By definition asthma is a chronic, ongoing disease prone to intermittent flare-ups requiring treatment. Yet the National Review of Asthma Deaths (NRAD) and more recent deaths due to asthma (such as the case of Tamara Mills described in this Blog) have demonstrated that asthma is being treated as if its an acute, short lived disease.
Most asthma attacks are preventable and more importantly are a signal that something has gone wrong and that the person’s chronic underlying asthma is not being adequately managed.
Attacks are often treated as isolated events without follow-up or optimisation of chronic treatment. What often happens is that patients suffering from asthma attacks or flare-ups are prescribed a fixed period of corticosteroid tablets (for 3, 5 or 7 days) without arranging a review in two working days, as stipulated in the BTS/SIGN Guideline. The problem being that no one knows how long an asthma attack will last, and without a review before patients run out of the corticosteroid tablets, the high numbers of re-admissions and re-attendances for persisting attacks will continue.
Asthma reviews are intended to provide opportunities for clinicians to assess current control as well as the risk of future attacks and to optimise treatment to gain control and reduce risk of future attacks.
In the UK, meeting the requirements of the Quality Outcomes Framework, which provides a proportion of GPs pay, includes an annual asthma review. Unfortunately, many clinicians interpret this single annual review as sufficient for monitoring people with asthma. As asthma is a chronic relapsing disease, this is a ludicrous assumption – people with asthma should be reviewed more frequently, at least every time treatment is changed and certainly after an attack or flare-up.
A thorough asthma review opportunistically, after attacks, and also at regular intervals provides a method for maintaining control of the disease and ending asthma attacks, and deaths.Post attack reviews have long been recommended, within two working days after the attack irrespective of where this is treated (ie by the patient, in the GP surgery or in hospital or emergency departments).
- to assess current control; and also
- to find out what went wrong, to establish whether there are any risk factors for future attacks and most importantly to optimise care
It is really important to understand that current symptom control – i.e presence of daytime or night-time symptoms, or limitation of activity due to asthma (as measured by using the RCP 3 Questions or similar instruments) – only provides a clinician with information on how the patient’s asthma is currently controlled at the time of the assessment. While it is clear that someone who has got current asthma symptoms is at risk and needs urgent optimisation of treatment, the converse is not true.
Someone who has good current asthma control (no symptoms or limitation of lifestyle) may still be at risk of future attacks and as recommended in the NRAD, and the GINA Strategy document – Table 2-2, and the BTS/SIGN Guideline – Table 11, risk must be assessed during a review, as a component of the overall assessment of asthma control .
Examples of risk factors include identification of triggers (such as food allergy), pregnancy, obesity, requirement for excess reliever bronchodilator medication, low FEV1, poor inhaler technique, the need for 3 or more asthma treatment types, a previous attack, a previous life-threatening attack.
Asthma is a chronic ongoing disease and therefore, treatment should not be limited to managing attacks & flare ups. Treatment must be optimised in those people with poor control, as well as those with good control who also have risk factors for future attacks (detailed in BTS/SIGN, GINA and NRAD – and which include recent attacks; excess reliever use; inadequate preventer use; poor inhaler technique; comorbidities like obesity, allergic rhinitis & food allergy; pregnancy and a past history of a life threatening attack.