The career of a GP can be peppered with tragic events, professional and personal. Perhaps none could be more poignant than the unexpected death of a child. This child was a few days from their 12th birthday and a typical football playing, wise-cracking young man who was unfortunate in having asthma.
He was a good asthmatic - had good inhaler technique, attended for check-ups when asked and readily took on board the advice offered by the asthma nurse. Then one day he had an attack which escalated very rapidly and he died; despite everyone's attempts to save him. Why it escalated so quickly when he had been well controlled, will never be known.
What makes this story even worse is that it is repeated (with variations) around the UK far too many times a year. According to Asthma UK, every day three families lose a loved one because of a fatal asthma attack. They also estimate that every 10 seconds in the UK, someone is having a potentially life-threatening asthma attack.
However, there are also many individuals who only experience symptoms when otherwise challenged by an infection or allergen. Where you have an illness that has such a wide-ranging spectrum of morbidity, it can be difficult to tailor care that suits all individuals. We need to safeguard those most at risk but should avoid over-medicalising those who can cope. In August 2015 the Royal College of Physicians (RCP) released the National Review of Asthma Deaths (NRAD) report: Why asthma still kills.(1)
This contains 5 recommendations for medical care:
1. All people with asthma should be provided with written guidance in the form of a personal asthma action plan that details their own triggers and current treatment, and specifies how to prevent relapse and when and how to seek help in an emergency. These are available online at the Asthma UK website (see: https://www.asthma.org.uk/globalassets/health-advice/adult-asthma-action-plan.pdf) and are also downloaded onto the EMIS Web system.
2. People with asthma should have a structured review by a healthcare professional with specialist training in asthma, at least annually. People at high risk of severe asthma attacks should be monitored more closely, ensuring that their personal asthma action plans are reviewed and updated at each review.
3. Factors that trigger or exacerbate asthma must be elicited routinely and documented in the medical records and personal asthma action plans of all people with asthma, so that measures can be taken to reduce their impact.
4. An assessment of recent asthma control should be undertaken at every asthma review. Where loss of control is identified, immediate action is required, including escalation of responsibility, treatment change and arrangements for follow-up. Recognition may be from monitoring requests for repeat prescriptions for inhalers. Overuse of salbutamol and underuse of corticosteroid should prompt action, such as calling the patient for a review.
5. Health professionals should also bear in mind the features that increase the risk of asthma attacks and death, including the significance of concurrent psychological and mental health issues.
In addition the RCP suggest that patients:
- Should be encouraged to reflect their known triggers, eg increasing medication before the start of the hay fever season, avoiding non-steroidal anti-inflammatory drugs or by the early use of oral corticosteroids with viral- or allergic-induced exacerbations
- Should be made aware that smoking and/or exposure to secondhand smoke can affect their condition and such exposure should be written in the medical records of all people with asthma. Current smokers should be offered referral to a smoking-cessation service.
- Should be educated about managing asthma. This should include emphasis on 'how', 'why' and 'when' they should use their asthma medications, recognising when asthma is not controlled and knowing when and how to seek emergency advice.
- Should try to minimise exposure to allergens and secondhand smoke, especially young people with asthma.
Current estimates are that one in 11 people in the UK have asthma. This means an average (7,000 patient) practice will be looking after approximately 640 patients. When did your practice last discuss your care for this group? Perhaps, as hay fever season comes upon us, it's time to make sure all your staff are asthma aware. Patient has several asthma-related pages to assist you.
NB: Scottish Intercollegiate Guidelines Network is due to release new guidelines on asthma management in summer 2016 and National Institute for Health and Care Excellence has a release date for their guidance, of June 2017. We will update our articles thereafter.
1. Why asthma still kills; Royal College of Physicians, August 2015.