SECTION 2:

Components of an asthma review

The core components of an asthma review are:1

  • Current symptom control
    • Bronchodilator use
    • Validated symptom score
    • Time off work/school due to asthma

  • Future risk of asthma attacks
    • Past history of asthma attacks
    • Oral corticosteroid use
    • Prescription data: frequent short-acting beta-2 agonist (SABA) and infrequent ICS
    • Exposure to tobacco smoke

  • Tests/investigations
    • Lung function (spirometry or peak expiratory flow [PEF])
    • Growth (height and weight centile) in children

  • Management
    • Inhaler technique
    • Adherence (self report, prescription refill frequency)
    • Non-pharmacological management
    • Pharmacological management

  • Supported self management
    • Education/discussion about self management
    • Provision/revision of a written personalised asthma action plan

Monitoring current symptom control

Asking general questions such as ‘how is your asthma today?’ is likely to result in a non-specific answer, such as ‘I am OK’.1 Most practices use the Royal College of Physicians ‘3 Questions’ – as this is specified in the Quality and Outcomes Framework – but symptomatic asthma control is best measured using validated questionnaires, such as the Asthma Control Test (ACT), or Childhood Asthma Control Test (C-ACT) for children under 11 years.2

ACT includes four symptom/reliever questions plus a patient self-assessed level of control, which together provide a score: >20 represents good symptom control, 16–19 means not well controlled, and ≤15 is very poorly controlled.2

Lung function

Measure FEV1 at start of treatment, after 3-6 months of controller treatment to record the patient’s personal best lung function, then periodically for ongoing risk assessment.2 In most adults, lung function should be recorded at least every 1-2 years, but more frequently in higher risk patients and in children based on asthma severity and clinical course.2 Lung function does not correlate strongly with asthma symptoms in adults or children, but low FEV1 is a strong independent predictor of risk of asthma attacks.2

Inhaler technique

Patients with asthma who are unable to use their inhaler correctly are at increased risk of poor asthma control, potentially resulting in an attack.3 The NRAD report found that in the 135 cases where the last asthma review was recorded in primary care, 29% did not have an assessment of inhaler technique.3 Most patients (up to 70–80%) are unable to use their inhaler correctly. Unfortunately, many healthcare professionals are unable to correctly demonstrate how to use the inhalers they prescribe.1 Inhaler technique should be checked at every opportunity – ask the patient to show you how they use their inhaler, don’t just ask if they know how to use it, and identify any errors using a device-specific checklist.1

Smoking

As part of the non-pharmacological management of asthma, BTS/SIGN highlights the importance of avoiding direct or passive exposure to cigarette smoke, which adversely affects lung function, need for rescue medications for acute episodes of asthma and long-term control with ICS.1 People with asthma and parents/carers of children with asthma should be advised about the dangers of smoking and second-hand tobacco smoke exposure, and should be offered appropriate support to stop smoking.1

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

References

  1. 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]
  2. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention; 2019. https://www.ginaasthma.org [Accessed May 2020]
  3. BTS/SIGN British Guideline on the Management of Asthma; 2019. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ [Accessed May 2020]