Category: Chronic Management of Asthma

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.

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

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/

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’

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.

How long does an asthma flare up take to resolve?

No one knows how long an asthma attack lasts

No one knows how long an asthma flare up lasts. Asthma flare ups are also known as asthma attacks or an asthma exacerbation. Asthma exacerbations and hospital admissions can be prevented by anti-inflammatory treatment. Well controlled asthma should not flare up.

Doctors often treat attacks for a fixed time period

No one knows how long an asthma attack takes to resolve. However health professionals often treat attacks as if they do! Most asthma guidelines recommend oral corticosteroid treatment for attacks. The UK SIGN Guideline states very clearly that these corticosteroids should be continued until the attack resolves. From my knowledge, most people are treated for attacks with fixed corticosteroid courses of 3, 5 or 7 days. How do these doctors & nurses know the attack will be over in 3, 5 or 7 days?’

Oral corticosteroids should be continued as long as an attack lasts

According to the United Kingdom (BTS/SIGN) Asthma guideline section on treatment of acute asthma attacks/ Flare ups / exacerbations:

  • In Adults: Continue prednisolone (40–50 mg daily) until recovery (minimum 5 days).
  • In Children: Treatment for up to three days is usually sufficient. But the length of course should be tailored to the number of days necessary to bring about recovery. Tapering is unnecessary unless the course of steroids exceeds 14 days.

So the key message is that oral corticosteroids should be continued until the attack is over. The excellent acute asthma section (chapter 9) in the 2019 version of the BTS/SIGN Guideline is essential reading. To download it click here.

How to tell if an asthma attack is over

It may take days or weeks for an asthma flare-up to resolve. An asthma flare up or attack is over when a person is free of symptoms. An asthma attack is not over yet If rescue reliever medication is needed. When the Peak Expiratory Flow or Spirometry has returned to the patients usual best level the attack is over. Therefore treatment for attacks should continue until the attack has resolved.

Asthma is a chronic ongoing disease – not an acute disease

Asthma is a chronic ongoing disease, nonetheless it is often treated as if it is an acute illness. The attack is usually treated very well although, surprisingly, a large majority of these people are not followed up for a review to identify and deal with any modifyable features.

An asthma flare up or attack means something has gone wrong

Someone whose asthma is appropriately treated with preventer medication, should be free of attacks, and therefore an attack signals a failure of treatment. In addition, asthma attacks are a well known risk factor for future attacks and therefore people are most vulnerable after an attack.

It follows that clinicians should aim to ensure that after asthma attacks are resolved that any modifiable factors are identified and dealt with to try and prevent another attack. Listen to my asthma podcast (second from bottom) here. This is one of the two main purpose of a post attack review.

Post asthma attack reviews

The purpose of the post attack review is:

i) to assess the progress of the current attack to determine the need for treatment. Including:

  • assessing current symptoms for example using the Asthma Control Test (ACT),
  • requirement for reliever treatment,
  • night time symptoms including waking due to asthma
  • lung function (Peak Flow or spirometry).
Peak flow chart showing when an attack was over
Peak flow chart showing resolution of an asthma attack. This woman presented for the first time with an asthma attack. I did not know what her normal peak flow was so we used a peak flow chart to inform us when it would be safe to stop her oral corticosteroids

ii) to identify modifiable risk factors causing the attack and optimise care. Modifiable risk factors include:

  • failure by doctors to prescribe controller medication (mainly inhaled corticosteroids);
  • failure by patients to refill prescriptions for controller medication,
  • excess reliever prescriptions and over-reliance by patients on these.
  • For more information on modifiable risk factors see GINA Table 2-2 and Table 11 (page 82)  in the BTS/SIGN Guideline).

More details on post attack reviews here.

Conclusion

Keep patients safe and reduce GP’s workload by using post attack reviews to maintain asthma control.

An asthma attack signals something needs to change. Identifying modifiable risk factors and dealing with them will reduce future attacks. This will help to prevent asthma flare ups, hospital admissions and avoidable deaths. When should post asthma attack reviews be done? Ideally before the oral corticosteroids run out or within a week. Many primary care colleagues argue that this is not feasible due to heavy worlkload. A practical solution is to simply block off one appointment every afternoon for a post asthma attack review. If not taken up by midday it could be used for another patient that day.