The many faces (various clinical phenotypes) of asthma

I was planning to make this blog post very pretty with some graphs and tables from a recent journal alrticle. Imagine my dismay to discover that my tardiness to renew my ATS membership had resulted in the suspension of my access to the online blue journal. All good now; subs paid, but access not yet restored. Still, the blog must be posted. Ugly though it may be....

Around 8% of the adult Australian population suffers from 'asthma'. This means that asthma is a big public health problem. As such, asthma has been given the 'pathway' treatment; that is, rules and guidelines have been generated to direct asthma management. These rules and guidelines are also brought into play when asthma management is evaluated.

However, all of this 'proceduralising' of asthma mangement assumes that we know and are agreed on what asthma actually is, and how we diagnose it and measure its severity. Unfortunately, this is more of a problem than it should be!

Classically, asthma has been said to be a disease of allergic inflammation in the airways. Eosinophils and mast cells are supposed to be the main mediators of this inflammation; fibrosis and scarring develops early; corticosteroids (such as prednisolone) settle the
inflammation down. If we are agreed on that definition – and that it applies to all ‘asthmatics’ - we then measure severity of asthma by frequency of symptoms and use of bronchodilator medications (such as salbutamol / Ventolin), measurements of airway 'obstruction' (such as spirometry and peak flow variability) and 'exacerbations' requiring attendances at the doctor's clinic or hospital and/or use of oral corticosteroids (such as prednisolone).

Those of us who see lots of patients with asthma know how deeply unsatisfactory this approach to classification can be. Some patients present with profound symptoms which settle quickly on classic treatment with inhaled steroids, while others have persistent symptoms and lung function abnormality in spite of mulitple treatments. Some never take their puffers but struggle on with persistent symptoms, never getting very sick. Others have no symptoms for months and months, take their medication then present desperately unwell after an inadvertent exposure.

We need fresh eyes on asthma classificatoins.

I have been encouraged to read a paper, with accompanying editorial, in the Blue Journal from the middle of February which sought to reevaluate how we 'categorise' asthma sufferers. Over seven-hundred subjects from the 'Severe asthma research program' (SARP) in the USA completed questionnaires as well as physiological tests of lung function. Biological markers of disease were also measured in some patients (exhaled nitric oxide, induced sputum eosinophils). Not all of the subjects had 'severe' asthma.

Ultimately five 'clusters' of patients were identified:

Cluster 1: 15% of subjects. Younger, predominantly women (80%), childhood onset / atopic asthma and normal lung function. 40% on no controller medication; those on controllers generally on two or fewer. 70% reported no significant exacerbations in the previous year. However 30 to 40 % had almost daily symptoms (perhaps predominantly exercise related?)

Cluster 2: 44% of subjects. Slightly older, 67% women. Mainly childhood onset / atopic asthma. Baseline pre-bronchodilator lung function normal or can be reversed to normal in 94% of subjects. More prevalent medication use (only 26% on no medication, more on 3 puffers). Higher doses of inhaled steroids.

Cluster 3: only 8% of subjects. Significantly different. older women, with older age at onset of asthma and more overweight (58% BMI > 30). Less likely to be atopic. Lower baseline FEV1 with only 64% whose lung function 'normalised' after bronchodilator. Higher doses
of medication use and, in spite of this, health care utilisation. (Despite the fact that they are a small portion of the patient population, they are disproprotionately represented in hospitals I think). They have symptoms / quality of life impairments that seem out of proportion to their physiological impairment.

Cluster 4 and 5: the remaining 33% of subjects. 70 or 80% fulfill the ATS criteria for severe asthma. These are the patients with legitimate bad asthma. Cluster 4 was the only cluster in which both genders were equally represented, and atopy predominated (83%). Cluster 5 was later onset, mainly women with less atopy. Each cluster has long duration of disease, and significantly impaired pre- bronchodilator FEV1 commonly. More subjects in cluster 4 had significant bronchodilator responsiveness. Health care utilisation and medication doses were high in both clusters.

These clusters ring true. They fit with my impression of the population of patients with asthma; they differ significantly in important markers of severity, and in particular health care and medication utilisation; ultimately they may provide us with a step towards identifying groups of patients with asthma who sholud be offered significantly different management programs.

Ultimately, the authors found that discrimination between these clusters was possible 80%of the time simply using FEV1 pre- and post- bronchodilator and gender (this is where the missing diagrams would've been helpful).

We should trawl through our patient data and assign patients to 'clusters' based on lung function and gender. I suspect that we would be weighted towards cluster 3-5. What would be really interesting would be to see if there were medications or management strategies that worked, or failed, for each cluster. Another audit project? Must discuss it with the clinical staff!

Andrew

Visiting sleep physicians

We are very fortunate to have additional physicians who regularly visit our practice. As demand for sleep services is high and continues to grow these visiting physician provide a valuable service, keep appointment wait times low and enable patients to be diagnosed and treated sooner. This additional consulting services also allows us to provide services in other regional areas.

A new visiting physician is Dr David Cunnington, a Melbourne based sleep physician who will begin consulting in Mildura in May.

Dr Cunnington has over 10 years experience running a comprehensive sleep service for the evaluation and treatment of sleep disorders in Melbourne. As well as managing snoring and sleep apnoea, Dr Cunnington manages the full-range of sleep conditions including insomnia, restless legs syndrome, excessive daytime sleepiness and sleep problems that occur as part of mental or physical illness.

Dr Cunnington completed a sleep medicine fellowship at Harvard Medical School, Boston USA and is one of a handful of recognised International Sleep Medicine Specialists. He is a regular invited speaker on sleep at national and international meetings, and has helped to develop training curricula in sleep medicine for doctors in Australia and overseas. Dr Cunnington's research interests include trials of new drugs for the treatment of insomnia, restless legs syndrome and sleepiness, evaluation of new technologies for the measurement of sleep and the use of non-drug strategies such as meditation and their effects on sleep.

We are very excited to have Dr. Cunnington on board with this new venture into Mildura.

Over the past two years Dr. Garun Hamilton, also a sleep physician from Melbourne has provided consulting services in Hamilton. He graduated with a MBBS from Melbourne University in 1994. After undertaking training as a respiratory physician, he completed training as a level 2 Sleep Physician, the highest such qualification available. He currently holds an appointment as Director of Sleep Research at Monash Medical Centre Clayton in the Department of Respiratory & Sleep Medicine, and in 2005 helped establish the Hamilton Sleep Disorders Centre with Dr Andrew Bradbeer. His special interest is the cardiovascular consequences of obstructive sleep apnoea and he completed a PhD on the topic in 2007.

Dr. Hamilton will be at the Hamilton practice this coming week.

Jessica

ANZSRS 30th Annual Scientific Meeting Brisbane

Heather and I have just returned from the Annual Scientific Meeting, which was held in hot humid Brisbane last weekend. What a challenge it was for both of us logistically just getting to and fro Brisbane from country Victoria. Heather chose to drive from Hamilton to Avalon then fly to Brisbane and return the same way. I decided to use public transport and took the coach from Hamilton to Ballarat, the shuttle bus to Tullamarine and finally plane to Brisbane. Unfortunately my return journey was a little more complex in that I flew from Brisbane to Melbourne, Skybus from Tullamarine to Southern Cross Station, train to Warrnambool and then finally a coach to Hamilton and 12 hours later as if by magic I was home!
Heather stayed in Mount Warren Park about half way between Brisbane and the Gold Coast…. so she had a pleasant 40 minute express train trip to and from the Convention centre every day whereas I stayed in an exotically sounding “Resort”. I have stayed in some quirky places in my travels but I must say I have never stayed in a room, which had a kitchen sink beside the bed ....not that I am saying that’s a bad thing. It was within walking distance of the venue and the staff were very friendly. This is view I had from my window.

We were both very fortunate to be given this opportunity so took full advantage of all that was on offer and Day 1 found us fresh and enthusiastic.

The amount of research that is being undertaken in Labs is overwhelming and we were impressed by quality presentations representing this. The sheer volume of oral presentations 29 in total and 19 poster presentations was a lot to process s in a couple of days.


By Day 2 we had visited all the trade exhibits and had been generously supplied with enough pens and note pads to open a stationery store and I almost had to pay excess luggage with the brochures and various information I bought back for our Respiratory Nurses. The Trade Exhibition was a great place for collegiate binding and to view the many toys displayed. We were beginning to tire by this stage but sparked up after a few refreshing beverages. A highlight at the trade exhibition was meeting David Sinks, Director Technical Marketing CareFusion from California. He has given us 3 fabulous ideas to enhance our current reporting method and will email us the details upon his return to the States.
It was a treat to hear Sandi Anderson from NSW speak as she actually discovered Mannitol for bronchial provocation and to be present for her retirement presentation.
Even though we were in awe of the research and work performed by the big labs many were equally in awe of the volume and scope of tests we perform and especially the remote work we undertake with the planning, travel and machine set-up that that entails.
It was exciting to hear the Oral presentation of a study presented by the Austin, which we contributed to last year looking at the “Inter-rater reliability in the interpretation of lung function tests”. We were also involved in contributing data for the poster presented by Royal Adelaide Hospital titled “Six minute walk test: Compliance with ATS Guidelines”.
It was interesting listening to work being done in the field of exhaled breath biomarkers and the diseases that are being diagnosed by non-invasive breath testing.
The presentation “Evaluating a child with perceived exercise limitation” by A/Professor Selvadurai from NSW was very entertaining but interesting to note that this group may constitute a phenotype.

Thanks again to RRM for this opportunity and once we recover we will look forward to the ASM in Perth next year.

Vanessa & Heather

WHAT'S NEW IN THE WORLD OF CPAP

We recently had a visit and training session from one of our CPAP providers to introduce some new masks and a new machine that has recently been launched into the market. During the last 6 months a few of the well known suppliers have launched their products which is exciting news for those that have Obstructive Sleep Apnea. It is a competitive market out there but this is always good news for consumers as this provides choice.

The latest advances in technology from each company for this specific market is still aimed (and rightly so) at comfort and ease of use for the client. There are new masks and new CPAP machines on the market with some great features which are worth thinking about.

Some of the new features seen in the latest APAP/CPAP machines so far include
• Smaller, lightweight machines with easy to use controls
• Water/humidification chambers that can be cleaned in the dishwasher, one machine also boasts dry box technology to prevent water accidentally being spilt into the machine
• Advanced humidification technology to ensure optimal humidity, reduce condensation and improved levels of comfort
• Breath by breath pressure relief
• System Leak Reporting and event detection technology.

And the list goes on.

So, if you find yourself in the position of needing to get set up for CPAP therapy, do your research and tap into your local CPAP provider’s knowledge. My advice is to try on all available masks while you are connected to a CPAP machine .This includes nasal, full face, nasal pillows, and combination masks of different brands. As I always say – get the mask right and you are well on the way to successful treatment.

Our challenge is to keep up with the latest technologies. As you can see, Irene and I took the opportunity to try out a couple of masks. And yes, we do like to try them all out!



We always learn something new with these visits and enjoy increasing our knowledge in this ever changing area. I haven’t even talked about all the latest software programs out there to complement therapy, or the latest masks. Perhaps another time.

Lisa

Reflection

This year I have undertaken some additional study. The first few weeks have been a whirlwind of new experiences, not so much in the context of the content of the subjects but in the method of learning.

Firstly, the technology involved in studying has blown me away (lucky the practices has a strong emphasis on IT). As an off campus student I attend tutes through the university student website. With a headset and microphone I can hear the tutor and be involved in discussions with other students in my class. Geographically these students are from throughout Australia, with some international. The application allow students to move into different 'room' in cyberspace and for the tutor to roam between these rooms. Its just like being in a class room except you don't see anyone and don't need to leave home.Perfect!

Secondly, the major concept that has been emphasised is reflective learning. I've googled this with hundreds of thousand of hits and various definitions arising but my rudimentary understanding is that we reflect on what we learn thus leading to deeper learning. Sounds easy but the problem is often we rush forward to get to the next thing and this can be especially true in our work places.

As we talked about this further in last nights tutorial and I began to jot down points in my own reflective process i realised our workplace through this blog has its own reflective learning process.

Staff are encouraged to contribute to the blog. The fact that we all read it and learn from each other is fantastic but I think the process of us writing about what we do makes us delve a bit deeper and encourages us to be life long learners.

Jessica

Early intervention into COPD

Are you a smoker? If so, are you thinking of trying to give up but are putting the idea in the “Too Hard” basket? I wonder what President Obama is deciding to do about his Doctor’s advice to give up smoking as mentioned in Jess’s previous Blog posted 5/03/10 titled “Doctors advice to smokers”?

There are many very important reasons to quit, there are many resources out there that can help, and spirometry testing could help you be more motivated to stop smoking and to stay on track towards a healthier life.

Why would you try harder to stop smoking? The Quit websites are excellent resources to assist in all the steps of successfully stopping smoking. The national site: http://www.quitnow.info.au/ or the various state sites: give so much information to help you under the following categories: the reasons to quit, how to make a plan, putting your plan into action, and staying on track. They offer online Quit coaches and telephoning the Quitline. Various other pathways are available through Community Health Centres, Hospitals and others who offer Quit facilitators to assist you. Can these services be improved upon to become more effective?

My interest in this subject was tweaked by an article I read in the Primary Care Respiratory Journal, Volume 18 Issue 4 December 2009 titled “A feasible program for early intervention in patients with chronic obstructive pulmonary disease (COPD): a pilot study in primary care” Of 72 smokers aged 40-70 yrs who had spirometry testing, 30 subjects were diagnosed as having COPD (a high percentage). Of these only 21% reported airway symptoms as the primary cause for seeking help, which supports previous studies that show mild COPD may not always be associated with symptoms. These subjects were offered an intervention program for one year which involved a specially designed smoking cessation program and counseling programs on physical activities and diet. Of these subjects, 19 completed the whole 1 year program, and 9 of those (47%) stopped smoking. Of a smaller group of 16 out of the 42 smokers who did not have COPD and who completed the 1 year smoking cessation program only, 19 % stopped smoking.

The researchers concluded that the intervention program was feasible and effective with a very high smoking cessation rate in the spirometry-diagnosed COPD subjects. Because the smoking cessation rate was greater in the COPD group it suggested that the diagnosis itself was a motivating factor. These data also reinforced the importance of performing spirometry in smokers because early COPD can be asymptomatic and spirometry is the only way to detect the disease. The benefit from early detection is that stopping smoking is effective in preventing further rapid decline in lung function.

COPD is a major health problem worldwide, and in 2020 the World Health Organisation predicts that it will be the third most common cause of death. The National Lung Health Education Program in the USA recommends that smokers over the age of 45 should undergo spirometry irrespective of the presence of symptoms.

If you are a smoker, especially if you are aged 45 or over, does this give you more incentive to seek out medical help, have a spirometry test, see if you have the early stages of COPD, and get the help you need to give up smoking?

Heather

ANZSRS

2010 marks the 30th Annual Scientific Meeting of the ANZSRS (Australian & New Zealand Society of Respiratory Science). Regional Respiratory Medicine is generously sponsoring Heather and me to attend the Annual Scientific Meeting March 19th -24th in sunny Brisbane. The program looks interesting in that it looks back at the history of respiratory science and celebrates past achievements of the Society, but also looks to the future and ponders what challenges await us. The program will look at the past, present and future and cover such varied topics as the development in the recording of lung function measurements; the use of exhaled breath biomarkers; and a “clinical controversies” session on the pre-operative assessment using cardio-pulmonary exercise test, or the clinical utility of expired Nitric Oxide. The organizing committee has recruited some outstanding international speakers to provide input, educate and challenge us. We not only look forward to this opportunity to attend the meeting but also the opportunity to share the knowledge we gain with our team at Regional respiratory Medicine upon our return.

Vanessa

Nasal Irrigations

Even the sound of it may make one cringe a little but there is strong evidence that a saline nasal rinse can relieve, or decrease incidence of, allergy and sinus symptoms,

Allergies and infections can cause excessive mucous production from the nasal and sinus lining. This leads to symptoms such as a runny or stuffy nose or post nasal drip. An effective nasal rinse will wash away excess mucous and allergens such as pollen, dust particles, pollutants and bacteria, so reducing inflammation of the mucous membrane. Normal mucosa will fight infections and allergies better which will reduce or maybe even cure symptoms.

There are various nasal irrigation products on the market which fulfill this purpose. There are also some home recipes utilizing distilled, filtered or cooled boiled water, non iodized salt and bicarbonate of soda, which if mixed in the correct proportions performs adequately.

The main aim is to deliver enough volume of solution into a nostril so that it washes all in its path out of the nose through the other nostril. This is achieved by leaning over a basin with the head forward and to the side and gently instilling the recommended amount of saline solution into the upper nostril and allowing it to drain out the lower nostril. After gently blowing each nostril this procedure is repeated on the other side.

Sometimes the solution may continue to drain for some time after, so it is not recommended that you do this just before bed (or other important engagements) and prescription nasal sprays should not be administered until at least 30 minutes post irrigation for this same reason. The nasal rinse is usually prescribed once or twice a day.

It is best that nasal irrigations are recommended by a physician or ENT surgeon as they are not suitable for everyone. They are contraindicated for individuals who have an ear infection or completely blocked ears. For those who have had ear surgery medical guidance is necessary. The procedure is also not advised for young children, adults who have reduced comprehension, or debilitated or bed bound patients.
The procedure is often recommended to patients following sinus surgery.


In short saline irrigations are a quick, simple, well tolerated and cost effective option in the management of sinus disease, and may reduce the need for prescription drugs.

So if your physician recommends this treatment for you, don’t screw up your nose, it is for a good reason.

Irene

Measurement of Lung Volumes

More detailed assessment of lung function usually involves the measurement of the static lung volumes. These can be very helpful in sorting out restrictive and obstructive disorders. The most important measurements are total lung capacity (TLC), residual volume (RV) and functional residual capacity (FRC) which is the gas volume remaining in the lungs after the vital capacity (VC) has been exhaled. We are able to measure absolute lung volumes beyond the inspired and expired volumes measured by spirometry.

Several methods can accomplish this. Each method has its own advantages and disadvantages. The two dilutional lung volume methods, helium (He) dilution and nitrogen (N2) washout involve having the patient breathe gases or gas concentrations not normally present in the lungs whilst the third method uses the body plethysmograph to measure the volume of thoracic gas (VTG).

We are fortunate in our lab to have the “Gold-standard” measurement VMAX body plethysmograph which delivers precision engineering of the highest quality.

The body plethysmograph is a pulmonary function system consisting of a panorama glazed cabinet in which the patient sits during the test and a computer that controls testing and data output.

Our body box’s ease of operation, patient comfort and reliability will meet pulmonary function testing needs for years to come. The streamlined testing allows the scientist to focus on the patient.

FRC measured with the body plethysmograph (FRCpleth) refers to the volume of intrathorax gas measured when airflow occlusion occurs at FRC. The technique is based on Boyle’s law relating pressure to volume. Boyle’s law states that volume varies inversely with pressure if temperature is held constant. Measurement of FRCpleth is a complex procedure achieved by carefully instructing each patient in the required manoeuvres.

Plethysmography offers several advantages over other methods of measuring lung volumes.

1. VTG is not affected by the distribution of ventilation
2. Multiple measurements can be made quickly and averaged
3. and it provides a more accurate estimate of lung volumes in patients who have airway obstruction.

In general, the body box is regarded as the more acceptable technique, but is more demanding for the patient and more technically complex.

It is often useful to compare FRC values obtained by plethysmography with values obtained by gas dilution methods, particularly in patients with obstructive disease. The ratio of FRCpleth/FRCN2 or FRCpleth/FRCHE can be used as an index of gas trapping. This ratio is usually near 1.0 in patients with normal lungs, or even those with a restrictive lung disorder. Values greater than 1.0 indicate gas volumes detectable by the plethysmograph but hidden to the gas dilution techniques. This ratio has been used to evaluate candidates for lung volume reduction surgery.

Some evidence suggests that in severe airway obstruction, FRC may actually be overestimated when the plethysmographic technique is used. This occurs primarily because PMOUTH (measured when the shutter is closed) may not equal alveolar pressure if the airways are severely obstructed. Rapid panting rates aggravates this inaccuracy. Care should be taken that patients with spirometric evidence of obstruction pant at a rate of 0.5 – 1 HZ.

In the above photo of our plethysmograph in our Hamilton Lab you will also see four gas cylinders two are required for our gas transfer testing and the remaining two are gases used to calibrate the analyser and cross reference for calibration.

Also note the dual computer screen which is used with the cycle ergometer which you can just see the tip of at the right of the photo. I will showcase our cardio pulmonary exercise test next month.

Vanessa

Pneumothorax

Two weekends ago I was able to talk to a conference of local GPs gathered in Warrnambool. The brief was to discuss respiratory emergencies around a scenario that involved a hypothetical bus crash. Amongst other conditions we discussed management of pneumothorax.

Management of a traumatic pneumothorax is something which I am generally very happy to leave in the hands of the surgeons. Spontaneous pneumothorax is much more in my ball-park.

Spontaneous pnemothoraces – where the surface of the lung develops a ‘blow-out’ type of air leak, and the lung – as a consequence – collapses are considered as either:
- primary (no underlying lung disease) or
- secondary (underlying lung disease)

Management is different for the two different sorts of patients. The British Thoracic Society guidelines published in 2003 are excellent. They simplify evaluation of spontaneous pneumothorax, so that we differentiate in addition to the above discriminators (primary or secondary) predominantly only on whether the pneumothorax is small (less than 2cm rim between the lung edge and the ribs) or large (more than a two centimeter rim). Once that discrimination has been made, the acute management will follow along the lines indicated in the following flow charts:

Note that conservative management is very seldom pursued if the pneumothorax is secondary.

Once the emergency management plan has been implemented, the question is whether to refer for surgical treatment – either resection of blebs on the lung surface or pleurodesis (usually done videoscopically). There is around about a 40% risk of pneumothorax after the first spontaneous pneumothorax. The following is a fair list of indicators for referral for surgical intervention / referral
- second ipsilateral (same side) pneumothorax
- first contralateral (other side) pneumothorax
- bilateral spontaneous pneumothorax
- persistent air leak once a chest tube has been inserted (>5-7 days of tube drainage, air leak persist or lung has failed to fully re-expand)
- spontaneous haemothorax
- professions at risk – eg pilots, divers – where a recurrence would be disastrous.

Andrew

What is organic-dust toxic syndrome?

Two weeks ago, for five days, the National Centre for Farmer Health, which is based in Hamilton and affiliated with Deakin University, ran a five day Agricultural Health and Medicine course.

I spoke on the first day of the course about respiratory disease affecting farmers. There were two aspects of the talk I considered to be blog-worthy.

The first is ‘Organic dust toxic syndrome’ (ODTS). This is an entity about which I was entirely naïve until I began to practice in the Western District and read about occupational hazard facing farmers.

Organic dusts are those inhalable particles that arise from grains, and also from animal dung when it is dried and crushed – for example, under foot in a stock yard on a dry day. They contain multiple potentially hazardous compounds, but perhaps the most significant (and most prevalent) is endotoxin. This fragment of gram negative bacteria is thought to be very significant in inducing immune system inflammatory response, and a key mediator of illness in life-threatening gram negative sepsis.

Farmers, grain workers, swine handlers (enclosed livestock environments are particularly hazardous) may inhale this substance. If they do, then it can act in the airways to induce an acute inflammatory response. The resultant illness – ODTS – is ‘flu like’ and, I am sure, often misdiagnosed as such. The key is that there will usually be a history of massive exposure to inhaled organic dusts; for example, a particularly dry and busy day at the stockyards or silo with a lot of dust in the air. If many workers had the same exposure then many of them will likely to be sick at the same time. It resolves, like the flu, over several days but will recur after similar repeated exposure.

A good description of ODTS, along with a comparison of the less common ‘Farmers Lung’, is found on the University of Missouri website. I am concerned that this entity is common, but often misdiagnosed as viral illness or pneumonia, and remains therefore as a hidden, significant occupational hazard for agricultural workers. Those of us who provide care to such workers – particularly GPs – need to be aware of it and ask the appropriate occupational questions.

The second thing I wanted to share was the following graph from the Sustainable Farm Families research.

This research used the Piko6 device as a sort of spirometer (it measures FEV1/FEV6 rather than FEV1 over FVC) to obtain lung function measures from farmers. If the ratio was below 75% then it was reported as 'poor' lung function. Note the discrepancy between dairy farmers and other farmers - with five to seven percent more farmers in cropping, cattle and sheep ventures having ‘low’ lung function when compared with dairy farmers. This needs to be teased out further, but does lend one to suspect that there are less respiratory toxins in dairy farms than in other farming environments in our district.

Andrew

Now practicing at our new rooms at 2/14 Crouch Street, South Mt Gambier

After some time our desire to have our own practice in Mt Gambier has reached fruition and we commence consulting and lung function testing there on Wednesday 10 March.

We identified that our patients in the Mt Gambier region were keen to have Dr Bradbeer consult on a more regular basis and in Mt Gambier. We are also keen to provide a service to our patients reflective of that which they receive in our practice at Lonsdale Street in Hamilton.

We are currently consulting and performing lung function testing on Wednesdays, from 10am to 4pm and over the next few months expect to secure the services of another physician who will also consult at the Crouch Street South practice. Further to this, we are taking steps to have a nurse in attendance for consulting; we will keep you updated on the progress of this service.

To make appointments, please continue to contact our Hamilton office on 1800 184 828. Until we increase our hours at the new practice, Crouch Street South will only be contactable by phone on Wednesdays from 10am to 4pm.

Payments can be made during our office hours on Wednesdays or posted to PO Box 573 Hamilton Vic 3300. To ensure we receive the payment please do not leave at any other location.

There are 4 car parks at the back of the premises which are clearly identified as Regional Respiratory Medicine.

If you have any questions relating to the new practice please phone us and we will gladly take your inquiry.

Maureen

Doctors advice to smokers

I was prompted to write this blog for a couple of reasons.
The first was Heather and I had been discussing the role of spirometry for all smokers over 45 years old. This can show signs of early COPD and be a powerful incentive to quit. A few years ago now I worked as a quit facilitator and in the courses a peak flow meter and norms for their age were used as a means to show smokers the damage they were doing.

The second was that in the news this week Barack Obama latest medical was made public (apparently the public has a right to this normally confidential information as the status of his health may affect the way he governs). One of the pieces of advice that has given to the leader of the USA by his doctor was to quit smoking (it was a little know fact that he smoked).

A study by the Centre for Behavioural Research in Cancer that was prepared for Quit Victoria looked at Doctors advise to their patients about smoking: 2004.

Previously research has demonstrated that advice from health professional, even during brief interventions can be effective in encouraging quitting smoking.

Since the introduction of guidelines under the five A's model (Ask, Assess, Advise, Assist and Arrange) it was reported that advice to stop smoking increased from 11% to 37% (between 1990-1998).

The 2004 report looked at the experiences of smokers and those who had recently quit who had visited the Gp in the last 12 months; whether their doctor asked about their smoking behaviours and if so whether they were given advice to quit and if on receiving this advice it was associated with attempts to quit and motivation to quit.

The results showed that 73% of Victorian adults, who were either current smokers or who had quit within the past 12 months, were asked by their GP whether they smoked. Smokers aged between 30-49 years (75%) and those who smoked 15 cigarettes or more per day were most likely to be given advice on ways to quit smoking by their GP.

Respondents were most likely to be recommended to cut down their smoking (57%) and also given information regarding the use of NRT (30%), followed by other advice (21%). Advice to call the quit line was given to only 13% of respondents.

The respondents that received advice were more motivated to quit with over half reporting they were seriously considering quitting in the next 6 months, compared with those who had not received advice.

It is evident smokers are being asked about their smoking status and that advice from a GP has a demonstrated impact on making at least one quit attempt and increased motivated to quit smoking. It will be interesting to see what impact Obama's doctors recommendation will have on his smoking status.

Jessica