Dr Peter Saul Draws on Current Guidance on Asthma in Children and Adults to Establish 10 Top Tips for General Practice
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Key points can be found at the end of this article.
According to a 2016 analysis, asthma resulted in at least 6.3 million primary care consultations, 93,000 hospital admissions, and 1160 deaths between 2011 and 2012.1 In the study, the UK lifetime prevalence of patient-reported symptoms suggestive of asthma was estimated to be 29.5%; for patient-reported, clinician-diagnosed asthma, the UK lifetime prevalence was 15.6%.1 Around 14% of children and young people worldwide have a diagnosis of asthma, making it the most common chronic respiratory disease of childhood.2,3 Diagnosis of asthma is based on the recognition of a characteristic pattern of respiratory symptoms, signs, and test results in the absence of an alternative explanation.4 However, because the symptoms can be intermittent and may evolve over time, asthma can be difficult to diagnose in both children and adults.2,5
The management of patients with asthma has been led by national guidelines for many years. Currently, NICE Guideline (NG) 80, Asthma: diagnosis, monitoring and chronic asthma management,6 which was last updated in March 2021, and the British Thoracic Society/Scottish Intercollegiate Guidelines Network (SIGN) British guideline on the management of asthma (SIGN 158),4 which was last updated in July 2019, are the ‘go-to’ guides for GPs and practice teams in the UK. However, guidance from other sources is increasingly influencing existing policy, and this needs to be considered if we are to offer the best treatment for patients with asthma. In particular, the 2022 Global Initiative for Asthma (GINA) strategy diverges from existing UK guidance in recommending the use of as-needed ICS-formoterol therapy for symptom relief first line.7
Environmental considerations are also influencing asthma prescribing. Greener Practice has produced the guide How to reduce the carbon footprint of inhaler prescribing,8 which offers advice on how to prescribe inhalers that minimise the release of greenhouse gases.
Faced with this constellation of guidance, what are the top tips for contemporary asthma management in primary care?
1. Consider the Patient’s History, Risk Factors, and Triggers
NICE guidance advises clinicians to take a structured clinical history when asthma is suspected that specifically checks for wheeze, cough, or breathlessness, and any daily or seasonal variation in these symptoms.6 NICE recommends that diagnosis should include an objective test, and cautions against using a history of atopic disorders alone.6
Children and adults with asthma typically present with a triad of symptoms—wheeze, shortness of breath, and cough.2 If wheeze is not present, then a diagnosis of asthma is less likely.2
Interpretation of wheeze in young children is a particular challenge because, in the first few years of life, many children will experience wheeze, but not all will go on to develop asthma.2 Clinical examination may also be normal if they present during asymptomatic periods.2
Identifying risk factors in the patient’s history may support a diagnosis and help to answer the questions ‘Why this patient?’ and ‘Why now?’. Reviewing risk factors can provide insight into the patient’s situation and, in some cases, offer opportunities to modify the patient’s exposure to them. The risk factors shown in Box 1 should be considered when a diagnosis of asthma is suspected.2,4,9–11
|Box 1: Risk Factors for Asthma2,4,9–11|
Enquiring about triggers for symptoms can also be helpful when considering a diagnosis of asthma, and may offer opportunities to advise the patient to avoid them.12 Common triggers of asthma are shown in Box 2.12
|Box 2: Common Triggers of Asthma12|
2. Confirm the Diagnosis Using Clinical Investigations
NICE recommends that spirometry should be offered to adults and children aged over 5 years if a diagnosis of asthma is being considered.6 A forced expiratory volume in 1 second (FEV1):forced vital capacity (FVC) ratio of less than 70% is considered positive for obstructive airway disease.6 A bronchodilator reversibility test should be offered to adults aged 17 years or older (and considered for children aged 5–16 years) who have had a positive spirometry result; an improvement in FEV1 of 12% or more (together with an increase in volume of 200 ml or more in adults aged 17 years and older) is considered a positive result.6
It is important to bear in mind that the FEV1:FVC ratio changes with age, and can be as high as 90% in children—therefore, the standard fixed ratio of 70% will likely underestimate airflow limitation in children.4 It may overestimate airflow limitation in adults aged over 40 years as well, so variable limits of normal may be preferred.4
High Probability of Asthma
When the diagnosis is clear, a 6-week trial of inhaled corticosteroids (ICSs) should be commenced.4 This time can be used to gather more information by getting the patient to record symptoms backed by lung function tests—typically, home-based serial peak expiratory flow (PEF) monitoring.4 These test results can then be correlated with symptoms. A good response to treatment confirms the diagnosis, and this should be recorded.4
Intermediate Probability of Asthma
When the clinical features are less clear cut, or when treatment has not achieved the desired outcome, spirometry with a test of reversibility is recommended in adults and children.4,7 Additionally, if available, fractional exhaled nitric oxide can be measured as a test of eosinophilic inflammation, which increases the likelihood of asthma if present.4 Doubts about diagnosis in children can be addressed by watchful waiting if the clinical picture allows, or by continued drug treatment with monitoring.4 The diagnosis should be reviewed in the light of the evolving clinical situation.4 As the child becomes older, formal testing may become an option.2
3. Be Vigilant For Red-Flag Signs and Symptoms
Remember to consider red flags and signs of other potential diagnoses. These include systemic features of illness, unexpected clinical findings or investigations, persistent symptoms, or a possible occupational cause. In children, in particular, clinicians should be vigilant for the following signs, which may suggest an alternative diagnosis:4
- symptoms present from birth
- failure to thrive
- family history of unusual chest disease
- persistent productive cough.
4. Tailor Treatment According to Symptom Severity
The main goals of managing asthma are to:4
- alleviate symptoms
- minimise the use of rescue medication
- allow normal activity
- preserve normal lung function
- avoid side effects from medication.
GPs will be familiar with the ‘step-up’ and ‘step-down’ guidance; this is well documented in SIGN 158, NG80, and the GINA strategy.4,6,7,13,14 Treatment should be started at the most appropriate level for symptoms, increased as necessary to improve asthma, and decreased when asthma control is good.4
Historically, use of a short-acting beta2 agonist (SABA) alone has been the first-line therapy of choice for patients with mild asthma (step 1), and remains so in the NICE and SIGN guidance.4,6 However, short-acting bronchodilators have been linked to increased patient risk—exacerbations, hospitalisations, and mortality rates are reportedly increased by their regular or frequent use.15
In light of this evidence, there has been a major change in the GINA strategy regarding recommendations on the use of SABAs in patients with mild asthma.7 GINA now recommends that if an adolescent or adult at any treatment step experiences asthma symptoms, they should use low-dose ICS-formoterol as needed for symptom relief (note: ICS-formoterol therapy is not licensed for this indication in the UK).7 In children aged 6 years and older, dual use of a SABA with a low-dose ICS as needed (or, alternatively, use of an as-needed SABA with a regular low-dose ICS) is recommended.7 The advice for children aged less than 6 years remains unchanged: a SABA is recommended for initial treatment using an appropriate delivery device, and a regular low-dose ICS can be added if maintenance therapy is needed.7
For both adults and children, all pathways involve increasing the ICS dose as needed to gain symptom control.4,6,7,13,14 Given the changes in the use of SABAs outlined in the preceding section, and pending updates to the UK guidance, the GINA strategy offers the most straightforward and up-to-date advice, and also provides guidance on other treatment options, such as leukotriene receptor antagonists and long-acting muscarinic antagonists.7
When asthma symptoms are well controlled on pharmacological therapy, stopping or stepping down medication should be considered to minimise unnecessary adverse effects.4,6,7 The GINA strategy advises that clinicians should consider stepping down asthma management to the lowest effective treatment regimen when good symptom control has been achieved for at least 3 months.7 When stepping down treatment, an individualised risk–benefit approach should be taken, with focus on the patient’s history, including frequency of oral corticosteroid use, frequency of asthma attacks, and previous intensive care admissions.2
5. Carry Out Asthma Reviews to Assess and Ensure Control
Asthma control should be reviewed at least once a year by a healthcare professional with appropriate training in asthma management; more frequent reviews are recommended for people with a history of severe episodes or poor lung function.4 This review should assess current symptoms, future risk of attacks, management strategies, and growth in children; the things it should consider include:4,7
- number of asthma attacks, time off school or work due to asthma, nocturnal symptoms
- oral corticosteroid use, bronchodilator use, adherence to treatment (which can be assessed by reviewing prescription refill frequency)
- possession and use of a self-management plan or written personalised asthma action plan
- exposure to tobacco smoke.
The Royal College of Physicians ‘Three Questions’ is a useful tool for assessing asthma control—it has been validated for use in adults, but can also be used in children (see Box 3).16 Try to ask children directly about their own symptoms and inhaler use, and check their growth.4 Inhaler technique is important and should be checked at every review, especially if there has been a recent device change, deterioration in control, or attack.6
|Box 3: Royal College of Physicians ‘Three Questions’ for Asthma16|
Answering ‘no’ to all three questions is consistent with controlled asthma.
In the last month:
Pearson M, Bucknall C, editors. Measuring clinical outcomes in asthma: a patient focused approach. London: RCP, 1999. Reproduced with permission.
Assess the Risk of Future Attacks
In both adults and children, the greatest predictor of future attacks is previous attacks.4 Other predictors include inappropriate use of SABAs, older age, female sex, reduced lung function, obesity, smoking, and depression in adults.4 In children, a suboptimal drug regimen, comorbid/atopic allergic disease, low-income family, and vitamin D deficiency are risk factors for future asthma attacks.4,17
6. Provide Advice on Lifestyle Changes
The SIGN guideline provides the most comprehensive review of nonpharmacological management.4 The guideline points out that, although many patients and carers perceive that avoiding environmental, dietary, and other triggers of asthma will improve asthma and reduce the requirement for pharmacotherapy, evidence to support this can be difficult to obtain.4 However, failure to address a patient or carer’s concerns about such triggers may compromise concordance with recommended pharmacotherapy.4
Primary and secondary nonpharmacological measures to prevent asthma are summarised in Box 4.4,7
|Box 4: Primary and secondary prevention of asthma4,7|
GINA recommends that people with asthma should engage in regular physical activity because of its general health benefits; it may also have a small benefit for asthma control and lung function.7 GPs should provide advice about the management of exercise-induced bronchoconstriction.
7. Ensure That Exacerbations Are Managed Effectively
It is vital to determine the severity of an asthma attack, bearing in mind that people with a severe or life-threatening exacerbation sometimes do not appear to be distressed.4 Clinicians should:
- note the person’s degree of agitation and consciousness;4 agitation and behavioural changes in a child may be a sign of hypoxia18
- look for signs of exhaustion, and use of accessory muscles while the person is at rest4
- examine the person’s chest, and record their respiratory rate, pulse, and blood pressure4,7
- record the person’s PEF (if possible), and compare to their best recorded value4
- measure the person’s oxygen saturation (SpO2).4
Further management in respect of hospital admission will depend on the severity of the attack and the response to treatment of the patient.4
The spectrum of attack severity ranges from moderate acute asthma, in which PEF is 50–75% of the best or predicted value with no severe symptoms, to acute severe asthma, in which PEF has deteriorated to 33–50% of the best or predicted value, respiratory rate is increased to more than or equal to 25 breaths per minute, heart rate is more than or equal to 110 beats per minute, and the person is unable to complete sentences in one breath.4 Further worsening, with PEF less than 33%, SpO2 less than 92%, and severe systemic symptoms, represents life-threatening asthma.4
Initial treatment for acute asthma is a high-dose inhaled beta2 agonist; if symptoms are severe, oxygen-driven nebulisation is recommended.4 Patients with life-threatening asthma need urgent admission, as do those with severe asthma who do not respond to initial treatment.4 While waiting for an ambulance, give supplemental oxygen if hypoxaemia is suspected, and aim to maintain an SpO2 of 94–98%.4
Steroids should be given to all patients with an acute asthma attack until recovery—typically, prednisolone 40–50 mg daily for a minimum of 5 days.4 Routine prescription of antibiotics is not indicated for patients with acute asthma.4
Children Aged 1 Year or Older
Acute severe and life-threatening asthma have similar markers to adults in terms of oxygen saturation and PEF. The cut-offs for heart rate are:4
- age 1–5 years—more than 140 beats per minute
- age over 5 years—more than 125 beats per minute.
The cut-offs for respiratory rate are:4
- age 1–5 years—more than 40 breaths per minute
- age over 5 years—more than 30 breaths per minute.
Cyanosis, poor respiration, and exhaustion indicate that the condition is life-threatening.4
Management is led by increasing the beta2 agonist dose by giving one puff at a time every 30–60 seconds,18 up to a maximum of 10 puffs.4 For children experiencing a severe or life-threatening attack, a nebulised bronchodilator driven by oxygen is recommended.4 Children with life-threatening asthma need urgent admission, as do those with severe asthma who do not respond to initial treatment.4 As with adults, while waiting for an ambulance, give supplemental oxygen via face mask if hypoxaemia is suspected in children aged 2 years or older, and aim to maintain an SpO2 of 94–98%.4
8. Know When to Consider Referral
Although asthma can be effectively managed in primary care in most patients, some situations will require referral to a specialist. Specialist input is required when:2,4,7
- the diagnosis is uncertain
- the results of objective testing are inconclusive
- the response to treatment is poor
- there is a frequent need for oral corticosteroids
- there is recent history of a severe or life-threatening attack.
9. Remember Special Patient Populations
SIGN guidance indicates that, in general, the drugs used to treat asthma are safe to use during pregnancy.4 Women should be advised of the importance of maintaining good control of their asthma.4 Those who smoke should be advised of the dangers to themselves and their baby.4
Patients With Recurrent Episodes
After specialist referral, for people aged 50–70 years who have ongoing symptoms despite the use of a high-dose ICS, and who have experienced at least one exacerbation requiring oral corticosteroids in the preceding year, clinicians could consider prescribing 500 mg azithromycin once daily three times per week for a minimum of 6–12 months.7,19
People With Occupational Asthma
Always check for possible occupational asthma by asking employed people with suspected new-onset asthma, or established asthma that is poorly controlled, the following questions:6
- Are symptoms better on days away from work?
- Are symptoms better when on holiday (time away from work longer than usual breaks at weekends or between shifts)?
Refer people with suspected occupational asthma to an occupational asthma specialist.6
10. Understand the Environmental Impact of Pharmacotherapy
Environmental considerations are becoming increasingly important. All four UK health services have committed to net-zero climate targets,20 with strategies being implemented to achieve these targets in England,21 Scotland,22 and Wales.23 These strategies will likely have important implications for inhaler prescribing.21,23
Inhalers account for approximately 13% of the carbon footprint related to delivery of care.8 Pressurised metered-dose inhalers (pMDIs) contain hydrofluoroalkane propellants, greenhouse gases that are 1300–3350 times more potent than carbon dioxide.8 In England, approximately 70% of inhalers prescribed are pMDIs, in contrast to Sweden, which prescribes 13% of inhalers as pMDIs.8 Alternatives to pMDIs, such as dry powdered inhalers (DPIs) and soft-mist inhalers (SMIs), have a much lower carbon footprint.8How to reduce the carbon footprint of inhaler prescribing, published by Greener Practice, offers the following guidance on reducing the carbon footprint of inhaler prescribing for asthma:8
- optimise asthma care by following national guidelines
- offer DPIs or SMIs first line when clinically appropriate
- if a pMDI is unavoidable, choose a brand and regimen that takes care to minimise carbon emissions
- encourage patients to return used or unwanted inhalers to community pharmacies or dispensaries for proper disposal.
A salbutamol pMDI with a spacer should be given when there is concern that a patient may be unable to use a DPI during exacerbations; consider prescribing an emergency pack.8
It is important for GPs and their teams to keep up to date with asthma guidance, which continues to evolve as knowledge of optimal management develops. Key changes in management strategies and delivery systems enable better patient identification and symptom control, and correct device choice can benefit the environment.
RCP=Royal College of Physicians; pMDI=pressurised metered-dose inhaler; DPI=dry powdered inhaler; SMI=soft-mist inhaler
|Note: At the time of publication (September 2022), some of the drugs discussed in this article did not have UK marketing authorisation for the indications discussed. Prescribers should refer to the individual summaries of product characteristics for further information and recommendations regarding the use of pharmacological therapies. For off-licence use of medicines, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.|
Dr Peter Saul
GP, North Wales; Associate Dean, Health Education and Improvement Wales; Clinical Undergraduate Tutor, Cardiff University; Visiting Professor, Wrexham Glyndwr University; former Chair, RCGP Wales.