Abstract

Studies in adult patients have suggested that 30% of those diagnosed with asthma do not have the condition and it is likely that the diagnosis is missed in many others. Initial clinical assessment should explore symptoms of wheeze, breathlessness, chest tightness and cough. The probability of asthma is increased if more than one of these symptoms is present and particularly if symptoms are worse at night and in the early morning or are exacerbated by triggers such as exercise, allergen exposure, cold air or drugs. The BTS/SIGN guideline advocates spirometry after taking the history. If airflow obstruction is present, a trial of treatment can commence, but a firm diagnosis also requires a symptomatic response and an improvement in the measured airflow obstruction. The FeNO level correlates well with airway inflammation, and is therefore a good indicator of asthma and in particular of the likely response to inhaled corticosteroids. The test is especially useful for patients with suggestive symptoms but normal spirometry. The cornerstone of asthma monitoring is a structured clinical review conducted in primary care on at least an annual basis. Health outcomes are improved by education in self-management, incorporating written personalised asthma action plans. Checking concordance with existing therapies and inhaler technique before escalating treatment is an important part of improving the pharmacological management of asthma. Any patient prescribed more than one short-acting bronchodilator device a month should be identified and have their asthma assessed urgently and measures taken to improve overall control.

There are 5.4 million people with asthma in the UK,¹ representing a significant disease burden for patients and a substantial workload for both primary and secondary care. Effective treatment is available and only a small proportion of those with asthma have treatment-resistant, difficult asthma. However, asthma still causes significant morbidity, and occasional mortality, related to inadequate management of the disease. This is highlighted in the National Review of Asthma Deaths, published earlier this year,² and it is clear that more needs to be done to provide optimal care for patients with asthma. To this end, NICE published a quality standard for asthma in February 20133 and BTS and SIGN co-published an updated guideline on the management of asthma in October 2014.⁴

Diagnosis in primary care

Perhaps the most challenging aspect of asthma management is getting the diagnosis right. Studies in adult patients have suggested that 30% of those diagnosed with asthma do not actually have the condition⁵ and it is likely that the diagnosis is missed in many others.

Asthma is diagnosed principally on clinical history and relies on careful recognition of a characteristic pattern of symptoms and signs. Initial clinical assessment should explore symptoms of wheeze, breathlessness, chest tightness and cough. The probability of asthma is increased if more than one of these symptoms is present and particularly if symptoms are worse at night and in the early morning or are exacerbated by triggers such as exercise, allergen exposure, cold air or drugs.

Although the history can be sufficiently classical as to leave no diagnostic doubt, it is advisable to try to obtain objective evidence to support the diagnosis.

The hallmark of asthma is airflow obstruction varying over short periods of time, and traditionally this has been explored by asking the patient to make serial measurements of peak expiratory flow. Unfortunately, this is a very insensitive test. The BTS/SIGN guideline advocates spirometry after taking the history, and this is now widely available in primary care. If airflow obstruction is present, a trial of treatment can commence, but it is important to note that the diagnosis should not be regarded as confirmed at this point.

A firm diagnosis also requires a symptomatic response and an improvement in the measured airflow obstruction.

Normal spirometry does not exclude the diagnosis of asthma and the BTS/SIGN guideline suggests that further investigation may be needed at this stage. The tests performed will depend on the likelihood of asthma versus other diagnoses.

The diagnosis section of the BTS/SIGN guideline was not updated for the 2014 version, but if it had been, we think it highly likely that measurement of FeNO (fractional exhaled nitric oxide) would have been recommended, particularly for patients with suggestive symptoms but normal spirometry. FeNO is measured via a simple breath test, using equipment which is becoming increasingly cheap and available, see figure 1. The FeNO level correlates well with airway inflammation, and is therefore a good indicator of asthma and in particular of the likely response to inhaled corticosteroids. NICE has advocated the use of FeNO measurement in a recent appraisal of the technology⁶ and we believe it is likely to become a widely acceptable test for asthma over the next few years. 

Other tests are available including sputum eosinophil measurement and tests of airway hyperresponsiveness. Experience with these measures is limited to specialist respiratory centres and at present they are only likely to be performed here, although it has been questioned whether they should be more widely employed. If they help establish an accurate diagnosis more quickly, they may be cost effective. NICE is due to publish a full guideline on asthma diagnosis late in 2015 and it will be interesting to see how these newer tests feature in their diagnostic pathway.

Monitoring in primary care

The cornerstone of asthma monitoring is a structured clinical review conducted in primary care on at least an annual basis. The importance of this annual review is highlighted in both the NICE quality standard for asthma³ and statistics from the National Review of Asthma Deaths:² 43% of those who died had no evidence of an asthma review in the previous year and 77% had no personal asthma action plans.

Furthermore, there was evidence of excessive prescribing of reliever medication and underprescribing of preventer medications.

The specific factors to be monitored and recorded in primary care are highlighted in box 1.

Monitoring in primary care also enables identification of patients whose asthma is suboptimally controlled, prompting review of their medication and escalation of their management as appropriate.

Supported self-management

Health outcomes are improved by education in self-management, incorporating written personalised asthma action plans. The BTS/SIGN guideline⁴ cites numerous pieces of evidence of benefit, yet they remain woefully underused. There are several different personalised asthma action plans, including an excellent free version from Asthma UK, see figure 2.

Key factors for successful plans are:

• The plans should be simple, with only two or three action points

• The action points should be personalised to the individual

• The actions themselves should be clear and easy for the patient to implement when required

They should be offered to all patients with asthma.³

It is also recommended that any acute consultation for asthma should be taken as an opportunity to reinforce or refine the patient’s self-management strategy and to review adherence to long-term asthma treatment.

Pharmacological management

The fundamental approach to the pharmacological treatment of asthma remains unchanged in the updated BTS/SIGN guideline and is based on a stepwise strategy tailored to the severity of the patient’s asthma.

The aim of asthma management is to achieve complete control of the disease and treatment should be commenced at the step most appropriate to initial severity, with control maintained by stepping up treatment as necessary and stepping down treatment when control is good. 

The most common problem with pharmacological management is non-adherence to treatment.

A number of risk factors are recognised and various interventions are mentioned in the BTS/SIGN guideline, but these are modestly effective at best. Nonetheless, checking concordance with existing therapies and inhaler technique before escalating treatment remains an important part of improving the pharmacological treatment of asthma, since it is clearly impossible to address unless it is recognised.

It is certainly important to consider inadvertent non-adherence by virtue of poor inhaler technique.

Training and regular assessment of inhaler technique is important and both the BTS/SIGN guideline and the NICE quality standard emphasise that this should be incorporated into a structured annual review, but also undertaken as opportunities arise when patients present with exacerbations. 

Computer repeat prescribing systems in primary care provide an index of adherence. Any patient prescribed more than one short-acting bronchodilator device a month should be identified and have their asthma assessed urgently and measures taken to improve overall control.

Non-pharmacological management

Evidence that non-pharmacological management of asthma is effective is difficult to obtain, but addressing patients’ concerns in this area is an important part of holistic care.

The BTS/SIGN guideline reviews an extensive range of management options.

The key recommendations are:

• Advising patients with asthma about the dangers of smoking and taking appropriate steps to support smoking cessation

• Supporting weight loss in overweight patients with asthma

• Offering breathing exercise programmes as an adjunct to pharmacological management to improve symptoms and overall quality of life

There are many environmental, dietary and other triggers implicated in the non-pharmacological management of asthma, but more studies are required before positive recommendations can be made for their use.

Management of acute asthma

The BTS/SIGN guideline sets out the optimal management pathway for acute asthma attacks of varying severity. The basics of treatment are well known, and the usual source of error is failing to assess severity adequately. The important features are outlined in table 1.

Once severity has been determined, the management of patients presenting with an acute attack will include bronchodilators, corticosteroids in all but the mildest cases, and may also include treatment with oxygen.

Of note, nebulisers offer no greater benefit than bronchodilators given via a spacer in an acute asthma exacerbation⁷ and if nebulisers are used, it is preferable that they are driven by oxygen.⁴ The severity assessment is also important in determining whether the attack can be managed at home or in hospital.

The NICE quality standard stipulates that patients who have received treatment for an acute exacerbation of their asthma either in hospital or in out-of-hours services should be reviewed within two working days by a healthcare professional in their own GP practice. This appointment should serve as a means of exploring reasons for the acute exacerbation and taking appropriate steps to prevent further attacks.

Conclusion

While asthma is a commonly encountered condition within both primary and secondary care, the intrinsic variability of the disease guarantees that at times diagnosis and management will pose a challenge to healthcare professionals.

Following the updated BTS/SIGN guideline and NICE quality standard should help healthcare professionals avoid the known shortcomings in asthma management, and provide a clear template for optimising the holistic care of people with asthma.