Section 1:

The importance of routine and opportunistic reviews in patients with asthma

Asthma is a heterogeneous disease, usually characterised by chronic airway inflammation, and defined by a history of respiratory symptoms (wheeze, shortness of breath, chest tightness and cough), that vary over time and intensity, together with variable expiratory airflow limitation.1 Patients can experience episodic exacerbations – or attacks – that may be life threatening.1

Regular review of people with asthma offers the opportunity to monitor current symptom control and the impact asthma is having on daily activities and quality of life, to assess future risk of asthma attacks, and to link these to management options.2

Asthma is best monitored by routine clinical review on at least an annual basis.2,3

The National Review of Asthma Deaths (NRAD) emphasises the importance of routine reviews in primary care, stating that while a structured review should take place at least annually, review should be more frequent in people with poor asthma control or at high risk of severe attacks.3 But among patients who died from asthma, around one in five (22%) missed their routine asthma appointment in the year before they died, and of the 195 patients who died, 31% had no record of an asthma review in primary care in the previous 12 months.3

The Global Initiative for Asthma, GINA, recommends reviews as part of a continuous ‘control-based asthma management cycle.1 This means that pharmacological and non-pharmacological treatment is adjusted in a continuous cycle involving assessment, treatment and review.1 As asthma symptoms such as wheeze, chest tightness, shortness of breath and cough typically vary in frequency and intensity, asthma symptom control should be assessed at every opportunity, including during routine prescribing.1 Both opportunistic asthma reviews, when the patient consults for something else, and those planned to evaluate the effect of a change of inhaler device or medication – usually 6-12 weeks after the change – should focus on assessing current control and identifying risk.4

In addition, any patient who has been admitted to hospital or attended an emergency department – or out of hours service – for an asthma attack should be reviewed in general practice regularly over the following weeks until good symptom control is achieved and personal best lung function reached or exceeded.1 Post attack reviews performed within a few days of treatment, and before the patient completes the course of oral steroids, should include identification of modifiable risk, red flag signs, and assessment of current control to determine whether the attack has resolved or is resolving.4 A careful history should elicit the reasons for the asthma attack and explore possible actions the patient should take to prevent future emergency presentations. Medication should be altered depending upon the assessment and the patient provided with a written, personalised asthma action plan aimed at preventing relapse, optimising treatment and preventing delay in seeking assistance in the future.2

Lessons from fatal and near-fatal asthma attacks

The importance of asthma reviews is illustrated by the key findings of the NRAD report.3 This found that many of the patients who died of asthma had experienced:

  • Inadequate ICS treatment/excessive use of shorting acting beta-2 agonists (SABA)
  • Inadequate objective management of their asthma
  • Inadequate follow up (for some patients) or delayed referral for specialist advice
  • Underuse of written personalised asthma action plans.2

Job code: UK/RES-19014e DOP: May 2020

References

  1. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention; 2019. https://www.ginaasthma.org [Accessed May 2020]
  2. BTS/SIGN British Guideline on the Management of Asthma; 2019. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ [Accessed May 2020]
  3. Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report; 2014. https://www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf [Accessed May 2020]
  4. Levy M. Asthma reviews: a new look. Practice Nurse 2020;50(1):30-35