monitoring of asthma control, and is a member of the working group on assessment of asthma exacerbations (flare-ups).

b. Viral Exacerbation Study
This study included a telephone survey of 224 patients who had presented to the Emergency Department with severe asthma. It confirmed previous anecdotal observations that patients with clinical colds perceived that their bronchodilator (reliever) medication was less effective, compared with patients with other causes for their asthma flare-up. More detailed study of 53 of these patients showed that clinical colds contributed to an impaired lung function response to Ventolin within the Emergency Department, but did not result in an increased risk of admission to hospital. Further analysis of this study is underway.

c. Asthma Action Plan for Symbicort
In 2006, authorisation was obtained in Australia for use of Symbicort as maintenance and reliever treatment, a new way of using Symbicort in the management of asthma. Dr Reddel and Dr Matthew Peters, of Concord Hospital, developed an action plan for use with this management programme, in conjunction with the Australian AstraZeneca Advisory Board. The action plan will be given to patients to show them how to change their medication when their asthma worsens.

d. Asthma Action Plan for Seretide
Design of an asthma action plan for patients on Seretide is underway, and will incorporate the findings of last year’s literature review by Dr Reddel and Professor David Barnes about appropriate management of asthma flare-ups, which was published during 2006.

e. Tools for assessing asthma control
As part of the study carried out by the two students from the Netherlands, Suzanne Vrenken and Johanna van Gaalen, we assessed the responses of patients with asthma or upper airway dysfunction to standard asthma assessment tools such as the Asthma Control Questionnaire. Upper airway dysfunction is a condition in which the vocal cords fail to adequately open during breathing, and is commonly mis-diagnosed as asthma. We found that patients with upper airway dysfunction may be assessed as having poor asthma control, and that anxiety strongly influenced the results of the Asthma Control Questionnaire. These results will be followed up in a new NHMRC project grant application next year. Other aspects of this study included the assessment of difficulty breathing by patients with asthma and those with upper airway dysfunction, using simple devices which add resistance to either breathing in or breathing out.

f. Survey of asthma educators about home monitoring in asthma
Home monitoring is recommended for patients with moderate to severe asthma, patients with poor perception of airway obstruction, and patients with frequent asthma flare-ups. In Australia, the majority of patient education about peak flow monitoring is carried out by asthma educators. This survey was conducted in order to find out how asthma educators currently teach their patients to carry out peak flow monitoring. The survey showed that asthma educators use a wide variety of peak flow charts, and that they usually obtain charts from pharmaceutical representatives, with the educators’ choices being driven by ready availability and free supply rather than consistent use of a single chart. As we have previously shown (Reddel et al, Thorax 2005), the use of different charts is likely to lead to problems in interpreting the patient’s lung function results.

g. The Woolcock Peak Flow Chart
The Woolcock Peak Flow Chart was developed at the Woolcock following our previous research (Reddel et al, Thorax 2005) which identified the need for a standardised, patient-friendly chart which would facilitate identification of asthma flare-ups. The new chart was extensively pilot tested in the RPAH Asthma Clinic and in the primary care practice of Dr Mark Levy, editor of the Primary Care Respiratory Journal (UK). In early 2007, the chart will be made available free of charge to health care professionals and consumers through the national website of the National Asthma Council, and the chart will also be placed on the website of the Australian Association of Asthma Educators and made available through pharmaceutical representatives and of course the Woolcock’s website at www.woolcock.org.au. Application has been made
to Global Initiative for Asthma (GINA) to lodge the chart on
its website.

h. Effect of lung function monitoring on adherence
Patients with moderate to severe asthma, or those who are participating in asthma research studies, are often asked to monitor their asthma on a daily basis. Adherence with such monitoring is notoriously poor, partly due to the burden to the patient, but we have previously shown that adherence can be markedly improved by use of patient-friendly electronic devices. This study showed that, contrary to common belief, asking patients to record their lung function actually improved adherence rather than impairing it, possibly by providing the patients with objective information about their asthma. This study was carried out in conjunction with the Breathing Techniques study, which was funded by the CRC for Asthma.

APPROPRIATE USE OF ASTHMA MEDICATIONS
a. Improving Inhaler Technique
Although correct use of inhaler devices is essential for the delivery of asthma medications, the majority of patients and health care professionals are found to have incorrect technique. This study, the results of which were presented at the American Thoracic Society meeting and the Australian Asthma Conference, showed that a simple intervention about Turbuhaler or Accuhaler technique, delivered by community pharmacists to their patients, resulted in improved clinical and humanistic outcomes. This study used a novel inhaler technique label which was attached to the patient’s inhaler, showing the steps on which they needed to improve. The benefit in asthma outcomes which was seen after 3 rounds of monthly education declined somewhat after a further 3 month period with no education, indicating that inhaler technique education needs to be repeated on an ongoing basis. The study tools have since been incorporated into an educational module suitable for teaching health care professionals about inhaler technique. This study was carried out in collaboration with the Faculty of Pharmacy at The University of Sydney.

b. Reduction of asthma medications (Seretide dose reduction study)
Over-treatment of asthma is a common problem, and leaves patients at risk of side-effects. This study, which was initiated by Professor Christine Jenkins and carried out at the Woolcock, Concord Hospital and John Hunter Hospital with funding from GlaxoSmithKline, compared two ways of reducing maintenance treatment in patients who were initially being treated with Seretide. The study compared outcomes in patients whose dose reduction was carried out with fluticasone (Flixotide) alone, and those whose dose reduction was carried out with fluticasone/salmeterol combination (Seretide). The results showed that patients randomised to Seretide reached a lower minimum dose, without loss of asthma control. The study was also designed to investigate the patient and environment factors that predicted successful dose reduction and these analyses will be carried out in 2007.

c. An algorithm to assess the role of nitric oxide monitoring compared to usual care for dose titration of inhaled steroids
This CRCA study is the final study in the Targeting treatment project in the CRC for Asthma. It has been completed in collaboration with CRC investigators at Liverpool Hospital, the Alfred Hospital, and John Hunter Hospital, and it is hoped we will present the results at the American Thoracic Society and TSANZ meetings in 2007.

ATTITUDES, BELIEFS AND NEEDS OF PATIENTS WITH AIRWAYS DISEASE
a. Qualitative study of patient attitudes towards breathing techniques for asthma
This study was carried out in conjunction with the CRC for Asthma, in patients who had participated in the Breathing Techniques study. It showed that patients perceived considerable benefit from using breathing techniques, particularly in the reduction of need for reliever medication, and it highlighted some factors that contributed to these responses.

b. Effect of cognitive behaviour interventions for anxiety and panic disorder on asthma outcomes
This study is being undertaken by Vandana Deshmukh, a clinical psychologist, for her PhD. People with asthma attending the Emergency Department were surveyed to determine the prevalence of anxiety and panic disorder and to select those who may benefit from a cognitive behaviour intervention in group sessions over 4 weeks. Those identified were invited to participate in group sessions and their asthma outcomes are being assessed and compared to those who received a simple educational intervention only.

c. Development, trial and implementation of a tool to assess the asthma needs of older people in clinical care.
This CRCA&A project is being run in collaboration with A/Professor Joanne Douglass and Diane Goeman, at the Alfred Hospital in Melbourne. It will form part of Dianne’s PhD on older people with asthma. At the Woolcock we are completing a literature review of what is known about the needs of older people with asthma in preparation for the development of this tool,
a questionnaire which will be piloted and validated for use in primary care.