Managing acute asthma in adults in primary care

• Published in: Practitioner Vol. 265; no. 1853; pp. 19 - 23
• Main Authors: Jones, Gareth Huw, Randles, Victoria, Leung, Wing Yin
• Format: Trade Publication Article
• Language: English
• Published: London Practitioner Medical Publishing Ltd 01.11.2021
• Subjects: Asthma; Education; Inhalers; Patients; Primary care; Risk factors; Steroids; United Kingdom > UK
• ISSN: 0032-6518

Asthma is a common, chronic respiratory condition affecting around 8% of adults in the UK.1 The National Review of Asthma Deaths (NRAD) report Why asthma still killsfound that most fatal asthma attacks occurred in patients who were not under specialist supervision at the time of their death.2 All patients presenting with a flare of their asthma should be assessed Which patients should be admitted to hospital? clinically with particular attention to objective observations and pulmonary function should be measured, typically by peak expiratory flow rate (PEFR), in the community setting. Most guidelines do not recommend routine prescription of antibiotics, unless infection is suspected (e.g. fever and purulent sputum).3,4 Nonetheless, the diagnosis of bacterial infection is often overestimated in acute asthma exacerbations, as most infective exacerbations of asthma are viral.3 Likewise, a chest X-ray for community managed exacerbations is not routinely recommended, unless there is an unsatisfactory response to treatment or a superadded diagnosis is suspected e.g. pneumothorax.4 In moderate exacerbations the decision about hospital admission is based on multiple factors, including response to initial treatment, known reduction in baseline lung function, history of exacerbations, particularly previous need for critical care involvement, and the patient's ability to cope at home.4 Patients with features of acute severe or life-threatening asthma should be referred to hospital immediately following initial assessment.3,5 In an emergency situation, oxygen saturations should be maintained at 94-98% with supplemental oxygen although care should be taken in patients with coexisting COPD or with known oxygen sensitivity. Checking and correcting inhaler technique using a standard checklist takes minutes and can lead to improved asthma control.4 For patients prescribed a pressurised metered dose inhaler, use of a spacer significantly improves delivery and for ICS reduces the potential of local side effects.4 Smoking and exposure to secondhand smoke in the home are also important modifiable factors. The BTS/SIGN guideline recommends that all patients on the 'active asthma' register should receive self-management education, supported by a written PAAP in primary care.3 Measures that may be helpful in implementing effective self-management interventions include: proactive triggers to ensure routine reviews; structured protocols for asthma reviews; support from community pharmacists; routine mailing of educational resources; ongoing phone support and advice; and IT-based education and monitoring.3 REFERRAL Individuals who persistently require multiple courses of oral steroids should be considered for referral to secondary care for further investigation, as should patients with suspected superadded conditions and any potential occupational component to their