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.

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

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’

Asthma is not an acute disease

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.

Asthma reviews:

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

PostAttackReview

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.