In July 2019, the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) updated their guidelines on the management of asthma to make approaches to care more personalised, with the aim of better outcomes for people with asthma (BTS/SIGN, 2019). These updates give health professionals involved in the care of people with asthma new approaches to provide personalised care and help better manage an individual's condition. This article will summarise these changes for practice nurses.
The importance of asthma care
According to Asthma UK (2019a), there are 4.3 million adults and 1.1 million children currently receiving treatment for asthma. Asthma is the most common lung disease in the UK (British Lung Foundation, 2019) and costs the NHS around £1 billion per year (BTS/SIGN, 2019).
Every 10 seconds someone is having a potentially life-threatening asthma attack, and an average of three people each day die from an asthma attack in the UK (BTS/SIGN, 2019).
When most asthma deaths are preventable (Royal College of Physicians, 2014) and most people should be able to control their asthma (Asthma UK, 2018), better care for people with asthma has the potential to improve quality of life for many and significantly reduce mortality.
What are the key updates for primary care?
Targeted care
The updated guidelines focus on giving targeted care to those with poor symptom control and those who are at risk of future asthma attacks. This enables people with poorly controlled asthma to improve their quality of life and prevent avoidable deaths from asthma (BTS/SIGN, 2019). The aim of treatment is for patients to have good control of their asthma. This would mean that they have few to no symptoms and therefore have no, or very occasional, need to use their reliever inhaler (BTS/SIGN, 2019).
Risk of future attack
There is guidance on identifying a person with asthma's future risk of attack based on a number of factors, such as history of attacks, past and current medication and tobacco smoke exposure.
The BTS/SIGN guidelines detail the different risk factors in adults, school children (those aged 5–12 years) and, although the data are more limited, pre-school children (<5 years) separately. They also give an indication of the level of increased risk for each factor (BTS/SIGN, 2019) (Table 1).
Table 1. Factors associated with increased risk of future asthma attacks
| In adults | |
|---|---|
| Level of increased risk | Factor |
| Greatly increased risk |
|
| Moderately increased risk |
|
| Slightly increased risk |
|
| Unclear (evidence limited or equivocal) |
|
| In school-aged children (5–12 years) | |
| Level of increased risk | Factor |
| Greatly increased risk |
|
| Moderately increased risk |
|
| Slightly increased risk |
|
| No increased risk |
|
| Unclear (evidence equivocal) |
|
British Thoracic Society/Scottish Intercollegiate Guidelines Network, 2019.
ACT, Asthma Control Test; ACQ, Asthma Control Questionnaire; COPD, chronic obstructive pulmonary disease; FeNO, exhaled nitric oxide test; SABA, short-acting beta2 agonist
Pharmacological management
The step-wise approach to asthma care from previous guidelines remains, but has been updated, making it clearer when people with asthma should be referred to and managed under specialist care, and what the different options are, with drug combinations to suit the individual (BTS/SIGN, 2019).
Adults
The visual summary of pharmacological management of adults now includes maintenance and reliever therapy (MART) (BTS/SIGN, 2019).
The first step after diagnosis is a low-dose inhaled corticosteroid (ICS), which is defined within the guidelines, alongside a short-acting beta2 agonist (SABA). If the person with asthma is using their SABA at least three times a week, the next step should be considered. A long-acting beta2 agonist (LABA) should be added on to a low-dose ICS, either as a fixed dose or using the MART approach.
If asthma control remains inadequate, the patient's response to their LABA should be reviewed. The LABA should only be continued if there is a response to it. As part of this step, either the ICS can be increased to a medium dose or a leukotriene receptor antagonist (LTRA) can be added.
Where this approach is still not adequately controlling a person's asthma, they should be referred to specialist care. Those with good control should be stepped down to the lowest level of therapy possible to control their asthma.
Children
The first step for children is a very low-dose ICS alongside their SABA, followed by an initial add-on therapy of a LTRA for under 5's or the choice of a LTRA or an inhaled LABA for those aged 5 years and over (BTS/SIGN, 2019).
Where control is inadequate, the patient's response to any LABA that was prescribed at the previous step should be reviewed. The LABA should be continued only if there has been a response. Increasing the ICS to a low dose should be considered as part of this step. For children aged 5 years and over, there is the alternative of adding in a LTRA or LABA, whichever has not been previously tried.
As with the recommendations for adults, children not adequately controlled with this therapy should be referred to specialist care, and those with good control should be moved down to the lowest controlling therapy.
Differences between BTS/SIGN and NICE guidelines
The National Institute for Health and Care Excellence (NICE) guidelines for asthma differ in their advice about the order of pharmacological treatment options. White et al (2018) discuss this in detail, with the main reason for the differences being a different methodology used for reviewing the evidence and making recommendations. There is also a difference in the cost of LTRAs and LABAs, which impacts on the NICE recommendation (White et al, 2018).
In July 2019 it was announced that BTS, SIGN and NICE will jointly produce a UK-wide guideline for the diagnosis and management of asthma in adults, young people and children in future, providing health professionals with a single evidence-based approach to asthma care.
What should an asthma review look like?
The guidelines detail five areas which should be included as part of an asthma review (BTS/SIGN, 2019):
- Current symptom control
- Future risk of attacks
- Tests/investigations
- Management
- Supported self-management.
In order to include all of these elements, an asthma review should combine information taken from the patient's record, measurements and tests, and a discussion with the patient. These factors will give a personalised understanding of the current control of the patient's condition, their risk of future attack and it will inform the decision of an appropriate medicine regime, and the counselling and education requirements that are unique to the individual.
Patient records
Much important information that will feed into the care of the patient can be gained from looking at their medical record.
Age
Starting at a very basic level, it is important to know the age of the patient. As well as being required to determine the appropriate treatment for the patient, it will also help build the picture of risk of future asthma attacks. In adults, an older age—and in 5–12-year-olds, a younger age—is associated with a slight increased risk of a future asthma attack.
Gender
For adults and children under 5, it is also important to know the patient's gender. There is a slight increased risk of future attack in male pre-school children and female adults. For women of child-bearing age, a confirmed or possible pregnancy also needs to be considered to ensure the appropriate management of the condition.
Co-morbidities
Co-morbidities should be reviewed for each patient for consideration when choosing an appropriate management approach, and when determining the risk of future attacks. There is a moderate increased risk in children aged 5–12 years who also have atopic/allergic disease or a vitamin D deficiency, and a slight to moderate increase in risk in pre-school children with atopic disease. There is a slight increase in risk in adults who suffer from depression.
Prescription history
The patient's prescription history should be reviewed, both for asthma and any co-morbidities. As well as informing drug choice, it will also give an indication of adherence with currently prescribed asthma treatment. This information alone, however, is not enough to be confident about adherence, since the writing of a prescription does not confirm that the patient has had it dispensed at the pharmacy. Non-adherence occurs for a number of reasons including cost of treatment, since each separate medication used to control their asthma incurs a prescription levy charge (Lycett et al, 2018). Non-adherence could also be due to a lack of understanding of the importance of the medicine in controlling their asthma or side-effects (Lycett et al, 2018). Therefore, it is important to use the information on the patient record to support a conversation with the patient about their adherence to treatment.
Infrequent prescriptions for preventer therapy and/or excessive prescriptions for SABAs are indicators of a lack of adherence to treatment and poor asthma control.
Adults who excessively use their SABA are at a moderate increased risk of future asthma attack, and those using more than one SABA inhaler per month should have their asthma management reviewed urgently, even if this falls out of their normal scheduled review. The Asthma Slide Rule developed by the Asthma Right Care project gives a clear visual guide on SABA use and control of asthma. Those needing one or two 200 dose SABA inhalers per year have good control. Those using 3 or more have poor control, with control worsening as the number of SABA inhalers used in a year increases (Asthma Right Care, 2018).
The prescription history will also inform you of any oral corticosteroid use for previous asthma attacks, which is associated with a greatly increased risk of a future attack in adults and school-aged children.
The risk for school-aged children is moderately increased in those whose medication regime is not adequately controlling their asthma. This can be determined by working out the ratio of prescriptions the child has received for controller medication to the total number of prescriptions for asthma treatment. Where this is less than 0.5, the treatment is considered suboptimal (see Box 1). This is also an indicator that their current regime may need changing. For pre-school children, their risk is increased if they are on preventer medicine.
Box 1.Calculating suboptimal treatmentWorking out the ratio of prescriptions the child has received for controller medication to the total number of prescriptions for asthma treatment can determine if treatment is optimal. Where the ratio is less than 0.5, the treatment is considered suboptimal. For example:
- A child has had 8 prescriptions for their inhaled corticosteroid (ICS) and 10 for their short-acting beta2 agonist (SABA), giving a total of 18 prescriptions for their asthma treatment. The ratio would be calculated as 8/18 = 0.44, indicating that therapy is sub-optimal in this patient.
History of asthma attacks
It is also important to check for any other past history of asthma attacks, for example those managed in hospital or through an out of hours service, which may not be apparent from looking at the prescription history of the patient. Knowing this history will help tailor the management of the patient's asthma, including their written action plan.
Other indicators of risk
Other indicators of an increased risk of attack may be obtained from the patient's record, such as body mass index (BMI), smoking status of the patient (or family for children) and family circumstances where the patient is under 12 years. These indicators should be checked with the patient/carer at the asthma review as these factors may change over time and so the record may not contain the most up-to-date information.
While it is not routine to measure an adult's BMI as part of an asthma review, obesity in adults, as well as school children, slightly increases the risk of an asthma attack, as does smoking in adults and exposure to environmental tobacco in children aged 5–12 years.
Knowing the smoking status of the patient/family will enable advice to be provided about the impact of tobacco smoke on the patient's asthma, give an opportunity for signposting to smoking cessation services and will help to tailor the education given to the patient/carer as part of their supported self-management.
The factors affecting school-aged children's risk of an asthma attack in relation to their family circumstances are coming from a low-income family, which is associated with a moderate increase, and low parental education, which is associated with a slight increase in risk. For younger children, there is a slight to moderate increase in risk in those from families with a low socio-economic status.
Tests and investigations
Lung function testing, either with spirometry or using a peak flow meter, is particularly useful in identifying current asthma control (Latifi and Khatri, 2017; Myatt, 2017). This in turn can help identify risk factors for future attacks. It will help inform the appropriate pharmacological treatment for the patient and will indicate if there may be gaps in the patient's understanding of their condition that can be addressed as part of their supported self-management. Checking a patient's lung function therefore remains an important part of an asthma review.
There is an increased risk of attack in overweight preschool children and obese school-aged children. The height and weight of these patients should be measured, and their growth centiles identified to inform their future risk of attack and to ensure normal growth is observed.
Understanding the patient's symptoms
When discussing the patient's symptoms, it is important to consider the way questions are asked. The guidelines (BTS/SIGN, 2019) suggest using the Royal College of Physicians ‘3 Questions’ (see Table 2), which will help determine if there are any issues with asthma control that warrant further investigation. This is due to there being fewer exacerbations seen in patients who receive pro-active, structured reviews (National Institute for Health and Care Excellence (NICE), 2016).
Table 2. Royal College of Physicians ‘3 questions’
| No to all questions is consistent with controlled asthma |
|---|
In the last month:
|
‘It is important that patients are encouraged to be honest about their inhaler use in order for them to receive the best care to control their asthma.’
For patients answering ‘yes’ to any of the questions, a validated symptom score such as the Mini Asthma Quality of Life Questionnaire (AQLQ) or the Asthma Control Test (ACT) should be used to help understand the level of control the patient has over their asthma.
In addition to this, patients should be asked about their inhaler use. Information such as which inhaler they use, when and how often, will give a vast amount of insight into the patient's asthma management, especially when combined with details about their prescribed medication obtained from their records. It is important that patients are encouraged to be honest about their inhaler use in order for them to receive the best care to control their asthma.
Frequent reported use of reliever therapy could indicate poor control and under-use of preventer therapy would indicate a need for education, or a need to alter the medication if symptom control is good despite the patient not using the medicine as prescribed.
Where there is a lack of adherence to therapy resulting in poor symptom control, the reasons for this should be identified, if possible, in order to address the issues and attempt to improve compliance (Boulet et al, 2012).
As part of this conversation with the patient, their inhaler technique should be checked and corrected where needed. These insights into inhaler use will give the health professional an understanding of the patient's current symptom control and the risk of future attacks. Adults with poor symptom control have a moderately increased risk of a future attack. For children aged 5–12 years, there is a greatly increased risk in those with persistent asthma symptoms.
Having this full picture of the patient and their needs will inform both the pharmacological and the non-pharmacological management at an individual level.
The most appropriate pharmacological management should then be determined, along with any other non-pharmacological interventions, such as avoiding triggers, where appropriate. Where risk factors for a future attack which are not associated with the patient's asthma have been identified, the non-pharmacological management could include advice and/or signposting for managing these factors, such as losing weight or quitting smoking. This should be done in collaboration with the patient or carer for better adherence (Boulet et al, 2012; Klok et al, 2015).
As part of the asthma review, the person's inhaler technique should be checked and corrected where needed
When determining the most appropriate pharmacological management of a patient's asthma, consideration should be made to the environmental impact of pressured metered dose inhalers (MDIs). MDIs contain compressed gases in order for them to be able to deliver the medicine when they are used. While the known greenhouse gases previously used were phased out, their replacements have a high potential to contribute to global warming.
It is therefore advised that inhalers with low global warming potential, such as dry powder inhalers, are used when they are likely to be as effective (BTS/SIGN, 2019). Where MDIs are needed, patients should be informed to ask if their pharmacy offers a recycling scheme.
Once the holistic management has been agreed, any further education the patient requires can be given and a written action plan should be supplied to reinforce the conversations in the review and support the management of any future attacks. The use of a written action plan means that a patient is four times less likely to need a hospital stay for their asthma and so this remains an important part of an asthma review (Asthma UK, 2019b).
Tools to support asthma reviews
The guidelines contain a checklist to help ensure patients are informed about their condition, its diagnosis and management. While it is not an exhaustive list, it contains details of steps that should be taken when speaking to patients and carers about asthma management. This is important to support a shared care approach.
SIGN also produce booklets, accessible on their website, which can be used to help explain asthma care for adults, children and pregnant women. These are designed to help patients, carers, friends and family members better understand the condition.
Asthma UK provides asthma action plans for adults and children. They can be downloaded for free from their website, or printed copies can be ordered. They provide action plans in 11 languages and have advice for health professionals on helping those who do not speak English to use their action plan.
There is also information and a video to support health professionals in completing asthma action plans as well as a video which health professionals can use with patients to improve their inhaler technique.
NICE has a decision aid available on their website for patients aged 17 years and over, to help them select the right type of inhaler for them (NICE, 2019). This guides them through various factors relating to inhaler use, including the carbon footprint of the inhalers, to help them choose a device that best suits them. There is also a guidance document detailing how to use the decision aid.
Conclusion
The updated guidelines are a comprehensive summary of the evidence supporting the management of asthma. There is a lot of information to remember and a number of things to implement in a short appointment for a patient's review. Where health professionals take the time to learn and implement the full updated guidance and overcome any barriers they have to doing this, they can improve the quality of life for many people with asthma and save lives.
KEY POINTS:
- An important part of an asthma review is to consider the risk of future attack
- Patients' records should be used to gain information about current asthma control and future risk of attack
- How patients are questioned about their asthma is important to ensure accurate assessment of their asthma control
- The environmental impact of inhalers should be considered when choosing appropriate pharmacological treatment
- Asthma care should be tailored to the individual and reinforced with a written asthma plan
CPD reflective practice
- What are the risk factors for a future asthma attack in adults and school-aged children?
- What is meant by ‘targeted care’?
- How do asthma reviews need to be adapted to implement the new recommendations?