Originally published: September 2017
Key learning points
- It is important to achieve and maintain a patient’s overall asthma control and not just the current symptom control
- Asthma patients need to be reviewed at appropriate intervals and not just treated for acute attacks
The key to avoiding unscheduled care due to asthma is logically to reduce the incidence of asthma attacks. It is useful to extrapolate lessons from research on patients who have died from asthma when trying to improve management of this condition in the future. Repeated key findings in the UK over the last five decades include a failure by health professionals, carers and patients:
- To recognise and act on danger signals
- To implement evidence-based management detailed in studies and guidelines
- To adequately monitor and control the disease with medication
- To educate patients and to manage and follow up after treatment of acute attacks.1
Many of those who have had attacks, including the majority of those who have died from asthma, had evidence of poor control, risk factors for future attacks and symptoms that had been present for days or weeks before the attacks.
Two issues are key to preventing attacks and keeping patients out of hospital: achieving and maintaining asthma control, and reviewing asthma patients at appropriate intervals.
There may be are two misconceptions or false beliefs by health professionals caring for people with asthma, which are largely due to the UK Quality Outcomes Framework (QoF).
Many health professionals believe that:
- Simply asking patients whether their asthma is currently causing symptoms is a complete assessment of asthma control; this is certainly not the case!
- Asthma reviews only need to be performed once a year; yet doctors do not rely on only one assessment a year for any other chronic disease.
Achieving and maintaining control of asthma
Simply asking the three Royal College of Physicians questions (ie presence of cough, wheeze, or limited activity due to asthma) or even the validated asthma control test (ACT) is not a full assessment of asthma control. This sort of assessment serves to establish a patient’s current symptom control and not their overall asthma control. In addition to assessing current symptom control, it is essential to also establish the presence of any current or past risk factors for future attacks, including a history of previous attacks (and emergency attendances or admissions), food allergy or occupational risks, usage of excess short-acting reliever medication, as well as overall stability and level of lung function (peak expiratory flow or spirometry).
Anyone with risk factors of future attacks or evidence of poor current or overall control, or severe asthma, should be assessed by a clinician with appropriate asthma experience. If this persists despite treatment then an expert opinion should be sought to confirm the diagnosis and advise on treatment.1,2
Review the patient at appropriate intervals
Asthma is defined as a chronic, ongoing disease. However, it is often treated as if it were an acute illness. For example, many patients are simply treated for their acute attacks – usually but not always with short courses of oral corticosteroids – and then sent home without any follow up. As a result many are re-admitted to hospital or seen again soon for emergency care.
One way to establish good control of asthma is to perform a thorough post-attack review before the patient runs out of oral corticosteroids, in order to:
- establish whether the attack is over and, if not, to extend the course of oral corticosteroids or to refer the person to an specialist
- identify and deal with those factors that contributed to the attack.
Contributing factors include poor inhaler technique or not taking or not having been prescribed sufficient preventer medication. In particular, failure by parents to collect prescriptions for preventer medication, in the author’s view, constitutes a child safeguarding alert, a serious matter, and should be addressed as such and actively managed.
In the author’s opinion, these two areas of asthma management by all those caring for people with asthma could drastically reduce attacks and therefore unscheduled care.
Dr Mark Levy is the respiratory lead at Harrow CCG, clinical lead on the National Review of Asthma Deaths (2011-2014), a member of the acute section of the BTS/SIGN guidelines and board member of the Global Initiative on Asthma (GINA).
- For assessment of asthma control & severity and identifying risk factors of future attacks: See Chapter 2: www.ginasthma.org
- For useful resources for management of children with asthma: www.healthylondon.org/children-and-young-people/london-asthma-toolkit
- For a childhood asthma attack audit – which helped reduce admissions in Harrow, NW London by 18% in 2016/17: endasthmadeaths.wordpress.com/about/childhood-asthma-audit
- For lessons from asthma death studies: Appendix 9 Literature review of key findings in asthma death confidential enquiries and studies: www.rcplondon.ac.uk/file/882/download?token=57KGtGd3
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