literature review on asthma

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Muhammad F. Hashmi ; Maryam Tariq ; Mary E. Cataletto .

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Last Update: August 8, 2023 .

• Continuing Education Activity

Asthma is a chronic disease of the air passages characterized by inflammation and narrowing of the airways. Symptoms of asthma include shortness of breath, cough, and wheezing. It commonly presents in childhood and is usually associated with conditions such as eczema and hay fever. This activity outlines the evaluation and treatment of asthma and explains the role of the interprofessional team in managing patients with this condition.

• Review the epidemiology of asthma.
• Identify the typical patient history of asthma.
• Summarize the use of pulse oximetry and peak flow measures in the bedside evaluation of asthma.
• Outline the importance of collaboration and communication among the interprofessional team members to improve outcomes in patients affected by asthma.
• Introduction

Asthma is a common disease and has a range of severity, from a very mild, occasional wheeze to acute, life-threatening airway closure. It usually presents in childhood and is associated with other features of atopy, such as eczema and hayfever. [1] [2] [3]

Asthma is a very common childhood illness leading to multiple hospital admissions and increased healthcare costs. The key feature is airway hyper-responsiveness, which can be triggered by many factors. If not treated promptly, asthma has a high mortality. [4]

Asthma comprises a range of diseases and has a variety of heterogeneous phenotypes. The recognized factors that are associated with asthma are a genetic predisposition, specifically a personal or family history of atopy (propensity to allergy, usually seen as eczema, hay fever, and asthma). [5] [6]

Asthma also is associated with exposure to tobacco smoke and other inflammatory gases or particulate matter.

The overall etiology is complex and still not fully understood, especially when it comes to being able to say which children with pediatric asthma will carry on to have asthma as adults (up to 40% of children have a wheeze, only 1% of adults have asthma), but it is agreed that it is a multifactorial pathology, influenced by both genetics and environmental exposure.

Triggers for asthma include:

• Viral respiratory tract infections
• Gastroesophageal reflux disease
• Chronic sinusitis
• Environmental allergens
• Use of aspirin, beta-blockers
• Tobacco smoke
• Insects, plants, chemical fumes
• Emotional factors or stress
• Epidemiology

Asthma is a common pathology, affecting around 15% to 20% of people in developed countries and around 2% to 4% in less developed countries. It is significantly more common in children. Up to 40% of children will have a wheeze at some point, which, if reversible by beta-2 agonists, is termed asthma, regardless of lung function tests. Asthma is associated with exposure to tobacco smoke and inhaled particulates and is thus more common in groups with these environmental exposures. [7] [8]

In childhood, asthma is more common in boys with a male to female ratio of 2:1 until puberty when the ratio becomes 1:1. After puberty, the prevalence of asthma is greater in females, and adult-onset cases after the age of 40 years are mostly females. Asthma prevalence is greater in extreme of ages due to airway responsiveness and lower levels of lung function. [9]

Of all the asthma cases, about 66% are diagnosed before the age of 18 years. almost 50% of children with asthma have a decrease in severity or disappearance of symptoms during early adulthood. [10]

• Pathophysiology

Asthma is a condition of acute, fully reversible airway inflammation, often following exposure to an environmental trigger. The pathological process begins with the inhalation of an irritant (e.g., cold air) or an allergen (e.g., pollen), which then, due to bronchial hypersensitivity, leads to airway inflammation and an increase in mucus production. This leads to a significant increase in airway resistance, which is most pronounced on expiration.

Airway obstruction occurs due to the combination of:

• Inflammatory cell infiltration.
• Mucus hypersecretion with mucus plug formation.
• Smooth muscle contraction.

These irreversible changes may become irreversible over time due to

• Basement membrane thickening, collagen deposition, and epithelial desquamation.
• Airway remodeling occurs in chronic disease with smooth muscle hypertrophy and hyperplasia.

If not corrected rapidly, asthma may become more difficult to treat, as the mucus production prevents the inhaled medication from reaching the mucosa. The inflammation also becomes more edematous. This process is resolved (in theory complete resolution is required in asthma, but in practice, this is not checked or tested) with beta-2 agonists (e.g., salbutamol, salmeterol, albuterol) and can be aided by muscarinic receptor antagonists (e.g., ipratropium bromide), which act to reduce the inflammation and relax the bronchial musculature, as well as reducing mucus production. [11]

• Toxicokinetics

The only relevant toxicokinetics in asthma relates to its management as the absorption and systemic side effects of the beta-2 agonists must be monitored. Typically these will be removed from the body in 2 to 4 hours if salbutamol and albuterol, 18 to 24 hours if salmeterol, or 48 to 72 hours if clenbuterol, which is no longer used in the management of asthma.

The side effects of the beta-2 agonists include tachycardia, flushing, sweating, and other signs of sympathetic system overdrive. There is also the chance of iatrogenic hypokalaemia, which must be monitored.

• History and Physical

Patients will usually give a history of a wheeze or a cough, exacerbated by allergies, exercise, and cold. There is often diurnal variation, with symptoms being worse at night. Patients may give a history of other forms of atopy, such as eczema and hay fever. There may be some mild chest pain associated with acute exacerbations. Many asthmatics have nocturnal coughing spells but appear normal in the day time

Physical exam findings will depend on whether the patient is currently experiencing an acute exacerbation.

During an acute exacerbation, there may be a fine tremor in the hands due to salbutamol use, and mild tachycardia. Patients will show some respiratory distress, often sitting forward to splint open their airways. On auscultation, a bilateral, expiratory wheeze will be heard. In life-threatening asthma, the chest may be silent, as air cannot enter or leave the lungs, and there may be signs of systemic hypoxia.

Children with imminent arrest may appear drowsy, unresponsive, cyanotic, and confused. Wheezing may be absent, and bradycardia may occur, indicating severe respiratory muscle fatigue.

Life-threatening asthma is a type of asthma that does not respond to systemic steroids and beta 2 agonist nebulization. It is necessary to identify it early as it may lead to high mortality. It has the following characteristic findings on examination

• Peak expiratory flow less than 33% of personal best
• Oxygen saturation less than 92%
• The normal partial pressure of carbon dioxide
• Silent chest
• Feeble respiratory effort
• Bradycardia
• Arrhythmias
• Hypotension
• Confusion, coma

In near-fatal asthma, the partial pressure of carbon dioxide is raised, or mechanical ventilation is required with raised inflation pressures.

Pulse oximetry can be useful in assessing the severity of an asthma attack or monitoring for deterioration. Note that pulse oximetry lag, and the physiological reserve of many patients means that a falling pO2 on pulse oximetry is a late finding, indicating a severely unwell or peri-arrest patient.

Peak flow measures also can be used to assess asthma and should always be checked against a nomogram as well as the individual patient's normal baseline function. The different severities of acute asthma attacks have an associated peak flow measurement, recorded as a certain percentage of expected peak flow.

Urea and electrolytes (kidney function) should be taken if the patient has a high dose or repeat salbutamol, as one of the side effects of salbutamol is to cause potassium to shift into the intracellular space transiently, which can induce a transient, iatrogenic hypokalaemia. Eosinophilia is common but is not specific for asthma. Recent studies show that levels of sputum eosinophils may guide therapy. In addition, some patients may have an elevation of serum IgE.

Arterial blood gas may reveal hypoxemia and respiratory acidosis. Studies indicate that periostin may be a marker for asthma, but its clinical role remains unsettled.

An ECG will reveal sinus tachycardia, which may be due to asthma, albuterol, or theophylline.

A chest x-ray is an important test, especially if patients have a history of risk of the potential foreign body or possible infection. A Chest CT scan is done in patients with recurrent symptoms who do not respond to therapy.

Special Tests

Spirometry is the diagnostic method of choice and will show an obstructive pattern that is partially or completely resolved by salbutamol. Spirometry should be done before treatment to determine the severity of the disorder. A reduced ratio of FEV1 to FVC is indicative of airway obstruction, which is reversible with treatment. Reversibility testing is done by giving the patient inhaled short-acting beta 2 agonists, and after that, the spirometry test is repeated. If there is a 12% or 200ml improvement in FEV1 from the previous value, then it shows reversibility and diagnostic for bronchial asthma. Peak expiratory flow measurement is common today and allows one to document response to therapy. A limitation of this test is that it is effort dependent.

In some patients, a methacholine/histamine challenge may be required to determine if airway hyper-reactivity is present. This test should only be done by trained individuals.

Exercise spirometry may help identify patients with exercise-induced bronchoconstriction.

• Treatment / Management

Conservative Measures

Measures to take include calming the patient to get them to relax, moving outside or away from the likely source of allergen, and cooling the person. Removing clothing and washing the face and mouth to remove allergens is sometimes done, but it is not evidence-based. [12] [13] [14]

Environmental control is vital if one wants to avoid recurrent attacks. Allergen avoidance can significantly improve the quality of life. This means avoiding tobacco, dust mites, animals, and pollen.

Weight reduction in obese asthmatics leads to improved control.

Allergen immunotherapy remains controversial. Large studies have not shown any significant benefit, and the technique is prohibitively expensive.

Monoclonal antibody therapy is indicated for patients with moderate to severe asthma who have a positive skin test. The treatment can lower IgE levels, which in turn decreases histamine production. However, the cost of the injections is high.

Bronchial thermoplasty is a relatively new technique that delivers thermal energy to the airway wall and reduces the narrowing of the airways. Several studies show that it can reduce emergency visits and days missed from school.

Medical management includes bronchodilators like beta-2 agonists and muscarinic antagonists (salbutamol and ipratropium bromide respectively) and anti-inflammatories such as inhaled steroids (usually beclometasone but steroids via any route will be helpful).

There are five steps in the management of chronic asthma; treatment is started depending on the severity and then escalated or de-escalated depending on the response to treatment. [15]

Step 1: The Preferred controller is as needed low dose inhaled corticosteroid and formoterol.

Step 2: The preferred controllers are daily low dose inhaled corticosteroid plus as-needed short-acting beta 2 agonists.

Step 3: The preferred controllers are low dose inhaled corticosteroid and long-acting beta 2 agonists plus as-needed short-acting beta 2 agonists.

Step 4: The preferred controller is a medium-dose inhaled corticosteroid and long-acting beta 2 agonist plus as-needed short-acting beta 2 agonists.

Step 5: High dose inhaled corticosteroid and long-acting beta 2 agonist plus long-acting muscarinic antagonist/anti-IgE.

Indications for admission

If a patient has received three doses of an inhaled bronchodilator and shows no response, the following factors should be used to determine admission:

• The severity of airflow obstruction
• Duration of asthma
• Response to medications
• Adequacy of home support
• Any mental illness

Patients with life-threatening asthma are managed with high flow oxygen inhalation, systemic steroids, back to back nebulizations with short-acting beta 2 agonists, and short-acting muscarinic antagonists and intravenous magnesium sulfate. Early involvement of the intensive care team consultation helps to reduce mortality. In the case of near-fatal asthma, early intubation and mechanical ventilation are needed.

There is no surgical input into the management of typical asthma.

Other/Long Term

Weight loss, smoking cessation, occupational change, and self-monitoring are all important in preventing disease progression and reducing the number of acute attacks.

• Differential Diagnosis

The main differential for an acute, life-threatening asthma attack is an anaphylactic reaction. In this case, the patient may also present with orofacial swelling, a rash, and itching. The patient will partially respond to salbutamol and steroids, but intramuscular adrenaline is the lifesaving medication needed to manage these patients.

Other differentials include vocal cord dysfunction, tracheal or bronchial obstruction due to foreign body or tumor, heart failure, gastroesophageal reflux, chronic sinusitis, and chronic obstructive pulmonary disease.

Chronic asthma is usually classified as follows:

• Intermittent
• Mild persistent
• Moderate persistent
• Severe persistent

Acute asthma is classified as below: 

• Acute severe asthma
• Life-threatening asthma
• Near-fatal asthma

Asthma is not a benign illness and accounts for 1 death per 100,000 people in some countries. The mortality is related to lung function and is exacerbated by smoking. Factors that affect mortality include age more than 40 years, cigarette smoking more than 20 pack-years, blood eosinophilia, FEV1 of 40-70% of predicted, and greater reversibility. [16] Asthma leads to loss of time from work and school; it also leads to multiple hospital admissions increasing the cost of healthcare. Poorly controlled asthma can be disabling and leads to poor quality of life.

• Postoperative and Rehabilitation Care

Patients with asthma need life-long follow up for monitoring of the disease, quality of life, and functional status. At each visit, compliance with medications should be emphasized.

Asthma is not a curable disorder, and patients need life long monitoring. Patients should be educated about the need for monitoring of the disease and compliance with medications. The patient should be given a written asthma action plan.

• Consultations
• Pulmonology consultation.
• Involvement of the intensive care unit early in cases of severe persistent asthma and life-threatening asthma.
• Deterrence and Patient Education

Patient education about the disease and modifying behavior is vital. The patient should also be encouraged to change lifestyle and control the environmental trigger factors.

Patients should be asked to maintain healthy body weight as evidence reveals that the disorder is more difficult to control in overweight individuals.

Patients should avoid tobacco and use of beta-blockers, aspirin, and sulfites.

• Pearls and Other Issues

Disposition

If the patient requires nebulized salbutamol and is not ordinarily on home nebulizers, he or she should be admitted. Anyone who has presented with severe or life-threatening asthma should usually be monitored to ensure that the disease does not return when the medication has worn off.

Issues include forgetting to remove the nebulizer mask once the nebulizer is done (thus leaving the patient on only 6L of 02/min, rather than changing them to 15 L/min via a non-rebreather mask), not assessing inhaler technique, and neglecting to stress the importance of maintenance therapy with inhaled steroids even when the patient is well.

• Enhancing Healthcare Team Outcomes

In many countries, including the US, asthma kills one out of every 100,000 persons. The worse the lung function, the higher the mortality. In addition, mortality has also been linked to poor management and lack of medication compliance, especially in young people. Other factors that increase the risk of death include smoking and use of illicit drugs.

Asthma also results in millions of school and workdays lost. In the US alone, close to 2 million asthmatics seek regular care in the emergency department, which also increases the costs of healthcare.

Even though asthma is a reversible disorder, poor lifestyle and lack of management can lead to airway remodeling that leads to chronic symptoms, which are disabling. [17]

The disorder has no cure, and thus life long monitoring is necessary. For best outcomes, an interprofessional approach is recommended.

Evidence-based Medicine

Many guidelines have been published for the diagnosis and management of asthma, but the most critical feature is patient education. The nurses are the last professionals to see the patient before discharge from the emergency department or the floors. Similarly, since most asthmatics are treated as outpatients, pharmacists encounter them regularly. Evidence shows that teaching patients about this disorder and the importance of compliance are critical for good outcomes. The patient should be taught about monitoring techniques, inhaler use, and modifying the environment. A social worker should be involved in the care to ensure that the patient has adequate home support and facilities.

Many evidence-based asthma plans are available for the management of asthma and should be handed out to patients. Finally, nurses also play a vital role in school-based asthma education programs that can help improve self-esteem, knowledge, and self-management behaviors. [18] [19] [20]  (Level II)

Management of asthma requires an interprofessional approach. Nurses work with the clinician in providing patient and family education regarding avoiding triggers, regular use of medications and being prepared with rescue inhalers. The pharmacist should assist with the appropriate use of inhalers and encouraging daily medication administration. The pharmacist should carefully examine the current medications and make sure the patient is not taking any medications that may trigger an attack, working with the prescriber to modify the treatment. an interprofessional approach will result in the best outcomes. [Level V]

Despite great awareness of the disease, asthma still results in high morbidity and even mortality. There are universal guidelines on managing the disorder, but patient compliance with medications remains a big problem. Hence, all healthcare workers have a responsibility to encourage medication compliance and close follow up with the primary care physician. [21] [22] (Level V)

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Asthma Pathology. Figure A shows the location of the lungs and airways in the body. Figure B shows a cross-section of a normal airway. Figure C shows a cross-section of an airway during asthma symptoms. Contributed by United States-National Institute (more...)

X-ray, COPD, Chronic Obstructive Disease, Asthma, Anterior, Lateral Contributed by chestatlas.com (H. Shulman MD)

Allergic Bronchopulmonary Aspergillosis on Computed Tomography. This image shows bronchiectasis in both upper lobes in a patient with bronchial asthma, which are findings consistent with allergic bronchopulmonary aspergillosis. Contributed by (more...)

Asthma Classification Table Contributed by Rina Chabra, DO

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Maryam Tariq declares no relevant financial relationships with ineligible companies.

Disclosure: Mary Cataletto declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Hashmi MF, Tariq M, Cataletto ME. Asthma. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Diagnosis and Management of Asthma in Adults : A Review

• 1 Division of Allergy and Clinical Immunology, University of Texas Medical Branch, Galveston
• 2 Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston
• 3 Division of Pulmonary Critical Care and Sleep, Department of Internal Medicine, University of Texas Medical Branch, Galveston
• Correction Incorrect Dosage Information in Table JAMA
• Original Investigation Inhaled Corticosteroids and Long-Acting Muscarinic Antagonists for Uncontrolled Asthma Diana M. Sobieraj, PharmD; William L. Baker, PharmD; Elaine Nguyen, PharmD, MPH; Erin R. Weeda, PharmD; Craig I. Coleman, PharmD; C. Michael White, PharmD; Stephen C. Lazarus, MD; Kathryn V. Blake, PharmD; Jason E. Lang, MD, MPH JAMA
• Original Investigation Use of Inhaled Corticosteroids and Long-Acting β-Agonists for Asthma Exacerbations Diana M. Sobieraj, PharmD; Erin R. Weeda, PharmD; Elaine Nguyen, PharmD, MPH; Craig I. Coleman, PharmD; C. Michael White, PharmD; Stephen C. Lazarus, MD; Kathryn V. Blake, PharmD; Jason E. Lang, MD, MPH; William L. Baker, PharmD JAMA
• Original Investigation Effect of Nebulized Magnesium vs Placebo Added to Albuterol Among Children With Refractory Acute Asthma Suzanne Schuh, MD; Judy Sweeney, RN, BScN; Maggie Rumantir, MD; Allan L. Coates, MDCM, BEng; Andrew R. Willan, PhD; Derek Stephens, MSc, BSc; Eshetu G. Atenafu, MSc; Yaron Finkelstein, MD; Graham Thompson, MD; Roger Zemek, MD; Amy C. Plint, MD, MSc; Jocelyn Gravel, MD, MSc; Francine M. Ducharme, MD, MSc; David W. Johnson, MD; Karen Black, MD, MSc; Sarah Curtis, MD; Darcy Beer, MD; Terry P. Klassen, MD, MSc; Darcy Nicksy, BSc, PhM; Stephen B. Freedman, MDCM, MSc; Pediatric Emergency Research Canada (PERC) Network JAMA

Importance   Asthma affects about 7.5% of the adult population. Evidence-based diagnosis, monitoring, and treatment can improve functioning and quality of life in adult patients with asthma.

Observations   Asthma is a heterogeneous clinical syndrome primarily affecting the lower respiratory tract, characterized by episodic or persistent symptoms of wheezing, dyspnea, and cough. The diagnosis of asthma requires these symptoms and demonstration of reversible airway obstruction using spirometry. Identifying clinically important allergen sensitivities is useful. Inhaled short-acting β 2 -agonists provide rapid relief of acute symptoms, but maintenance with daily inhaled corticosteroids is the standard of care for persistent asthma. Combination therapy, including inhaled corticosteroids and long-acting β 2 -agonists, is effective in patients for whom inhaled corticosteroids alone are insufficient. The use of inhaled long-acting β 2 -agonists alone is not appropriate. Other controller approaches include long-acting muscarinic antagonists (eg, tiotropium), and biological agents directed against proteins involved in the pathogenesis of asthma (eg, omalizumab, mepolizumab, reslizumab).

Conclusions and Relevance   Asthma is characterized by variable airway obstruction, airway hyperresponsiveness, and airway inflammation. Management of persistent asthma requires avoidance of aggravating environmental factors, use of short-acting β 2 -agonists for rapid relief of symptoms, and daily use of inhaled corticosteroids. Other controller medications, such as long-acting bronchodilators and biologics, may be required in moderate and severe asthma. Patients with severe asthma generally benefit from consultation with an asthma specialist for consideration of additional treatment, including injectable biologic agents.

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McCracken JL , Veeranki SP , Ameredes BT , Calhoun WJ. Diagnosis and Management of Asthma in Adults : A Review . JAMA. 2017;318(3):279–290. doi:10.1001/jama.2017.8372

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• Published: 17 June 2020

Improving primary care management of asthma: do we know what really works?

• Monica J. Fletcher 1 ,
• Ioanna Tsiligianni 2 ,
• Janwillem W. H. Kocks   ORCID: orcid.org/0000-0002-2760-0693 3 , 4 , 5 ,
• Andrew Cave 6 ,
• Chi Chunhua 7 ,
• Jaime Correia de Sousa   ORCID: orcid.org/0000-0001-6459-7908 8 , 9 ,
• Miguel Román-Rodríguez 10 ,
• Mike Thomas   ORCID: orcid.org/0000-0001-5939-1155 11 ,
• Peter Kardos   ORCID: orcid.org/0000-0002-4725-4820 12 ,
• Carol Stonham 13 ,
• Ee Ming Khoo   ORCID: orcid.org/0000-0003-3191-1264 14 ,
• David Leather 15 &
• Thys van der Molen 16  

npj Primary Care Respiratory Medicine volume  30 , Article number:  29 ( 2020 ) Cite this article

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• Health policy

Asthma imposes a substantial burden on individuals and societies. Patients with asthma need high-quality primary care management; however, evidence suggests the quality of this care can be highly variable. Here we identify and report factors contributing to high-quality management. Twelve primary care global asthma experts, representing nine countries, identified key factors. A literature review (past 10 years) was performed to validate or refute the expert viewpoint. Key driving factors identified were: policy, clinical guidelines, rewards for performance, practice organisation and workforce. Further analysis established the relevant factor components. Review evidence supported the validity of each driver; however, impact on patient outcomes was uncertain. Single interventions (e.g. healthcare practitioner education) showed little effect; interventions driven by national policy (e.g. incentive schemes and teamworking) were more effective. The panel’s opinion, supported by literature review, concluded that multiple primary care interventions offer greater benefit than any single intervention in asthma management.

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Vicky Kritikos, David Price, … Sinthia Bosnic-Anticevich

Introduction

Asthma is a common chronic condition that is estimated to affect 339 million people worldwide 1 , 2 . Despite major advances in asthma treatment and the availability of both global 2 and national guidance, asthma continues to cause a substantial burden in terms of both direct and indirect costs 1 . In 2016, estimated worldwide asthma deaths were 420,000 1 and although there have been falls in some countries over the last decade, significant numbers of avoidable deaths still occur 3 . Mortality rates vary widely, with low- and middle-income countries faring worse 4 . For example, Uganda’s reported mortality rate is almost 50% higher 5 than that reported globally (0.19/100,000) 6 , although inter-country comparisons using different data sources and epidemiological methodologies have limitations. The World Health Organisation (WHO) has a global ambition for universal healthcare coverage by 2030 as millions of people worldwide do not have accessible affordable medical care 7 . The WHO moreover recognises that health systems with strong primary care have the utmost potential to deliver improved health outcomes, greater efficiency and high-quality care 7 . Perversely the availability of good quality primary and social care tends to vary inversely, those having the greatest needs being least likely to receive it 8 .

In addition to the issues of access and the quality of care, both under- and over-diagnosis of asthma is common in all healthcare settings, but the issue is of particular concern in primary care, where most initial diagnoses are made 9 , 10 .

For people with asthma, high-quality, local and accessible primary care could be a solution to poor control 11 . Our aim was to identify the factors that experts believe enable the delivery of high-quality asthma care and to review the evidence that confirms that these factors do indeed have positive outcomes in primary care.

Key drivers and their underpinning components

The expert panel identified five key drivers for the delivery of quality respiratory care in primary care and a number of components underpinning each of these drivers. These are summarised in Table 1 .

Of the 50 articles selected from the review, there were comparatively smaller numbers of publications relating to the impact of National Health Policy and Guidelines. However, there was more substantial evidence relating to the other three key drivers, which is summarised in tabular format (Tables 2 – 4 ).

National Health Policy

The expert panel reached an agreement that the political will to prioritise asthma and to support both primary care and respiratory disease were fundamental elements for the achievement of a sustainable change. In their opinion this required national and local programmes supporting the improvements. There was however little evidence published to support this opinion with respect to patient outcome as it is not the area of research that is commonly undertaken. A review of seven national European asthma programmes to support strategies to reduce asthma mortality and morbidity concluded that national/regional asthma programmes are more effective than conventional treatment guidelines 12 . One of the most well-known and successful national programmes in Europe, which has resulted in reduced morbidity and mortality and decreased costs, is the Finnish National Asthma Programme 13 . Programmes outside of Europe have also demonstrated the impact that prioritisation of primary care can have on respiratory outcomes. Changing structures and policies in South Africa and in Brazil may start to impact on primary care 13 , 14 .

Few studies have explored the extent of adherence to guidelines for asthma management based on data provided directly by GPs. One study aimed to evaluate adherence to GINA guidelines and its relationship with disease control in real life. According to GINA guideline asthma classification, the results indicated overtreatment of intermittent and mild persistent asthma, as well as a general poor adherence to GINA treatment recommendations, despite its confirmed role in achieving a good asthma control 15 . In the US, nationally representative data showed that agreement with and adherence to asthma guidelines was higher for specialists than for primary care clinicians, but was low in both groups for several key recommendations 16 .

Reward for performance

Pay-for-performance (P4p) schemes are those that remunerate physicians for achieving pre-defined clinical targets and quality measures—so based on value—that contrasts to schemes that are simply a fee-for-service payment, which pay for volume of activity (Data from Review Table 2 ). In the UK, primary care has moved towards group practices with P4p compensation in which performance is measured using several defined quality indicators 17 , 18 . A systematic review of 94 studies showed increased practice activity but only limited evidence of improvements in the quality of primary care or cost-effectiveness, despite modest reductions in mortality and hospital admissions in some domains 18 . In another review of seven studies from the US and UK, the effects of financial incentive schemes were found to improve patient’s well-being, whilst the effects on the quality of primary healthcare were found to be modest and variable 19 .

An evaluation of three primary care incentive models, namely a traditional fee-for-service model, a blended fee-for-service model and a blended capitation model, demonstrated that the quality of asthma care improved over time within each of the primary care models 20 . The model that combined blended fee-for-service with capitation appears to provide better quality care compared to the traditional fee-for-service model in terms of outcome indicators such as a lower rate of emergency department visits.

A P4p programme in the Netherlands containing indicators for chronic care, prevention, practice management and patient experience was designed by target users 21 . A study of 65 practices that implemented the programme showed a significant improvement in the mean asthma score after 1 year. It showed that a bottom-up developed P4p programme might lead to improvements in both clinical care and patient experience.

Practice resources and organisation

Optimal patient care requires targeted and tailored management (Data from Review Table 3 ). The experts felt that the organisation of both the GP practice and the local healthcare system had an influence on the provision of high-quality care. Registered patient lists and fully integrated computer systems were its foundation. An approach called SIMPLES—developed in the UK, incorporated into a desktop reference tool by the International Primary Care Respiratory Group and adapted for use in the Netherlands 22 , 23 —identifies patients who have uncontrolled symptoms or difficult-to-manage disease and addresses preventable or treatable factors to guide their management. Electronic alerts in patient records have also been used to identify those at increased risk of an exacerbation, in order to modify care and treatment 24 , 25 , 26 .

A systematic review of the effectiveness of computerised clinical decision systems (CCDS) in the care of patients with asthma demonstrated improvements in healthcare process measures and patient outcomes 27 . Conversely another systematic review focussing on their implementation in practice concluded that the limiting factors were the lack of their regular use by healthcare practitioners (HCPs) and adherence to the advice offered 28 . These reviews both concluded that CCDS have the potential to improve patient outcomes, practice efficiency and produce cost-saving benefits if implemented 27 , 28 .

Computerised systems linked with internet programmes to monitor asthma control can also afford benefits for patients. One study identified that the use of both weekly internet-based self-monitoring using the Asthma Control Questionnaire (ACQ) and treatment adjustment using an online management tool resulted in significant improvements in ACQ 29 .

Clinical prediction models could theoretically aid the diagnosis of asthma in primary care but supportive evidence is currently lacking 30 . However, there is strong evidence that service models aimed at supporting primary care practitioners with the diagnosis or ongoing monitoring of patients result in improved accuracy and patient outcomes 31 , 32 , 33 .

The expert panel felt that having access to dedicated and appropriately trained personnel preferably as part of multidisciplinary teams was essential (Data from Review Table 4 ). This need was accentuated because of increasing GP workloads and a shortage of primary care physicians in many countries.

There was extensive evidence 34 , 35 , 36 , 37 , 38 , 39 , 40 that a variety of models involving a range of healthcare practitioners within both the core primary healthcare team and extended community teams improve patient outcomes and healthcare process measures—such as an increased use of asthma action plans, improved medication adherence 36 , 39 —and reduces the use of emergency care 34 , 38 .

One approach in Canada is based on using primary care networks, in which additional non-physician healthcare providers are funded to help provide coordinated healthcare 34 . In these networks patients were shown to be less likely to visit the ED than patients in practices that were not part of the network.

Evidence from a range of countries supports the beneficial role of pharmacists, working alone or in teams 36 , 37 , 38 . In a study utilising community pharmacists to review patients with either poorly controlled asthma or no recent asthma review, there were benefits in terms of asthma control, inhaler technique, action plan ownership, asthma-related QOL and medication adherence 36 . The pharmacists were able to recruit patients and incorporate this as part of daily practice. Availability of referral to a physician was an important component of the service.

Evidence also indicates that education delivered by a variety of methods enhances the quality of care delivered and improves patient outcomes 41 , 42 , 43 , 44 , 45 . Approaches integrating education with other interventions, such as the Colorado Asthma Toolkit Programme (CATP) that combines education with decision support tools, electronic patient records and other online support materials, have been shown to have positive outcomes 41 , 42 . Another team-based approach that combined an educational intervention with the integration of an electronic clinical quality management system with a reminder system found that the number of action plans increased significantly 39 .

Patient education is an important factor for the improvement of self-management and asthma control. An educational programme from Australia demonstrated that patients who received person-centred education had improved asthma outcomes compared to those receiving a brochure only 46 . One review paper 47 about patient enablement concluded that HCPs need to develop their understanding of this concept to integrate this into practice as the level of this is linked to better patient outcomes.

Primary care is pivotal to any health system; however, there is no universal definition of what we mean by primary care and certainly not one standardised model of care. Without focussing on a single model, we have attempted to bring together expert opinion and the most recent evidence on strategies that improve outcomes in asthma patients in primary care. To our knowledge the methodology used in this project has not been used before. The panel of experts who identified the key drivers were knowledgeable of asthma in primary care at a national level in their respective countries and globally. A literature search to investigate the individual key drivers and their underpinning components was undertaken using a keyword search. This identified many publications but very few measured the effect on patient outcome and those that did reported conflicting results. Furthermore, we found a paucity of research relating to the components relating to national healthcare policy and guidelines.

The evidence suggests that health systems that have primary care as a cornerstone and place asthma as a healthcare priority improve asthma care and improve outcome on patient level. The highly regarded Finnish asthma initiative carried out more than 25 years ago not only identified asthma as a national priority, but also placed primary care at the centre of the programme, recognising the key role of General Practitioners and nurses and greatly reduced asthma mortality and morbidity 48 . After the successful implementation of the Finnish asthma plan, many other countries and regions have attempted to implement similar initiatives 13 , 14 . For example, in Poland and Brazil, asthma burden was reduced utilising such a strategy 49 .

Poor health outcomes in asthma patients have been attributed in primary care to gaps between evidence-based recommendations and practice 50 , 51 . Studies show that adherence to clinical guidelines is poor, whatever the clinical setting, with the main barriers being time pressures and limited resources 52 , reflecting that it is not the guidelines per se that improve care, but it is the implementation of the recommendations.

Most guidelines are complex, lengthy and generally biased towards a secondary care perspective. The Global Initiative for Asthma (GINA) committee acknowledges the difficulty of implementing their recommendations in primary care, but they are almost exclusively developed by tertiary care physicians 2 . In the Netherlands, the Dutch Royal Society of General Practitioners writes its own guidelines, which are all presented in the same recognisable brief format. Their asthma guidelines were first published in 1986 with revisions every 4 years and are relatively well followed 53 . However, there are now 194 different clinical guidelines in the Netherlands, illustrating just how difficult it is for General Practitioners to adopt all the recommendations of each clinical guideline and its update.

A survival analysis of guidelines has concluded that 86% are still up to date 3 years after their publication and yet the median lifespan of a clinical guideline is about 60 months 54 . New evidence is continually emerging and this implies that regular updates of clinical guidelines are necessary 55 , 56 . It is therefore important that all guidelines have a process for regular scrutiny 57 and are updated for contemporary applicability. Indeed, asthma and COPD guidelines published by the Association of Scientific Medical Societies in Germany and the Asthma Guidelines of the German Respiratory Society are regularly updated, at least every 5 years (more frequently as necessary); if not they are deleted from the website.

The proliferation of guidelines and their asynchronicity can result in conflicting recommendations. For example, in the UK, four asthma guidelines could be followed (the GINA Report, British Thoracic Society and Scottish Intercollegiate Guidelines (BTS) and the NICE recommendations next to local guidelines) 2 , 58 , 59 , none of which are fully aligned. A review of three contemporaneous international guidelines updated in 2012 (The Canadian Thoracic Society (CTS), BTS and GINA) also revealed significant inconsistency arising from varying approaches to evidence interpretation and recommendation formulation 60 .

Globally, there is a move away from pure fee-for-service payments towards primary care payment schemes linked to performance, which recognise and reward good practice to improve quality and reduce costs 61 . These schemes combine quality standards and targets but still tend to be process driven, not outcome based. The evidence for the effectiveness of such schemes in general on improving quality of care is both inconclusive and inconsistent 62 .

The UK quality and outcomes framework (QOF), which includes asthma, is the world’s largest primary care payment for performance (P4p) scheme 63 . Evidence however shows that improved patient outcomes may not be sustained, cost reduction is unproven 18 and leads to increased GP activity, but this does not necessarily correlate with improved individual patient benefit 64 , 65 . Furthermore, in Portugal, the recording of asthma and COPD prevalence as performance indicators in pay-for-performance contracts showed a modest but steady increase over time in physician’s diagnosis and ICPC-2 coding of these two conditions, but no direct patient benefits 66 .

Disease-specific schemes are usually aligned to clinical guidelines and some focus on prescribing. In Norway, under such a scheme, combination asthma medications were only reimbursed for patients diagnosed with asthma. As a result, asthma diagnosis significantly increased 67 .

The effect on health inequalities has also been studied. The results from UK QOF have shown that the gap between achievements from practices in the most deprived and least deprived areas narrowed 68 . Nevertheless, inequalities in morbidity and premature mortality persisted 69 , 70 . Additionally incentives can increase inequalities because those conditions that are ‘incentivised’ are afforded greater priority and resource allocation, to the detriment of those that are not 71 .

It would appear that simplistic fee-for-service schemes based purely on an activity—such as performing spirometry tests—which are not part of reimbursement of a more comprehensive assessment, have the potential to inadvertently lead to an increase in unnecessary tests. Pay-for-performance schemes have the potential to improve asthma care, but will be reliant on the specifics of the scheme and the quality indicators applied. They can be useful as part of a wider programme to raise quality and afford benefits over rewarding fee-for-service activity.

Appropriate practice organisation and systems focussing on the identification, diagnosis and treatment are pivotal for quality asthma care. There was compelling evidence to indicate that integrated, multi-faceted practice-based approaches for the management of patients improves outcomes and reduces the need for referral to secondary care 22 , 25 , 72 . Coordinated practice systems that combine several interventions such as decision support tools, flagging of electronic records, use of care pathways, staff training and structured approaches to patient education, if consistently implemented, afford the greatest benefits. Implementation of practice schemes is likely to be enhanced where there is dedicated clinical and administrative leadership.

Intuitively an accurate diagnosis should lead to better patient outcomes, although we found conflicting evidence that access to proper diagnosis has an impact on patient outcomes 33 , 73 . Nevertheless, an accurate diagnosis remains the fulcrum on which optimal asthma management depends. Indeed programmes in which an expanded medical team improved the quality of asthma care within the primary care setting (such as a diagnostic and management support organisation) show clear benefit on patient outcome 32 .

Spirometry combined with an assessment of reversibility has been set as gold standard for asthma diagnosis 2 . However, standards on quality of spirometry such as those set by the ERS and ATS are often not achieved 74 , 75 , 76 and impose an unnecessarily high and potentially unachievable threshold in primary care 73 . Nevertheless, some studies have demonstrated that primary care office spirometry can meet the acceptability criteria 77 , 78 , 79 . Although such standards are laudable particularly in a specialist setting, their practicability in primary care, where patients commonly have mild–moderate, intermittent disease, is debatable. The latest ATS-ERS spirometry guidelines (published in October 2019) may address some of these issues. 80 However, the use of spirometry in the diagnosis of asthma remains beyond reach in primary care around the world.

In many countries primary care physicians have limited or no access to tests of lung function or airway inflammation. The creation of diagnostic hubs in the community may open access to these tests 32 . A structured approach to diagnosis including applicability and feasibility for primary care is currently under development by an ERS taskforce; its outcome not available at the time of writing.

With rising clinical workloads, increasing clinical complexity and in many countries a shortage of trained primary care physicians, multi-professional teamworking is increasingly important. 81 , 82 This is accentuated by the expectation for primary care to manage patients with chronic illness.

In many parts of the world, appropriately asthma-trained personnel, such as primary care nurses, are key to the delivery of high-quality asthma care. Dedicated nursing staff can offer continuity to patients, providing education and routine follow-up 35 . Evidence supports the concept that pharmacists working alone or in teams in collaboration with GPs are an accessible asset for the effective management of asthma and can positively influence asthma outcomes 36 .

Healthcare practitioner education is pivotal and the need for guideline-focused training in primary care is well established 82 . The literature seems to support this viewpoint but in many studies the effect on outcome has not been adequately considered, highlighting a need for more outcome-focussed research. Healthcare systems faced with the challenge of moving the care of people with long-term conditions such as asthma from established specialist services to primary care should consider implementing collaborative educational strategies 44 . Matrix-support collaborative care that includes training and support for primary care physicians/nurses from specialists, including joint consultations, case discussions and tailored education, has been shown to be well-accepted by primary care professionals and was associated with improved knowledge and reduced respiratory secondary care referrals 44 . A scoping exercise and literature review of the effectiveness of educational interventions in either changing health professional practice or in improving health outcomes was commissioned by The International Primary Care Respiratory Group (IPCRG) 83 . The impact of education interventions on their own was inconclusive, although there was some evidence of effectiveness when they are combined with other quality improvement strategies or incentives 83 .

Asthma continues to be a substantial cause of morbidity and mortality worldwide and there is need for a coordinated effort to improve care. A well-resourced primary care service is central to the provision of accessible and effective asthma care. An expert team identified the drivers that could enable improvements in both clinical management and patient outcomes, and a literature search showed that each of these individual drivers is supported by varying degrees of evidence. Objectively assessing the outcomes of such interventions is challenging because studies in this area are inherently complex, difficult to undertake and resource intensive, and so definitive research is seldom undertaken. In contrast single interventions studies are easier to conduct but frequently methodologically less robust and therefore tend to be inconclusive. Nevertheless, if substantial improvements in the management of asthma in primary care at a global level are to be achieved, combinations of interventions appear to be most effective. Well-supported holistic interventions involving the entire healthcare system and including the patient voice appear to provide the best outcomes.

Expert panel

An expert panel of 12 primary care global asthma experts—ten General Practitioners and two specialist nurses—was convened in Amsterdam. An initial teleconference between the panel preceded the meeting to gather ideas. The expert panel undertook a brainstorming exercise as part of a force-field analysis in order to reveal their ideas and experience regarding drivers of successful management of asthma in primary care 84 . A force-field analysis can be used to determine the forces (factors) that may prevent change from occurring and to identify those that cultivate change. During the brainstorming session, the experts were divided into facilitated groups to discuss the relative importance of the drivers and identify the factors which underpin each of them. Results were analysed thematically and circulated after the meeting for comment and agreement.

Literature review

To identify whether evidence existed for the drivers and factors identified by the expert panel, literature was searched from PUBMED using the terms asthma and primary care in combination with other terms listed in Table 5 . Proposed search terms were combined using Boolean operators. The initial search was limited to papers published in English over the last 10 years and studies in adults aged over 18 years old. The experts were also asked for additional papers and in addition, more articles were identified from the references from the selected papers. Papers identified were subsequently screened for eligibility by MF and TM (Fig. 1 ). A total of 171 were included in the summary table of which 50 papers were identified as having evidence for the factors identified by the panel.

Process by which papers identified by literature review were subsequently screened for eligibility and the different stages in this process. This highlights the number of articles that were selected at each stage of the process, as well as the number of articles excluded and the reasons for exclusion. n number of articles.

Data availability

Anonymised individual participant data from this study and its associated documents can be requested for further research from www.clinicalstudydatarequest.com .

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Acknowledgements

The authors gratefully acknowledge the Expert Panel contributions of Tan Tze Lee (Singapore). Editorial support (in the form of writing assistance, collating author comments, assembling tables/figures, grammatical editing, fact checking, and referencing) was provided by Diana Jones, Ph.D., of Cambrian Clinical Associates Ltd. (UK) and was funded by GlaxoSmithKline plc. The expert panel meeting was funded by GlaxoSmithKline plc.

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Monica J. Fletcher

Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece

Ioanna Tsiligianni

General Practitioners Research Institute, 59713 GH, Groningen, The Netherlands

Janwillem W. H. Kocks

University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands

Observational and Pragmatic Research Institute, Singapore, Singapore

Department of Family Medicine, 6-10 University Terrace, University of Alberta, Edmonton, AB, T6G 2T4, Canada

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Peking University First Hospital, Beijing, China

Chi Chunhua

Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal

Jaime Correia de Sousa

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Respiratory, Allergy and Sleep Unit at Red Cross Maingau Hospital, Friedberger Anlage 31-32, 60316, Frankfurt, Germany

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All authors participated in the expert panel meeting. M.F. and T.v.d.M. were responsible for screening the papers identified in the literature search for suitability for inclusion in the article. All authors developed the manuscript and approved the final version to be submitted.

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D.L. is an employee of GlaxoSmithKline plc., and holds stocks in GlaxoSmithKline plc. M.F. and T.v.d.M. are former employees of GlaxoSmithKline plc., and M.F. holds stocks in GlaxoSmithKline plc. I.T. reports advisory boards from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline plc. and Novartis and a grant from GlaxoSmithKline Greece, outside the submitted work. J.K. reports grants and personal fees from AstraZeneca, grants and personal fees from Boehringer Ingelheim, grants from Chiesi, grants and personal fees from GlaxoSmithKline plc., grants and personal fees from Novartis, grants from Mundipharma, grants from TEVA, outside the submitted work. A.C. reports a grant from AstraZeneca for an asthma study. C.C. reports grants from Pfizer China, outside of the submitted work. M.T. reports the following conflicts of interest: neither M.T. nor any member of his close family has any shares in pharmaceutical companies; receipt in the last 3 years of speaker’s honoraria for speaking at sponsored meetings or satellite symposia at conferences from GlaxoSmithKline plc. and Novartis, companies marketing respiratory and allergy products; receipt of honoraria for attending advisory panels with Boehringer Inglehiem, GlaxoSmithKline plc. and Novartis; membership of the BTS SIGN Asthma guideline steering group and the NICE Asthma Diagnosis and Monitoring guideline development group. P.K. reports personal fees from AstraZeneca, GlaxoSmithKline plc., Chiesi, Menarini, Novartis, Klosterfrau, Bionorica, Willmar Schwabe and MSD, and other support (for a phase 3 investigator cough study) from MSD, all outside the submitted work. C.S. has no shares in any pharmaceutical companies, she has received consultant agreements and honoraria for presentations from several pharmaceutical companies that market inhaled medication including AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline plc., Napp Pharmaceuticals and Teva. J.C.d.S. reports personal fees and speaker’s honoraria from Boheringer Ingelheim, personal fees and speaker’s honoraria from GlaxoSmithKline plc., personal fees and speaker’s honoraria from AstraZeneca, personal fees and speaker’s honoraria from Mundipharma outside the submitted work. M.R.R. reports personal fees from AstraZeneca, personal fees from Boehringer Ingelheim, personal fees from Chiesi, grants and personal fees from GlaxoSmithKline plc., personal fees from Menarini, personal fees from Mundipharma, personal fees from Novartis, personal fees from Pfizer, personal fees from Teva, personal fees from Bial, outside the submitted work. E.M.K. received honoraria for attending advisory board meeting from GlaxoSmithKline plc., Boehringer Inglehiem and grant from Novartis outside the submitted work.

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Fletcher, M.J., Tsiligianni, I., Kocks, J.W.H. et al. Improving primary care management of asthma: do we know what really works?. npj Prim. Care Respir. Med. 30 , 29 (2020). https://doi.org/10.1038/s41533-020-0184-0

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DOI : https://doi.org/10.1038/s41533-020-0184-0

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• Assessment and...

Assessment and management of adults with asthma during the covid-19 pandemic

Read our latest coverage of the coronavirus pandemic.

• Related content
• Peer review
• Thomas Beaney , academic clinical fellow in primary care 1 ,
• David Salman , academic clinical fellow in primary care 1 ,
• Tahseen Samee , specialist registrar in emergency medicine 2 ,
• Vincent Mak , consultant in respiratory community integrated care 3
• 1 Department of Primary Care and Public Health, Imperial College London, London, UK
• 2 Barts Health NHS Trust, London, UK
• 3 Imperial College Healthcare NHS Trust, London, UK
• Correspondence to: T Beaney Thomas.beaney{at}imperial.ac.uk

What you need to know

In patients with pre-existing asthma, a thorough history and structured review can help distinguish an asthma exacerbation from covid-19 and guide management

In those with symptoms of acute asthma, corticosteroids can and should be used if indicated and not withheld on the basis of suspected covid-19 as a trigger

Assessment can be carried out remotely, ideally via video, but have a low threshold for face-to-face assessment, according to local arrangements

A 35 year old man contacts his general practice reporting a dry cough and increased shortness of breath for the past three days. He has a history of asthma, for which he uses an inhaled corticosteroid twice daily and is now using his salbutamol four times a day. Because of the covid-19 outbreak, he is booked in for a telephone consultation with a general practitioner that morning.

Asthma is a condition commonly encountered in primary care, with over five million people in the UK prescribed active treatment. 1 While seemingly a routine part of general practice, asthma assessment is a particular challenge in the context of the covid-19 pandemic, given the overlap in respiratory symptoms between the two conditions and the need to minimise face-to-face assessment. Over 1400 people died from asthma in 2018 in England and Wales, 2 while analyses of non-covid-19 deaths during the covid-19 outbreak have shown an increase in deaths due to asthma, 31 highlighting the need to distinguish the symptoms of acute asthma from those of covid-19 and manage them accordingly.

This article outlines how to assess and manage adults with exacerbations of asthma in the context of the covid-19 outbreak ( box 1 ). We focus on the features differentiating acute asthma from covid-19, the challenges of remote assessment, and the importance of corticosteroids in patients with an asthma exacerbation.

Asthma and covid-19: what does the evidence tell us?

Are patients with asthma at higher risk from covid-19.

Some studies, mostly from China, found lower than expected numbers of patients with asthma admitted to hospital, suggesting they are not at increased risk of developing severe covid-19. 3 4 5 However, these reports should be viewed cautiously, as confounding by demographic, behavioural, or lifestyle factors may explain the lower than expected numbers. Recent pre-print data from the UK suggest that patients with asthma, and particularly severe asthma, are at higher risk of in-hospital mortality from covid-19. 6 In the absence of more conclusive evidence to indicate otherwise, those with asthma, particularly severe asthma, should be regarded as at higher risk of developing complications from covid-19. 7

Can SARS-CoV-2 virus cause asthma exacerbations?

Some mild seasonal coronaviruses are associated with exacerbations of asthma, but the coronaviruses causing the SARS and MERS outbreaks were not found to be. 8 9 In the case of SARS-CoV-2 virus, causing covid-19, data from hospitalised patients in China did not report symptoms of bronchospasm such as wheeze, but the number of patients with pre-existing asthma was not reported. 10 More recent pre-print data from hospitalised patients in the UK identified wheeze in a minority of patients with Covid-19. 11 Given the overlap of symptoms, such as cough and shortness of breath, until further published data emerges, SARS-CoV-2 may be considered as a possible viral trigger in patients with an asthma attack.

What you should cover

Challenges of remote consultations.

Primary care services have moved towards telephone triage and remote care wherever possible to minimise the risk of covid-19 transmission. This brings challenges to assessment as visual cues are missing, and, unless the patient has their own equipment, tests involving objective measurement, such as oxygen saturation and peak expiratory flow, are not possible. In mild cases, assessment via telephone may be adequate, but, whenever possible, we recommend augmenting the consultation with video for additional visual cues and examination. 12 However, many patients, particularly the elderly, may not have a phone with video capability. If you are relying on telephone consultation alone, a lower threshold may be needed for face-to-face assessment.

Presenting symptoms

Start by asking the patient to describe their symptoms in their own words. Note whether they sound breathless or struggle to complete sentences and, if so, determine whether immediate action is required. If not, explore what has changed, and why the patient has called now. The three questions recommended by the Royal College of Physicians—asking about impact on sleep, daytime symptoms, and impact on activity—are a useful screening tool for uncontrolled asthma. 13 Alternative validated scores, such as the Asthma Control Questionnaire and Asthma Control Test, which include reliever use, are also recommended. 14 In assessing breathlessness, the NHS 111 symptom checker contains three questions—the answers may arise organically from the consultation, but are a useful aide memoire:

Are you so breathless that you are unable to speak more than a few words?

Are you breathing harder or faster than usual when doing nothing at all?

Are you so ill that you’ve stopped doing all of your usual daily activities?

Consider whether an exacerbation of asthma or covid-19 is more likely. Both can present with cough and breathlessness, but specific features may indicate one over the other (see box 2 ). Do the patient’s current symptoms feel like an asthma attack they have had before? Do symptoms improve with their reliever inhaler? Do they also have symptoms of allergic rhinitis? Pollen may be a trigger for some people with asthma during hay fever season.

History and examination features helping distinguish asthma exacerbation from covid-19 10 11 14 15 16

Exacerbation of asthma*.

Improvement in symptoms with reliever inhaler

Diurnal variation

Absence of fever

Coexisting hay fever symptoms

Examination:

Reduced peak expiratory flow

Close contact of known or suspected case

Dry continuous cough

Onset of dyspnoea 4-8 days into illness

Flu-like symptoms including fatigue, myalgia, headache

Symptoms not relieved by inhaler

Absence of wheeze

Peak expiratory flow may be normal

*Note SARS-CoV-2 infection may be a trigger for an asthma exacerbation

Risk factors and medications

To assess the risk of deterioration, ask specifically about any previous hospital admissions for asthma and about oral corticosteroid use over the past 12 months. Does the patient have any other high risk conditions or are they taking immunosuppressive drugs? Ask the patient if they smoke and take the opportunity to offer support to quit.

Are they prescribed an inhaled corticosteroid (ICS) or a long acting β agonist (LABA) and ICS combination inhaler? Are they using this regularly? Are they using a spacer device, and do they have a personal asthma action plan to guide management?

Psychosocial factors

Taking a psychosocial history can be more challenging over the telephone, where cues are harder to spot. Lessons from asthma deaths have shown that adverse psychosocial factors are strongly associated with mortality. 14 17 These include a history of mental health problems, lack of engagement with healthcare services, and alcohol or drug misuse, along with employment and income problems. Social isolation is also a risk factor, which may be exacerbated during social distancing measures. 17 The covid-19 outbreak is an anxious time for many patients, and symptoms of anxiety can contribute to the overall presentation.

Examination

In remote assessment, video can help guide decision making, and we recommend its use in asthmatic patients presenting with acute symptoms. First, assess the general appearance of the patient. A fatigued patient sitting up in bed, visibly breathless, and anchoring their chest will raise immediate concerns, as opposed to someone who is walking around while talking. Vocal tone and behaviour may indicate any contributing anxiety. Observe if the patient can speak in complete sentences, listen for audible wheeze, and count the respiratory rate. Assess the work of breathing, including the use of accessory muscles, and consider the use of a chaperone where appropriate. The Roth score is not advocated for assessment of covid-19 or asthma. 18

Further objective assessment can be made, such as measuring peak expiratory flow (PEF). If the patient does not have a PEF device at home, one can be prescribed, though this may not be feasible in an acute scenario. We recommend that PEF technique be witnessed via video to assess reliability. Silent hypoxia may be a feature of covid-19, and oxygen saturations should be measured if this is a concern. 19 In some regions, oxygen saturation probe delivery services are being implemented, which may facilitate this. Heart rate can also be provided by the patient if they use conventional “wearable” technology, although, given the potential inaccuracies with different devices, the results should not be relied on. 20 If time allows, inhaler technique can also be checked.

What you should do

Determine the most likely diagnosis.

Decide on the most likely diagnosis on the basis of the history and clinical features (see box 2 and fig 1 ) or consider whether an alternative or coexisting diagnosis is likely, such as a bacterial pneumonia or pulmonary embolus. If you suspect covid-19 without asthmatic features, manage the patient as per local covid-19 guidance.

Assessment and management of patients with known asthma during the covid-19 outbreak 14

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Determine severity and decide if face-to-face assessment is necessary

If asthmatic features are predominant, determine severity and treat according to Scottish Intercollegiate Guidelines Network (SIGN) and British Thoracic Society (BTS) guidance ( fig 1 ). 14 If the patient cannot complete sentences or has a respiratory rate ≥25 breaths/min, treat the case as severe or life threatening asthma and organise emergency admission. A peak expiratory flow (PEF) <50% of best or predicted or a heart rate ≥110 beats/min also indicate severe or life threatening asthma. If the patient does not meet these criteria, treat as a moderate asthma attack—a PEF of 50-75% of best or predicted helps confirm this. If they do not have a PEF meter, or if you are unsure as to severity, brief face-to-face assessment to auscultate for wheeze and assess oxygen saturations can help confirm the degree of severity and determine if the patient may be suitable for treatment at home with follow-up. Do not rely solely on objective tests and use clinical judgment to decide on the need for face-to-face assessment, based on knowledge of the patient, risk factors, and any adverse psychosocial circumstances.

Wheeze has been reported as a presenting symptom in a minority of patients with confirmed covid-19, and it may be difficult to rule out the presence of SARS-CoV-2 via remote assessment. 11 We recommend that, when a face-to-face assessment is needed, it should take place via local pathways in place to safely assess patients with suspected or possible covid-19—for example, at a local “hot” clinic. At present, performing a peak flow test is not considered to be an aerosol generating procedure, but the cough it may produce could be, so individual risk assessment is advised. 21 Consider performing PEF in an open space or remotely in another room via video link. Any PEF meter should be single-patient use only and can be given to the patient for future use.

Initial management when face-to-face assessment is not required

For moderate asthma exacerbations, advise up to 10 puffs of a short acting β agonist (SABA) inhaler via a spacer, administered one puff at a time. There is no evidence that nebulisers are more effective: 4-6 puffs of salbutamol via a spacer is as effective as 2.5 mg via a nebuliser. 22 Alternatively, if the patient takes a combined inhaled corticosteroid and long acting β agonist (LABA) preparation, then maintenance and reliever therapy (MART) can be used according to their action plan. 14 Management of an acute exacerbation should not rely solely on SABA monotherapy, so advise patients to follow their personal asthma action plan and continue corticosteroid treatment (or start it if they were not taking it previously) unless advised otherwise ( box 3 ). Antibiotics are not routinely recommended in asthma exacerbations.

Risks and benefits of inhaled and oral corticosteroids in asthma and covid-19

There is substantial evidence for the benefits of steroids in asthma. Regular use of inhaled steroids reduces severe exacerbations of asthma 23 and the need for bronchodilators, 24 while the prompt use of systemic corticosteroids during an exacerbation reduces the need for hospital admissions, use of β agonists, 25 and relapses. 26

The evidence for corticosteroid use in early covid-19 is still emerging. A systematic review of steroid use in SARS reported on 29 studies, 25 of which were inconclusive and four of which suggested possible harm (diabetes, osteoporosis, and avascular necrosis) but no reported effects on mortality. 27 WHO have cautioned against the use of systemic corticosteroids for the treatment of covid-19 unless indicated for other diseases. 28

In light of the strong evidence of benefits in patients with asthma, inhaled and oral corticosteroids should be prescribed if indicated in patients with symptoms of bronchoconstriction. Steroids should not be withheld on the theoretical risk of covid-19 infection, in line with guidance from the Primary Care Respiratory Society (PCRS), British Thoracic Society (BTS), and Global Initiative for Asthma (GINA). 15 22 29

Response to initial SABA or MART treatment can be assessed with a follow-up call at 20 minutes. If there is no improvement, further treatment may be necessary at a local hot clinic for reviewing possible covid-19, emergency department, or direct admission to an acute medical or respiratory unit depending on local pathways. For those who do respond, BTS-SIGN and GINA advise starting oral corticosteroids in patients presenting with an acute asthma exacerbation (such as prednisolone 40-50 mg for 5-7 days). 14 15 There is an increasing move in personalised asthma action plans to early quadrupling of the inhaled corticosteroid dose in patients with deteriorating control for up to 14 days to reduce the risk of severe exacerbations and the need for oral steroids. 15 30 However, there may be a ceiling effect on those who are already on a high dose of inhaled corticosteroid (see BTS table 14 ), so quadrupling the dose may not be effective in this group of patients. A personalised asthma action plan is an extremely helpful guide to treatment and should be completed or updated for all patients.

Follow-up and safety-netting

We recommend that all patients with moderate symptoms are followed up via remote assessment within 24 hours. Asthma attacks requiring hospital admission tend to develop relatively slowly over 6-48 hours. 14 However, deterioration can be more rapid, and symptoms can worsen overnight. Patients should be advised to look out for any worsening breathing or wheeze, lack of response to their inhalers, or worsening PEF. They should receive clear advice on what to do, including use of their reliever, and who to contact (such as the local out-of-hours GP provider, 111, or 999). With potential long waits for remote assessment, particularly out of hours, they should be advised to have a low threshold to call 999 if their symptoms deteriorate. If covid-19 infection is also suspected, advise them to isolate for seven days from onset of symptoms and arrange testing, according to the latest guidance. 7

How this article was created

We performed a literature search using Ovid, Medline, and Global Health databases using the search terms (asthma OR lung disease OR respiratory disease) AND (coronavirus OR covid-19)). Articles from 2019-20 were screened. We also searched for specific guidelines, including NICE, British Thoracic Society, Scottish Intercollegiate Guidelines Network, Primary Care Respiratory Society, European Respiratory Society, International Primary Care Respiratory Group, Global Initiative for Asthma, and the American Academy of Allergy, Asthma and Immunology.

Education into practice

Do you feel confident in completing personalised asthma plans in collaboration with patients?

How often do you start or increase inhaled corticosteroids in patients at initial presentation with an exacerbation of asthma?

If you manage a patient with acute asthma remotely, what safety netting advice would you give and how could you check understanding?

How patients were involved in the creation of this article

No patients were involved in the creation of this article.

This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.

Contributors: TB and TS conceived the article. TB, DS, and TS carried out the literature review and wrote the initial drafts. All four authors contributed to editing and revision, and VM provided expert advice as a respiratory specialist. All authors are guarantors of the work.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Commissioned, based on an idea from the author; externally peer reviewed.

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