Author: Dr Mark L Levy

I am a part time family doctor with a strong interest in the care of people with asthma. I have authored or co-authored over 165 papers in peer review journals (https://orcid.org/0000-0002-1807-3246), and co-authored 6 books on asthma and was the Clinical Lead for the UK National Review on Asthma Deaths (NRAD). Following the NRAD I have decided to devote much of the rest of my career to educating health professionals and people with asthma with the aim of eradicating asthma attacks, and therefore preventable deaths due to this common disease.

An Asthma Attack is a Medical Emergency

Introduction

Public information on First Aid for Asthma should be widely available. An asthma attack is a medical emergency. It should be taken very seriously. Asthma attacks are also known as flare ups or exacerbations. When someone has an asthma attack, many people don’t know when or at what stage to call for emergency help. In the UK National review of asthma deaths (NRAD), nearly half of those who died had not called for or got help when they were dying.  

In the NRAD 45% of those who died did not get medical assistance

We will never know why those people did not get medical assistance when they were dying from an asthma attack. Clearly many had not been provided with an asthma self management plan. However, even some with a plan and still they did not call for help. I think it may have been because they were not clear when they should have called for help.

Personal asthma self management plans need improvement

Clear instructions on calling for emergency help not often included

Many plans do not clearly state when emergency assistance for someone having an asthma attack is needed. Personal asthma action plans (PAAPs) provide information on asthma. Including its medication, how to recognise danger signs and what to do in asthma flare ups. However, most plans include information on when to call for help. Listen to my podcast on emergency help for people with asthma and members of the public here also available on spotify and Apple Podcast platforms.

One size does not fit all – Asthma education should include details on

  • What asthma is and how it causes problems for you
  • What triggers (or sparks off your asthma attacks)
  • What is your treatment, how does work in simple terms, and when you should take it.
  • You need to know how to use your inhaler.
  • How do you know when your asthma is going out of control or flaring up.
  • What do you need to do when it does flare up and of course what medication to take.
  • You also need to know when to worry and when you need to call for medical assistance.
  • Most importantly you need to know when to call for emergency help.  

Therefore provision of asthma education to prevent flare ups needs expertise!

People with asthma need lots of information on their disease. For that reason training, expertise and sufficient time is needed for anyone delegated to teach patients. Expertise is needed to provide asthma self management plans for patients and parents of children with asthma. The tasks listed above do not all have to be provided by one individual. For example, inhaler technique could be taught by a pharmacist who has had training.

Different personal asthma plans should be tailored to individual needs

In the UK most general practice computer systems have only one template for personal asthma plans. As I have noted in this blog, ‘one size does not fit all’. One single ‘off the shelf’ template of a personal asthma management plan cannot contain all the information needed to manage every patient’s asthma. To put it another way, I think there should be a suite of different asthma plans each with a different purpose. Some examples of different plans are:

  • A general asthma self management plan for children or for adults and adolescents
  • A plan for Maintenance and Reliever Therapy (MART), see here for a description and an example.
  • A plan for ‘As Needed Anti-inflammatory Reliever (AIR) Therapy’, see example
  • A ‘Three step Asthma Plan’, see example

So there are many different types of asthma management plans!

A special plan – First AID for asthma flare ups

General training on first aid is widely available. In addition training in resuscitation is available in fact its compulsory for all health care professionals and key people in organisations. However, Asthma First AID training is not widely available for asthma – an asthma attack is a medical emergency. Its important to realise that asthma is the commonest chronic childhood disease and affects about 7% of adults. Asthma attacks could and do happen in public places. It follows that First Aid Training for managing asthma should be compulsory for organisations, schools and public recreation facilities.

Examples of Asthma FIRST AID posters and plans:

Some examples of First Aid for Asthma are shown below. Easily accessible information is needed to enable a member of the public to assist them. Specific features needed in an Asthma First AID plan- the australian one is an excellent example

  • National Asthma Council Australia, link here. There is one for adults and adolescents, and one for children under 12. The under 12 one includes use of a spacer with and without a mask.

An example of an Asthma First Aid Plan for children which includes use of a spacer with and without a mask

Reproduced with permission from the (c) National Asthma Council Australia. https://www.nationalasthma.org.au/asthma-first-aid accessed 5th September 2023

An example of First Aid information for members of the public to assist a child under 12 who is having an asthma attack. (c) National Asthma Council Australia, reproduced with permission

An example of an Asthma First Aid Plan for Adolescents and Adults

Reproduced with permission from the (c) National Asthma Council Australia https://www.nationalasthma.org.au/asthma-first-aid accessed 5th September 2023

An example of First Aid information for members of the public to assist an Adult or Adolescent over 12 who is having an asthma attack. (c) National Asthma Council Australia, reproduced with permission

Carers and parents should be provided with clear emergency instructions

Clear specific indications for calling for emergency help for someone having a severe asthma attack should be available for anyone responsible for day to day care of people with asthma. This also applies to the workplace, schools, public recreation facilities.

Conclusion

When to call for emergency help for a life threatening asthma attack

An asthma attack is a medical emergency because this is a signal that something serious has gone wrong. So anyone who has had an asthma attack needs a detailed assessment, in other words a post-attack asthma review by someone trained to do so. The purpose of the review is to identify any modifiable risk factors and deal with them to prevent future attacks.

Clear instructions are needed

Identify the red flags for emergency asthma assistance. In my view this should be very clearly stated in all asthma self management plans and Asthma First Aid Posters and infograms. My ‘Top 3 List’ of red flags below could be used in addition to any advice from the patient’s own doctor. The problem is that someone having a severe asthma attack may not have any of the signs or symptoms associated with severe attacks – so call for medical help if at all concerned about an asthma flare up!

  1. The short acting reliever (usually blue ie salbutamol, albuterol, terbutyline) should last for at least 4 hours – So the first thing the plan should state is: I need emergency help if my blue short acting reliever is not helping my symptoms or if I need it again within 4 hours.
  2. Next, waking due to cough, wheeze, breathing difficulty and shortness of breath is a danger sign. So next, I need emergency help if I’m waking up at night with cough or wheeze or shortness of breath
  3. Many people have their own Peak Flow Meter and if you have one: I need emergency help if my peak flow rate falls below 60% of my best : Enter best x 0.6 =        (l/min)

 

Then the additional item on this emergency plan should be about what you tell the emergency services: What you tell them will determine how rapidly emergency assistance is dispatched:

Information to include: That the person has asthma; say if they have breathing difficulty;  and to say if they are waking because of asthma; say if the reliever is not working; and if they can do Peak Flow, what their reading is now and what their best reading is.

How to recognise an asthma exacerbation (attack)

Asthma attacks can be dangerous

Early warning signs or symptoms of an asthma exacerbation (asthma attack) include cough, extra use of reliever inhaler, difficulty breathing, wheezing, or difficulty sleeping because of these symptoms. Asthma Control test (ACT)score below 20 also indicates a possible exacerbation or attack. Asthma attacks can be very severe and dangerous. They can flare up without warning. Early warning signs of an asthma attack must be recognised both by patients and doctors to prevent deterioration This applies to patients and health care professionals.

Asthma is a chronic ongoing disease

Asthma is an ongoing chronic disease and what happens is that there are times when people with this disease are very well, and others when it flares up. These flare-ups can be very sudden or they can develop slowly over weeks.

Acute sudden asthma attacks are easy to diagnose

When someone with asthma suddenly becomes short of breath, which may include wheezing (that is a whistling nose coming from the chest) most people with asthma and most doctors will recognise this and make the diagnosis. In these circumstances treatment will usually be started quickly.

Asthma awareness is needed to recognise gradual onset attacks

Clinical awareness of asthma by doctors and attention to detail is necessary to diagnose an asthma attack that is developing slowly. It can take a few weeks sometimes for an attack to develop.

Asthma expertise essential in primary care and ED/A&E

Asthma is a very common disease. Therefore anyone working in Early warning signs of an asthma flare up include new difficulty breathing, wheezing and coughing. Doctors often get caught out because asthma attacks can develop slowly. So its essential that any doctor (or nurse) who sees patients in primary care or in emergency departments should know how to diagnose an asthma attack that is developing. See information on asthma here.

Diagnose asthma flare-up until proved otherwise

Any patient presenting with increased use of their reliever inhaler, cough, wheeze, or shortness of breath is developing an asthma attack until proved otherwise. Detailed history and lung function measurement is essential – take asthma seriously. Waking at night and failure to respond to bronchodilator reliever and fluctuating peak flow help facilitate early diagnosis.

By the time wheezing is heard FEV1 has dropped up to 30%

A common mistake made by health care professionals is that they rely on their stethoscope to assess severity of asthma. The problem is that by the time wheezing is heard with a stethoscope there may be up to 30% obstruction of airflow. 1, 2,3,4,5,6 So the terms ‘mild wheeze’ or ‘slight wheeze’ are misleading and provide a false sense of reassurance for clinicians. Much more important to measure lung function (spirometry or Peak Expiratory Flow (PEF) and respiratory rate. Most importantly, during a severe attack there may be no abnormal findings – so the medical history and lack of response to reliever medication are essential to take note of.

  1. Spence DP, Graham DR, Jamieson G, Cheetham BM, Calverley PM, Earis JE. The relationship between wheezing and lung mechanics during methacholine-induced bronchoconstriction in asthmatic subjects. American Journal of Respiratory and Critical Care Medicine. 1996;154(2):290-4. Link
  2. Springer C, Godfrey S, Picard E, Uwyyed K, Rotschild M, Hananya S, et al. Efficacy and safety of methacholine bronchial challenge performed by auscultation in young asthmatic children. Am J Respir Crit Care Med. 2000;162(3 Pt 1):857-60.
  3. Sanchez I, Avital A, Wong I, Tal A, Pasterkamp H. Acoustic vs. spirometric assessment of bronchial responsiveness to methacholine in children. Pediatr Pulmonol. 1993;15(1):28-35.
  4. KOH YY, CHAE SA, MIN KU. Cough variant asthma is associated with a higher wheezing threshold than classic asthma. Clinical & Experimental Allergy. 1993;23(8):696-701. Link
  5. Noviski N, Cohen L, Springer C, Bar-Yishay E, Avital A, Godfrey S. Bronchial provocation determined by breath sounds compared with lung function. Arch Dis Child. 1991;66(8):952-5.
  6. McFadden ER, Jr., Kiser R, DeGroot WJ. Acute bronchial asthma. Relations between clinical and physiologic manifestations. N Engl J Med. 1973;288(5):221-5.

Evolving asthma attacks need aggressive treatment

Increase corticosteroid treatment – inhaled or orally – should be initiated soon as possible to avoid an attack developing.

Self-Management plans should include how to recognise attacks

People with asthma must be taught that onset of cough, wheeze, shortness of breath or difficulty breathing are early warning signs of a developing exacerbation or attack. This would help patients prepare for consultations for uncontrolled asthma. It is extremely helpful for a clinician if a patient brings recordings of lung function (Peak Flow, spirometry) and also details of symptoms in the last few weeks (Ideally the results of an ACT (Asthma Control Test) and a record of the number of times the reliever has been used and how effective it has been. This information will help both patient and doctor (or asthma trained nurse) in deciding on treatment for the attack.

Pressurised asthma inhalers and the environment

Pressurised asthma inhalers contribute very little to global warming

There is a lot of pressure for doctors to prescribe dry powder inhalers rather than pressurised dose inhalers – this is potentially harmful and may increase contribution to global warming. The reason for this advice is to protect the environment; however asthma inhalers contribute very little (less than 0.1%) to global warming. Furthermore, someone who cannot use a prescribed inhaler there is a risk of having an asthma attack. The downside is that treatment of asthma attacks then contribute substantially to global warming. So simply switching people from pressurised inhalers to dry powder types without ensuring they can be used correctly is potentially harmful for the environment.

There are two main kinds of inhalers

Pressurised metered dose inhalers (pMDIs) and dry powder inhalers (DPIs). The pMDIs contain propellants called Fluorinated Gasses (F-Gasses). F-gasses contribute to global warming, however the pMDIs contribute less than zero point one percent (<0.1%) of global warming potential.  Our GINA Lancet paper discusses future risks posed for people with asthma because of new regulatory proposals to limit availability of F-gasses for medical use.

There is an environmental crisis

The UK Government announcement that new oil drilling licences are being considered and last year an announcement was made on the news that a new coal mine is to be opened in the UK. However, peoples lives are potentially being threatened by recommendations to change people’s asthma inhalers ‘to save the planet’.

 Discussion to reduce use of pMDIs

There is currently a lot of discussion about the environment and the effect of the F-Gasses on the potential for global warming. These F-Gasses are used mainly for industries such as those in air conditioning and heat pumps, and a very small proportion of these gasses are used as propellants in pressurised metered dose inhalers (pMDIs) used for treating lung diseases like asthma and chronic obstructive pulmonary disease (COPD).

 Inhaled medication is essential for people with lung disease

Ensure people can use their inhaler correctly

These inhaler devices are necessary and in fact essential for controlling the symptoms of these lung diseases and for preventing attacks that can lead to hospitalisation and sometimes death. So it is essential that people are shown how to use their inhaler correctly and this cannot be done if these are switched without a face to face consultation.

 Not everyone can use all of the inhaler devices

Many people, including doctors and nurses, cannot use inhaler devices correctly. Therefore the patient’s needs should be the first consideration when changing from a pressurised inhaler to another type. As the pressurised inhalers contribute very little to global warming clinicians should think carefully before switching someone to a device they cannot or will not use.

 Many people argue that doctors should be prescribing dry powder inhalers(DPIs)

Doctors are encouraged to prescribe dry powder inhalers (DPI), instead of pMDIs.

 Lifestyle versus life-saving argument

This switch from pMDIs to DPIs is justified by statements comparing the global warming effect of a pMDI with a journey by car or aeroplane. For example see the advice from NICE, see here.

 The unintended consequences of switching people inappropriately to inhalers they cannot or don’t want to use

One of the main risks of people not using their inhaler correctly is that they may have an asthma attack/exacerbation/flare-up – which could be life threatening.

Treating asthma attacks contribute to global warming
Global warming impact of treating an asthma attack

 Treatment of asthma attacks have consequences for global warming

 The arguments for switching inhalers from pMDI to DPI do not include unintended consequences such as asthma attacks and the global warming potential resulting from their treatment.

Estimates derived from one paper :

 Example calculation of the effect of an asthma attack on the environment: (with help from Patrick Henry Gallen)*

  • Average number of days spend in hospital per asthma discharge in the UK: 3.4 (OECD 2018)
  • Number of asthma-related hospitalisations in the UK: 94.6 per 100,000 population = ~63,694 hospitalisations (OECD 2018)
  • Average CO2e for newly registered vehicles: 121.3 g/km (Department for Transportation 2015)
  • Hypothetical journey: 16.09 km/10 miles (5 miles to and from hospital)
  • Hypothetical number of journeys and visitors: 2 visitors visiting twice

Example of Global warming potential due to treating an asthma attack

  • 507.8 kg CO2e per hospitalisation
  • 32,343,813 kg CO2e / 32343.8 tonnes CO2e per year due to asthma hospitalisations in the UK

 Note that this model does not into account emissions related to a possible outpatient trip prior to hospitalisation or emissions related to inhaler usage and other devices or maintenance/manufacturing thereof (e.g. O2/nebulisers).

Further evidence of hospital care of an asthma attack and its contribution to the environmental footprint: see https://link.springer.com/article/10.1007/s11367-021-01998-8 which concludes “The ICU generates more solid waste and Greenhouse Gasses (GHGs) per bed day than the acute care unit. With resource use and emission data, sustainability strategies can be effectively targeted and tested. Medical device and supply manufacturers should also aim to minimize direct solid waste generation.”

Choose the right inhaler for the patient

Our our GINA Lancet paper makes it clear that the patients needs must be prioritised when choosing an inhaler.

Global initiative for asthma inhaler choice figure
Inhaler selection – first ensure what is best for a patient

Conclusion

When considering prescribing inhalers for asthma the most important thing is to select one that the patient likes and can use properly. One of the consequences of getting this wrong is that the person may have an asthma attack which may be very serious. In addition the treatment of an asthma attack contributes adversely to global warming.

  • I was priveledged to work with Patrick on the severe asthma index of the Copenhagen Institute for Futures Studies

Asthma information for all

Information to control asthma , prevent asthma attacks and deaths:  Updated  June 8th 2023

Dr Mark L Levy FRCGP: @bigcatdoc ; @ginasthma

People with asthma can ensure they keep safe by learning as much about asthma as possible. In this way you can learn what questions to ask your doctor and what you could expect for your or your child’s asthma care. Health care professionals of course need access to the most up to date information to keep their patient’s asthma well controlled in order to prevent attacks.

This page contains information and links to resources and publications on asthma. There is a podcast that explains the rationale and use of this information and you can listen to the podcast as well as my other podcasts on asthma at: https://bigcatdoc.com/podcast-asthma-spotlight-2/ and on spotify and Apple Podcasts

Examples of innovative implementation to improve asthma care:

National and International Societies for people with asthma:

International Patient associations:

Self management plans to help control asthma to prevent attacks and hospital admission.

Monitoring and checking your asthma control:

Specialist Medical Societies: These societies all work to improve the health of people with asthma (and other diseases)- many of their events and educational videos and materials are accessible online . Some of these also have patient working groups and patient representatives.

International professional respiratory / asthma organisations:

Patient resources from GINA and specialist societies available in Individual countries: These ones listed are those that I’m aware of that have patient representatives or resources for people with asthma

Guidance and Guidelines to control asthma to prevent attacks and hospitalisation

Some examples of Country specific Asthma Guidelines on diagnosis, control, treatment and asthma self-management:

Further Reading and some lectures / webinars:

  • National Review of Asthma Deaths (NRAD) – this was a review of asthma deaths during the year from February 2012 in the United Kingdom. A panel of 176 doctors, nurses and pharmacists with expertise in asthma were tasked with assessing the medical records to determine if i) These people had evidence of asthma; ii) If these people died from asthma and iii)  if there were any lessons that could be learned from these sad cases: https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
  • This is a link to a half hour webinar I did on the post attack review – if you have had an asthma attack, it means that something serious went wrong and therefore by listening to this talk that was intended for health care professionals, you can find out what to expect, and to ask for when you attend your doctor for a check-up or review after you had an attack
  • Chapter on acute asthma: SIGN/BTS 158 (2019) https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ (Ch 9) – this was last updated in 2019, and the chapter on acute asthma is helpful for assessment by health professionals and also for people with asthma (and parents of children with asthma)
  • Article summarising GINA 2022 recommendations – intended for General Practitioners and General physicians and Paediatricians – and may be useful for people with asthma to understand how some treatment decisions are based on evidence and used by doctors: https://www.nature.com/articles/s41533-023-00330-1
  • JACI Paper on MART- this is an article explaining Maintenance and Reliever Treatment for asthma which also includes a link to a MART self management plan : https://www.jaci-inpractice.org/article/S2213-2198(21)01128-4/fulltext

Training Resources on Asthma for doctors and nurses:

UK Resources:

Press

Correct use of inhaler images can help to educate people with asthma and health care professionals. The blue reliever inhalers are NOT intended for regular use – they are for emergency use and for temporary relief of symptoms. For royalty free images available from IPCRG click here

Occupational Asthma – some resources:

Asthma and other conditions

Anaphylaxis:

End asthma attacks- Post attack Review

There have been at least  4 asthma deaths in children and young people in London recently. Asthma attendances at the ED and Urgent Care Centres are increasing and there is considerable variation in hospital admissions throughout the United Kingdom. Furthermore the UK has the highest number of childhood asthma deaths in Europe and third highest overall in the high income countries world wide. These stats are shocking despite the fact that the UK has Nationally produced guidelines (SIGN/BTS and NICE) and free access to medication for children.

While there are local pockets of evidence based care for asthma there has been no clear national directive to implement the NRAD recommendations.

It seems that little has changed nationally  in asthma management in the ten years following the National Review of Asthma Deaths. What on earth is going on??  In essence, we don’t seem to have learnt any lessons from past research by implementing change in practice in managing asthma. This was so clearly illustrated in the tragic cases of Michael Uriely, who died from asthma at the age of 9 years and Sophie Holman who died at age 10   and also Kalila Griffiths  who died age 24. The coroner’s regulation 28 statement (on a potentially preventable death) is published on the Chief Coroners website at https://www.judiciary.gov.uk/publications/michael-uriely/ .

In my view, the UK asthma guidelines while very detailed, are not user friendly and very out of date. While it great for academics to read about specific research findings, jobbing, busy GPs and nurses need very clear simple advice. In particular related to post attack reviews.

An asthma attack is a signal that something serious has gone wrong – an urgent review to identify modifiable risk factors and optimise care is needed.

The post attack review has two aims.

i) To determine whether the attack is over

ii) to identify modifiable risk factors and optimise care to fix these. A list of modifiable risk factors is available in Box 2-2 in the GINA Strategy document at https://ginasthma.org/reports/   and are also discussed in my Asthma Spotlight Podcast: see  youtube https://t.co/mYvVZ4qGf7, Asthmaspotlight, https://apple.co/3Eo2OjR

Please also see my lecture on this topic at: https://www.pcrs-uk.org/resource/demand-webinar-keeping-people-asthma-safe

 

Pulse Oximeters overestimation in dark skinned people

What is an oximeter

Pulse oximeters are unreliable in dark skinned people. I learnt some worrying news at the 2022 Winter British Thoracic Society meeting . This relates to pulse oximeters that are in common use to assess people with heart or lung diseases. These are the small devices that fit on a fingertip measure the amount of oxygen circulating in the bloodstream. These devices measure the oxygen level by shining a light through the fingernail.

Oxygen is essential for life – how are levels measured in your body

Two methods are generally used to measure oxygen levels in the blood. One is by using a pulse oximeter described above, and the level is summarised as SpO2. The other method is by measuring arterial blood gas by drawing a small ammount of blood from an artery (usually in the arm) and this measurement is depicted as SaO2. The arterial blood gas (SaO2) being the more accurate measurement. So the ‘gold standard’ measurement of blood oxygen levels is by arterial blood gas measurement – however this is an invasive test involving an experienced person taking blood from an artery and then taking it, packed in ice, quickly to a laboratory or a machine in a hospital ward if available to do the measurement. The reason why pulse oximetry has become so popular is that its very convenient and patients as well as health care professionals and assistants can easily do the measurements.

The function of the lungs is to get oxygen from the air into the blood via the lungs, and also to expel (get rid of) carbon dioxide which is harmful if it builds up in the body. Pulse oximetry only measures oxygen levels while arterial blood gas measures both oxygen and also carbon dioxide levels and the latter is therefore more reliable in determining if someone is going into or in respiratory (or lung) failure.

Usually when a person is well, the oxygen readings are between 95 and 100%. When someone is unwell, for example with a lung disease like pneumonia or during an asthma attack, doctors usually get concerned if the readings drop down towards and below 94% and they get very worried if these are below 91%.

Now, Ive always been aware that the pulse oximetry readings (SpO2) can be slightly innacurate and also that the readings may be very inaccurate if someone has nail polish. However, what I knew a little about, but not how serious, was the size of the inaccuracy is in people with dark skins.

Oxygen levels are misleading in people with dark skins

The problem in everyone, irrespective of the colour of their skin, is that the pulse oximetry level is always higher than the true arterial levels. is that the readings may be falsely high in people with dark skin. There has been some research that shows that the difference between the true oxygen level in the blood (SaO2) and the pulse oximetry reading (SpO2) in dark skinned people can be as high as 11.7% compared with those with white skin which can be 3.6%. One study showed that the mean over-estimate of oxygen saturation is 1.4% ( 95% Ci +0.5 to +2.3) in people with non-white skin compared with white skin. What this means in real life is that there is a big risk that doctors may underestimate the severity of oxygen depletion in dark skinned people if they only rely on pulse oximetry.

Possible dangerous implications of reliance on oximeters alone

This has implications for people having asthma attacks and therefore, medical personnel as well as people with asthma need to be taught not to ONLY rely on pulse oximetry levels when deciding on the severity of an asthma attack (or severity of pneumonia or other conditions that result in reduced blood oxygen levels). Other measurements need to be taken into account, for example in the case of asthma, symptoms (cough, wheeze, shortness of breath, or difficulty breathing) respiratory rate, peak expiratory flow (PEF) or FEV1 with a spirometer, as well as pulse rate and blood pressure, And Therefore, if there are signs of worsening asthma despite ‘normal’ SpO2 people with asthma should seek medical assistance.

Conclusion

When assessing a patient with dark skin, be aware that pulse oximetry will overestimate the true blood oxygen level (the arterial oxygen level). Therefore – dont only rely on the pulse oximetry reading when assesing a person having an asthma attack (or a chest infection). Use the clinical history, other vital signs (NB Respiratory rate, pulse, blood pressure), other indictions of respiratory failure (drowsiness, altered breathing, cyanosis) and response to treatment. Also refer early to a specialist and test the arterial oxygen level early in people with dark skin and pulse oximetry readings of 94% and lower.

Comment on the NICE,SIGN,BTS Guideline scope: Asthma: diagnosis, monitoring and chronic asthma management

Comment on the NICE,SIGN,BTS Guideline scope: Asthma: diagnosis, monitoring and chronic asthma management.

Dr Mark L Levy FRCGP, 28.9.2021 Clinical Lead NRAD 2011-2014 (CV at http://www.consultmarklevy.com)

  1. The key problems related to asthma care and the comparatively bad UK asthma outcomes worldwide have not been addressed by this scoping document. These relate to quality and consistency of care within primary and secondary sectors as well as the interface between these and the tertiary care sector.  The issues have  been detailed in a number of  UK reports of note the NRAD (2014), the APPG report (2020), the HSIB report (2021), the NACAP results as well as in the HM Coroners Regulation 28 reports on Ella Kissi-Debra,Tamara Mills, Michael Uriely, Sophie Holman and countless others (published on HM Chief Coroners website). Furthermore the NICE QS 25 published in 2013 made a number of recommendations that are still valid. (the shortened version cut this down innapropriately in my view). To date only one of the NRAD recommendations (the NACAP) has been implemented and one has to ask whether the new guidelines will have any requirement for change in the management of asthma.
  • We have seen during the SARS-COV-19  pandemic how our brilliant UK scientists have addressed and dealt with problems as they arose. So it would make far more sense, in my view, rather than relying solely on past  published material intended for other purposes (including regulatory studies), to pose the key problems related to asthma care in the UK, for our scientists to address; perhaps using an adaptive type of design that so quickly and effectively identified how best to treat Covid-19 in the ICU. We were able to solve problems so quickly, and collectively during the pandemic, so its hard to reconcile this with our inability in 50 years, to make a difference to the lives of people with asthma.
  • Unfortunately, in my view, this update only due in 2023, which will still result in two separate UK guidelines for asthma will not address the key issues related to poor asthma outcomes in the UK, particularly disjointed management where quality of patient’s care is subject to a postcode lottery, unacceptably high rates of admissions poor quality of life, preventable deaths due to asthma, the process of asthma care, the lack of appropriately trained personnel the care across the interface, and particularly dealing with the particular problems patients experience due to a lack of joined up thinking and approach.
  • Einstein said insanity is doing the same thing over and over again and expecting different results. The new guideline process is like just shuffling the deck chairs on the titanic rather than jumping ship and starting afresh. We have shown in many publications (starting with the one by the GPIAG soon after publication of the first UK asthma guideline – British Medical Journal. 1993;306:559-62) that guidelines are not adhered to, so we need to adopt a new approach regarding their presentation. It’s time for different approaches and questions that might yield different/ improved outcomes rather than rehashing the same PICO questions over and over again.
  • The key questions (particularly related to diagnosis, FeNO and Spirometry) have in the main been answered by the NHLBI update (2020), and the 2021 GINA update, so its difficult to justify the time until 2023 by reconsidering these questions and expecting different conclusions. This planned review will no doubt utilise previously published data and by 2023, that will all be out of date. Similarly the questions on drug treatment have also been recently dealt with and updated in these two publications. One large gap in the planned revision relates to the management of  so called mild asthma which affects about half of the asthma population. In particular the overwhelming evidence in favour of ICS-formoterol in reducing severe attacks compared with using SABA currently advocated by NICE and SIGN/BTS. This is one area, in my view, that requires an urgent decision by this group in keeping with the NICE statement that recommendations may be made outwith current regulatory status of medications. (40 countries worldwide have advocated this approach as a population safety measure to reduce moderate and severe attacks in people aged over 12.
  • The major problems with the list of key questions on diagnosis seem to be the failure to accept that there is no single diagnostic test for confirming asthma coupled with the fact that asthma is defined as a disease characterised by variable respiratory symptoms and variable airflow obstruction. So relying on a single test of lung function (spirometry or PEF) for diagnosis is simply ludicrous. The NICE feasibility study showed that less than 30% of people diagnosed with asthma had abnormal spirometry.  So to expect GPs (or secondary care) to do serial spirometry  in order to pick up variable airflow obstruction cannot work – so why persist with the question. Similarly, guidelines all over the world have concluded that FeNO alone cannot help in diagnosis – what’s needed is a clinician with the skills to incorporate the history, response to treatment as well as the tests to make a diagnosis – so how will a string of statements in response to this long list of questions help a generalist to make a diagnosis?
  • The omission of severe and difficult to treat asthma from the scope is also a major flaw in my view. These patients t contribute significantly to the burden and cost of asthma in the UK – so why are they not being addressed. Similarly, the fact that asthma is a chronic condition requiring constant monitoring and adjustment of treatment when poorly controlled (ie risk factors like attacks as well as symptoms) is an indication that the key recommendation in NRAD ie referral to specialists after 2 attacks, plus a detailed post attack review should be done. The latter to assess and act if the attack is not resolved, as well as identification of modifiable risk factors which should be dealt with. 
  • In my view, our aim should be to eradicate asthma attacks (and deaths) through a completely new national approach akin to that used in Finland would be a more appropriate method for solving our UK asthma situation. This should include a personalised asthma management cycle as described in GINA (the assess, adjust, review ongoing cycle)  which addresses issues related to diagnosis, identification and dealing with modifiable risk factors, patient preferences & goals, optimisation of management (not just drugs, but also education and inhaler technique) as well as appropriately timed review (not just an annual ‘ how’s your asthma’ check-up.
  • So instead of wasting a lot of specialist’s time in tinkering with the current guidelines by answering these PICO questions, which don’t really address the needs of people with asthma in the UK, we would do far better by starting with a clean sheet and trying to address the problems related to asthma care in the UK.  Furthermore, by ensuring we implement bundles of care, such as the recently published NHSE CYP Bundle starting immediately, we may achieve better outcomes.
  1. NHLBI 2020: https://www.jacionline.org/article/S0091-6749(20)31404-4/fulltext
  2. NRAD
  3. APPG report 2020
  4. HSIB report 2021
  5. Coroners Regulation 28 reports (eg Tanmara Mills, Michael Uriely, Sophie Holman, Ella Kissi-Debra  etc)

https://www.england.nhs.uk/publication/national-bundle-of-care-for-children-and-young-people-with-asthma/

Keeping safe -some information for people with asthma

Corona Virus infection and asthma

This information is based on my personal views – intended for people with asthma – and to be used in addition to advice from the persons own doctor (this advice is not intended to replace that from your doctor – its to be used in addition)

Virus infections can cause asthma to go out of control and may result in asthma flare-ups or attacks. The current situation with Corona Virus could put people with asthma at risk. While Corona Virus infection (COVID19) is mild in most people, about 15% of those who have been infected for example in Italy are more severe. About half of these people need hospital admission and some will need intensive care treatment.

People with underlying diseases, like asthma,  are more at risk of having a bad Corona Virus infection. Therefore, it is really important for people with asthma, and carers or parents looking after people with asthma to make sure that medical advice is followed. This includes making sure that preventer medication is taken as prescribed by the doctor – usually twice a day in the case of Inhaled Corticosteroid medication.

If the spread of the COVID19 in the UK follows what’s happening in other countries like Italy, it is possible that people will not be able to get appointments to see a doctor face to face. Therefore it is really important to make sure you know as much as possible about your asthma to enable you to keep safe . This includes knowing the difference between regular, preventer medication and the releiever medication used for symptoms (cough, wheeze and shortness of breath). Most importantly, preventer medication should be taken regularly, as advised by your own doctor.

Two types of inhaled medicines are used for asthma:

  • Controllers / Preventers – these are inhaled Corticosteroids
  • Relievers: These are
    • Short acting (usually blue) – salbutamol or terbutaline
    • Long Acting – Formoterol and Salmeterol

The Controller / preventer inhalers contain inhaled corticosteroids and these must be taken as advised by the doctor. Usually this means taking the inhaler;er twice a day, sometimes people are advised to use this once a day. In some cases, SMART, or MART treatment is advised – this is where the inhaler contains an  Inhaled Corticosteroid and a particular long acting reliever called  Formoterol – in these cases, people will be advised by the doctor to use the inhaler twice a day, and also for relief ( ie rather than the blue short acting reliever) – because this is regarded as safer than just using the Blue inhaler for relief.

Recognising when asthma is going out of control:

Asthma is an ongoing (chronic) disease that is prone to flare ups/ attacks.  There are three main danger signals to be aware of: These are the need to use the blue reliever inhaler; low or dropping Peak Flow Readings and Low or dropping oxygen saturation levels.

  1. Needing to use the blue inhaler for symptoms

If asthma is flaring up, symptoms like cough, wheeze (whistling noise conning from the chest), and shortness of breath/difficulty breathing occur.  When this happens, it is important to use the prescribed reliever (either blue inhaler, or combined Inhaled Corticosteroid-with Formoterol) and this should improve the symptoms. If the relief from a blue inhaler doesn’t last more than 4 hours – medical advice or urgent help should be sought.

2.  If the Peak Expiratory Flow reduces, or is dropping

It is advisable to ask your doctor for a prescription for a Peak Flow Meter. This instrument is used to measure your PEAK Flow – – you need to blow as hard as you can into the meter – and it measures how much air you camn blow out; in other words it measures how tight your air passages are.

In order to know if your airways are tight, you fist need to know what your best (or normal) Peak Flow is. To find this out – you measure your peak flow  (best of three) twice a day for a few weeks while you are well and the highest readings represent your normal or best.

If you get symptoms and your peak flow has dropped by 20% from your best (multiply the best reading by 0.8) then your ashthma is going out of control. If the readings continue to drop, or if they go below 60% of your best, you should seek urgent medical assistance. If the Peak Flow reading has dropped below 30% of the best/normal reading – this is a very serious situation and urgent medical assistance should be sought.

3. If you have severe asthma, or are prone to severe attacks – buy an oximeter 

A pulse oximeter placed on your finger measures the amount of oxygen that is getting through your lungs to your blood. If the reading is below 92% the asthma attack is very serious and urgent medical assistance should be sought.

 

So the key messages are:

  • Take controller / preventer medication regularly
  • Seek urgent medical assistance/ advice if:
    • Short acting reliever is not helping, or if you need to use this more than twice a week
    • Peak Flow is dropping
    • Oxygen Saturation (if you have an oximeter) is dropping

More information available at:

Asthma UK /BLF – UK: manage-your-asthma  ; asthma

My website  for an example of a  self management plan: player.html

New report on asthma severity by Asthma UK

While I welcome the fact that Asthma UK (https://bit.ly/2muKIFh)  have drawn attention to the fact that patients with severe asthma are not well managed in the UK,  however, I am surprised that the authors failed to cite the well known findings of the American Thoracic Society/European Respiratory Societytask force findings on asthma control and exacerbations where the terms ‘control’ and ‘severity’ were defined and accepted in an official statement by the two organisations. (1) In the UK due to the Quality Outcomes Framework, the basis for general practitioners pay, it has become standard practice to simply assess a patient’s asthma once a year, where they are asked about current symptoms – not a good basis for assessing control in a chronic disease defined by fluctuations in symptoms and airflow obstruction from day to day throughout the year!

The report also fails to acknowledge that the international Global Initiative in Asthma (GINA) (2)  Strategy document which is used as the basis for national guidelines in most countries in the world. GINA has since 2009 included a definition of asthma severity and control (the latter includes both current symptoms and future risk of attacks) ; where asthma severity is defined as the amount of treatment needed to maintain control (including the risk elements eg of previous attacks – Table 2-2 GINA many of these risk factors are included in Table 11 SIGN/BTS 153).  (3)

Furthermore, the report states in conclusion that it is “worrying that, four years later, many of the problems identified in the NRAD report (4) have not been addressed”. In fact it’s not worrying, it is incomprehensible! Deaths due to asthma continue at a higher level than most developed countries (5) and is the highest for childhood asthma in Europe.  (6) Of the 19 (NRAD) recommendations only one has been partially implemented nationally. The NRAD found that (similar to findings in the last 50 years) risk of future asthma attacks was not recognised, that patients were undertreated and that guidelines were not followed. Furthermore asthma severity (31% of the deaths were considered severe) was empirically defined without reference by clinicians at that stage to the only published definitions of severity detailed above.

I agree that there is a need to define severity and to accurately determine the numbers of patients with true severe asthma so they can be adequately treated, however, there is an equally pressing need to optimise therapy and management of all people with asthma by implementing the other 18 NRAD recommendations. By optimising treatment and management to include ensuring every person with asthma has a personal asthma action plan, such as the excellent one produced by Asthma UK, and also by identifying risk factors (2-4) and including their presence in defining asthma control (2) rather than simply asking patients how they are once a year, we may then progress towards reducing asthma attacks and identifying and quantifying the levels of asthma severity in the UK.

  1. Reddel HK, Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW, et al. An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med. 2009;180(1):59-99. https://www.atsjournals.org/doi/full/10.1164/rccm.200801-060ST
  2. The Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA).2018 http://www.ginasthma.org.
  3. British Thoracic Society, Scottish Intercollegiate Guideline Network. SIGN 153 – The British Guideline on the Management of Asthma. 2016 [Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/
  4. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report Royal College of Physicians. London; 2014 https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
  5. Global Asthma Network. The Global Asthma Report 2014. 2014. Available from: http://www.globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf
  6. Wolfe I, Thompson M, Gill P, Tamburlini G, Blair M, van den Bruel A, et al. Health services for children in western Europe. The Lancet. 2013;381(9873):1224-34.

Asthma Admissions: Inherent Bias in favour of Hospitals & Urgent Care Centres

 

One of the major problems in the United Kingdom is the cost of preventable recurrent treatment for people with asthma attacks in hospitals, Accident & Emergency Departments (EDs) and Urgent Care Centres.

Commissioners actively encourage General Practitioners to reduce admissions however, it is not in the interest of the providers, simply because they will lose income. That is possibly one of the major reasons that up to 10% of adults and 15% of children and young people are readmitted or re-attend for emergency care for asthma within 6 and 12 weeks of treatment. Similarly, downward pressure on GPs to prescribe expensive preventer medication for asthma results in increased attacks and secondary care utilisation – so savings in prescribing are translated into increased unscheduled care costs.

Sadly, successive governments have failed to tackle this problem by persisting with allocation of separate  budgets to the primary & secondary care sectors. This is also due to the loss of the ‘National’ in the NHS. Instead of a centralised, long term forward plan for managing health care, we have to undergo major wasteful change every time a new Minister for Health is appointed.

It really is time for change! My suggestions:

i) Stop paying Hospitals, A&E Departments and Urgent Care Centres if patients re-attend for asthma exacerbations within 4 weeks. ii) Lets have a referendum – ‘ Politicians IN or OUT of the National Health Service’