- 30 Mar 2021
- 20 min 36
- 30 Mar 2021
- 20 min 36
Justin Coleman chats with fellow GP Malcolm Clark about the extensively revised Respiratory guidelines published by Therapeutic Guidelines.
Welcome to the Australian Prescriber Podcast. Australian Prescriber, independent, peer-reviewed and free.
Hi, I'm Dr Justin Coleman, a GP on the Tiwi Islands, where the air is clear and the humidity is nature's own moisturiser for your nasopharynx. And here to talk all things air and nasopharynxes and lungs, I'm joined from down south by Dr Malcolm Clark, who's Associate professor in the Department of General Practice at Melbourne Uni, and who is a GP on the writing group for the newly released update of the Therapeutic Guidelines Respiratory. Welcome, Malcolm.
Thank you very much, Justin, for that kind introduction, and I'm very jealous of that lovely humid air that you must be having. It's been freezing in Melbourne this summer.
Ah, well, if one wants to come up north, you can come up during winter in the dry season. Respiration, in some ways respiration is the human animal's greatest weakness. We have to do it all the time, from our very first breath to our last, hopefully a long time later, and if anything goes wrong, we've just a minute or two to do something about it. It's a bit of a design flaw.
It is a curious thing that we are so worried about breathing. I mean, it's a natural thing that we do automatically.
Hardwired very deep down inside our primitive brain. But let's have a look at the new content from the respiratory guidelines, and I thought we might tackle this in terms of the order of increasing age. Not the order of yours and my increasing age, of course, Malcolm, as that's confidential, although I note that you did go to school with my older brother, if listeners want to make some sort of assumption there. But let's start with the little tackers, start with babies and look at acute bronchiolitis and what's new there. There's two things that really do work, which is oxygen, if their oxygen saturations are below 92%, and hydration, particularly if they've drunk less than 50% of their usual hydration. And then there's a bunch of things which aren't recommended, and that includes steroids, antibiotics, adrenaline, we don't need to x-ray, and also salbutamol, which isn't of much use in bronchiolitis.
We had a great time talking to our paediatric experts about this, and I can only say there was a bit of discussion from some of the people who look after older people, scratching their heads about all these sorts of things. But this all comes from clinical trials, so it's all very much knowledge rather than guesswork. And one of the difficulties for parents is when they see their child so unwell with bronchiolitis and the doctor's not really doing anything, not using any drugs, it be quite confronting for them. Similarly, for general practitioners, if we're a GP, like you are up in the Tiwi Islands, and you have a kid come in who's very unwell with bronchiolitis and you're not giving them any drugs, then maybe some of the people might scratch their heads and say, "Oh, I don't know if this fellow knows what he's doing."
You're right, Malcolm, it can be a very uncomfortable situation to be in, and I suppose we do have to remind ourselves that there's not much point in doing something if there's trials really showing it doesn't help all that much. But I guess the main thing there for GPs is really to be able to pick the difference between a mild to moderate bronchiolitis, versus something that really does require hospital admission for fluids and oxygen.
And I can't agree with you more there, but I always say that electronic Therapeutic Guidelines are a doctor's best friend, especially a GP’s best friend, because in those scenarios when you do have a concerned family, and they might be asking questions about that, you can say, "Hey look, I've got this really, really up-to-date guidance, which is from the best experts, who suggest this is what we should do." And I think that gives GPs a lot of comfort.
Looking at a similar age group, with croup, probably even more so than bronchiolitis, it really can progress from being a nasty croup into being a very life-threatening croup fairly quickly.
In terms of the updates, one of the main issues is that they're looking at increasing the doses of prednisolone, or dexamethasone. So usually, I always learned it was 1 mg/kg of prednisolone, and now looking at croup, I think it's 2 mg/kg, and also repeating the dose the next day.
One of the things that always surprises me amongst my GP colleagues is a bit of fear about prednisolone, that you can give someone too much prednisolone. But in an acute situation, you can't really do that, unless you give incredibly large doses. And people respond so much better to a bit more prednisolone than a bit less. Kids with croup, if they're unwell, I don't think we should be worried about giving them prednisolone in a timely way, because it works.
Indeed, whip out the roids. There's also a new section on non-drug strategies for croup, which I think if we were to sum it up, has that wonderful Hitchhikers Guide to the Galaxy phrase, "Don't panic."
But it's hard not to panic, isn't it? I mean, it can be really hard when you've a very sick child with croup, and that terrible cough, and wheezy noises, for the parents to do nothing at all. So traditionally people have done family treatments, and things like that, because it makes them feel like they're doing something. So I think reassuring people that they should spend time with their child and just be there and not get too stressed, is very good advice.
So that sitting down, I guess, with the child calmly, seeking medical attention, obviously, but I do think the rushing around and fussing and panicking, I guess, for want of a better word, can actually make the child more distressed and isn't good for him or her.
Yes, and more noisy too, because the children pick up on the parent's distress, and they'll cry more, and they'll breathe faster, and it'll sound all the more worse.
Moving on to asthma now, this is a quick rush through respiratory guidelines, but asthma, there's a few new little things one of them being underlying, again, spirometry as being an excellent tool, and ideally doing that before starting regular preventive treatment. It is possible afterwards, but you're already on an inhaled corticosteroid, it can increase the false negatives on the result. Spirometry does certainly have a reasonable number of false positives and negatives, and one comment I was pleased to read is that if there is a negative spirometry while you actually have symptoms, then that probably is going to be a true negative, and you do have to consider other diagnoses, whereas a negative spirometry when the person is well isn't necessarily a strong sign that they don't have asthma, because it might be intermittent.
Well, I think this goes back to that old nugget that the respiratory revision always say is, "It's not asthma unless the spirometry says it's so." And Justin, both you and I, being GPs, have seen that a lot of doctors will prescribe steroid preventers to patients, and to young people, on the impression that they have asthma, without a spirometry reading. And I think part of the guidance here is to reinforce that it's very important to do a spirometry on everybody. Of course, the caveat there is we're in COVID times, which is why I can't come to visit you up in the Tiwi Islands to do our interview, so using nebulisers and various other things have been banned now, and in our practice, certainly, there's no allowance to do spirometry until we've been given clearance. So I think it's a bit hard to diagnose asthma in kids at the moment, so we'll have to do what we're not supposed to do for a little bit longer, and give the steroids for a little while, until the child's better, or we're comfortable that they can come off them and do spirometry.
Yes, unfortunately we do live in interesting times, which is not usually a good thing. There's an emphasis also on puffers. What's the message there?
Using puffers via spacer is much better than most other methods. The dry powder inhalers certainly have a place, but ideally using a spacer and a puffer is better. And then I suppose the other thing that we always say is, it's very important to make sure that your patient is using their inhaler of any sort properly. Every time you see them for a prescription, it's recommended that you don't forget just to say, "Hey, pull that out of your pocket and let me see how you use it." So you don't end up looking like the famous episode of Dr House with the lady who, he asks her, "Do you know how to use the inhaler?" and she says, "Do I look stupid to you?" And then she showed us that she wasn't using it properly, which was very funny.
Spraying it as a neck deodorant, or something.
As a neck deodorant, that's right.
I don't know if there's such a thing now, when I think about it. Then there's a new section on asthma management plans. What have you done there?
One of the things that all us GPs like is we like flow charts. We especially like flow charts that are easy to read, that gives us guidance to what we're doing, rather than reading long reams of text. So we went to a lot of trouble to try and have easy-to-read guidance for GPs, so nice spreadsheets and charts, and things like that, that tell us what sort of puffers to use, and when to use them, when to add on, and when to take off, because that's something that a lot of us don't really think about is, someone's been stable for a while, we can actually step them down and see how they go, and if they don't do well, we can step them back up again.
One of the difficulties for GPs is finding asthma care plans for kids to bring to school. Parents come into us and they say, "Well, we need an asthma management plan for little Johnny for his asthma," and we have to hunt around for the correct forms to fill in. These forms have all been put onto the guidance that's linked to the Australia Asthma Management Plans, so we're quite excited about being able to have that available for GPs on their desktop so they can find it very easily. It's a once-a-year care plan that's required by the schools, and it's also a really good time to make sure the kids are using their puffers properly.
Anything that saves me time searching for paperwork is always much appreciated by me. Let's move on now to cough, and in particular, chronic cough, and the guidelines are saying that there's really two components to it. One is the trigger, and the other is the upper airway hypersensitivity, and we need to look at both of those in order to effectively manage chronic cough. So I guess the trigger, there's a very long list of many things that can cause chronic cough, anywhere from viruses and pertussis, and asthma, and COPD, to reflux and ACE inhibitors, that sort of thing. And then there's a second component which is this upper airway hypersensitivity, and I think that's meant to be sort of laryngeal irritation from the cough itself, and you get a bit of inflammation and an urge to cough. A bit of a vicious cycle, is it?
Vicious cycle, and the only treatment that is effective is listening to my wife. So I've occasionally had a cough that's persisting after a virus, and she was very good at telling me, "Don't cough, you don't need to cough, it'll only make it worse." But I don't think she made it into the guidelines. The other thing about chronic cough is people do tend to go down to their friendly local pharmacy, or other places, to buy all sorts of cough medicines, and linctuses, and mixtures. And certainly there's no evidence that any of those products really do help to relieve a cough. They may have some placebo effect at best, but probably better to keep your money in your pocket.
Yeah, it's interesting. I was reading the individual evidence, which is listed in the Therapeutic Guidelines for each one of them, and it's like that big busted stamp comes down on nearly all of them, and that includes codeine, and antihistamines, and expectorants, Senega with Ammonia. There was one slight evidence for mucolytics, bromhexine, may reduce cough frequency, but really there's not much in the bag there, is there?
No, but the thing is, patients are used to going to the pharmacy when they have a cough. I do some work with the pharmacists, and they certainly are very keen on people coming down to their pharmacies and trying to help them with cough medicines, and all sorts of things. But again, there's no evidence that they help more than placebo, but sometimes placebo is not such a bad thing.
Let's move right along, pneumothoraces. Now interestingly, I was just updating Murtagh’s General Practice chapter on the management of this, and the traditional way of dividing them in terms of whether you put a catheter in or not was the size of the pneumothorax, and it was listed, if it's more than 25%, put the needle in, but based on recent evidence, I think for primary spontaneous pneumothoraces, regardless of size, you don't whip out the needle straight away. Is that right?
Yes, unfortunately this is going to be a great disappointment for all the medical students in the emergency departments, and the junior residents who are dying to do this.
Yeah, no, it was quite conclusive really. So those who are treated just with analgesia initially, and oxygen if they need it, do have shorter stays in hospital and better outcomes, fewer complications, less eventual surgery, so really on all the useful measures, close observation is suggested rather than putting needles in. Obviously a tension pneumothorax is an entirely different topic, and a deteriorating patient if the 02 stats are going down, and the pulse and respiratory rate are going up, then we need to sit and rethink, but by that stage, hopefully they'll be sitting in their emergency department.
Yeah. It goes back to that famous old axiom, at first do no harm. And you can be actively passive, so you can say, "No, we're not putting a tube in because we don't need to, but what we do need to do is we do need to see you if things change, but we definitely will see you in 24 hours and have another x-ray and see how you're going, and we'll continue to do that until we're all happy and we've made a joint decision that we don't need to do any more things for you."
I might borrow that phrase actively passive for my wife next time I sit down and read the paper and have a coffee on Sunday morning. I like it.
I thought we'd finish now, we've covered a lot, on the approach to management of allergic rhinitis. There's a bit of a scale stepping upwards from mild symptoms, starting on an antihistamine, and either oral or intranasal, but not both, and also don't go up above a certain dose. So it looks like the antihistamines either work or they don't work.
That's a great comment. We tried to make it similar to the management of asthma, because they're synonymous in a lot of ways. One of the problems is, well, what to use first? And how do you know what to do? So some people will hand out antihistamine pills, and other people will hand out nasal steroids. So we tried to sort of make a fairly straightforward process because we certainly know that above cetirizine 10 mg, or equivalent, you don't get any more benefit from having two or three or four.
Okay, so for milder symptoms we start with an antihistamine, and then if it persists, we can move up to an intranasal steroid?
Yes, and it's an either-or as well. So if somebody says, "Well look, I use an oral antihistamine and that's very convenient, and I don't have to shove something up my nose," then that's a great first step. As you know well, Justin, one of the biggest problems is most people don't use their intranasal steroid spray properly, so I think most of it goes down the back of their throat and gives an unpleasant taste. So we also had some pictures that we included of how to use your intranasal spray properly, which kind of sounds a bit funky, you've got to shove it up your nose and then twist it around and shoot it up towards your ear to get it into the right spot, which apparently is easier to do when you're looking at yourself in the mirror torturing yourself, but there you go.
And then if the intranasal steroid on its own isn't sufficient, then adding an oral antihistamine makes good sense, or as there is one particular brand that's got both the intranasal steroid and the antihistamine combined, if you know how to use the nasal spray properly, then at least you're just doing it once a day.
Excellent, maybe that's where the woman on the House episode went wrong, they told her to aim towards her ear and she didn't realise that it had to be inserted into the nose first.
Exactly, well done.
And avoiding decongestants, I think that suggestion has been around for a long time now.
But if you want to use them, use them for a day or two, but we wouldn't particularly recommend them.
No, especially that they have all sorts of other unpleasant effects over the longer term. So they make you sleepy, and having a dry mouth, xerostomia. One of the biggest problems that we see in general practice is chronic rhinitis, and there's quite a bit of work in the new chapter about chronic rhinitis and managing it, because really all we have for these people, who are usually males and a bit older, is intranasal steroids, things like ipratropium bromide nasal spray, and nasal saline, and pretty much all of them, even combined altogether, don't do a great deal for it. So it can be nice to be able to reassure your patient that a trial of these nasal sprays may be of some benefit, but they probably won't, but they usually want something, and that it's okay to have a postnasal drip, apart from it being annoying and them announcing themselves every time they come into the room with a [ahem, ahem], it's quite normal and not associated with any dangerous later outcome.
Well, thank you very much, Dr Malcolm Clark, it's been a delight and a privilege chatting to a fellow GP, and one who helped write the respiratory therapeutic guidelines update for 2020. Thanks for coming along, and I'll see you one day in the Tiwi Islands, if you ever make it this far north.
Justin, I would love to come up, and it's been a pleasure talking to you again, and I hope we have another opportunity in the not-too-distant future.
My guests views are their own and don't represent Australian Prescriber, and my views are certainly all mine.