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Case 1: poorly controlled asthma

A 14 year old girl with poorly controlled asthma presents with her and her family asking what she can do to stop coughing all the time. They live close to the main road in town. You note on her medication history she has had 8 Ventolin pMDI inhalers and 2 Clenil pMDI in the last 6 months. They’re asking for more cough syrup.
Should people with asthma cough all the time?

Persistent coughing is a sign of poorly controlled asthma. Coughing all the time should indicate a review of the current treatment. This would include checking her inhaler technique and understanding of how she uses her inhalers. As she is 14 this might include offering a change from a pressurised metered dose inhaler (pMDI) to a Dry powder inhaler.

What is the relevance of living near the main road?

Air pollution is a well established exacerbator of asthma (as well as being associated with COPD, Lung Cancer, Ischaemic Heart Disease and strokes, Diabetes, Dementia, etc.) The closer to the road the bigger the effect. Royal College of Physician data suggests that 36,000 people per year die from air pollution in UK. 

What do you think about the ratio of Clenil to Salbutamol?

She is using more SABA inhalers than is appropriate (using more than 3 per year should trigger a review of her asthma). She is not receiving/requesting enough Clenil to act as a treatment / preventer for her asthma. It might be appropriate to consider a MART inhaler so that she receives both SABA and ICS with each dose.

How good is asthma care in UK compared to comparable countries?

UK asthma outcomes are poor compared to equivalent countries. The UK Asthma Death study demonstrated that most asthma deaths were preventable with better care. The national review of asthma deaths: what did we learn and what needs to change?.  The UK is also an outlier for use of pMDI using this type of inhaler much more (70%) than Sweden Denmark and Norway which have better outcomes.

Is cough syrup effective? What is the relevance of this request to planetary health?

Cough syrup is a black triangle medicine i.e. one that is established as having little clinical value in changing outcomes. Prescribing medications which do not work is wasteful and consumes resources so this is an example of overprescribing enlarging healthcare’s excessive carbon footprint.

How could this situation be prevented or the patient’s care improved whilst also improving the health of the planet?

Discuss patient understanding of her treatment, review her inhaler technique (the majority of users of pMDI use a technique more suited to DPI), offer options for treatment including ICS led inhalers and consider MART, ensure she understands the relevance of the road ( and that walking or cycling  in general will expose her to less air pollution than travelling in a car). Have a look at the Asthma toolkit resources for more information.