Improving future asthma care

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5.4 million people in the UK have asthma, and every ten seconds, someone in the UK has a potentially life-threatening asthma attack. On average, three people a day die from an asthma attack in the UK – in 2014 (the most recent data available), 1216 people died from asthma. Many of these deaths are preventable, and continued use of asthma medication is an important factor in this (Asthma UK, 2017). But many people don’t stick to their asthma medication routines. Kathy Hetherington writes about her research into a new method of asthma treatment which is significantly reducing the risks associated with severe asthma.

My PhD investigates patient’s response to inhaled steroids using novel monitoring technology. I have spent the past year coordinating this project throughout the UK, within the Refractory Asthma Stratification Programme-UK, (RASP-UK). I work alongside Professor Liam Heaney and Professor Judy Bradley in Queen’s University, and Professor Richard Costello in the Royal College of Surgeons Ireland. As a young researcher in Northern Ireland I am excited in the knowledge that my PhD has the potential to improve future asthma care.

The Problem

Many asthmatics do not use their inhalers correctly. As a result, they don’t receive their prescribed dosage of inhaled steroid. Within Queen’s University Belfast and the Belfast City Hospital, we have developed and implemented a new method of observing and monitoring how patients use their inhalers. This revelation is significantly reducing the risks associated with severe asthma.

In RASP-UK severe asthma centres we record Fractional exhaled Nitric Oxide (FeNO), which is a measure of lung inflammation. An elevated FeNO is a predictor of worsening asthma symptoms or even an asthma attack. Those who continue to have an elevated FeNO are usually considered high-risk patients who need daily oral steroids alongside their inhalers. This elevated FeNO could be due to steroid resistance, or not continuing to use their inhaler (this is known as non-adherence). Determining inhaled steroid response in a difficult asthma population is a major problem in a clinical setting.

The Intervention

Within RASP-UK, we have established and further validated a clinical test using daily FeNO measurements (using a Niox Vero machine – Figure 2) alongside some additional inhaled steroid. The remote monitoring technology we use alongside this test is called an INCA™ (INhaled Compliance Aid) device. The INCA™ (Figure 1) was developed by Professor Richard Costello in conjunction with Vitalograph and is designed to work with the diskus inhaler. The INCA™ device records a time and date when the microphone inside it is activated, and records a sound file of the inhaler being used; these sound files can then be transferred to a computer. The sound files are then uploaded onto a server via a data compression utility programme where it is analysed by an automated and validated sound analysis algorithm. This combination allows us to create a remote assessment of inhaled steroid response and thus identify non-adherence to inhalers. We then communicate this information to the patients to try and improve their adherence to their inhaled treatment.

With further development, we created a web-based interface (Figure 3) to deploy FeNO suppression testing across the UK though our established RASP-UK Severe Asthma Centres. Here, we examined the utility of FeNO suppression testing to predict inhaled steroid responsiveness after a further 30 days on a normal inhaler. This period of prolonged monitoring provides further feedback on patient inhaler use and technique, using the unique presentation method below, enabling us to identify facilitators and barriers which may be involved in optimising inhaler adherence. We are constantly increasing the precision and user-friendliness of this hardware and software so that the data is easily interpreted and demonstrated to the patient.

asthma3

Figure 3 Data from the Vitalograph server following upload of one week FeNO suppression data and INCA™. The Vitalograph server shows activation and usage of both FeNO machine and INCA™ device (A) and depicts the FeNO data as precentage change from baseline as originally described (y1-aixs figure A).  The INCA™ device time and date stamps the number of inhaler uses (y2-axis – Figure A) and this is shown alongside technique analysis (B). Possible technique errors which can be identified and reported are shown in Graphic 3.

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The Future

Though we are only a year into our project, 250 patients in severe asthma centres throughout the UK have carried out FeNO suppression testing. Many have gone on to improve their inhaler usage and asthma control and decrease the inflammation in their lungs. We have presented our UK multi-centre data at conferences all over the world and interest in our project is increasing. In the past 6 months I have had the privilege of being a key note speaker at Severe Asthma Masterclasses and Specialist Asthma Meetings. This summer I have been invited as a symposium speaker at the European Academy of Allergy & Clinical Immunology in Helsinki, Finland which will undoubtedly be the highlight of my career to date!

My PhD has given me the opportunity to be able to work with a wide range of fantastic professors, clinicians, patients and co-ordinators. This PhD has convinced me that we can use this unique test and methods of presentation to improve asthma care throughout the world. I can’t express how much this thought excites and drives me; it is with great humility and privilege that I will continue to contribute to this extraordinary field.

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