Asthma attacks- a chance to intervene

Asthma is a common condition affecting children and adults across the UK, responsible for 2-3% of primary care consultations. Whilst we will all be familiar with managing patients with asthma, fewer of us will have seen first-hand the devastating event of an asthma related death. However, with the UK topping the list for number of hospitalisations per 100,000 population out of 29 OECD countries, a recent BJGP editorial raises concerns about asthma management. Have we become complacent about the risks it poses? 

William Gray was a 10 year old boy who tragically died from asthma in 2021.  In December 2023 the coroner released the  ‘William Gray: Prevention of future deaths report’. The following excerpt is both incredibly difficult and important to see:

‘William’s death was contributed to by neglect. William’s death was avoidable. There were multiple failures to escalate and treat William’s very poorly controlled asthma by healthcare professionals that would and should have saved William’s life’

In the months prior to his death, 10 year old William had been treated in the hospital for life-threatening asthma, and had subsequently received multiple courses of oral steroids for exacerbations from his GP practice. Key issues identified with his care include repeated prescription of short courses of oral corticosteroids, lack of ongoing preventor medication (one was issued but it was not renewed/ continued), excessive reliever inhaler prescriptions, lack of ongoing secondary care follow up (lost to follow up) and lack of escalation of poorly controlled asthma when recognised in primary care.

The BJGP editorial ‘Asthma deaths in children in the UK: the last straw!’ argues that asthma in the UK is not taken seriously enough, with acute attacks being treated as isolated events rather than as a ‘red flag’ for poorly controlled disease, leading to adverse outcomes. It highlights that major preventable risk factors keep recurring, suggesting that lessons from the National Review of Asthma Deaths (NRAD) are not being learnt. 

So how can we improve care?

NICE guidelines and GINA guidelines agree on the importance of arranging timely clinical review after an acute attack. This is an opportunity to check that the acute symptoms are resolving, but also to ensure that the underlying chronic condition is being adequately treated. Underlying risk factors should be explored, and modifiable risk factors addressed (e.g. poor inhaler technique, inadequate preventer medication (inhaled corticosteroids), allergy, smoking/ vaping). Action plans should be checked for understanding/use and modified if needed, and referral to secondary care generated if indicated (e.g. >1-2 exacerbations per year or any admission with asthma). 

A recent study published in the BJGP entitled ‘Post-hospitalisation asthma management in primary care: a retrospective cohort study’ looked at whether this is happening in practice. The study looked at 17,457 patients aged ³5yrs who had had at least one asthma-related admission between January 2017-December 2019. The primary outcome was a composite of ANY of the following delivered from primary care within 28 days of discharge: asthma review, asthma management plan, asthma medication prescription, demonstration of inhaler technique or smoking cessation counselling. Only 60.2% received at least one of these interventions within 28 days. 13.2% received an asthma review, 8.4% an asthma management plan, 57.3% an asthma medication, 8.6% demonstration of inhaler technique and 1.2% of smokers received smoking cessation counselling. This implies that we are missing a valuable opportunity to address modifiable risk factors and adjust management for a significant proportion of our patients, potentially leaving them at increased risk of further acute attacks and poor outcomes.

An interesting quality improvement idea has been proposed by Dr Mark Levy (GP and Clinical Lead for NRAD), who advocates for performing a structured review of high-risk asthma patients within a regular primary care MDT meeting (e.g. every 2-4 weeks), identifying and managing modifiable risk factors, sharing knowledge across the team and utilising different expertise. See further details in his 7 step action plan. 

Take home message: acute asthma attacks should be seen as a red flag for poor asthma control and an opportunity to intervene. You may just save a life.