Conducting asthma review at scheduled asthma visits
Validated checklists or questionnaires can be used at each visit to assess recent asthma symptom control or to screen for poor asthma control, e.g:
- Asthma Score (Asthma Control Test)
- Primary care Asthma Control Screening
- Asthma Control Questionnaire (ACQ)
- How this recommendation was developed
At scheduled asthma visits, assess (all of):
- any problems or issues the person is having with their asthma
- current level of control based on symptoms and reliever use during the previous 4 weeks
- flare-ups during the previous 12 months
- lung function (every 1–2 years for most people; more often when good asthma control has been lost or not achieved, or when the person has a known risk factor for accelerated loss of lung function)
- other risk factors (e.g. smoking, exposure to other triggers) or comorbid conditions
- current treatment, including adherence to preventer if prescribed. Do not assume the person is taking the dose most recently prescribed. Ask which asthma medicines the person is using, in a non-judgmental, empathic manner.
- inhaler technique
- whether the person has a written asthma action plan and knows how to use it, and whether it is up to date.
Table. Definition of levels of recent asthma symptom control in adults and adolescents (regardless of current treatment regimen)
Table. Risk factors for adverse asthma outcomes in adults and adolescents Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/40
Table. Suggested questions to ask adults and older adolescents when assessing adherence to treatment
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available).
- Ongoing monitoring of asthma in adults
Asthma monitoring includes both self-monitoring by patients and periodic assessments by the clinician.
Asthma management in primary care should include periodic reassessment of (both):1
- recent asthma symptom control based on symptoms over the previous 4 weeks, with or without lung function testing. In many patients in primary care, symptoms, reliever use and lung function are useful surrogate measures of the degree to which the underlying disease process is controlled.
- risk factors that predict poor asthma outcomes (e.g. flare-ups, accelerated decline in lung function, or treatment-related adverse effects) independent of the person’s level of recent asthma symptom control.
Planned asthma check-ups should be made at intervals determined by both the individual’s level of recent asthma symptom control and risk factors. The following is a guide:
- 1–3 months after each adjustment to medications
- yearly for a person with no flare-up in the past 12 months and good symptom control for at least a year
- every 6 months for a person who has had a flare-up within the past 12 months or who has other risk factors for flare-ups or life-threatening asthma (e.g. smoking, previous recording of poor lung function on spirometry, history of admission to an intensive care unit for asthma)
- at least every 3 months for a person with severe asthma, work-exacerbated asthma, poor perception of airflow limitation, frequent rhinosinusitis symptoms, or other comorbid conditions that affect asthma control
- every 4–6 weeks for pregnant women.
Note: For patients with occupational asthma, management and follow-up by a specialist with experience in occupational asthma is recommended.Close
- Assessing recent asthma control in adults: symptoms
Questionnaire-based tools can be used to standardise review of asthma symptoms, e.g.:
- Primary care Asthma Control Screening tool (also known as Pharmacy Asthma Control Screening tool)2 – a quick screening test to detect poor asthma control, developed and validated for use with Australian patients attending primary care
- UK Royal College of Physicians ‘3 Questions’3
- Asthma Score (also known as Asthma Control Test).4
- Asthma Control Questionnaire (ACQ)
The questionnaires can be completed on paper in the waiting room and scored by the practice nurse. They have also been administered via an application on hand-held personal electronic devices,5, 6 or by telephone.7Note: Clinicians and researchers should only use the versions of the ACQ and Asthma Score that have been validated for use in the Australian population. The wording and layout of questionnaires must not be changed.
Data from one UK study suggest that, for the majority of patients attending primary care, asthma symptoms are concordant with eosinophilic airway inflammation, and that symptoms can therefore be used as a guide to changing anti-inflammatory treatment.8
However, if symptoms do not improve as expected after a change in treatment, or if the person continues to experience flare-ups, it is necessary to measure lung function and consider other possible causes:
- Respiratory symptoms in a person with asthma may be due to non-asthma factors (e.g. cough due to post-nasal drip, shortness of breath due to obesity). Increasing the preventer treatment in such patients could result in unnecessarily high doses. A careful history (with lung function measurement in some patients) is necessary to confirm that symptoms are due to asthma, before deciding to change a person’s treatment.
- Patients vary in their ability to perceive airflow limitation, so symptoms may be an unreliable measure of asthma control in some patients. Spirometry can help identify if the person is a poor perceiver of airflow limitation (e.g. person is unable to feel the difference when FEV1 increases or decreases by 15%).
- Assessing asthma control in adults: spirometry
Spirometry is necessary when making the diagnosis of asthma and when establishing the patient’s baseline and personal best status.
In ongoing asthma management, spirometry is useful in the following clinical situations:
- During a flare-up, spirometry provides objective evidence about the severity of bronchoconstriction.
- After a dose adjustment (either an increase or a decrease), change in lung function measured by spirometry provides additional information about the response to treatment.
- Spirometry can help identify if the person’s symptoms may be due to non-asthma conditions (e.g. for a patient with frequent respiratory symptoms, FEV1 above 80–90% predicted should prompt consideration of an alternative cause).
- Spirometry can help identify if the person is a poor perceiver of airflow limitation (e.g. person is unable to feel the difference when FEV1 increases or decreases by 15%).
- Repeating spirometry over time may identify lung function decline that is more rapid than expected decline due to ageing alone, so the person can be referred for specialist review. (Spirometry should be repeated approximately every 1–2 years in most patients but more frequently as indicated by individual needs.)
There are limits to the amount of information that can be gained from spirometry alone:
- For an individual, spirometry readings are not closely reproducible between visits, so only a change in FEV1 of greater than 0.2 L and 12% from baseline can be considered clinically meaningful in adults.9
- Older people with long-standing asthma may develop fixed (irreversible or incompletely reversible) airflow limitation. Reliance solely on lung function expressed as percentage predicted value as a guide to adjusting preventer treatment would risk dose-escalation and over-treatment in these patients.
- At the population level, spirometry correlates poorly with symptom-based measures of asthma control,10 so in individual patients it is not possible to predict lung function from symptoms or vice versa.
To obtain reliable, good-quality readings, the spirometer must be well maintained and correctly calibrated, and the operator must be adequately trained and experienced.Close
- Assessing risk factors for adverse asthma outcomes in adults
Predicting poor asthma outcomes
As well as assessing recent asthma symptom control, it is necessary to assess each patient’s risk of future asthma events or adverse treatment effects. (Recent asthma symptom control and risk of adverse events are both components of overall asthma control.)
Table. Risk factors for adverse asthma outcomes in adults and adolescents Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/40
Poor clinical control, as indicated by frequent asthma symptoms and frequent reliever use, is a very strong predictor of the risk of flare-ups in the future. Any asthma flare-up during the previous 12 months indicates higher risk of flare-up over the next 12 months. A history of artificial ventilation due to acute asthma, and admission to an intensive care unit due to acute asthma have been associated with increased risk of near-fatal asthma,11 but there is not enough evidence to indicate how long this risk may persist over a person’s lifetime. Other risk factors indicate increased probability of future flare-ups or accelerated decline in lung function, independent of the person’s level of recent asthma symptom control. 12, 4, 13
Other factors may increase a person’s risk of treatment-associated adverse effects. The most important of these are prescription of high dose treatment and frequent courses of oral steroids.
People with risk factors need more frequent asthma review, a carefully tailored written asthma action plan, and close attention to adherence and correct inhaler technique.
Inflammatory markers, such as sputum eosinophil percentage or exhaled nitric oxide, are used in research and for managing severe asthma in patients attending secondary or tertiary care. Elevated sputum eosinophil levels and, to a lesser extent, elevated exhaled nitric oxide, are associated with increased risk of flare-ups. At present, treatment based on inflammatory markers is not recommended for routine use in primary care.
The value of inflammatory markers is being evaluated:
- Adjusting asthma treatment by monitoring exhaled nitric oxide does not reduce the rate of flare-ups or improve asthma control in adults and children, compared with adjusting treatment according to clinical symptoms or spirometry, based on a meta-analysis of randomised controlled clinical trials.14 However, many of the studies were not optimally designed to answer this question,15 and some comparator regimens did not match current recommended treatment options.
- In some studies, asthma treatment algorithms based on monitoring sputum eosinophil counts reduced flare-ups, compared with control-based management.1, 16 However, most studies assessing treatment guided by sputum eosinophilia have been conducted in selected populations in a few research centres, and therefore may not apply to the general community population. Assessment of sputum inflammatory cells is not generally available at present even in secondary care.
- Limited evidence8 suggests that patients whose symptoms do not match their degree of eosinophilic inflammation may benefit more from treatment monitoring using sputum eosinophil count than other patients.
- Monitoring inflammatory markers might enable safer down-titration of maintenance inhaled corticosteroid doses.
- Correct use of inhaler devices
High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,19, 20, 21, 22, 23 even among regular users.24 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.25
Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.19, 26, 24, 27, 28 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.24
Common errors and problems with inhaler technique
Common errors with manually actuated pressurised metered dose inhalers include:25
- failing to shake the inhaler before actuating
- holding the inhaler in wrong position
- failing to exhale fully before actuating the inhaler
- actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
- actuating the inhaler too late while inhaling
- actuating more than once while inhaling
- inhaling too rapidly (this can be especially difficult for chilren to overcome)
- multiple actuations without shaking between doses.
Common errors for dry powder inhalers include:25
- not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
- failing to exhale fully before inhaling
- failing to inhale completely
- inhaling too slowly and weakly
- exhaling into the device mouthpiece before or after inhaling
- failing to close the inhaler after use
- using past the expiry date or when empty.
Other common problems include:
- difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
- inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
- inability to generate adequate inspiratory flow for the inhaler type
- failure to use a spacer when appropriate
- use of incorrect size mask
- inappropriate use of a mask with a spacer in older children.
How to improve patients’ inhaler technique
Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.25 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.31, 19, 32, 33 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.32 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).17, 30
The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.Close
- Written asthma action plans for adults
Every person with asthma should have their own written asthma action plan.
When provided with appropriate self-management education, self-monitoring and medical review, individualised written action plans consistently improve asthma health outcomes if they include two to four action points, and provide instructions for use of both inhaled corticosteroid and oral corticosteroids for treatment of flare-ups.34 Written asthma action plans are effective if based on symptoms35 or personal best peak expiratory flow (not on percentage predicted).34
How to develop and review a written asthma action plan
A written asthma action plan should include all the following:
- a list of the person’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
- clear instructions on how to change medication (including when and how to start a course of oral corticosteroids) in all the following situations:
- when asthma is getting worse (e.g. when needing more reliever than usual, waking up with asthma, more symptoms than usual, asthma is interfering with usual activities)
- when asthma symptoms get substantially worse (e.g. when needing reliever again within 3 hours, experiencing increasing difficulty breathing, waking often at night with asthma symptoms)
- when peak flow falls below an agreed rate (for those monitoring peak flow each day)
- during an asthma emergency.
- instructions on when and how to get medical care (including contact telephone numbers)
- the name of the person writing the action plan, and the date it was issued.
Table. Options for adjusting medicines in a written asthma action plan for adults Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/42
Templates for written asthma action plans
Templates are available from National Asthma Council Australia:
- National Asthma Council Australia colour-coded plan, available as a printed handout that folds to wallet size and as the Asthma Buddy mobile site
- Asthma Cycle of Care asthma action plan
- A plan designed for patients using budesonide/formoterol combination as maintenance and reliever therapy
- Remote Indigenous Australian Asthma Action Plan
- Every Day Asthma Action Plan (designed for remote Indigenous Australians who do not use written English – may also be useful for others for whom written English is inappropriate).
Some written asthma action plans are available in community languages.Close
- Health system initiatives that support asthma care
Chronic Disease Management Medicare items
Patients with asthma are eligible for Chronic Disease Management Medicare items.38 These include:
- Preparation of a GP Management Plan (Item 721)
- Review of a GP Management Plan (Item 732)
- Coordination of Team Care Arrangements (Item 723) for patients who need ongoing care from a multidisciplinary team of at least three health or care providers
- Coordination of a Review of Team Care Arrangements (Item 732)
- Contribution to a multidisciplinary care plan being prepared by another health or care provider (Item 729)
- Contribution to a multidisciplinary care plan being prepared for a resident of an aged care facility (Item 731).
GPs can be assisted by practice nurses, Aboriginal and Torres Strait Islander health practitioners, Aboriginal health workers and other health professionals.38
Asthma cycle of care
The Asthma cycle of care is an Australian Government initiative to support primary care health professionals (GPs, other medical practitioners and trainees) to provide asthma care. It is implemented through the Practice Incentives Program (PIP) Asthma Incentive and applies to the clinical care of people with moderate-to-severe asthma, generally defined as people with (any of):39
- symptoms on most days
- use of preventative medication
- bronchodilator use at least three times per week
- hospital attendance or admission following an acute asthma flare-up.
The Asthma cycle of care involves at least two asthma-related consultations within 12 months for a patient with moderate-to-severe asthma, of which at least one visit is a planned asthma review. Each consultation includes:
- documenting the diagnosis, assessing asthma severity and assessing level of recent asthma symptom control
- reviewing the patient’s use of and access to asthma medicines and inhaler devices
- providing a written asthma action plan (or documented alternative, if the patient is unable to use a written action plan)
- providing asthma self-management education
- reviewing the written or documented asthma action plan.
The Personally Controlled eHealth Record System
The eHealth record is an electronic record for a patient that contains a summary of their health information. Patients can choose to register for an eHealth record. Authorised healthcare professionals can access a patient’s record and upload information to the record if their healthcare organisation has registered for the eHealth record system.
Health system initiatives for Aboriginal and Torres Strait Islander people
Health system initiatives to support the care of Aboriginal and Torres Strait Islander people include:
- Health Assessment Medicare items
- The Indigenous Chronic Disease Package
- The Asthma Spacer Ordering System.
- Taylor DR, Bateman ED, Boulet LP, et al. A new perspective on concepts of asthma severity and control. Eur Respir J. 2008; 32: 545-554. Available from: http://erj.ersjournals.com/content/32/3/545.long
- LeMay KS, Armous CL, Reddel HK. Performance of a brief asthma control screening tool in community pharmacy: a cross-sectional and prospective longitudinal analysis. Prim Care Respir J. 2014; 23 (1): 79-84. Available from: http://www.nature.com/articles/pcrj201411
- British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
- Thomas M, Kay S, Pike J, et al. The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J. 2009; 18: 41-49. Available from: http://www.nature.com/articles/pcrj200910
- Peters SP, Jones CA, Haselkorn T, et al. Real-world Evaluation of Asthma Control and Treatment (REACT): Findings from a national Web-based survey. J Allergy Clin Immunol. 2007; 119: 1454-1461. Available from: http://www.jacionline.org/article/S0091-6749(07)00619-7/fulltext
- Juniper EF, Langlands JM, Juniper BA. Patients may respond differently to paper and electronic versions of the same questionnaires. Resp Med. 2009; 103: 932-934. Available from: http://www.resmedjournal.com/article/S0954-6111(08)00385-5/fulltext
- Kosinski M, Kite A, Yang M, et al. Comparability of the Asthma Control Test telephone interview administration format with self-administered mail-out mail-back format. Curr Med Res Opin. 2009; 25: 717-727. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19196218
- Haldar P, Pavord ID, Shaw DE, et al. Cluster analysis and clinical asthma phenotypes. Am J Respir Crit Care Med. 2008; 178: 218-224. Available from: http://ajrccm.atsjournals.org/content/178/3/218.full
- Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005; 26: 948-968. Available from: http://erj.ersjournals.com/content/26/5/948
- Schatz M, Sorkness CA, Li JT, et al. Asthma Control Test: Reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol. 2006; 117: 549-556. Available from: http://www.jacionline.org/article/S0091-6749(06)00174-6/fulltext
- Turner MO, Noertjojo K, Vedal S, et al. Risk factors for near-fatal asthma. A case-control study in hospitalized patients with asthma. Am J Respir Crit Care Med. 1998; 157: 1804-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9620909
- Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available from: http://www.ginasthma.org
- Osborne ML, Pedula KL, O'Hollaren M, et al. Assessing future need for acute care in adult asthmatics: the Profile of Asthma Risk Study: a prospective health maintenance organization-based study. Chest. 2007; 132: 1151-61. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1085456
- Petsky HL, Cates CJ, Li A, et al. Tailored interventions based on exhaled nitric oxide versus clinical symptoms for asthma in children and adults. Cochrane Database Syst Rev. 2009; Issue 4: CD006340. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006340.pub3/full
- Gibson PG. Using fractional exhaled nitric oxide to guide asthma therapy: design and methodological issues for asthma treatment algorithm studies. Clin Exp Allergy. 2009; 39: 478-490. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19260871
- Petsky HL, Cates CJ, Lasserson TJ, et al. A systematic review and meta-analysis: tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils). Thorax. 2012; 67: 199-208. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20937641
- Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
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- Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23098685
- Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
- Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18083019
- Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24779482
- Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ primary care respiratory medicine. 2014; 24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
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- National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
- Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762
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- Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
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- Lavorini, F.. Inhaled drug delivery in the hands of the patient. Journal of aerosol medicine and pulmonary drug delivery. 2014; 27: 414-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25238005
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- Powell H, Gibson PG. Options for self-management education for adults with asthma. Cochrane Database Syst Rev. 2002; Issue 3: CD004107. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004107/full
- Roberts NJ, Mohamed Z, Wong PS, et al. The development and comprehensibility of a pictorial asthma action plan. Patient Educ Couns. 2009; 74: 12-18. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18789626
- Roberts NJ, Evans G, Blenkhorn P, Partridge M. Development of an electronic pictorial asthma action plan and its use in primary care. Patient Educ Couns. 2010; 80: 141-146. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19879092
- Australian Government Department of Health. Chronic Disease Management (CDM) Medicare Items. Australian Government, Canberra, 2013. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdiseasemanagement
- Australian Government Medicare Australia. Practice Incentives Program Asthma Incentives Guidelines – August 2011. Medicare Australia, Canberra, 2011. Available from: http://www.medicareaustralia.gov.au/provider/incentives/pip/forms-guides.jsp#N10068