Monitoring adult asthma in primary care

In primary care, people with asthma should be reviewed at least annually by a nurse or doctor with appropriate training in asthma management.

• when assessing asthma control use closed questions e.g. “do you use your reliever (blue inhaler) every day?” which is likely to yield more useful information
• review should incorporate a written action plan
• healthcare professionals should be aware that the best predictor of future asthma attacks is current control (1)
  • patients with good control of symptoms with treatment have a lower risk of exacerbation
  • in contrast, patients with poor lung function and with a history of exacerbation in the previous year may be at greater risk of future exacerbation for a given level of symptom. Hence closer monitoring of these individuals should be considered

The factors that should be monitored and recorded include:

• symptomatic asthma control: best assessed using directive questions such as the RCP ‘3 questions’ or the Asthma Control Questionnaire or Asthma Control Test, since broad non-specific questions may underestimate symptoms
• lung function, assessed by spirometry or by PEF. Reduced lung function compared to previously recorded values may indicate current bronchoconstriction or a long term decline in lung function and should prompt detailed assessment. Patients with irreversible airflow obstruction may have an increased risk of exacerbations
• exacerbations, oral corticosteroid use and time off work or school since last assessment
• inhaler technique
• adherence, which can be assessed by reviewing prescription refill frequency
• bronchodilator reliance, which can be assessed by reviewing prescription refill frequency
• possession of and use of self management plan/personal action plan (1).

Notes:

• UK has one of the worst asthma death rates in Europe, with the rate of people dying from an asthma attack increasing by more than 20% in five years (2)
  • Asthma UK's analysis of the most recent Europe-wide figures from 2011 to 2015 found that:
    • rate of asthma deaths in the UK has increased by more than 20% in five years, with figures from 2015 showing 1,434 people died from an asthma attack
    • UK's average asthma death rate over five years is worse than countries such as Greece, Italy and the Netherlands - and it is almost 50% higher than the average death rate in the European Union
      
      
• National Review of Asthma Deaths revealed two thirds of asthma deaths could have been prevented with basic asthma care (3)

Reference:

• (1) British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) 2016. British Guideline on the Management of Asthma. A national clinical guideline
• (2) Falling Through the Gaps: Why more people need basic asthma care https://www.asthma.org.uk/share/?rid=7044
• (3)Royal College of Physicians, Why Asthma Still Kills: The National Review of Asthma Deaths (NRAD), May 2014. https://www.asthma.org.uk/globalassets/campaigns/nrad-full-report.pdf