Key learning points:
- The asthma annual review should be meaningful to the patient rather than a tick-box exercise
- All patients should receive a personalised, asthma action plan that is supported by regular professional review
- Patient education and inhaler technique should be offered at every encounter
Complete the asthma CPD module here.
Giving the correct treatment for asthma can mean the difference between patients managing the chronic condition or struggling with it long term. At their first review, the patient may still be symptomatic and finding it hard to cope with day-to-day activities. Of course, asthma cannot be cured, but with good education and tailored treatment based on inhaler technique and therapy optimisation, patients can improve and become symptom-free. However, this takes time and may require a number of consultations before the patient gains good control.
Asthma deaths in the UK increased by 20% between 2007 and 2016,1 and to tackle this healthcare professionals need to start looking at asthma care differently. We need to engage with our patients and use every consultation as an opportunity to educate them about good asthma management, reducing the risk of fatal exacerbations in the future.
Patients often learn to live with asthma without realising they have poor control. They may avoid certain situations they know trigger their asthma; for example, sports, exercise, or playing with their children. At the first consultation, it is important to explain to the patient that their asthma review is to assess their asthma control, and that you want to work with them to improve their asthma management. They may also wake at night but see this as ‘normal’ rather than the exception. It is imperative that annual asthma reviews are useful consultations and not just tick-box exercises.
A good asthma review should ensure patients and carers have a good understanding of basic asthma care. It should be based around:
- Inhaler technique.
- Lung function.
- Adherence, including use of oral corticosteroids, overuse of SABAs, and poor compliance with preventative therapy.
- A personalised asthma action plan (PAAP).
Children should have their height and weight measured. Research has looked at the growth rates of asthmatic children over a four-year period and found that, on the whole, children’s growth was not affected by asthma. But those who were on high-dose inhaled corticosteroids and used hospital services were found to be shorter and lighter than their contemporaries.2 Children who receive regular oral corticosteroids may be overweight.3 Children who are obese should be encouraged to lose weight.
Asthma control is best assessed using a validated questionnaire rather than broad non-specific questions. The Royal College of Physicians RCP3 questions or the Asthma Control Questionnaire (ACQ) are both readily available and simple to use, although the ACQ does require lung function to be measured.4,5 Be prepared to act on the results of the questionnaire as completing an assessment of asthma control without following this up with the patient is both meaningless and frustrating for the patient. If poor control is ascertained, start back with the basics:
- Check adherence: look at the patient’s repeat prescription history.
- Do they not like, or struggle to use, their inhaler?
- Do they understand the importance of their treatment?
- Do they pay for their prescriptions, and would they benefit from a pre-payment certificate?6
- Do they have asthma triggers and know what they are?
- Do they have an underlying comorbidity contributing to their poor asthma control, such as allergic rhinitis? If other comorbidities are identified, ensure the patient receives suitable treatment and is referred to the GP if necessary.
- Is there an occupational element to the poor asthma control? If occupational asthma is suspected, consider a referral to a specialist.
All patients should have the opportunity to have a PAAP as they will be four times less likely to be admitted to hospital than if they do not have one.7 This is supported by the latest BTS and NICE guidelines.8,9 The plans should be based on either:
- Peak flow readings.
- A combination of both.
There are numerous management plans available, including ones from Asthma UK.10 All management plans should be individualised to each patient and include instructions on regular treatment and any additional treatment that may be prescribed; for example, nasal steroids, antihistamines, etc.
PAAPs should also include clear instructions on treatment during an exacerbation and when to start oral steroids as rescue treatment. Advice should also be given on how to administer rescue SABA treatment and when to seek medical advice during an asthma exacerbation.
If your patient has a smartphone, you could suggest they take a photograph of their PAAP on their phone and save it for emergency use. BTS recommends that primary care practices have adequately trained healthcare professionals and an environment conducive to providing supported self-management.8
Management plans should be available in alternative formats for other languages. Management plans adapted for those who are illiterate or who have learning difficulties should also be available. These plans can be picture-based and should concentrate on changes in symptoms and increased rescue inhaler use rather than peak flow. Resources are available from Asthma UK (see resources).
An acute consultation is an opportunity to look at how well the patient used their management plan and whether it needs refining.
When patients present in primary care with an upper respiratory tract infection or other known asthma trigger, it should be used as an opportunity to go over their self-management plan with them and discuss what to do if their asthma is deteriorating.
Consider every encounter with your patient as an opportunity to educate and reinforce the importance of using their preventative treatment, update their management plan if necessary, and check their inhaler technique.
Checking a patient’s inhaler technique is the most important part of the asthma review. Inhaler technique should be checked at every consultation and advice given if technique is poor. If the patient’s technique does not improve after education, consider changing their device. One study looked at inhaler technique and found that 53-59% of patients could use a dry power inhaler (DPI) and 23-43% could use a metered dose inhaler (MDI) correctly.11 The use of an MDI did improve to 55-57% when using a spacer. As you can see from the figures, your patients probably think they are using their inhaler correctly but in most cases are not.
It is also important to measure a patient’s inspiratory effort. There are many devices to choose from, but the In-Check Dial12 is very effective and reasonably priced. It is worth discussing with your patient what their inspiratory effort is like when they have an asthma attack, particularly if using a DPI or MDI without a spacer. Some patients may find it useful to have a SABA MDI and be taught how to use 10 puffs of SABA in a spacer for emergency use. This is at least as good as a nebuliser in mild to moderate asthma exacerbations.13
If you have explored all other possibilities for poor asthma control and there is still a problem, consider increasing the patient’s treatment. Both BTS/SIGN (2016)8 and NICE (2017)9 have published guidance on the treatment of chronic asthma. PCRS-UK (2017)14 has published a briefing document on both guidelines. You may also need to consult your local pharmacy guidelines to assist you in your clinical decision-making. Guidelines are, however, just that and are not written in stone. If the next treatment option does not feel right for your patient, then look at what other treatment options are available instead. Patients should be on asthma therapy that works for them and that they are willing to use.
A cheaper treatment option is only cheap if the patient uses it and it works. Always ensure that any new treatment is explained to the patient, inhaler technique is demonstrated and an explanation is given as to how the new treatment fits in with any previous medication. For example, is this an add-on therapy or to replace a previous treatment? Ask the patient to repeat back to you their new treatment regime and ensure their PAAP is updated accordingly.
It is also important to explain to the patient what the common side effects are, what to do if they have any, and how quickly the new medication may take to be effective as, for example, it can take anywhere from a few days to a few weeks for the anti-inflammatory effect of an inhaled corticosteroid (ICS) to reach maximum effectiveness, depending on the severity of inflammation in the lungs. From personal experience, in clinical practice, when patients understand that treatment may not afford a quick result they are more likely to persevere with it. Arrange to review the patient following any changes to treatment. Consider the risk of future exacerbations, and if in doubt ensure your patient is on an ICS as a minimum preventative treatment.
Review appointments are also a good opportunity to discuss what your patients can do in terms of their lifestyle to improve their asthma, such as smoking cessation and weight loss. Smoking cessation advice during your consultation is paramount. We know that ICS is less effective in those who smoke.15 Smoking causes irritation of the small airways and increases the patient’s likelihood of having an exacerbation. The increased risk of chronic obstructive airways, lung cancer and ischaemic heart disease is well known.16 Weight loss in asthmatics can improve overall asthma control,17 although weight loss can be difficult for those on oral corticosteroids. Patients should be offered NRT as it increases a patient’s chances of quitting.18 Patients can be referred to a local weight-loss programme or smoking cessation group (see resources).
All patients who are on the asthma register should be seen at least annually. Patients may require a further follow-up appointment if poor control is noted or treatment changes are made at the initial review. If patients have good control it may be possible to step down their treatment. If stepping treatment down, ensure patients know to contact the surgery if they notice deterioration in their asthma control. There are certain groups of patients that will require more frequent routine appointments than once a year. These include: those with mental health/alcohol/drug issues (also children whose parents have mental health issues or have a chaotic home life), patients with other chronic comorbidities, those with learning disabilities, those with poor lung function and those patients who attend out of hours or A&E for their asthma.8
If your patient is requiring numerous courses of oral steroids or continues to have poor asthma control despite your best efforts, consider an alternative diagnosis. Could this be bronchiectasis or COPD? Consider performing further tests, such as spirometry, or referring them to secondary care for further testing; for example, high-resolution CT, and specialist treatment such as targeted monoclonal antibody therapy.
Sonia Greenwood is the lead asthma nurse specialist at Royal Derby Hospital
Complete the asthma CPD module here.
- Asthma UK. Asthma facts and statistics. London;AsthmaUK
- C Mc Cowen etal, Effect of asthma and it’s treatment on growth: four year follow up of cohort of children form general practice in Tayside, Scotland; ncbi.nlm.nih.gov/pmc/articles/PMC284741
- BNF/NICE. Prednisone side effects. BNF on line; bnf.nice.org.uk/drug/prednisone.html#effect
- Horne D. Asthma annual reviews should include RCP ‘three questions’. Buckinghamshire; M GP:2012
- EF Juniper, PM O’Byrne, Guyatt GH, et al. Development and validation of a questionnaire to measure asthma control. Eur Respir J 1999;14:902-7
- NHS Business Services Authority. Prescription prepayment certificates. Newcastle upon Tyne; NHSBSA7.Adams RJ, Smith BJ, Ruffin RE.
- Factors associated with hospital admissions and repeat emergency department visits for adults with asthma. Thorax 2000;55:566-73
- BTS, SIGN. QRG 153 British Guideline on the Management of Asthma. Edinburgh;BTS/SIGN:2016
- NICE. NG80: Asthma – diagnosis, monitoring and chronic asthma management. London;NICE:2017
- Asthma UK. Resources: Written asthma action plans. London;Asthma UK:2017
- Brocklebank D, Ram F, Wright J, et al. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess 2001;5:1-149
- Alliance Tech Medical. In-Check DIAL G16 Inhaler Technique Training and Assessment Tool. Texas;Alliance Tech Medical:2016
- Cates CJ, Crilly JA, Rowe BH. Holding Chamber versus nebuliser for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2006; CD000052
- Primary Care Respiratory Society UK. PCRS-UK briefing document – Asthma guidelines. Solihull;PCRS-UK:2017
- Thomson NC, Spears M. The influence of smoking on the treatment response in patients with asthma. Curr Opin Allergy Clin Immunol 2005:5;57-63
- NHS Choices. What are the health risks of smoking? NHS Choices; nhs.uk/chq/Pages/2344.aspx?Category/D=53
- Asthma UK. Could weight loss help your asthma? asthma.org.uk/advice/living-with-asthma/weight-loss/
- World Health Organisation. Tobacco Free Initiative who.int/tobacco/quitting/en/
Asthma UK – asthma.org.uk/for-professionals/
British Lung Foundation – blf.org.uk/health-care-professionals/blf-professionals
Smoke Free/local smoking cessation services – nhs.uk/smokefree/help-and-advice/local-support-services-helplines
NHS Weight loss Support groups/services- nhs.uk/Service-Search/Weight-loss-support-groups/LocationSearch/1429