CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.
Asthma - Management
What follow up is needed in someone with asthma?
- Review a person with stable asthma at least once a year. More frequent follow up may be needed after the initial diagnosis e.g. reassess within 2–3 months, when there is a change to medication, or in people with severe asthma or recurrent exacerbations.
- Review asthma control:
- Ask about symptoms during the day; difficulty sleeping; and the impact of asthma on such activities as exercise, work, school, and psychological well-being in the past week or month.
- Assess lung function using spirometry or Peak Expiratory Flow.
- Ask about past exacerbations and their frequency, and whether oral corticosteroids or hospital admission was needed.
- Ask about possible trigger factors, such as exercise, work, and allergens.
- Ask about other conditions that are known to co-exist with asthma and aggravate symptoms e.g. allergic rhinitis, sleep apnoea, and gastro-oesophageal reflux disease.
- Look for signs of complications which may necessitate referral to a specialist.
- Review asthma medication:
- Ask about the use of reliever medication, any benefits seen with changes in medication, and compliance with treatment (which can be assessed by reviewing prescription refill frequency).
- Assess inhaler technique and check peak expiratory flow rate to compare with the previously recorded value.
- Review smoking habit. Encourage people with asthma or parents of children with asthma to stop smoking.
- Review self-management education and make any necessary changes to written action plans.
Clarification / Additional information
- Some people may not wish to attend for regular review. A structured interview by telephone may be an alternative approach. Ideally, candidates should have stable asthma, and face-to-face contact should be encouraged at a later date to assess their inhaler technique.
- Control of asthma can be assessed by reviewing symptoms or a person's peak flow diary. Tailor the approach and questions asked to the individual's age and severity of disease:
- In adults (over 16 years), use the Royal College of Physicians' 'three questions' approach (Table 1). Responses can be recorded easily and can form the basis of a symptom diary.
- In children (16 years or younger), ask about symptoms and how they affect school, sport, and play.
- Reinforce the correct use of inhalers at each review. Ask the person to show you how they use their inhaler, and correct any problems by demonstrating the technique and having the person repeat it back to you. For more information on how to use inhalers (with demonstrations), see www.asthma.org.uk or www.ginasthma.org.
Table 1. Royal College of Physicians' 'three questions' for assessing asthma control.
In the last week/month: | Yes | No |
|---|
Have you had difficulty sleeping because of your asthma symptoms (including cough)? | 1 | 0 |
Have you had your usual asthma symptoms during the day (e.g. cough, wheeze, chest tightness, or breathlessness)? | 1 | 0 |
Has your asthma interfered with your usual activities (e.g. housework, work, school)? | 1 | 0 |
3 questions score (0–3) |
|
Basis for recommendation
- These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].
- The aim of a structured review is to assess how well a person's asthma is controlled and to identify possible triggers of poor control. Then, if needed, treatment can be changed (stepped up, down or changed) to help optimize control and reduce exacerbations and hospitalizations.
- Structured reviews: The evidence shows that people have fewer exacerbations, have improved symptoms, and miss less school or work if they undergo structured asthma reviews, especially if the assessments are done by trained professionals. Telephone consultations may be as effective as face-to-face consultations [Pinnock and Shah, 2007].
- Assessing lung function: Reduced lung function compared to previously recorded values may indicate current bronchoconstriction or a long term decline in lung function and should prompt detailed assessment [SIGN and BTS, 2009].
- Asthma morbidity questionnaires: Questionnaires have been developed to standardize the assessment of asthma symptom control. Asking people about asthma symptoms and their effects on everyday life is important to improve asthma management [Rees, 2006].
- Comorbidities: Gastro-oesophageal reflux disease, allergic rhinitis, obesity, and obstructive sleep apnoea have been reported in greater proportions of people with difficult-to-treat asthma. It is important to recognize such conditions because they appear to aggravate asthma symptoms and need treatment. However, to date, no evidence indicates that treating these conditions improves asthma control [GINA, 2006; SIGN and BTS, 2009].
- Smoking: Smoking may cause poor asthma control. Past smoking can be associated with poor control due to fixed airway obstruction, and current smoking reduces the effectiveness of inhaled and oral corticosteroids [GINA, 2006].
© NHS Institute for Innovation and Improvement