A key component of many asthma management guidelines is the recommendation for patient education and regular asthma review. Patients need to learn how to live with a variable condition and we need to emphasise the importance of recognising and acting on symptoms and signs of deterioration.
People with asthma should have a structured review at least once a year with a health professional who has specialist asthma knowledge. The focus of these reviews should be:
Explaining their asthma diagnosis
When you see the patient for review, it’s important that the patient understands what asthma is, and why they are being prescribed the therapy.
Patients often don’t have the asthma diagnosis explained to them and they don’t understand the importance of the inhalers. They rely on their reliever inhaler because they get an immediate symptomatic improvement, but they don’t understand that asthma is an inflammatory condition which can only be controlled with corticosteroids.
Understand the goal of asthma therapy
The current asthma guidelines define good control as having no symptoms, no exacerbations and normal or near normal spirometry. The presence of mild, intermittent symptoms (twice a week or less) may be compatible with good control, but night-time symptoms indicate loss of control.
Signs of deteriorating asthma control
Generally, exacerbations develop slowly over a period of hours or days. If we educate patients about how to spot symptoms of deteriorating asthma control, and what to do, we can hopefully prevent hospitalisation, A&E attendance, and deaths from asthma.
Validated asthma control questionnaires
Asthma Control Questionnaire (ACQ) or the Asthma Control Test (ACT) are useful tools in the assessment of asthma control. These both use a series of questions to assess asthma control. It is important to consider where, when and how they are completed as this may affect the answers given. Some practices choose to send them out for patients to complete at home and bring to the review, while others may ask patients to complete the questionnaire in the waiting room before and appointment.
Assess adverse events
Understanding the patient’s acute asthma exacerbations history in the last year can indicate an increased risk of future attacks even in the presence of current good control.
Incorrect inhaler technique is common, so this element of care must be tackled during the review. It’s widely acknowledged that if patients have a choice about inhaler they are much more likely to be compliant with it.
Preventer inhalers compliance
It is widely recognised that poor compliance to Inhaled Corticosteroids is an important reason for poor control and increases the risk of asthma death. Underuse of ICS can result in increased symptoms and poor control so this must be explored before therapy is stepped up.
We should target patients who are having regular prescriptions of SABA; patients who are well controlled will only need one SABA per year. If you have a patient who is using their SABA less than 3 times a week, you should expect them to need maximum of 3-4 relievers per year. Practices are beginning to remove SABA from repeat prescription, or limit the repeat prescription to 3 per year. If the patient needs more than that, they should be called for urgent asthma review.
Review medication and adjust if necessary
Once good control has been established, the aim should be the lowest possible dose of medication to remain symptom free. Stepping down medication is often overlooked in asthma management and many people are on higher levels of medication than they need. It is important, therefore, to consider stepping therapy down. A reasonable approach is to reduce ICS dose by 25-50% every three months, and check that control is maintained.
Other factors of self management include lifestyle advice, avoidance of triggers, smoking cessation advice and vaccinations.