Asthma is a common condition which produces a significant workload for general practice, hospital outpatient clinics and inpatient admissions. It is clear that much of this morbidity relates to poor management, particularly around the use of preventative medicine.
Globally, over 300 million people have asthma, and this number is expected to rise by 100 million by 2025. In the UK, 5.4 million people are currently receiving treatment for asthma and there are over six million primary care appointments for asthma each year.2
Asthma prevalence is thought to have plateaued since the late 1990s, although the UK still has some of the highest rates in Europe and on average three people a day die from asthma. In 2014 (the most recent data available), 1,216 people died from asthma. The NHS spends around £1 billion a year treating and caring for people with asthma.2
Two thirds of people are still not receiving the basic care they need to manage their asthma, with wide variations in the level of care reported between different parts of the UK, according to a recent report by Asthma UK. More worryingly, the Annual Asthma Survey 2016 Report found that seven out of 10 people with asthma who end up in hospital are not given a follow-up appointment with a GP or nurse—an essential step in preventing many people from being readmitted to hospital.3
Of the 4,650 people who responded to the survey from across the UK, 42% were given an asthma action plan in 2016—up from 36% last year and 24% in 2013. This is important as not having a written asthma action plan makes a patient four times more likely to end up in hospital with an asthma attack.3
According to Asthma UK, some people don’t like the idea of taking medicine every day. Yet if their asthma is well managed they are actually less likely to need to use their reliever inhaler very often. So, overall, managing asthma well can mean using less medicine.
The aim of asthma management is control of the disease and complete control is defined as:
- No day-time symptoms
- No night-time awakening due to asthma
- No need for rescue medication
- No asthma attacks
- No limitations on activity including exercise
- Normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best)
- Minimal side effects from medication.1
The British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) published new guidance recently with a major focus on supporting health professionals to make accurate diagnoses and provide effective treatments to control asthma and prevent life-threatening asthma attacks.1
It includes a complete revision of the section on diagnosis, a major update to the section on pharmacological management of asthma, and updates to the sections on supported self management, non-pharmacological management of asthma, acute asthma, difficult asthma, occupational asthma, and organisation and delivery of care.
The BTS/SIGN guideline emphasises that there is still no single test that can definitively diagnose asthma and an individual’s asthma status can change over time.
It states that the diagnosis of asthma is a clinical one. The absence of consistent gold-standard diagnostic criteria means that it is not possible to make unequivocal evidence-based recommendations on how to make a diagnosis of asthma.
It recommends that if a health professional suspects asthma, they should undertake a ‘structured clinical assessment’ using a combination of patient history, examination and tests to assess the probability of asthma.1
The updated guideline includes new or revised content in the following areas: asthma drug treatment (replacing the previous stepwise approach), non-drug treatments, supported self-management, and the role of telehealthcare. Key highlights include:
- Short acting beta2 agonists—a group of drugs that can provide quick relief of asthma symptoms—are the key ‘rescue therapy’ from symptoms or asthma attacks and can form part of all treatment plans, but should rarely be used on their own
- A key emphasis on medication to prevent future asthma attacks—inhaled corticosteroids remain the most effective ‘preventer’ drug for all adults and children
- Asthma inhalers should not be prescribed generically to avoid patients being given an unfamiliar device that they may not know how to use properly
- If a patient has poor control of their asthma, it is essential to check whether they are using their current drug treatment correctly and regularly, before stepping up treatment
- Weight loss initiatives—including dietary and exercise programmes—can be offered for overweight or obese adults with asthma and may improve their asthma control
- Each patient should be offered a written asthma action plan as it is key to the effective management of their asthma
- The use of new electronic technologies can help in the delivery of asthma care, and evidence shows they can be at least as good as traditional methods, although outcomes do vary.
In efficacy studies, where there is generally good adherence, there is no difference in efficacy in giving inhaled corticosteriod and a long-acting β2 agonist in combination or in separate inhalers. In clinical practice, however, it is generally considered that combination inhalers aid adherence and also have the advantage of guaranteeing that the long-acting β2 agonist is not taken without the inhaled corticosteroid.1
Non pharmacological management
According to the guidance, there is a common perception amongst patients and carers that there are numerous environmental, dietary and other triggers of asthma and that avoiding these triggers will improve asthma and reduce the requirement for pharmacotherapy. Evidence that non-pharmacological management is effective can be difficult to obtain and more well-controlled intervention studies are required.
Secondary prevention relates to interventions introduced after the onset of disease to reduce its impact. Interventions such as physical and chemical methods of reducing house dust mite levels in the home (including acaricides, mattress covers, vacuum cleaning, heating, ventilation, freezing, washing, air filtration and ionisers) are ineffective and should not be recommended by healthcare professionals.
Appropriate support to stop smoking should be offered and weight-loss interventions (including dietary and exercise-based programmes) can be considered for overweight and obese adults with asthma to improve asthma control.
In addition, breathing exercise programmes (including physiotherapist-taught methods) can be offered to people with asthma as an adjuvant to pharmacological treatment to improve quality of life and reduce symptoms.1
TABLE 1– KEY POINTS FROM BTS/SIGN GUIDELINES1
Adherence to long-term asthma treatment should be routinely and regularly addressed by all healthcare professionals within the context of a comprehensive programme of accessible proactive asthma care.
A recent report from Asthma UK called Connected Asthma: how technology will transform care, outlines how technologies already in existence, including smart inhalers, electronic alerts and digital action plans could be used to completely transform the NHS asthma care pathway by reducing routine GP appointments and enabling people to manage their own condition.4 The report explains where several key innovations could make the biggest impact for people with asthma.
Smart inhalers are designed to link to a smartphone and detect when an inhaler is used—tracking use in real-time and building a picture of overall medication use for a person with asthma. It is believed that in the future smart inhalers could help more people to take their medications properly.
It states that smart inhalers are poised to enter the UK healthcare system with the potential to transform care for people with asthma, but proper planning and rigorous testing is needed to ensure smart-enabled care pathways deliver the best outcomes for people with asthma and the NHS.
Smart inhalers are designed to help people with asthma ensure they are taking their medication as prescribed, by recording the timing and dosage taken on their smartphone. The data collected can be used by a clinician to check that prescribed treatment is working and to personalise asthma reviews to focus on root causes of worsening symptoms, as well as to inform early warning systems for when to seek medical attention. This technology could enable a move away from one-size-fits-all asthma reviews, and lead to fewer routine appointments, which could help relieve pressure on the NHS.
Asthma could provide a template for the use of connected technologies at scale, according to the report. However, it identifies the need for investment in a significant programme of research and testing to assess the accuracy, cost effectiveness and user experiences of these new technologies, as well as the right implementation models to deliver the best care and clinical outcomes.
Whilst smart inhalers have been shown to be effective in previous studies, there are practical considerations for real-world implementation in the NHS. With over 90 (non-smart) inhalers currently on the UK market and many people with asthma prescribed at least two, people with asthma will need to be able to switch between their treatments and prescriptions seamlessly, without being tied to a particular device or app, or be expected to manage two different systems.
NHS commissioners will no longer be purchasing just medication in the form of inhalers, says the report, but also other components to make the whole system work—such as the sensors, cloud services, user mobile apps and clinical support systems. How these are designed and priced from the start could have far-reaching impacts on how smart inhaler technology is adopted across the NHS, and whether the maximum number of people could potentially benefit.
Health apps on smart devices could also help people with asthma receive personalised information to help self-manage their asthma. These need to be better developed to suit user needs, but these could give people information on triggers such as air pollution, in addition to storing a person’s asthma action plan.
Remote monitoring could help healthcare professionals to better support people with asthma, with technology potentially able in the future to detect when a person’s asthma is worsening and respond appropriately to prevent an attack. Asthma UK is currently supporting research aimed at creating a personalised asthma monitoring system.
Innovative systems and data
Innovative systems and data could help ensure that those most at risk of an asthma attack are identified and their asthma is managed effectively as a result. This includes linking systems to ensure GPs are informed when people have an emergency admission due to their asthma.
There needs to be a suitable process to help ensure that innovations are rapidly introduced in a safe way, according to Asthma UK. As a first step, they want to see the NHS introduce a testing programme for smart inhalers in the UK so that people with asthma can begin to benefit from the exciting innovations being developed.
1. BTS/SIGN guidelines. https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-quick-reference-guide-2016/ (accessed 20/02/17)
2. Asthma UK. https://www.asthma.org.uk/about/media/facts-and-statistics/ (accessed 20/02/17)
3. Asthma UK. Annual Asthma Survey. https://www.asthma.org.uk/get-involved/campaigns/publications/survey/ (accessed 20/02/17)
4. Asthma UK. https://www.asthma.org.uk/get-involved/campaigns/asthma-needs-research/connected-asthma/ (accessed 20/02/17)
5. Asthma UK. Smart Asthma. https://www.asthma.org.uk/get-involved/campaigns/publications/smartasthma/ (accessed 20/02/17)