Patient discussions
All patients with asthma should be provided with self-management education, including how to monitor symptoms and/or lung function, a personalised written asthma action plan, and regular review by a healthcare professional. Asthma and Lung UK: adult asthma action plan Opens in new window[1][13] Information on correct inhaler use, importance of drug adherence (in particular, correctly taking any prescribed inhaled corticosteroid [ICS]-containing drugs), and avoiding asthma triggers is also emphasised.[1] The written asthma action plan helps patients to recognise when their asthma is deteriorating and how to respond appropriately. This may include instructions on how and when to:[1]
Change usual reliever medication
Change usual preventer (controller) medication
Use oral corticosteroids
Contact a healthcare professional
The advice and criteria will vary from patient to patient and should be tailored to health literacy and sociocultural factors.[1] The patient may be given a peak flow meter with proper instruction on technique, and their action plan may be based on changes in the measured peak flow: this approach can be useful for patients with a history of sudden severe exacerbations, or for earlier detection of exacerbations in patients with poor perception of airflow limitation.[1] Depending on patient ability and clinical appropriateness, drug changes may be patient-initiated (by following instructions in the written action plan) or initiated by a healthcare provider.[1] Patients with a history of rapid deterioration may be advised to seek medical attention immediately if their asthma starts to worsen.[1]
For patients taking maintenance-only ICS-containing treatment, the maintenance treatment should generally be increased if there is a clinically important change from the patient's usual level of asthma control: for example, if asthma symptoms are interfering with normal activities, or peak expiratory flow rate has reduced by more than 20% for more than 2 days.[1]
An unblinded, randomised trial involving 1871 adults and adolescents with asthma looked at the effect of a personalised asthma action plan that included a temporary quadrupling of the dose of ICS when asthma control started to deteriorate. This resulted in fewer severe asthma exacerbations than a plan in which the ICS dose was not increased.[74] This approach is now recommended by some guidelines, including the Global Initiative for Asthma (GINA), the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN), in the self-management of asthma exacerbations in adults.[1][13]
In adults, increased asthma morbidity benefits are seen when the written action plan includes both increasing ICS and adding oral corticosteroids.[1] If oral corticosteroids are part of the written action plan, the patient should be advised against inappropriate use of these.[1] While oral corticosteroids can be necessary and life-saving (especially for severe exacerbations), there are long-term risks associated with repeat courses: even 4 to 5 courses in an adult is linked to an increased dose-dependent risk of diabetes, osteoporosis and heart failure, among other conditions.[1] There are also important short-term adverse effects, including mood changes and increased thromboembolism and infection risk.[1] Steps should be taken to reduce risk of future exacerbations and thus minimise future use of oral corticosteroids.[1] The British Thoracic Society (BTS) advises that patients who require frequent use of oral corticosteroids should be under the care of a specialist asthma service.[13]
If home treatment is not appropriate, then treatment in primary care, an acute care facility, the emergency department, or in hospital will be required. Patients should contact their doctor if they start oral corticosteroids at home and should be advised to urgently seek medical attention if their symptoms worsen despite (or do not respond to) appropriate self-management.[1]
After a self-managed exacerbation, GINA recommends that the patient should have a semi-urgent review in primary care within 1 to 2 weeks, ideally before stopping any oral corticosteroids.[1] If the patient needed treatment in primary care, an acute care facility, the emergency department, or in hospital, then a follow-up visit should be scheduled within 2 working days.[13] The follow-up review should assess:[1]
Whether or not the exacerbation has resolved
Whether or not oral corticosteroids can be stopped
The patient's level of symptom control
The patient's risk factors
The potential cause of the exacerbation
The patient's written asthma action plan (e.g., was it understood and followed appropriately; does it need to be amended or updated)
The patient's inhaler technique and adherence to treatment.
The follow-up review also provides opportunity for additional education.[1][13] GINA recommends that patients discharged from the accident and emergency department or after hospitalisation should in particular be targeted for an asthma education programme if available.[1] Patients who have been hospitalised may be especially receptive to education, and there is evidence that comprehensive intervention (with optimisation of treatment and inhaler technique, and self-management education) after accident and emergency department presentation significantly improves asthma outcomes.[1] Educational interventions in the emergency department that target either patients or primary care providers may help reinforce the need for primary care follow-up visits after asthma exacerbations.[75]
Patients with a high risk of life-threatening asthma exacerbations (e.g., one or more risk factors present for asthma-related death) should be flagged for more frequent review, and are encouraged to seek urgent medical care early in the course of an exacerbation.[1] Risk factors for asthma-related death should be clearly identified in the patient’s medical notes.[1] BTS guidelines highlight an increased risk of near-fatal or fatal asthma in patients with severe asthma and one or more adverse behavioural or psychosocial features (e.g., failure to attend appointments, non-adherence with treatment/monitoring, psychiatric illness, learning difficulties, alcohol or drug abuse, employment/income issues, social isolation, severe domestic/legal stress).[13] GINA also identifies risk factors for asthma-related death.[1]
A history of near-fatal asthma requiring intubation and mechanical ventilation
Hospitalisation or emergency care visit for asthma in the past year
Currently using or having recently stopped oral corticosteroids
Not currently using ICS
Over-use of short-acting beta-2 agonists, especially use of one or more inhalers of salbutamol (or equivalent) monthly on average, or use of nebulised short-acting beta-2 agonist
Poor adherence to ICS-containing medications and/or poor adherence to (or lack of) a written asthma action plan
A history of psychiatric disease or psychosocial problems
Food allergy (or anaphylaxis) in a patient with asthma
Certain comorbidities including pneumonia, diabetes, and arrhythmias
Women with asthma who are pregnant or planning a pregnancy should be advised not to stop any prescribed ICS-containing therapy, as doing so will increase their risk of exacerbations.[1] Exacerbations in pregnancy are associated with increased risk of poor pregnancy outcomes (e.g., low birthweight) but well controlled asthma during pregnancy poses little or no increased risk of maternal or fetal complications.[1][13] Counsel the patient that the benefits of treating asthma during pregnancy (and the risks of not controlling asthma during pregnancy) heavily outweigh any potential risks of using standard asthma treatments in pregnancy.[1]
How to use a peak flow meter to obtain a peak expiratory flow measurement.
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