case study for asthma patient

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• Published: 16 October 2014

A woman with asthma: a whole systems approach to supporting self-management

• Hilary Pinnock 1 ,
• Elisabeth Ehrlich 1 ,
• Gaylor Hoskins 2 &
• Ron Tomlins 3  

npj Primary Care Respiratory Medicine volume  24 , Article number:  14063 ( 2014 ) Cite this article

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A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and international and national guidelines emphasise the importance of providing a written asthma action plan. Effective implementation of this recommendation for the lady in this case study is considered from the perspective of a patient, healthcare professional, and the organisation. The patient emphasises the importance of developing a partnership based on honesty and trust, the need for adherence to monitoring and regular treatment, and involvement of family support. The professional considers the provision of asthma self-management in the context of a structured review, with a focus on a self-management discussion which elicits the patient’s goals and preferences. The organisation has a crucial role in promoting, enabling and providing resources to support professionals to provide self-management. The patient’s asthma control was assessed and management optimised in two structured reviews. Her goal was to avoid disruption to her work and her personalised action plan focused on achieving that goal.

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A 35-year-old sales representative attends the practice for an asthma review. Her medical record notes that she has had asthma since childhood, and although for many months of the year her asthma is well controlled (when she often reduces or stops her inhaled steroids), she experiences one or two exacerbations a year requiring oral steroids. These are usually triggered by a viral upper respiratory infection, though last summer when the pollen count was particularly high she became tight chested and wheezy for a couple of weeks.

Her regular prescription is for fluticasone 100 mcg twice a day, and salbutamol as required. She has a young family and a busy lifestyle so does not often manage to find time to attend the asthma clinic. A few weeks previously, an asthma attack had interfered with some important work-related travel, and she has attended the clinic on this occasion to ask about how this can be managed better in the future. There is no record of her having been given an asthma action plan.

What do we know about asthma self-management? The academic perspective

Supported self-management reduces asthma morbidity.

The lady in this case study is struggling to maintain control of her asthma within the context of her busy professional and domestic life. The recent unfortunate experience which triggered this consultation offers a rare opportunity to engage with her and discuss how she can manage her asthma better. It behoves the clinician whom she is seeing (regardless of whether this is in a dedicated asthma clinic or an appointment in a routine general practice surgery) to grasp the opportunity and discuss self-management and provide her with a (written) personalised asthma action plan (PAAP).

The healthcare professional advising the lady is likely to be aware that international and national guidelines emphasise the importance of supporting self-management. 1 – 4 There is an extensive evidence base for asthma self-management: a recent synthesis identified 22 systematic reviews summarising data from 260 randomised controlled trials encompassing a broad range of demographic, clinical and healthcare contexts, which concluded that asthma self-management reduces emergency use of healthcare resources, including emergency department visits, hospital admissions and unscheduled consultations and improves markers of asthma control, including reduced symptoms and days off work, and improves quality of life. 1 , 2 , 5 – 12 Health economic analysis suggests that it is not only clinically effective, but also a cost-effective intervention. 13

Personalised asthma action plans

Key features of effective self-management approaches are:

Self-management education should be reinforced by provision of a (written) PAAP which reminds patients of their regular treatment, how to monitor and recognise that control is deteriorating and the action they should take. 14 – 16 As an adult, our patient can choose whether she wishes to monitor her control with symptoms or by recording peak flows (or a combination of both). 6 , 8 , 9 , 14 Symptom-based monitoring is generally better in children. 15 , 16

Plans should have between two and three action points including emergency doses of reliever medication; increasing low dose (or recommencing) inhaled steroids; or starting a course of oral steroids according to severity of the exacerbation. 14

Personalisation of the action plan is crucial. Focussing specifically on what actions she could take to prevent a repetition of the recent attack is likely to engage her interest. Not all patients will wish to start oral steroids without advice from a healthcare professional, though with her busy lifestyle and travel our patient is likely to be keen to have an emergency supply of prednisolone. Mobile technology has the potential to support self-management, 17 , 18 though a recent systematic review concluded that none of the currently available smart phone ‘apps’ were fit for purpose. 19

Identification and avoidance of her triggers is important. As pollen seems to be a trigger, management of allergic rhinitis needs to be discussed (and included in her action plan): she may benefit from regular use of a nasal steroid spray during the season. 20

Self-management as recommended by guidelines, 1 , 2 focuses narrowly on adherence to medication/monitoring and the early recognition/remediation of exacerbations, summarised in (written) PAAPs. Patients, however, may want to discuss how to reduce the impact of asthma on their life more generally, 21 including non-pharmacological approaches.

Supported self-management

The impact is greater if self-management education is delivered within a comprehensive programme of accessible, proactive asthma care, 22 and needs to be supported by ongoing regular review. 6 With her busy lifestyle, our patient may be reluctant to attend follow-up appointments, and once her asthma is controlled it may be possible to make convenient arrangements for professional review perhaps by telephone, 23 , 24 or e-mail. Flexible access to professional advice (e.g., utilising diverse modes of consultation) is an important component of supporting self-management. 25

The challenge of implementation

Implementation of self-management, however, remains poor in routine clinical practice. A recent Asthma UK web-survey estimated that only 24% of people with asthma in the UK currently have a PAAP, 26 with similar figures from Sweden 27 and Australia. 28 The general practitioner may feel that they do not have time to discuss self-management in a routine surgery appointment, or may not have a supply of paper-based PAAPs readily available. 29 However, as our patient rarely finds time to attend the practice, inviting her to make an appointment for a future clinic is likely to be unsuccessful and the opportunity to provide the help she needs will be missed.

The solution will need a whole systems approach

A systematic meta-review of implementing supported self-management in long-term conditions (including asthma) concluded that effective implementation was multifaceted and multidisciplinary; engaging patients, training and motivating professionals within the context of an organisation which actively supported self-management. 5 This whole systems approach considers that although patient education, professional training and organisational support are all essential components of successful support, they are rarely effective in isolation. 30 A systematic review of interventions that promote provision/use of PAAPs highlighted the importance of organisational systems (e.g., sending blank PAAPs with recall reminders). 31 A patient offers her perspective ( Box 1 ), a healthcare professional considers the clinical challenge, and the challenges are discussed from an organisational perspective.

Box 1: What self-management help should this lady expect from her general practitioner or asthma nurse? The patient’s perspective

The first priority is that the patient is reassured that her condition can be managed successfully both in the short and the long term. A good working relationship with the health professional is essential to achieve this outcome. Developing trust between patient and healthcare professional is more likely to lead to the patient following the PAAP on a long-term basis.

A review of all medication and possible alternative treatments should be discussed. The patient needs to understand why any changes are being made and when she can expect to see improvements in her condition. Be honest, as sometimes it will be necessary to adjust dosages before benefits are experienced. Be positive. ‘There are a number of things we can do to try to reduce the impact of asthma on your daily life’. ‘Preventer treatment can protect against the effect of pollen in the hay fever season’. If possible, the same healthcare professional should see the patient at all follow-up appointments as this builds trust and a feeling of working together to achieve the aim of better self-management.

Is the healthcare professional sure that the patient knows how to take her medication and that it is taken at the same time each day? The patient needs to understand the benefit of such a routine. Medication taken regularly at the same time each day is part of any self-management regime. If the patient is unused to taking medication at the same time each day then keeping a record on paper or with an electronic device could help. Possibly the patient could be encouraged to set up a system of reminders by text or smartphone.

Some people find having a peak flow meter useful. Knowing one's usual reading means that any fall can act as an early warning to put the PAAP into action. Patients need to be proactive here and take responsibility.

Ongoing support is essential for this patient to ensure that she takes her medication appropriately. Someone needs to be available to answer questions and provide encouragement. This could be a doctor or a nurse or a pharmacist. Again, this is an example of the partnership needed to achieve good asthma control.

It would also be useful at a future appointment to discuss the patient’s lifestyle and work with her to reduce her stress. Feeling better would allow her to take simple steps such as taking exercise. It would also be helpful if all members of her family understood how to help her. Even young children can do this.

From personal experience some people know how beneficial it is to feel they are in a partnership with their local practice and pharmacy. Being proactive produces dividends in asthma control.

What are the clinical challenges for the healthcare professional in providing self-management support?

Due to the variable nature of asthma, a long-standing history may mean that the frequency and severity of symptoms, as well as what triggers them, may have changed over time. 32 Exacerbations requiring oral steroids, interrupting periods of ‘stability’, indicate the need for re-assessment of the patient’s clinical as well as educational needs. The patient’s perception of stability may be at odds with the clinical definition 1 , 33 —a check on the number of short-acting bronchodilator inhalers the patient has used over a specific period of time is a good indication of control. 34 Assessment of asthma control should be carried out using objective tools such as the Asthma Control Test or the Royal College of Physicians three questions. 35 , 36 However, it is important to remember that these assessment tools are not an end in themselves but should be a springboard for further discussion on the nature and pattern of symptoms. Balancing work with family can often make it difficult to find the time to attend a review of asthma particularly when the patient feels well. The practice should consider utilising other means of communication to maintain contact with patients, encouraging them to come in when a problem is highlighted. 37 , 38 Asthma guidelines advocate a structured approach to ensure the patient is reviewed regularly and recommend a detailed assessment to enable development of an appropriate patient-centred (self)management strategy. 1 – 4

Although self-management plans have been shown to be successful for reducing the impact of asthma, 21 , 39 the complexity of managing such a fluctuating disease on a day-to-day basis is challenging. During an asthma review, there is an opportunity to work with the patient to try to identify what triggers their symptoms and any actions that may help improve or maintain control. 38 An integral part of personalised self-management education is the written PAAP, which gives the patient the knowledge to respond to the changes in symptoms and ensures they maintain control of their asthma within predetermined parameters. 9 , 40 The PAAP should include details on how to monitor asthma, recognise symptoms, how to alter medication and what to do if the symptoms do not improve. The plan should include details on the treatment to be taken when asthma is well controlled, and how to adjust it when the symptoms are mild, moderate or severe. These action plans need to be developed between the doctor, nurse or asthma educator and the patient during the review and should be frequently reviewed and updated in partnership (see Box 1). Patient preference as well as clinical features such as whether she under- or over-perceives her symptoms should be taken into account when deciding whether the action plan is peak flow or symptom-driven. Our patient has a lot to gain from having an action plan. She has poorly controlled asthma and her lifestyle means that she will probably see different doctors (depending who is available) when she needs help. Being empowered to self-manage could make a big difference to her asthma control and the impact it has on her life.

The practice should have protocols in place, underpinned by specific training to support asthma self-management. As well as ensuring that healthcare professionals have appropriate skills, this should include training for reception staff so that they know what action to take if a patient telephones to say they are having an asthma attack.

However, focusing solely on symptom management strategies (actions) to follow in the presence of deteriorating symptoms fails to incorporate the patients’ wider views of asthma, its management within the context of her/his life, and their personal asthma management strategies. 41 This may result in a failure to use plans to maximise their health potential. 21 , 42 A self-management strategy leading to improved outcomes requires a high level of patient self-efficacy, 43 a meaningful partnership between the patient and the supporting health professional, 42 , 44 and a focused self-management discussion. 14

Central to both the effectiveness and personalisation of action plans, 43 , 45 in particular the likelihood that the plan will lead to changes in patients’ day-to-day self-management behaviours, 45 is the identification of goals. Goals are more likely to be achieved when they are specific, important to patients, collaboratively set and there is a belief that these can be achieved. Success depends on motivation 44 , 46 to engage in a specific behaviour to achieve a valued outcome (goal) and the ability to translate the behavioural intention into action. 47 Action and coping planning increases the likelihood that patient behaviour will actually change. 44 , 46 , 47 Our patient has a goal: she wants to avoid having her work disrupted by her asthma. Her personalised action plan needs to explicitly focus on achieving that goal.

As providers of self-management support, health professionals must work with patients to identify goals (valued outcomes) that are important to patients, that may be achievable and with which they can engage. The identification of specific, personalised goals and associated feasible behaviours is a prerequisite for the creation of asthma self-management plans. Divergent perceptions of asthma and how to manage it, and a mismatch between what patients want/need from these plans and what is provided by professionals are barriers to success. 41 , 42

What are the challenges for the healthcare organisation in providing self-management support?

A number of studies have demonstrated the challenges for primary care physicians in providing ongoing support for people with asthma. 31 , 48 , 49 In some countries, nurses and other allied health professionals have been trained as asthma educators and monitor people with stable asthma. These resources are not always available. In addition, some primary care services are delivered in constrained systems where only a few minutes are available to the practitioner in a consultation, or where only a limited range of asthma medicines are available or affordable. 50

There is recognition that the delivery of quality care depends on the competence of the doctor (and supporting health professionals), the relationship between the care providers and care recipients, and the quality of the environment in which care is delivered. 51 This includes societal expectations, health literacy and financial drivers.

In 2001, the Australian Government adopted a programme developed by the General Practitioner Asthma Group of the National Asthma Council Australia that provided a structured approach to the implementation of asthma management guidelines in a primary care setting. 52 Patients with moderate-to-severe asthma were eligible to participate. The 3+ visit plan required confirmation of asthma diagnosis, spirometry if appropriate, assessment of trigger factors, consideration of medication and patient self-management education including provision of a written PAAP. These elements, including regular medical review, were delivered over three visits. Evaluation demonstrated that the programme was beneficial but that it was difficult to complete the third visit in the programme. 53 – 55 Accordingly, the programme, renamed the Asthma Cycle of Care, was modified to incorporate two visits. 56 Financial incentives are provided to practices for each patient who receives this service each year.

Concurrently, other programmes were implemented which support practice-based care. Since 2002, the National Asthma Council has provided best-practice asthma and respiratory management education to health professionals, 57 and this programme will be continuing to 2017. The general practitioner and allied health professional trainers travel the country to provide asthma and COPD updates to groups of doctors, nurses and community pharmacists. A number of online modules are also provided. The PACE (Physician Asthma Care Education) programme developed by Noreen Clark has also been adapted to the Australian healthcare system. 58 In addition, a pharmacy-based intervention has been trialled and implemented. 59

To support these programmes, the National Asthma Council ( www.nationalasthma.org.au ) has developed resources for use in practices. A strong emphasis has been on the availability of a range of PAAPs (including plans for using adjustable maintenance dosing with ICS/LABA combination inhalers), plans for indigenous Australians, paediatric plans and plans translated into nine languages. PAAPs embedded in practice computer systems are readily available in consultations, and there are easily accessible online paediatric PAAPs ( http://digitalmedia.sahealth.sa.gov.au/public/asthma/ ). A software package, developed in the UK, can be downloaded and used to generate a pictorial PAAP within the consultation. 60

One of the strongest drivers towards the provision of written asthma action plans in Australia has been the Asthma Friendly Schools programme. 61 , 62 Established with Australian Government funding and the co-operation of Education Departments of each state, the Asthma Friendly Schools programme engages schools to address and satisfy a set of criteria that establishes an asthma-friendly environment. As part of accreditation, the school requires that each child with asthma should have a written PAAP prepared by their doctor to assist (trained) staff in managing a child with asthma at school.

The case study continues...

The initial presentation some weeks ago was during an exacerbation of asthma, which may not be the best time to educate a patient. It is, however, a splendid time to build on their motivation to feel better. She agreed to return after her asthma had settled to look more closely at her asthma control, and an appointment was made for a routine review.

At this follow-up consultation, the patient’s diagnosis was reviewed and confirmed and her trigger factors discussed. For this lady, respiratory tract infections are the usual trigger but allergic factors during times of high pollen count may also be relevant. Assessment of her nasal airway suggested that she would benefit from better control of allergic rhinitis. Other factors were discussed, as many patients are unaware that changes in air temperature, exercise and pets can also trigger asthma exacerbations. In addition, use of the Asthma Control Test was useful as an objective assessment of control as well as helping her realise what her life could be like! Many people with long-term asthma live their life within the constraints of their illness, accepting that is all that they can do.

After assessing the level of asthma control, a discussion about management options—trigger avoidance, exercise and medicines—led to the development of a written PAAP. Asthma can affect the whole family, and ways were explored that could help her family understand why it is important that she finds time in the busy domestic schedules to take her regular medication. Family and friends can also help by understanding what triggers her asthma so that they can avoid exposing her to perfumes, pollens or pets that risk triggering her symptoms. Information from the national patient organisation was provided to reinforce the messages.

The patient agreed to return in a couple of weeks, and a recall reminder was set up. At the second consultation, the level of control since the last visit will be explored including repeat spirometry, if appropriate. Further education about the pathophysiology of asthma and how to recognise early warning signs of loss of control can be given. Device use will be reassessed and the PAAP reviewed. Our patient’s goal is to avoid disruption to her work and her PAAP will focus on achieving that goal. Finally, agreement will be reached with the patient about future routine reviews, which, now that she has a written PAAP, could be scheduled by telephone if all is well, or face-to-face if a change in her clinical condition necessitates a more comprehensive review.

Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2012. Available from: http://www.ginasthma.org (accessed July 2013).

British Thoracic Society/Scottish Intercollegiate Guideline Network British Guideline on the Management of Asthma. Thorax 2008; 63 (Suppl 4 iv1–121, updated version available from: http://www.sign.ac.uk (accessed January 2014).

Article   Google Scholar  

National Asthma Council Australia. Australian Asthma Handbook. Available from: http://www.nationalasthma.org.au/handbook (accessed May 2014).

National Asthma Education and Prevention Program (NAEPP) Coordinating Committee. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. Available from: https://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (accessed May 2014).

Taylor SJC, Pinnock H, Epiphaniou E, Pearce G, Parke H . A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions. (PRISMS Practical Systematic Review of Self-Management Support for long-term conditions). Health Serv Deliv Res (in press).

Gibson PG, Powell H, Wilson A, Abramson MJ, Haywood P, Bauman A et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2002: (Issue 3) Art No. CD001117.

Tapp S, Lasserson TJ, Rowe BH . Education interventions for adults who attend the emergency room for acute asthma. Cochrane Database Syst Rev 2007: (Issue 3) Art No. CD003000.

Powell H, Gibson PG . Options for self-management education for adults with asthma. Cochrane Database Syst Rev 2002: (Issue 3) Art No: CD004107.

Toelle B, Ram FSF . Written individualised management plans for asthma in children and adults. Cochrane Database Syst Rev 2004: (Issue 1) Art No. CD002171.

Lefevre F, Piper M, Weiss K, Mark D, Clark N, Aronson N . Do written action plans improve patient outcomes in asthma? An evidence-based analysis. J Fam Pract 2002; 51 : 842–848.

PubMed   Google Scholar  

Boyd M, Lasserson TJ, McKean MC, Gibson PG, Ducharme FM, Haby M . Interventions for educating children who are at risk of asthma-related emergency department attendance. Cochrane Database Syst Rev 2009: (Issue 2) Art No.CD001290.

Bravata DM, Gienger AL, Holty JE, Sundaram V, Khazeni N, Wise PH et al. Quality improvement strategies for children with asthma: a systematic review. Arch Pediatr Adolesc Med 2009; 163 : 572–581.

Bower P, Murray E, Kennedy A, Newman S, Richardson G, Rogers A . Self-management support interventions to reduce health care utilisation without compromising outcomes: a rapid synthesis of the evidence. Available from: http://www.nets.nihr.ac.uk/projects/hsdr/11101406 (accessed April 2014).

Gibson PG, Powell H . Written action plans for asthma: an evidence-based review of the key components. Thorax 2004; 59 : 94–99.

Article   CAS   Google Scholar  

Bhogal SK, Zemek RL, Ducharme F . Written action plans for asthma in children. Cochrane Database Syst Rev 2006: (Issue 3) Art No. CD005306.

Zemek RL, Bhogal SK, Ducharme FM . Systematic review of randomized controlled trials examining written action plans in children: what is the plan?. Arch Pediatr Adolesc Med 2008; 162 : 157–163.

Pinnock H, Slack R, Pagliari C, Price D, Sheikh A . Understanding the potential role of mobile phone based monitoring on asthma self-management: qualitative study. Clin Exp Allergy 2007; 37 : 794–802.

de Jongh T, Gurol-Urganci I, Vodopivec-Jamsek V, Car J, Atun R . Mobile phone messaging for facilitating self-management of long-term illnesses. Cochrane Database Syst Rev 2012: (Issue 12) Art No. CD007459.

Huckvale K, Car M, Morrison C, Car J . Apps for asthma self-management: a systematic assessment of content and tools. BMC Med 2012; 10 : 144.

Allergic Rhinitis and its Impact on Asthma. Management of Allergic Rhinitis and its Impact on Asthma: Pocket Guide. ARIA 2008. Available from: http://www.whiar.org (accessed May 2014).

Ring N, Jepson R, Hoskins G, Wilson C, Pinnock H, Sheikh A et al. Understanding what helps or hinders asthma action plan use: a systematic review and synthesis of the qualitative literature. Patient Educ Couns 2011; 85 : e131–e143.

Moullec G, Gour-Provencal G, Bacon SL, Campbell TS, Lavoie KL . Efficacy of interventions to improve adherence to inhaled corticosteroids in adult asthmatics: Impact of using components of the chronic care model. Respir Med 2012; 106 : 1211–1225.

Pinnock H, Bawden R, Proctor S, Wolfe S, Scullion J, Price D et al. Accessibility, acceptability and effectiveness of telephone reviews for asthma in primary care: randomised controlled trial. BMJ 2003; 326 : 477–479.

Pinnock H, Adlem L, Gaskin S, Harris J, Snellgrove C, Sheikh A . Accessibility, clinical effectiveness and practice costs of providing a telephone option for routine asthma reviews: phase IV controlled implementation study. Br J Gen Pract 2007; 57 : 714–722.

PubMed   PubMed Central   Google Scholar  

Kielmann T, Huby G, Powell A, Sheikh A, Price D, Williams S et al. From support to boundary: a qualitative study of the border between self care and professional care. Patient Educ Couns 2010; 79 : 55–61.

Asthma UK . Compare your care report. Asthma UK, 2013. Available from: http://www.asthma.org.uk (accessed January 2014).

Stallberg B, Lisspers K, Hasselgren M, Janson C, Johansson G, Svardsudd K . Asthma control in primary care in Sweden: a comparison between 2001 and 2005. Prim Care Respir J 2009; 18 : 279–286.

Reddel H, Peters M, Everett P, Flood P, Sawyer S . Ownership of written asthma action plans in a large Australian survey. Eur Respir J 2013; 42 . Abstract 2011.

Wiener-Ogilvie S, Pinnock H, Huby G, Sheikh A, Partridge MR, Gillies J . Do practices comply with key recommendations of the British Asthma Guideline? If not, why not? Prim Care Respir J 2007; 16 : 369–377.

Kennedy A, Rogers A, Bower P . Support for self care for patients with chronic disease. BMJ 2007; 335 : 968–970.

Ring N, Malcolm C, Wyke S, Macgillivray S, Dixon D, Hoskins G et al. Promoting the Use of Personal Asthma Action Plans: A Systematic Review. Prim Care Respir J 2007; 16 : 271–283.

Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW, Casale TB et al. A new perspective on concepts of asthma severity and control. Eur Respir J 2008; 32 : 545–554.

Horne R . Compliance, adherence, and concordance: implications for asthma treatment. Chest 2006; 130 (suppl): 65S–72S.

Reddel HK, Taylor DR, Bateman ED, Boulet L-P, Boushey HA, Busse WW et al. An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med 2009; 180 : 59–99.

Thomas M, Kay S, Pike J, Rosenzweig JR, Hillyer EV, Price D . The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J 2009; 18 : 41–49.

Hoskins G, Williams B, Jackson C, Norman P, Donnan P . Assessing asthma control in UK primary care: use of routinely collected prospective observational consultation data to determine appropriateness of a variety of control assessment models. BMC Fam Pract 2011; 12 : 105.

Pinnock H, Fletcher M, Holmes S, Keeley D, Leyshon J, Price D et al. Setting the standard for routine asthma consultations: a discussion of the aims, process and outcomes of reviewing people with asthma in primary care. Prim Care Respir J 2010; 19 : 75–83.

McKinstry B, Hammersley V, Burton C, Pinnock H, Elton RA, Dowell J et al. The quality, safety and content of telephone and face-to-face consultations: a comparative study. Qual Saf Health Care 2010; 19 : 298–303.

Gordon C, Galloway T . Review of Findings on Chronic Disease Self-Management Program (CDSMP) Outcomes: Physical, Emotional & Health-Related Quality of Life, Healthcare Utilization and Costs . Centers for Disease Control and Prevention and National Council on Aging: Atlanta, GA, USA, 2008.

Beasley R, Crane J . Reducing asthma mortality with the self-management plan system of care. Am J Respir Crit Care Med 2001; 163 : 3–4.

Ring N, Jepson R, Pinnock H, Wilson C, Hoskins G, Sheikh A et al. Encouraging the promotion and use of asthma action plans: a cross study synthesis of qualitative and quantitative evidence. Trials 2012; 13 : 21.

Jones A, Pill R, Adams S . Qualitative study of views of health professionals and patients on guided self-management plans for asthma. BMJ 2000; 321 : 1507–1510.

Bandura A . Self-efficacy: toward a unifying theory of behavioural change. Psychol Rev 1977; 84 : 191–215.

Gollwitzer PM, Sheeran P . Implementation intentions and goal achievement: a meta-analysis of effects and processes. Adv Exp Soc Psychol 2006; 38 : 69–119.

Google Scholar  

Hardeman W, Johnston M, Johnston DW, Bonetti D, Wareham NJ, Kinmonth AL . Application of the theory of planned behaviour change interventions: a systematic review. Psychol Health 2002; 17 : 123–158.

Schwarzer R . Modeling health behavior change: how to predict and modify the adoption and maintenance of health behaviors. Appl Psychol 2008; 57 : 1–29.

Sniehotta F . Towards a theory of intentional behaviour change: plans, planning, and self-regulation. Br J Health Psychol 2009; 14 : 261–273.

Okelo SO, Butz AM, Sharma R, Diette GB, Pitts SI, King TM et al. Interventions to modify health care provider adherence to asthma guidelines: a systematic review. Pediatrics 2013; 132 : 517–534.

Grol R, Grimshaw RJ . From best evidence to best practice: effective implementation of change in patients care. Lancet 2003; 362 : 1225–1230.

Jusef L, Hsieh C-T, Abad L, Chaiyote W, Chin WS, Choi Y-J et al. Primary care challenges in treating paediatric asthma in the Asia-Pacific region. Prim Care Respir J 2013; 22 : 360–362.

Donabedian A . Evaluating the quality of medical care. Milbank Q 2005; 83 : 691–729.

Fardy HJ . Moving towards organized care of chronic disease. The 3+ visit plan. Aust Fam Physician 2001; 30 : 121–125.

CAS   PubMed   Google Scholar  

Glasgow NJ, Ponsonby AL, Yates R, Beilby J, Dugdale P . Proactive asthma care in childhood: general practice based randomised controlled trial. BMJ 2003; 327 : 659.

Douglass JA, Goemann DP, Abramson MJ . Asthma 3+ visit plan: a qualitative evaluation. Intern Med J 2005; 35 : 457–462.

Beilby J, Holton C . Chronic disease management in Australia; evidence and policy mismatch, with asthma as an example. Chronic Illn 2005; 1 : 73–80.

The Department of Health. Asthma Cycle of Care. Accessed on 14 May 2014 at http://www.health.gov.au/internet/main/publishing.nsf/Content/asthma-cycle .

National Asthma Council Australia. Asthma and Respiratory Education Program. Accessed on 14 May 2014 at http://www.nationalasthma.org.au/health-professionals/education-training/asthma-respiratory-education-program .

Patel MR, Shah S, Cabana MD, Sawyer SM, Toelle B, Mellis C et al. Translation of an evidence-based asthma intervention: Physician Asthma Care Education (PACE) in the United States and Australia. Prim Care Respir J 2013; 22 : 29–34.

Armour C, Bosnic-Anticevich S, Brilliant M, Burton D, Emmerton L, Krass I et al. Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community. Thorax 2007; 62 : 496–502.

Roberts NJ, Mohamed Z, Wong PS, Johnson M, Loh LC, Partridge MR . The development and comprehensibility of a pictorial asthma action plan. Patient Educ Couns 2009; 74 : 12–18.

Henry RL, Gibson PG, Vimpani GV, Francis JL, Hazell J . Randomised controlled trial of a teacher-led asthma education program. Pediatr Pulmonol 2004; 38 : 434–442.

National Asthma Council Australia. Asthma Friendly Schools program. Accessed on 14 May 2014 at http://www.asthmaaustralia.org.au/Asthma-Friendly-Schools.aspx .

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Hilary Pinnock & Elisabeth Ehrlich

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Pinnock, H., Ehrlich, E., Hoskins, G. et al. A woman with asthma: a whole systems approach to supporting self-management. npj Prim Care Resp Med 24 , 14063 (2014). https://doi.org/10.1038/npjpcrm.2014.63

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Article Contents

Case 1 diagnosis: allergy bullying, clinical pearls.

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Case 1: A 12-year-old girl with food allergies and an acute asthma exacerbation

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Lopamudra Das, Michelle GK Ward, Case 1: A 12-year-old girl with food allergies and an acute asthma exacerbation, Paediatrics & Child Health , Volume 19, Issue 2, February 2014, Pages 69–70, https://doi.org/10.1093/pch/19.2.69

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A 12-year-old girl with a history of asthma presented to the emergency department with a three-day history of increased work of breathing, cough and wheezing. She reported no clear trigger for her respiratory symptoms, although she had noted some symptoms of a mild upper respiratory tract infection. With this episode, the patient had been using a short-acting bronchodilator more frequently than she had in the past, without the expected resolution of symptoms.

On the day of presentation, the patient awoke feeling ‘suffocated’ and her mother noted her lips to be blue. In the emergency department, her oxygen saturation was 85% and her respiratory rate was 40 breaths/min. She had significantly increased work of breathing and poor air entry bilaterally to both lung bases, with wheezing in the upper lung zones. She was treated with salbutamol/ipratropium and received intravenous steroids and magnesium sulfate. Her chest x-ray showed hyperinflation and no focal findings.

Her medical history revealed that she was followed by a respirologist for her asthma, had good medication adherence and had not experienced a significant exacerbation for six months. She also had a history of wheezing, dyspnea and pruritis with exposure to peanuts, chickpeas and lentils; she had been prescribed an injectible epinephrine device for this. However, her device had expired at the time of presentation. In the past, her wheezing episodes had been seasonal and related to exposure to grass and pollens; this presentation occurred during the winter. Further history revealed the probable cause of her presentation.

Although reluctant to disclose the information, our patient later revealed that she had been experiencing significant bullying at school, which was primarily related to her food allergies. Three days before her admission, classmates had smeared peanut butter on one of her schoolbooks. She developed pruritis immediately after opening the book and she started wheezing and coughing later that day. This event followed several months of being taunted with peanut products at school. The patient was experiencing low mood and reported new symptoms of anxiety related to school. The review of systems was otherwise negative, with no substance use.

The patient's asthma exacerbation resolved with conventional asthma treatment. Her pulmonary function tests were nonconcerning (forced expiratory volume in 1 s 94% and 99% of predicted) after her recovery. The trigger for her asthma exacerbation was likely multifactorial, related to exposure to the food allergen as well as the upper respiratory infection. A psychologist was consulted to assess the symptoms of anxiety and depression that had occurred as a result of the bullying. During the hospitalization, the medical team contacted the patient's school to provide education on allergy bullying, treatment of severe allergic reactions and its potential for life-threatening reactions with exposure to allergens. The medical team also recommended community resources for further education of students and staff about allergy bullying and its prevention.

Allergy bullying is a form of bullying with potentially severe medical outcomes. In recent years, it has gained increasing notoriety in schools and in the media. Population-based studies have shown that 20% to 35% of children with allergies experience bullying. In many cases (31% in one recent study [ 1 ]), this bullying is related directly to the food allergy. From a medical perspective, there are little published data regarding allergy bullying, and many health care providers may not be aware of the issue.

Allergy bullying can include teasing a child about their allergy, throwing food at a child, or even forcing them to touch or eat allergenic foods. Most episodes of allergy bullying occur at school, and can include episodes perpetrated by teachers and/or staff ( 2 ).

Allergy bullying can lead to allergic reactions, which may be mild or severe (eg, urticaria, wheezing, anaphylaxis), but may also lead to negative emotional consequences (sadness, depression) ( 2 ) and an overall decrease in quality of life measures ( 1 ). Adolescents commonly resist using medical devices, such as injectible epinephrine devices, and bullying may be a contributing factor for this ( 3 ). Attempting to conceal symptoms in a bullying situation may place children at risk for a worse outcome.

Physicians can play a key role in detecting allergy bullying and its health consequences. In many cases, children have not discussed this issue with their parents ( 1 ). Given the prevalence of bullying, its potential to lead to severe harm, including death, and the lack of awareness of this issue, clinicians should specifically ask about bullying in all children and teens with allergies. Physicians can also work with families and schools to support these children, educate their peers and school staff, and help prevent negative health outcomes from allergy bullying.

Online resources

www.anaphylaxis.ca − A national charity that aims to inform, support, educate and advocate for the needs of individuals and families living with anaphylaxis, and to support and participate in research. This website includes education modules for schools and links to local support groups throughout Canada.

www.whyriskit.ca/pages/en/live/bullying.php − A website for teenagers with food allergies; includes a segment that addresses food bullying.

www.foodallergy.org − Contains numerous resources for children and their families, including a significant discussion on bullying and ways to prevent it.

Allergy bullying is common but is often unrecognized as a factor in clinical presentations of allergic reactions.

Physicians should make a point of asking about bullying in patients with allergies and become familiar with resources for dealing with allergy bullying.

Physicians can play roles as advocates, educators and collaborators with the school system to help make the school environment safer for children with allergies who may be at risk for allergy bullying.

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• Case report
• Open access
• Published: 21 February 2018

Pediatric severe asthma: a case series report and perspectives on anti-IgE treatment

• Virginia Mirra 1 ,
• Silvia Montella 1 &
• Francesca Santamaria 1  

BMC Pediatrics volume  18 , Article number:  73 ( 2018 ) Cite this article

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The primary goal of asthma management is to achieve disease control for reducing the risk of future exacerbations and progressive loss of lung function. Asthma not responding to treatment may result in significant morbidity. In many children with uncontrolled symptoms, the diagnosis of asthma may be wrong or adherence to treatment may be poor. It is then crucial to distinguish these cases from the truly “severe therapy-resistant” asthmatics by a proper filtering process. Herein we report on four cases diagnosed as difficult asthma, detail the workup that resulted in the ultimate diagnosis, and provide the process that led to the prescription of omalizumab.

Case presentation

All children had been initially referred because of asthma not responding to long-term treatment with high-dose inhaled steroids, long-acting β 2 -agonists and leukotriene receptor antagonists. Definitive diagnosis was severe asthma. Three out four patients were treated with omalizumab, which improved asthma control and patients’ quality of life. We reviewed the current literature on the diagnostic approach to the disease and on the comorbidities associated with difficult asthma and presented the perspectives on omalizumab treatment in children and adolescents. Based on the evidence from the literature review, we also proposed an algorithm for the diagnosis of pediatric difficult-to-treat and severe asthma.

Conclusions

The management of asthma is becoming much more patient-specific, as more and more is learned about the biology behind the development and progression of asthma. The addition of omalizumab, the first targeted biological treatment approved for asthma, has led to renewed optimism in the management of children and adolescents with atopic severe asthma.

Peer Review reports

Children with poor asthma control have an increased risk of severe exacerbations and progressive loss of lung function, which results in the relevant use of health resources and impaired quality of life (QoL) [ 1 ]. Therefore, the primary goal of asthma management at all ages is to achieve disease control [ 2 , 3 , 4 ].

According to recent international guidelines, patients with uncontrolled asthma require a prolonged maintenance treatment with high-dose inhaled corticosteroids (ICS) in association with a long-acting β 2 -agonist (LABA) plus oral leukotriene receptor antagonist (LTRA) (Table  1 ) [ 5 ].

Nevertheless, in the presence of persistent lack of control, reversible factors such as adherence to treatment or inhalation technique should be first checked for, and diseases that can masquerade as asthma should be promptly excluded. Finally, additional strategies, in particular anti-immunoglobulin E (anti-IgE) treatment (omalizumab), are suggested for patients with moderate or severe allergic asthma that remains uncontrolled in Step 4 [ 5 ].

Herein, we reviewed the demographics, clinical presentation and treatment of four patients with uncontrolled severe asthma from our institution in order to explain why we decided to prescribe omalizumab. We also provided a review of the current literature that focuses on recent advances in the diagnosis of pediatric difficult asthma and the associated comorbidities, and summarizes the perspectives on anti-IgE treatment in children and adolescents.

Case presentations

Table  2 summarizes the clinical characteristics and the triggers/comorbidities of the cases at referral to our Institution. Unfortunately, data on psychological factors, sleep apnea, and hyperventilation syndrome were not available in any case. Clinical, lung function and airway inflammation findings at baseline and after 12 months of follow-up are reported in Table  3 . In the description of our cases, we used the terminology recommended by the ERS/ATS guidelines on severe asthma [ 6 ].

A full-term male had severe preschool wheezing and, since age 3, recurrent, severe asthma exacerbations with frequent hospital admissions. At age 11, severe asthma was diagnosed. Sensitization to multiple inhalant allergens (i.e., house dust mites, dog dander, Graminaceae pollen mix, and Parietaria judaica ) and high serum IgE levels (1548 KU/l) were found. Body mass index (BMI) was within normal range. Combined treatment with increasing doses of ICS (fluticasone, up to 1000 μg/day) in association with LABA (salmeterol, 100 μg/day) plus LTRA (montelukast, 5 mg/day) has been administered over 2 years. Nevertheless, persistent symptoms and monthly hospital admissions due to asthma exacerbations despite correct inhaler technique and good adherence were reported. Parents refused to perform any test to exclude gastroesophageal reflux (GER) as comorbidity [ 6 ]. However, an ex-juvantibus 2-month-course with omeprazole was added to asthma treatment [ 7 ], but poor control persisted. Anterior rhinoscopy revealed rhinosinusitis that was treated with nasal steroids for six months [ 8 ], but asthma symptoms were unmodified. Treatment with omalizumab was added at age 12. Reduced hospital admissions for asthma exacerbations, no further need for systemic steroids, and improved QoL score (from 2.0 up to 6.7 out of a maximum of 7 points) were documented over the following months. Unfortunately, after one year of treatment, adherence to omalizumab decreased because of family complaints, and eventually parents withdrew their informed consent and discontinued omalizumab. Currently, by age 17, treatment includes inhaled salmeterol/fluticasone (100 μg/500 μg∙day -1 , respectively) plus oral montelukast (10 mg/day). Satisfactory symptom control is reported, with no asthma exacerbations.

A full-term male, who had a recurrent severe preschool wheezing, at 6 years of age developed exercise-induced asthma. At age 10, severe asthma was diagnosed. High serum IgE levels (1300 KU/l) and skin prick tests positive to house dust mites were found. Despite a 3-year treatment with progressively increasing doses of inhaled fluticasone (up to 1000 μg/day) combined with salmeterol (100 μg/day) and oral montelukast (5 mg/day), monthly hospital admissions with systemic steroids use were reported. At age 13, a 24-h esophageal impedance/pH study demonstrated the presence of acid and non-acid GER [ 7 ]. Esomeprazole was added to asthma medications, but with an incomplete clinical benefit for respiratory symptoms. Esomeprazole was withdrawn after 3 months, and parents refused to re-test for GER. As respiratory symptoms persisted uncontrolled despite treatment, severe asthma was definitively diagnosed [ 6 ]. BMI was within the normal range and anterior rhinoscopy excluded rhinosinusitis. Inhaler technique and adherence were good; thus we considered the anti-IgE treatment option [ 9 ]. Subcutaneous omalizumab was started, with fast improvement of both symptoms and QoL score (from 3.9 up to 6.5). Seventeen months later, the dose of ICS had been gradually tapered and oral montelukast definitely discontinued. Currently, at age 14, treatment includes the combined administration of bimonthly subcutaneous omalizumab and of daily inhaled salmeterol/fluticasone (50 μg/100 μg∙day - 1 , respectively). Asthma control is satisfactory and no side effects are reported. Omalizumab has been continuously administered for 2.6 years and is still ongoing.

A full-term male had severe preschool wheezing and, since age 3, recurrent, severe asthma exacerbations with acute respiratory failure that frequently required intensive care unit (ICU) admission. At age 6, sensitization to multiple perennial inhalant (i.e., house dust mites, dog and cat danders, Alternaria alternata , Graminaceae pollen mix, Artemisia vulgaris , Parietaria judaica , and Olea europaea pollen) and food allergens (i.e., egg, milk, and peanut) was diagnosed. Serum IgE levels were 2219 KU/l. Weight and height were appropriate for age and sex. The patient has been treated over 3 years with a combined scheme of high-dose inhaled fluticasone (up to 1000 μg/day) plus salmeterol (100 μg/day) and oral montelukast (5 mg/day), with correct inhaler technique and good adherence. Despite this, monthly hospital admissions with systemic steroids use were recorded. Rhinosinusitis and GER were excluded on the basis of appropriate testing; thus treatment with omalizumab was started when the patient was 9 years old. At age 11, adherence to treatment is satisfactory, with no side effects. More importantly, reduced hospital admissions for asthma exacerbations, no further need for systemic steroids, and improved QoL score (from 6.4 to 6.8) were reported. Finally, progressive step-down of anti-asthma treatment was started, and at present (by 11.5 years) inhaled fluticasone (200 μg/day) plus bimonthly subcutaneous omalizumab provide good control of symptoms. Omalizumab has been continuously administered for 2.6 years and is still ongoing.

A full-term male had severe preschool wheezing and, since age 4, recurrent, severe asthma exacerbations with frequent hospital admissions. At age 8, multiple perennial inhalants and food sensitization (i.e., house dust mites, dog dander, Graminaceae pollen mix, Olea europaea pollen, tomatoes, beans, shrimps, and peas) and high serum IgE levels (1166 KU/l) were found. The patient has been treated over 5 years with inhaled fluticasone (up to 1000 μg/day) in association with salmeterol (100 μg/day) and oral montelukast (5 mg/day). Despite this, monthly hospital admissions with systemic steroids need were recorded. After checking the inhaler technique and adherence to treatment, comorbidities including obesity, rhinosinusitis and GER were excluded. Omalizumab was proposed, but parents refused it. By 13.6 years, despite a treatment including the association of inhaled salmeterol/fluticasone (100 μg/1000 μg∙day − 1 , respectively) plus oral montelukast (10 mg/day), monthly exacerbations requiring systemic steroids are reported.

Discussion and conclusions

Most children and adolescents with asthma respond well to inhaled short-acting beta 2 -agonists (SABA) on demand if symptoms are intermittent, or to low dose controller drugs plus as-needed SABA if the risk of exacerbations increases [ 1 ]. Nevertheless, a proportion of patients is referred to specialists because this strategy is not working and asthma is persistently uncontrolled [ 4 ]. For these children, assessment is primarily aimed at investigating the reasons for poor control. Indeed, when the child is initially referred, before the label of “severe, therapy-resistant asthma” (i.e., not responding to treatment even when factors as exposure to allergens and tobacco smoke have been considered) is assigned, three main categories need to be identified: 1) “not asthma at all”, in which response to treatment is suboptimal because the diagnosis is wrong; 2) “asthma plus ”, when asthma is mild but exacerbated by one or more comorbidities; and 3) “difficult-to-treat asthma”, when asthma is uncontrolled because of potentially reversible factors [ 10 ].

The reported cases highlight some aspects of the disease process that may expand the diagnosis and improve patients’ care. At our institution, the severe asthma program includes a multidisciplinary approach with consultations by gastroenterologists as well as ear, nose and throat experts. Recently, sleep medicine experts joined this multidisciplinary team; thus, unfortunately, sleep-disordered breathing (SDB) could not be excluded at the time of our patients’ assessment. Inhalation technique is periodically evaluated by nurses or doctors in each patient. Unfortunately, in Italy an individual prescription database is not available and thus we cannot assess patients’ use of medication. In two cases, the filtering process eventually identified GER and rhinosinusitis, but poor control of asthma persisted even after comorbidities were treated. In all subjects, inhaler skills, treatment adherence, and environmental exposure to indoor/outdoor allergens as well as to second- and third-hand smoke were excluded as cause of lack of control. Eventually, three out of four patients started anti-IgE treatment; asthma control was obtained and maintenance drugs were progressively reduced. In the case that refused omalizumab therapy, pulmonary function, clinical features and controller treatment including high-dose ICS were unchanged.

Previous studies have highlighted an association between increasing asthma severity in children and reduced QoL [ 11 , 12 , 13 ]. Uncontrolled asthma symptoms not only affect children physically, but can impair them socially, emotionally, and educationally [ 13 ]. In line with previous observations, 3 out 4 of our cases had poor QoL, assessed by a standardized questionnaire [ 14 ]. It is well known that improving QoL in difficult asthma is not an easy task, despite a variety of treatments aimed at achieving control [ 12 ], and much more remains to be done to address the problem. Nevertheless, 2 of our 3 cases showed a remarkable improvement of QoL after one year of treatment with omalizumab.

Reduction in forced expiratory volume in the first second (FEV 1 ) is often used to define childhood asthma severity in treatment guidelines and clinical studies [ 5 , 11 , 15 ]. Nevertheless, children with severe asthma often have a normal FEV 1 that does not improve after bronchodilators, indicating that spirometry may be a poor predictor of asthma severity in childhood [ 6 , 16 , 17 ]. Actually, children with a normal FEV 1 , both before and after β 2 -agonist, may show a bronchodilator response in terms of forced expiratory flow between 25% and 75% (FEF 25–75 ) [ 18 ]. However, the utility of FEF 25–75 in the assessment or treatment of severe asthma is currently unknown. Interestingly, all the reported cases showed normal or slightly reduced values of FEV 1 but severe impairment of FEF 25–75 . Two cases showed a bronchodilator response in terms of FEV 1 (subjects 3 and 4), while 3 patients had a significant increase of FEF 25–75 (cases 1, 3 and 4). Unfortunately, we could not provide the results of bronchodilator response during or after the treatment with omalizumab in any case.

Available literature on the diagnostic approach to difficult asthma in children offers a number of reviews which basically summarize the steps needed to fill the gap between a generic diagnosis of “difficult asthma” and more specific labels (i.e., “severe” asthma, “difficult-to-treat” asthma, or even different diagnoses) [ 3 , 5 , 6 , 8 , 10 , 19 , 20 , 21 ]. So far, few original articles and case reports have been published, probably due to the peculiarity of the issue, which makes retrospective discussion of cases easier than the design of a prospective clinical study [ 4 , 22 , 23 , 24 , 25 , 26 ]. Available knowledge mainly derives from the experience of specialized centers.

The evaluation of a child referred for uncontrolled asthma should start with a careful history focused on typical respiratory symptoms and on the definition of possible triggers. In the “severe asthma” process, it is crucial for clinicians to maintain a high degree of skepticism about the ultimate diagnosis, particularly in the presence of relevant discrepancies between history, physical features and lung function, as many conditions may be misdiagnosed as asthma. In order to simplify this process, herein we propose an algorithm for the diagnosis of difficult-to-treat and severe asthma (Fig.  1 ). Confirmation of the diagnosis through a detailed clinical and laboratory re-evaluation is important because in 12–50% of cases assumed to have severe asthma this might not be the correct diagnosis [ 10 ]. Several documents have indicated the main steps of the process that should be followed in children with uncontrolled asthma [ 3 , 8 , 10 ]. The translation of these procedures into real life practice may deeply change from one subject to another due to the variability of individual patients’ history and clinical features, which will often lead the diagnostic investigations towards the most likely reason for uncontrolled asthma. For children with apparently severe asthma, the first step is to confirm the diagnosis and, before proceeding to broader investigations, to verify that the poor control is not simply determined by poor adherence to treatment, inadequate inhaler skills and/or environmental exposure to triggers. A nurse-led assessment, including a home visit, despite not being applicable in all settings, may be useful for identifying potentially modifiable factors in uncontrolled pediatric asthma [ 27 ].

A practical algorithm for the diagnosis of difficult-to-treat and severe asthma. ICS, inhaled corticosteroids; OCS, oral corticosteroids

A number of comorbidities have been increasingly recognized as factors that may impact asthma clinical expression and control in childhood [ 10 , 28 ]. Children with uncontrolled disease should be investigated for GER, rhinosinusitis, dysfunctional breathing and/or vocal cord dysfunction, obstructive sleep apnea, obesity, psychological factors, smoke exposure, hormonal influences, and ongoing drugs [ 3 , 6 , 8 , 20 ]. Indeed, the exact role played by comorbidities in pediatric asthma control is still debated [ 28 ]. The most impressive example is GER. Several pediatric documents recommend assessing for GER because reflux may be a contributing factor to problematic or difficult asthma [ 7 , 29 ]. Nevertheless, GER treatment might not be effective for severe asthma [ 30 , 31 ], as confirmed by current cases 1 and 2. There is an established evidence that chronic rhinosinusitis is associated with more severe asthma in children [ 32 , 33 , 34 ]. Therefore, examination of upper airways and ad hoc treatment if rhinosinusitis is evident are recommended in children with severe asthma [ 3 , 8 , 35 ]. However, intranasal steroids for rhinitis resulted in a small reduction of asthma risk in school-aged children [ 36 ], and actual placebo-controlled studies on the effect of treatment of rhinosinusitis on asthma control in children are lacking [ 10 , 37 ].

Dysfunctional breathing, including hyperventilation and vocal cord dysfunction, is associated with poorer asthma control in children [ 8 , 10 , 38 , 39 ]. Unfortunately, there is scarce literature on the effect of its treatment on the control of severe asthma in children [ 40 ]. SDB ranging from primary snoring to obstructive sleep apnea syndrome is very common in children [ 41 ], and an increased prevalence of SDB together with increasing asthma severity has been reported [ 42 ]. Interestingly, GER may also be worsened by recurrent episodes of upper airway obstruction associated with SDB, and this may further trigger bronchial obstruction. Asthma guidelines recommend the assessment of SDB through nocturnal polysomnography in poorly controlled asthmatics, particularly if they are also obese [ 5 ]. There are no studies examining whether pediatric asthma improves after SDB has been treated, for example, with nasal steroids, adenotonsillectomy, continuous positive airway pressure or weight reduction if the child is also obese [ 43 ]. The parallel increase in obesity and asthma suggests that the two conditions are linked and that they can aggravate each other [ 44 , 45 ], even though the exact mechanisms that underlie this association remain unclear [ 46 ]. Indeed, other coexisting comorbidities such as SDB or GER may play a confounding role in the development of the interactions between obesity and the airways [ 47 , 48 ]. Obesity is associated with increased markers of inflammation in serum and adipose tissue and yet decreased airway inflammation in obese people with asthma [ 49 ]. Several interventions, including behavioral and weight reduction programs or bariatric surgery, may result in improved asthma control, quality of life and lung function in adult obese asthmatics [ 50 ]. Although reports of adolescent bariatric surgery demonstrate a significant body weight decrease, this approach is not widely available and there are no published reports on its effect on pediatric severe asthma control [ 51 ]. Finally, although it is still unclear whether food allergy is causative or shares a common pathway with difficult asthma, it might explain the loss of asthma control at least in some children and thus be considered as a comorbid condition [ 10 , 16 , 52 ].

In conclusion, establishing the impact of comorbidities on asthma control may be cumbersome, and an ex-juvantibus treatment is sometimes necessary to assess their role. Comorbid conditions can also worsen each other, and symptoms arising from some of them may mimic asthma [ 6 ]. Although the ability to improve pediatric severe asthma by treating comorbidities remains unconfirmed, they should be treated appropriately [ 9 ].

The vast majority of asthmatic children exhibit a mild or at most a moderate disease that can be fully controlled with low-to-medium dose ICS associated or not with other controllers [ 5 , 6 ]. However, a subset of asthmatics remains difficult-to-treat [ 5 , 6 ]. With the advent of biologics, these severe steroid-dependent asthmatics have alternative options for treatment, as steroid-related adverse events are common in severe asthma [ 53 ]. Omalizumab, an anti-IgE monoclonal antibody, is the only biologic therapy recommended in children with moderate-to-severe asthma by the recent guidelines [ 5 , 6 ]. In Italy, this treatment is fully covered by the National Health System. Therefore, there is no influence by any funding on treatment decisions. It was approved by the US (Food and Drug Administration) in 2003 and by the European Union (European Medicines Agency) in 2005 as an add-on treatment for patients aged > 12 years with severe persistent allergic asthma and who have a positive skin test or in-vitro reactivity to a perennial aeroallergen, FEV 1  < 80% predicted, frequent daytime symptoms or nighttime awakenings, and multiple documented severe asthma exacerbations despite daily ICS plus a LABA [ 54 , 55 ]. In 2009, it also received approval in Europe for treating patients aged 6–12 years. Figure  2 illustrates current indications for treatment with omalizumab in children and adolescents with severe asthma.

Indications for omalizumab in children and adolescents with severe asthma

IgE antibodies, Th 2 -derived cytokines and eosinophils play a major role in the development of chronic airway inflammation in asthmatic subjects [ 56 ]. Once released from plasma cells, IgE binds principally to the high-affinity IgE receptor (FcεRI) on mast cells, triggering different effector responses, including the release of mediators leading to allergic inflammatory reactions [ 56 ]. The activation of the allergic cascade by IgE, under constant allergen stimulation, leads to the establishment of chronic allergic inflammation in the airways of asthmatic patients, with IgE being a key element of the vicious circle that maintains it. Cytokines produced during the late phase and subsequent chronic inflammation stage have been directly associated with the induction of airway remodelling, indirectly implicating IgE in the process [ 56 ]. At present, omalizumab is the only commercially available recombinant humanized anti-IgE monoclonal antibody that specifically binds serum free IgE at its CH 3 domain, in the proximity of the binding site for FcεRI, thus preventing IgE from interacting with its receptor on mast cells, basophils, antigen-presenting cells and other inflammatory cells [ 57 ]. The rapid reduction of free IgE levels leads to a downregulation of the FcεRI expression on inflammatory cells and an interruption of the allergic cascade, which results in the reduction of peripheral and bronchial tissue eosinophilia and of levels of granulocyte macrophage colony stimulating factor, interleukin (IL)-2, IL-4, IL-5, and IL-13 [ 58 ]. Moreover, basophils have a relevant role in the initiation and progression of allergic inflammation, suggesting that they may represent a viable therapeutic target. Indeed, in children with severe asthma, it has been reported that omalizumab therapy is associated with a significant reduction in circulating basophil numbers, a finding that is concurrent with improved clinical outcomes [ 59 ]. This finding supports a mechanistic link between IgE levels and circulating basophil populations, and may provide new insights into one mechanism by which omalizumab improves asthma symptoms.

Several clinical controlled and real-life studies of adults with severe, inadequately controlled allergic asthma have demonstrated the efficacy and safety of omalizumab in reducing asthma-related symptoms, corticosteroid use, exacerbation rates, and healthcare resource utilization, and in improving QoL and lung function [ 60 , 61 , 62 , 63 ]. Fewer studies have been published in children. In two double-blind, randomized, placebo-controlled trials (RCTs) of children aged 6 to 12 years with moderate-to-severe allergic asthma, treatment with omalizumab reduced the requirement for ICS and protected against disease exacerbations, but there was little change in asthma symptom scores or spirometry [ 9 , 64 ]. These findings were confirmed and extended in older children [ 65 , 66 , 67 ].

The results of the ICATA study, a multicenter RCT of 419 inner-city children, adolescents and young adults with persistent allergic asthma, showed that, compared to placebo, omalizumab reduces the number of days with asthma symptoms and the proportion of participants with at least one exacerbation by approximately 25% and 19%, respectively ( p  < 0.001), thus reducing the need for asthmatic symptom controllers [ 68 ]. Another multicenter RCT of inner-city children and adolescents showed that the addition of omalizumab to ongoing guidelines-based care before patients return to school reduces fall asthma exacerbations (odds ratio, 0.48), particularly in subjects with a recent exacerbation [ 69 ]. Moreover, in a real-life study of 104 children and adolescents with severe allergic refractory asthma followed over 1 year, treatment with omalizumab resulted in good asthma control in 67% of the cases ( p  < 0.001), while FEV 1 improved by 4.9% ( p  = 0.02) and exacerbation rates and healthcare utilisation decreased approximately by 30% ( p  < 0.001) [ 70 ]. The same authors also showed that, after two years of treatment, exacerbation rate and healthcare utilisation were further decreased by 83% and 100%, respectively, while level of asthma control, steroid use and lung function remained unchanged [ 71 ].

A systematic review of pediatric RCTs pooled the data of 1381 children and adolescents with moderate-to-severe allergic asthma in order to establish the efficacy of omalizumab as an add-on therapy [ 72 ]. During the stable-steroid phase, omalizumab decreased the number of patients with at least one exacerbation (risk ratio, 0.69; p  < 0.001), the mean number of asthma exacerbations per patient (risk ratio, 0.35; p  < 0.001), and the asthma symptom score (mean difference, 0.12; p  = 0.005) when compared to placebo. During the steroid reduction phase, omalizumab further reduced the number of patients with at least one exacerbation (risk ratio, 0.48; p  < 0.001) and the mean number of asthma exacerbations per patient (mean difference, 0.12; p  < 0.05).

Given the cost of omalizumab, many authors have argued for the importance of identifying specific asthma populations who will have significant benefit from it [ 68 , 73 , 74 ]. In the ICATA study, baseline predictors of good response to treatment were sensitization and exposure to cockroach allergen, sensitization to house dust mite allergens, a serum IgE level of more than 100 IU per milliliter, a BMI of 25 or more, and a history of at least one unscheduled medical visit in the previous year [ 68 ].

Several studies have assessed the long-term safety of omalizumab in children and adults. A pooled analysis of 67 RCTs conducted over 2 decades on 4254 children and adults treated with omalizumab showed no association between omalizumab treatment and risk of malignancy [ 75 ]. In an RCT evaluating 225 school-aged children, omalizumab was well tolerated, there were no serious adverse events, and the frequency and types of all adverse events were similar to the placebo group [ 9 ]. These results have been further confirmed by a recent systematic review of RCTs that concluded that treatment with omalizumab does not result in increased risk of malignancy or hypersensitivity reactions [ 72 ].

While the rationale for long-term treatment with omalizumab is supported by pharmacokinetic-pharmacodynamic models [ 76 ], the duration of treatment is still under discussion. Results from published studies suggest that omalizumab should be continued for > 1 year [ 77 , 78 ]. In a retrospective study of adults and children with uncontrolled severe asthma treated with omalizumab, the response to treatment was ‘excellent’ in 52.5% of patients, particularly in the subgroup of children aged 6 to 11 years [ 77 ]. After the discontinuation of treatment, loss of asthma control was documented in 69.2% of the patients who had received omalizumab for < 1 year, 59.1% of the subjects treated for 1–2 years, and 46.1% of the cases treated for > 2 years. Time to loss of control was shorter in younger children and longer in patients with an ‘excellent’ response compared with patients with a ‘good’ response. No early loss of control (within 6 months) was observed among patients with > 3.5 years of continuous treatment with omalizumab. Finally, 20% of patients in whom omalizumab was re-prescribed because of loss of control did not respond to the treatment anymore [ 77 ]. Despite these encouraging findings, the impact of omalizumab on the natural history of severe asthma in children deserves to be further investigated by long-term studies that will also define the criteria and timing for discontinuing the treatment.

It is well known that asthma pharmacotherapy is effective in controlling symptoms and bronchial inflammation, but cannot affect the underlying immune response, thus leading to the possibility of symptom reappearance after its discontinuation [ 79 ]. In this scenario, allergen-specific immunotherapy (AIT) has been proposed as the only therapeutic method that can modulate the underlying immune pathophysiology in allergic asthma [ 80 ].

AIT is currently indicated in children and adults with mild-moderate allergic asthma that is completely or partially controlled by pharmacotherapy and with the evidence of a clear relationship between symptoms and exposure to a specific allergen [ 81 , 82 , 83 , 84 ]. However, according to recent guidelines, the efficacy of AIT in asthmatic subjects is limited, and its potential benefits must be weighed against the risk of side effects and the inconvenience and costs of the prolonged therapy [ 5 ]. Moreover, severe or uncontrolled asthma (regardless of its severity) is a major independent risk factor for non-fatal or even fatal adverse reactions, thus representing a contraindication for AIT [ 85 , 86 , 87 ]. Finally, children with severe asthma are often sensitized to multiple allergens, thus making AIT prescription even more complicated [ 88 ].

In subjects with uncontrolled and/or severe allergic asthma, a combination of omalizumab and AIT has been proposed [ 88 ]. Surprisingly, only a few studies have addressed this issue [ 89 , 90 , 91 , 92 ]. However, pre-treatment with omalizumab seems to improve the efficacy and tolerability of subcutaneous AIT in children and adults with severe allergic asthma both during omalizumab treatment and after its discontinuation [ 89 , 91 , 92 ]. Omalizumab has also been successfully used as a supplementary treatment to AIT in order to improve asthma control in children ≥6 years with severe persistent allergic asthma [ 90 ]. Given the scarcity of studies on AIT plus omalizumab in children with severe allergic asthma, further research is warranted to assess risks and benefits of the combined treatment.

Children with severe asthma require a detailed and individualized approach including re-assessment for differential diagnoses, comorbidities and contributory factors, environmental triggers, lung function and inflammation, adherence and response to therapy, and QoL. Treatment of pediatric severe asthma still relies on the maximal optimal use of corticosteroids, bronchodilators and other controllers recommended for moderate-to-severe disease. However, the management of asthma is becoming much more patient-specific, as more and more is learned about the biology behind the development and progression of asthma.

In the current paper, we described the characteristics of four children with severe asthma in whom omalizumab was prescribed. A review of the relevant literature on the topic was also performed. Finally, we provided an algorithm for the diagnosis of difficult-to-treat and severe asthma in children and adolescents, based on the evidence from the literature review. As all algorithms, it is not meant to replace clinical judgment, but it should drive physicians to adopt a systematic approach towards difficult and severe asthma and provide a useful guide to the clinician.

The addition of omalizumab, the first targeted biological treatment approved for asthma, has led to renewed optimism of outcome improvements in patients with allergic severe asthma. As severe asthma is a heterogeneous condition consisting of different phenotypes, the future of asthma management will likely involve phenotypic and potentially even genotypic characterization in selected cases in order to determine appropriate therapy and thus to provide the highest possible benefit, especially if specific responder phenotypes can be identified and selected for this highly specific treatment.

Abbreviations

Anti-immunoglobulin E

Body mass index

IgE receptor

Forced expiratory flow between 25% and 75%

Forced expiratory volume in the first second

Gastroesophageal reflux

Inhaled corticosteroids

Intensive care unit

Interleukin

Long-acting β 2 -agonist

Oral leukotriene receptor antagonist

Quality of life

Randomized controlled trials

Short-acting β 2 -agonists

Sleep-disordered breathing

O'Byrne PM, Pedersen S, Schatz M, Thoren A, Ekholm E, Carlsson LG, et al. The poorly explored impact of uncontrolled asthma. Chest. 2013;143:511–3.

Article   PubMed   Google Scholar  

National Asthma Education and Prevention Program. Expert panel report 3 (EPR-3): guidelines for the diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120:S94–8.

Article   Google Scholar  

Hedlin G. Management of severe asthma in childhood-state of the art and novel perspectives. Pediatr Allergy Immunol. 2014;25:111–21.

Konradsen JR, Nordlund B, Lidegran M, Pedroletti C, Grönlund H, van Hage M, et al. Problematic severe asthma: a proposed approach to identifying children who are severely resistant to therapy. Pediatr Allergy Immunol. 2011;22:9–18.

Global Initiative for Asthma Report. Global strategy for asthma management and prevention (updated 2016). https://www.ginasthma.org . Accessed 07 June 2017.

Chung KF, Wenzel SE, Brozek JL, Bush A, Castro M, Sterk PJ, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J. 2014;43:343–53.

Article   CAS   PubMed   Google Scholar  

Vandenplas Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the north American Society for Pediatric Gastroenterology, Hepatology, and nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr. 2009;49:498–507.

Lødrup Carlsen KC, Hedlin G, Bush A, Wennergren G, de Benedictis FM, De Jongste JC, et al. Assessment of problematic severe asthma in children. Eur Respir J. 2011;37:432–40.

Milgrom H, Berger W, Nayak A, Gupta N, Pollard S, McAlary M, et al. Treatment of childhood asthma with anti-immunoglobulin E antibody (omalizumab). Pediatrics. 2001;108:E36.

Bush A, Saglani S. Management of severe asthma in children. Lancet. 2010;376:814–5.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Lang A, Mowinckel P, Sachs-Olsen C, Riiser A, Lunde J, Carlsen KH, et al. Asthma severity in childhood, untangling clinical phenotypes. Pediatr Allergy Immunol. 2010;21:945–53.

Nordlund B, Konradsen JR, Pedroletti C, Kull I, Hedlin G. The clinical benefit of evaluating health-related quality-of-life in children with problematic severe asthma. Acta Paediatr. 2011;100:1454–60.

Dean BB, Calimlim BC, Sacco P, Aguilar D, Maykut R, Tinkelman D. Uncontrolled asthma: assessing quality of life and productivity of children and their caregivers using a cross-sectional internet-based survey. Health Qual Life Outcomes. 2010;8:6.

Juniper EF, Guyatt GH, Feeny DH, Ferrie PJ, Griffith LE, Townsend M. Measuring quality of life in children with asthma. Qual Life Res. 1996;5:35–46.

British Thoracic Society. Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma, 2014. https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline . Accessed 13 Apr 2016.

Montella S, Baraldi E, Cazzato S, Aralla R, Berardi M, Brunetti LM, et al. Severe asthma features in children: a case-control online survey. Ital J Pediatr. 2016;42:9.

Article   PubMed   PubMed Central   Google Scholar  

Fitzpatrick AM, Gaston BM, Erzurum SC, Teague WG, National Institutes of Health/National Heart, Lung, and Blood Institute Severe Asthma Research Program. Features of severe asthma in school-age children: Atopy and increased exhaled nitric oxide. J Allergy Clin Immunol. 2006;118:1218–25.

Simon MR, Chinchilli VM, Phillips BR, Sorkness CA, Lemanske RF Jr, Szefler SJ, et al. Forced expiratory flow between 25% and 75% of vital capacity and FEV1/forced vital capacity ratio in relation to clinical and physiological parameters in asthmatic children with normal FEV1 values. J Allergy Clin Immunol. 2010;126:527–34.

Hedlin G, Bush A, Lødrup Carlsen K, Wennergren G, De Benedictis FM, Melén E, et al. Problematic severe asthma in children, not one problem but many: a GA2LEN initiative. Eur Respir J. 2010;36:196–201.

Fitzpatrick AM, Teague WG. Severe asthma in children: insights from the National Heart, Lung, and Blood Institute's severe asthma research program. Pediatr Allergy Immunol Pulmonol. 2010;23:131–8.

Konradsen JR, Caffrey Osvald E, Hedlin G. Update on the current methods for the diagnosis and treatment of severe childhood asthma. Expert Rev Respir Med. 2015;9:769–77.

Lang AM, Konradsen J, Carlsen KH, Sachs-Olsen C, Mowinckel P, Hedlin G, et al. Identifying problematic severe asthma in the individual child—does lung function matter? Acta Paediatr. 2010;99:404–10.

Rao DR, Gaffin JM, Baxi SN, Sheehan WJ, Hoffman EB, Phipatanakul WJ. The utility of forced expiratory flow between 25% and 75% of vital capacity in predicting childhood asthma morbidity and severity. Asthma. 2012;49:586–92.

Eid N, Yandell B, Howell L, Eddy M, Sheikh S. Can peak expiratory flow predict airflow obstruction in children with asthma? Pediatrics. 2000;105:354–8.

Cicutto LC, Chapman KR, Chamberlain D, Downey GP. Difficult asthma: consider all of the possibilities. Can Respir J. 2000;7:415–8.

Wener RR, Bel EH. Severe refractory asthma: an update. Eur Respir Rev. 2013;22:227–35.

Bracken M, Fleming L, Hall P, et al. The importance of nurse-led home visits in the assessment of children with problematic asthma. Arch Dis Child. 2009;94:780–4.

De Groot EP, Kreggemeijer WJ, Brand PL. Getting the basics right resolves most cases of uncontrolled and problematic asthma. Acta Paediatr. 2015;104:916–21.

Grimaldi-Bensouda L, Zureik M, Aubier M, Humbert M, Levy J, Benichou J, et al. Does omalizumab make a difference to the real-life treatment of asthma exacerbations? Results from a large cohort of patients with severe uncontrolled asthma. Chest. 2013;143:398–405.

American Lung Association Asthma Clinical Research Centers, Mastronarde JG, Anthonisen NR, Castro M, Holbrook JT, Leone FT, et al. Efficacy of esomeprazole for treatment of poorly controlled asthma. N Engl J Med. 2009;360:1487–9.

Article   PubMed Central   Google Scholar  

Writing Committee for the American Lung Association Asthma Clinical Research Centers, Holbrook JT, Wise RA, Gold BD, Blake K, Brown ED, et al. Lansoprazole for children with poorly controlled asthma: a randomized controlled trial. JAMA 2012;307:373-381.

Wright AL, Holberg CJ, Martinez FD, Halonen M, Morgan W, Taussig LM. Epidemiology of physician-diagnosed allergic rhinitis in childhood. Pediatrics. 1994;94:895–901.

CAS   PubMed   Google Scholar  

De Groot EP, Nijkamp A, Duiverman EJ, Brand PL. Allergic rhinitis is associated with poor asthma control in children with asthma. Thorax. 2012;67:582–7.

Rotiroti G, Roberts G, Scadding GK. Rhinitis in children: common clinical presentations and differential diagnoses. Pediatr Allergy Immunol. 2015;26:103–10.

Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, et al. Allergic rhinitis and its impact on asthma (ARIA). 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy. 2008;63:S8–160.

Deliu M, Belgrave D, Simpson A, Murray CS, Kerry G, Custovic A. Impact of rhinitis on asthma severity in school-age children. Allergy. 2014;69:1515–21.

Brozek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, et al. Allergic rhinitis and its impact on asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126:466–76.

Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. 2007;120:855–64.

De Groot EP, Duiverman EJ, Brand PL. Dysfunctional breathing in children with asthma: a rare but relevant comorbidity. Eur Respir J. 2013;41:1068–73.

Barker NJ, Jones M, O'Connell NE, Everard ML. Breathing exercises for dysfunctional breathing/hyperventilation syndrome in children. Cochrane Database Syst Rev. 2013;12:CD010376.

Google Scholar  

Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome, American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109:704–12.

Goldstein NA, Aronin C, Kantrowitz B, Hershcopf R, Fishkin S, Lee H, Weaver DE, et al. The prevalence of sleep-disordered breathing in children with asthma and its behavioral effects. Pediatr Pulmonol. 2015;50:1128–36.

Ross KR, Storfer-Isser A, Hart MA, Kibler AM, Rueschman M, Rosen CL, et al. Sleep-disordered breathing is associated with asthma severity in children. J Pediatr. 2012;160:736–42.

Santamaria F, Montella S, Greco L, Valerio G, Franzese A, Maniscalco M, et al. Obesity duration is associated to pulmonary function impairment in obese subjects. Obesity (Silver Spring). 2011;19:1623–8.

Sivapalan P, Diamant Z, Ulrik CS. Obesity and asthma: current knowledge and future needs. Curr Opin Pulm Med. 2015;21:80–5.

Rasmussen F, Hancox RJ. Mechanisms of obesity in asthma. Curr Opin Allergy Clin Immunol. 2014;14:35–43.

Santamaria F, Montella S, Pietrobelli A. Obesity and pulmonary disease: unanswered questions. Obes Rev. 2012;13:822–33.

Lang JE, Hossain J, Holbrook JT, Teague WG, Gold BD, Wise RA, et al. Gastro-oesophageal reflux and worse asthma control in obese children: a case of symptom misattribution? Thorax. 2016;71:238–46.

Santamaria F, Montella S, De Stefano S, Sperlì F, Barbarano F, Valerio G. Relationship between exhaled nitric oxide and body mass index in children and adolescents. J Allergy Clin Immunol. 2005;116:1163–4.

Van Huisstede A, Rudolphus A, Castro Cabezas M, Biter LU, van de Geijn GJ, Taube C, et al. Effect of bariatric surgery on asthma control, lung function and bronchial and systemic inflammation in morbidly obese subjects with asthma. Thorax. 2015;70:659–67.

Katzmarzyk PT, Bouchard C. Where is the beef? Waist circumference is more highly correlated with BMI and total body fat than with abdominal visceral fat in children. Int J Obes. 2014;38:753–4.

Article   CAS   Google Scholar  

De Groot EP, Duiverman EJ, Brand PL. Comorbidities of asthma during childhood: possibly important, yet poorly studied. Eur Respir J. 2010;36:671–8.

Sweeney J, Patterson CC, Menzies-Gow A, Niven RM, Mansur AH, Bucknall C, et al. Comorbidity in severe asthma requiring systemic corticosteroid therapy: cross-sectional data from the optimum patient care research database and the British thoracic difficult asthma registry. Thorax. 2016; https://doi.org/10.1136/thoraxjnl-2015-207630 .

Federal Drug Administration Advisory for Omalizumab. Available at: https://wayback.archive-it.org/7993/20170111075347/ . http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/TherapeuticBiologicApplications/default.htm . Accessed 4 Feb 2018.

European Medicines Agency: assessment report for Xolair. Available at: http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medicines/000606/human_med_001162.jsp&mid=WC0b01ac058001d124 . Accessed 7 June 2017.

Chung KF. Targeting the interleukin pathway in the treatment of asthma. Lancet. 2015;386:1086–96.

Jensen RK, Plum M, Tjerrild L, Jakob T, Spillner E, Andersen GR. Structure of the omalizumab Fab. Acta Crystallogr F Struct Biol Commun. 2015;71:419–26.

Holgate S, Smith N, Massanari M, Jimenez P. Effects of omalizumab on markers of inflammation in patients with allergic asthma. Allergy. 2009;64:1728–36.

Hill DA, Siracusa MC, Ruymann KR, Tait Wojno ED, Artis D, Spergel JM. Omalizumab therapy is associated with reduced circulating basophil populations in asthmatic children. Allergy. 2014;69:674–7.

Humbert M, Beasley R, Ayres J, Slavin R, Hébert J, Bousquet J, et al. Benefits of omalizumab as add-on therapy in patients with severe persistent asthma who are inadequately controlled despite best available therapy (GINA 2002 step 4 treatment): INNOVATE. Allergy. 2005;60:309–16.

Normansell R, Walker S, Milan SJ, Walters EH, Nair P. Omalizumab for asthma in adults and children. Cochrane Database Syst Rev. 2014;1:CD003559.

Lai T, Wang S, Xu Z, Zhang C, Zhao Y, Hu Y, Cao C, et al. Long-term efficacy and safety of omalizumab in patients with persistent uncontrolled allergic asthma: a systematic review and meta-analysis. Sci Rep. 2015;5:8191.

Abraham I, Alhossan A, Lee CS, Kutbi H, MacDonald K. “real-life” effectiveness studies of omalizumab in adult patients with severe allergic asthma: systematic review. Allergy. 2015; https://doi.org/10.1111/all.12815 .

Lanier B, Bridges T, Kulus M, Taylor AF, Berhane I, Vidaurre CF. Omalizumab for the treatment of exacerbations in children with inadequately controlled allergic (IgE-mediated) asthma. J Allergy Clin Immunol. 2009;124:1210–6.

Solèr M, Matz J, Townley R, Buhl R, O'Brien J, Fox H, et al. The anti-IgE antibody omalizumab reduces exacerbations and steroid requirement in allergic asthmatics. Eur Respir J. 2001;18:254–61.

Holgate ST. Cytokine and anti-cytokine therapy for the treatment of asthma and allergic disease. Cytokine. 2004;28:152–7.

Odajima H, Ebisawa M, Nagakura T, Fujisawa T, Akasawa A, Ito K, et al. Omalizumab in Japanese children with severe allergic asthma uncontrolled with standard therapy. Allergol Int. 2015;64:364–70.

Busse WW, Morgan WJ, Gergen PJ, Mitchell HE, Gern JE, Liu AH, et al. Randomized trial of omalizumab (anti-IgE) for asthma in inner-city children. N Engl J Med. 2011;364:1005–15.

Teach SJ, Gill MA, Togias A, Sorkness CA, Arbes SJ Jr, Calatroni A, et al. Preseasonal treatment with either omalizumab or an inhaled corticosteroid boost to prevent fall asthma exacerbations. J Allergy Clin Immunol. 2015;136:1476–85.

Deschildre A, Marguet C, Salleron J, Pin I, Rittié JL, Derelle J, et al. Add-on omalizumab in children with severe allergic asthma: a 1-year real life survey. Eur Respir J. 2013;42:1224–33.

Deschildre A, Marguet C, Langlois C, Pin I, Rittié JL, Derelle J, et al. Real-life long-term omalizumab therapy in children with severe allergic asthma. Eur Respir J. 2015;46:856–9.

Rodrigo GJ, Neffen H. Systematic review on the use of omalizumab for the treatment of asthmatic children and adolescents. Pediatr Allergy Immunol. 2015;26:551–6.

Oba Y, Salzman GA. Cost-effectiveness analysis of omalizumab in adults and adolescents with moderate-to-severe allergic asthma. J Allergy Clin Immunol. 2004;114:265–9.

Campbell JD, Spackman DE, Sullivan SD. The costs and consequences of omalizumab in uncontrolled asthma from a USA payer perspective. Allergy. 2010;65:1141–8.

Busse W, Buhl R, Fernandez Vidaurre C, Blogg M, Zhu J, Eisner MD, et al. Omalizumab and the risk of malignancy: results from a pooled analysis. J Allergy Clin Immunol. 2012;129:983–9.

Lowe PJ, Renard D. Omalizumab decreases IgE production in patients with allergic (IgE-mediated) asthma; PKPD analysis of a biomarker, total IgE. Br J Clin Pharmacol. 2011;72:306–10.

Molimard M, Mala L, Bourdeix I, Le Gros V. Observational study in severe asthmatic patients after discontinuation of omalizumab for good asthma control. Respir Med. 2014;108:571–6.

Busse WW, Trzaskoma B, Omachi TA, Canvin J, Rosen K, Chipps BE, et al. Evaluating Xolair persistency of response after long-term therapy (XPORT). Am J Respir Crit Care Med. 2014;189:A6576.

Guilbert TW, Morgan WJ, Zeiger RS, Mauger DT, Boehmer SJ, Szefler SJ, et al. Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med. 2006;354:1985–97.

Akdis CA. Therapies for allergic inflammation: refining strategies to induce tolerance. Nat Med. 2012;18:736–49.

National Heart, Lung, and Blood Institute. Expert panel report 3: Guidelines for the diagnosis and management of asthma—full report 2007. Available at: https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf . Accessed 4 Feb 2018.

Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunolgy. Allergen immunotherapy: a practice parameter second update. J Allergy Clin Immunol. 2007;120:S25–85.

Zuberbier T, Bachert C, Bousquet PJ, Passalacqua G, Walter Canonica G, Merk H, et al. GA(2) LEN/EAACI pocket guide for allergen-specific immunotherapy for allergic rhinitis and asthma. Allergy. 2010;65:1525–30.

Pajno GB, Bernardini R, Peroni D, Arasi S, Martelli A, Landi M, et al. Clinical practice recommendations for allergen-specific immunotherapy in children: the Italian consensus report. Ital J Pediatr. 2017;43:13.

Pitsios C, Demoly P, Bilo MB, Gerth van Wijk R, Pfaar O, Sturm GJ, et al. Clinical contraindications to allergen immunotherapy: an EAACI position paper. Allergy. 2015;70:897–909.

Tsabouri S, Mavroudi A, Feketea G, Guibas GV. Subcutaneous and sublingual immunotherapy in allergic asthma in children. Front Pediatr. 2017;5:82.

Jutel M, Agache I, Bonini S, Burks AW, Calderon M, Canonica W, et al. International consensus on allergy immunotherapy. J Allergy Clin Immunol. 2015;136:556–68.

Hedlin G, van Hage M. The role of immunotherapy in the management of childhood asthma. Ther Adv Respir Dis. 2012;6:137–46.

Lambert N, Guiddir T, Amat F, Just J. Pre-treatment by omalizumab allows allergen immunotherapy in children and young adults with severe allergic asthma. Pediatr Allergy Immunol. 2014;25:829–32.

Kopp MV, Hamelmann E, Zielen S, Kamin W, Bergmann K-C, Sieder C. Combination of omalizumab and specific immunotherapy is superior to immunotherapy in patients with seasonal allergic rhinoconjunctivitis and co-morbid seasonal allergic asthma. Clin Exp Allergy. 2009;39:271–9.

Massanari M, Nelson H, Casale T, Busse W, Kianifard F, Geba GP. Effect of pretreatment with omalizumab on the tolerability of specific immunotherapy in allergic asthma. J Allergy Clin Immunol. 2010;125:383–9.

Stelmach I, Kaczmarek-Woźniak J, Majak P, Olszowiec-Chlebna M, Jerzynska J. Efficacy and safety of high-doses sublingual immunotherapy in ultra-rush scheme in children allergic to grass pollen. Clin Exp Allergy. 2009;39:401–8.

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The authors gratefully thank Dr. Marco Maglione for his contribution in the clinical assessment of the described cases. Medical writing assistance was provided by Stephen Walters on behalf of City Hills Proofreading.

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Mirra, V., Montella, S. & Santamaria, F. Pediatric severe asthma: a case series report and perspectives on anti-IgE treatment. BMC Pediatr 18 , 73 (2018). https://doi.org/10.1186/s12887-018-1019-9

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Case Study: Management of a Middle-Aged Patient with Multiple Comorbidities

—a 52-year-old woman reports a 2-week history of dyspnea and wheezing, and presents with mild respiratory distress with audible wheezing. what should next steps be to provide optimal care.

By Shawn E. Kuhmann, PhD Reviewed by Joe G. Zein, MD

Societies are now caring for a higher number of older individuals with multiple chronic diseases, including asthma. 1  In addition to age-related comorbidities, older asthma patients are at a particular risk for severe asthma due to lower lung function compared with younger adults with asthma. 2  Consistent with this,  cluster analyses based on the National Heart, Lung, and Blood Institute (NHLBI)-Severe Asthma Research Program (SARP) cohort  identified a unique phenotype of older asthmatics with severe symptoms and reduced lung function. 3  Similarly, older asthmatics have been observed to have increased asthma treatment failures and to respond less well to inhaled corticosteroids (ICS). 4

Case presentation and patient history

Dr. L is a 52-year-old college professor with no significant medical history except for obesity (body mass index of 36). She reports occasional heartburn, which is self-medicated with over-the-counter antacids.

She presented in June to the emergency room (ED) reporting a 2-week history of dyspnea and wheezing. Upon arrival, she was in mild respiratory distress with audible wheezing. Yet, she was able to speak in full sentences and had a room air oxygen saturation of 92%. The physical exam was significant for tachycardia (heart rate of 110 bpm), tachypnea, and bilateral inspiratory and expiratory wheezing. There was no accessory muscle use. The peak expiratory flow (PEF) rate was only 250 L/min.

In the ED, she received nebulized albuterol and a corticosteroid injection. Albuterol resulted in significant improvement in her symptoms and resolution of the respiratory distress. She was discharged home with a 5-day prednisone taper and referred to the asthma center for further management.

In the asthma clinic, she continued to have mild expiratory wheezing. Upon additional questioning, she reported that she entered menopause about a year prior and was recently started on hormone replacement therapy (HRT) by her primary care physician for hot flashes and vaginal dryness. Since then, she started noticing more respiratory symptoms occurring mostly at night, which she linked to menopause. Similarly, she noticed more heartburn symptoms.

She did not report any previous history of childhood asthma, but her 17-year-old daughter is being treated with inhaled fluticasone and oral contraceptives for severe premenstrual asthma. She did not report having any food or environmental allergies or any pets at home. She also did not report any significant occupational or smoking history.

An office spirometry revealed a baseline forced expiratory volume in 1 second (FEV1) of 1.8 L (61%), which improved to 2.76 L (94%) after bronchodilator use. The percent FEV1 change was 53%, meeting the American Thoracic Society criteria for positive bronchodilator response. The measured exhaled nitric oxide was 16 ppb.

Dr. L is a middle-aged obese nonatopic woman with a lung function test showing airway obstruction and a positive bronchodilator response. Such clinical characteristics suggest late-onset asthma, and meet "cluster 3" phenotypic criteria according to the NHLBI-SARP cluster phenotypes, which include: 3  

• Moderate reductions in FEV1
• Mostly older obese women
• Increased medication requirements, including high-dose ICS
• Frequent oral corticosteroid use
• High healthcare utilization

It is likely that her asthma was triggered or exacerbated by HRT and gastroesophageal reflux disease (GERD).

Treatment options

According to  Global Initiative for Asthma (GINA) guidelines , initial therapy includes low-dose ICS and an as-needed short-acting beta2-agonist (SABA) such as albuterol. 5

Dr. L was advised that while high-dose ICS can place asthma patients at risk for osteopenia and cataracts, both asthma therapies are relatively safe. 5  She was also advised that a spacer is recommended with hydrofluoroalkane inhalers and that she needs to rinse her mouth after each ICS use. 5  She received asthma education and was provided an asthma action plan to help her manage her asthma. A follow-up appointment is set for 4 weeks in order to assess the efficacy of the treatment regimen and the need for stepping up therapy (ie, adding a long-acting beta2-agonist [LABA] to the ICS). 5

Additionally, GERD therapy is recommended to control heartburn and reflux symptoms, and she was advised to stop and avoid HRT. 5  A weight reduction plan is put into place; advice is given about the management of exercise-induced bronchoconstriction. 5

Treatment outcome

Dr. L returns 4 weeks later to the chest clinic for follow-up. She reports partial improvement in her dyspnea and exercise intolerance. However, she continues to report cough, wheezing, and dyspnea on exertion more than twice a week requiring rescue albuterol. She has been compliant with therapy and has been using her inhalers with a spacer routinely. She also reports losing 3 lb since her last visit and says that her heartburn has been controlled with therapy. Her peak flow measurement improved from an average of 250 to 350 L/min. A repeated office spirometry demonstrated a baseline percent predicted FEV1 of 72%. Since her asthma was not fully controlled, a LABA was added to her treatment regimen. She was advised to continue measuring peak flow and to return in 1 to 3 months to assess asthma control and response to therapy.

Although there are a wide variety of asthma phenotypes, treatment is uniformly applied to all patients in a stepped-care approach. 5-8  However, the morbidities and costs associated with the overtreatment and/or undertreatment of this common disease provide a rationale for precision medicine, particularly for older asthmatics (age 30 and older), who comprise a heterogeneous group of patients.

Aging and menopause Older asthmatics tend to have multiple comorbidities, such as GERD, rhinosinusitis, and obstructive sleep apnea, which may contribute to more severe asthma. 5  In addition, data suggest that older asthma patients have a greater risk of treatment failure, particularly for ICS, compared with younger adult patients; this finding was observed in a recent study based on data from ten Asthma Clinical Research Network trials. 4

Importantly, lung aging occurs over the course of life. 2  In a cross-sectional study of patients enrolled in NHLBI-SARP, the risk of severe asthma increased by 7% each year until age 45. 2  Asthma was more likely to be severe in older adult patients (older than age 45 versus age 18-45) independent of asthma duration or age-related comorbidities. 2  After age 45, the risk of severe asthma continued to increase with age in men but not women. 2  These data, along with other reports, suggest that asthma may improve with menopausal transition, when sex hormones wane. 9,10

Overview of comorbidities and factors affecting asthma relevant to this case

HRT Postmenopausal HRT may be disadvantageous and worsen asthma severity in menopausal women. 11  HRT was also shown to be associated with an increased risk of asthma diagnoses in postmenopausal women in the prospective Nurses' Health Study and in the prospective  French E3N study ; there was also an increased prevalence of asthma in perimenopausal women using HRT in the population-based, cross-sectional  Respiratory Health in Northern Europe study . 9,12,13  This finding regarding HRT emphasizes the importance of reviewing the medications asthma patients take.

GERD The most common digestive system disorder in the United States, GERD affects nearly one third of Americans and has been reported in 40% to 80% of asthma patients. 14  GERD may cause bronchoconstriction through microaspiration into airways or through effects on the vagus nerve. 14  Asthma may also favor the development of GERD. 14  A meta-analysis on the effects of proton pump inhibitor (PPI) therapy on asthma in adults found that PPI therapy yielded a small but significant improvement in morning PEF rate, with a larger benefit in morning PEF rate in patients with GERD than in those without. 14  However, other objective and subjective outcomes were not significantly altered by PPI treatment. 14  The authors concluded that the benefit from GERD treatment is unlikely to be clinically significant and there is not enough evidence to support the use of PPIs to treat asthma in adults. 14

Obesity Asthma is more severe in obese compared with nonoverweight patients. 15  In the  National Asthma Survey , obese respondents more often reported symptoms all of the time, missed more work days, and were more likely to use SABA and ICS treatments. 15  When classified according to the GINA guidelines, obese respondents were also more likely to use controller medications, less likely to be in remission, and more likely to have persistent and/or severe persistent asthma. 15

Asthma is also more difficult to control in obesity. 16,17  In a  post-hoc study of four placebo-controlled trials , the effect of an ICS on the number of asthma control days decreased with increasing body mass index. 17  Similarly, in  another pooled analysis , fewer obese individuals achieved asthma control with an ICS + LABA or an ICS alone compared with nonobese patients. 16

Importantly, the Global Initiative for Asthma guidelines recommend including a weight reduction program in the treatment of obese patients with asthma. 5  A randomized trial studying the effects of weight loss by dietary intervention, exercise intervention, or both on clinical asthma outcomes in overweight and obese men and women found that a 5% to 10% weight loss improved measures of lung function, asthma control, and quality of life. 18  Weight loss greater than 10% further improved lung function, but not asthma control or quality of life. 18

The treatment of older asthma patients may be complicated by the presence of comorbidities, such as GERD and obesity, and by the use of HRT in postmenopausal women. Addressing all of these factors in a personalized, precision medicine approach is essential to providing optimal care to older asthma patients and ensuring the best outcomes.

Published: April 16, 2018

• 1. Centers for Disease Control and Prevention. The State of Aging and Health in America 2013.
• 2. Zein JG, Dweik RA, Comhair SA, et al; Severe Asthma Research Program. Asthma is more severe in older adults. PLoS One . 2015;10:e0133490.
• 3. Moore WC, Meyers DA, Wenzel SE, et al; National Heart, Lung, and Blood Institute's Severe Asthma Research Program. Identification of asthma phenotypes using cluster analysis in the Severe Asthma Research Program. Am J Respir Crit Care Med . 2010;18:315-323.
• 4. Dunn RM, Lehman E, Chinchilli VM, et al; NHLBI Asthma Clinical Research Network. Impact of age and sex on response to asthma therapy. Am J Respir Crit Care Med . 2015;192:551-558.
• 5. Global Initiative for Asthma. Pocket Guide for Asthma Management and Prevention, 2015.
• 6. Marozkina NV, Wang XQ, Stsiapura V, et al. Phenotype of asthmatics with increased airway S-nitrosoglutathione reductase activity. Eur Respir J . 2015;45:87-97.
• 7. Holguin F, Bleecker ER, Busse WW, et al. Obesity and asthma: an association modified by age of asthma onset. J Allergy Clin Immunol . 2011;127:1486-1493.e2.
• 8. Wenzel SE. Asthma: defining of the persistent adult phenotypes. Lancet . 2006;368:804-813.
• 9. Troisi RJ, Speizer FE, Willett WC, et al. Menopause, postmenopausal estrogen preparations, and the risk of adult-onset asthma. A prospective cohort study. Am J Respir Crit Care Med . 1995;152:1183-1188.
• 10. O'Connor KA, Ferrell RJ, Brindle E, et al. Total and unopposed estrogen exposure across stages of the transition to menopause. Cancer Epidemiol Biomarkers Prev . 2009;18:828-836.
• 11. Bønnelykke K, Raaschou-Nielsen O, Bisgaard H, et al. Postmenopausal hormone replacement therapy is associated with increased risk of asthma hospitalization. Eur Respir J . 2011;38(suppl 55):P4111.
• 12. Romieu I, Fabre A, Fournier A, et al. Postmenopausal hormone therapy and asthma onset in the E3N cohort. Thorax . 2010;65:292-297.
• 13. Gómez Real F, Svanes C, Björnsson EH, et al. Hormone replacement therapy, body mass index and asthma in perimenopausal women: a cross sectional survey. Thorax . 2006;61:34-40.
• 14. Chan WW, Chiou E, Obstein KL, et al. The efficacy of proton pump inhibitors for the treatment of asthma in adults: a meta-analysis. Arch Intern Med . 2011;171:620-629.
• 15. Taylor B, Mannino D, Brown C, et al. Body mass index and asthma severity in the National Asthma Survey. Thorax . 2008;63:14-20.
• 16. Boulet LP, Franssen E. Influence of obesity on response to fluticasone with or without salmeterol in moderate asthma. Respir Med . 2007;101:2240-2247.
• 17. Peters-Golden M, Swern A, Bird SS, et al. Influence of body mass index on the response to asthma controller agents. Eur Respir J . 2006;27:495-503.
• 18. Scott HA, Gibson PG, Garg ML, et al. Dietary restriction and exercise improve airway inflammation and clinical outcomes in overweight and obese asthma: a randomized trial. Clin Exp Allergy . 2013;43:36-49.

More On This Topic

Treatable traits and future exacerbation risk in severe asthma, baker’s asthma, the long-term trajectory of mild asthma, age, gender, & systemic corticosteroid comorbidities, ask the expert: william busse, md, challenges the current definition of the atopic march, considering the curveballs in asthma treatment, do mucus plugs play a bigger role in chronic severe asthma than previously thought, an emerging subtype of copd is associated with early respiratory disease.

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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.

• Mukherjee M ,
• Stoddart A ,
• ↵ Asthma UK. Asthma facts and statistics. https://www.asthma.org.uk/about/media/facts-and-statistics/ .
• Scabini S ,
• Mornese Pinna S ,
• Di Perri G ,
• De Rosa FG ,
• Williamson E. ,
• Walker AJ ,
• Bhaskaran KJ ,
• ↵ Public Health England. Guidance on social distancing for everyone in the UK [Withdrawn]. 2020. https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults .
• Shaker MS ,
• Oppenheimer J ,
• Grayson M ,
• China Medical Treatment Expert Group for Covid-19
• Docherty AB ,
• Harrison EM ,
• Greenhalgh T ,
• Pinnock H ,
• Campbell S ,
• ↵ Scottish Intercollegiate Guidelines Network & British Thoracic Society. Sign 158 British guideline on the management of asthma. 2019. https://www.sign.ac.uk/sign-158-british-guideline-on-the-management-of-asthma .
• ↵ Primary Care Respiratory Society. PCRS Pragmatic Guidance: Diagnosing and managing asthma attacks and people with COPD presenting in crisis during the UK Covid 19 epidemic. 2020. https://www.pcrs-uk.org/sites/pcrs-uk.org/files/resources/COVID19/PCRS-Covid-19-Pragmatic-Guidance-v2-02-April-2020.pdf .
• Rapoport AB
• Royal College of Physicians
• ↵ Centre for Evidence-Based Medicine. Question: Should the Roth score be used in the remote assessment of patients with possible COVID-19? Answer: No. 2020. https://www.cebm.net/covid-19/roth-score-not-recommended-to-assess-breathlessness-over-the-phone/ .
• Goldstein BA ,
• ↵ Public Health England. Guidance: COVID-19 personal protective equipment (PPE). 2020. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe .
• ↵ British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/ .
• Pauwels RA ,
• Pedersen S ,
• START Investigators Group
• Bestall JB ,
• Lasserson TJ ,
• Spooner C ,
• Ducharme FM ,
• Bretzlaff JA ,
• Spooner CH ,
• Stockman LJ ,
• Bellamy R ,
• ↵ World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance 13th March 2020. 2020. https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf .
• ↵ Global Initiative for Asthma (GINA). 2020 GINA report, global strategy for asthma management and prevention. 2020. https://ginasthma.org/gina-reports/ .
• McKeever T ,
• Mortimer K ,
• ↵ Office for National Statistics. Analysis of death registrations not involving coronavirus (COVID-19), England and Wales: 28 December 2019 to 1 May 2020. Release date: 5 June 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/analysisofdeathregistrationsnotinvolvingcoronaviruscovid19englandandwales28december2019to1may2020/technicalannex .

NCLEX Case Studies: Handling Severe Asthma Attacks - What You Need to Know

Asthma is a chronic respiratory condition characterized by airway inflammation and hyperreactivity, leading to episodic airflow obstruction. Severe asthma attacks can be life-threatening and require prompt, effective management. For nursing students preparing for the NCLEX exam, understanding how to handle severe asthma attacks is crucial. This comprehensive guide will delve into the pathophysiology, assessment, and management of severe asthma attacks, providing you with the knowledge needed to excel in case studies and real-life scenarios.

Understanding Asthma Pathophysiology

Asthma involves chronic inflammation of the airways, which leads to:

• Bronchoconstriction : The smooth muscles around the airways tighten.
• Inflammation : The lining of the airways becomes swollen.
• Increased Mucus Production : Excess mucus can clog the airways.

These changes result in narrowed airways, making it difficult for the patient to breathe. Triggers such as allergens, exercise, cold air, and respiratory infections can exacerbate these symptoms.

Recognizing Severe Asthma Attacks

A severe asthma attack is a medical emergency. Key signs and symptoms include:

• Severe Dyspnea : Difficulty breathing, often with rapid, shallow breaths.
• Use of Accessory Muscles : Visible effort in the neck and chest muscles.
• Cyanosis : Bluish discoloration of the skin, indicating hypoxia.
• Silent Chest : Absence of wheezing due to severely restricted airflow.
• Altered Mental Status : Confusion or lethargy due to hypoxia.
• Peak Expiratory Flow Rate (PEFR) : Less than 50% of the patient’s personal best.

Initial Assessment and Interventions

Primary assessment (abcs).

• Airway : Ensure the airway is open. Position the patient to maximize airflow.
• Breathing : Assess the rate, depth, and effort of breathing. Administer high-flow oxygen if needed.
• Circulation : Monitor heart rate and blood pressure. Establish IV access for medication administration.

Secondary Assessment

• History : Obtain a quick history of the patient’s asthma, including triggers, previous attacks, and current medications.
• Physical Exam : Look for signs of respiratory distress, auscultate lung sounds, and check for cyanosis.
• Diagnostics : Obtain arterial blood gases (ABGs) to assess oxygenation and ventilation status.

Management of Severe Asthma Attacks

Pharmacological interventions.

• Short-Acting Beta-Agonists (SABAs) : Administer albuterol via nebulizer or metered-dose inhaler (MDI) with a spacer. SABAs are the first line of treatment to relieve bronchoconstriction.
• Anticholinergics : Ipratropium bromide can be added to the nebulizer treatment to enhance bronchodilation.
• Systemic Corticosteroids : Administer oral or IV corticosteroids (e.g., prednisone, methylprednisolone) to reduce airway inflammation.
• Magnesium Sulfate : In severe cases, IV magnesium sulfate can be used as a bronchodilator.

Non-Pharmacological Interventions

• Positioning : Sit the patient upright to facilitate breathing.
• Hydration : Ensure adequate hydration to thin mucus secretions.
• Calm Environment : Reduce anxiety by providing a calm environment and reassurance.

Monitoring and Follow-Up

Continuous monitoring is essential during a severe asthma attack. Key parameters to monitor include:

• Respiratory Rate and Effort : Watch for signs of fatigue or worsening distress.
• Oxygen Saturation : Maintain SpO2 levels above 90%.
• Heart Rate and Blood Pressure : Monitor for tachycardia and hypertension.
• Response to Treatment : Assess improvement in symptoms and lung function.

Patient Education and Long-Term Management

Educating patients on asthma management is crucial to prevent future attacks. Key points include:

• Trigger Avoidance : Identify and avoid known triggers.
• Medication Adherence : Emphasize the importance of taking prescribed medications, including inhaled corticosteroids for long-term control.
• Asthma Action Plan : Develop a personalized action plan outlining steps to take during an exacerbation.
• Regular Follow-Up : Encourage regular visits to a healthcare provider to monitor asthma control and adjust treatment as needed.

Handling severe asthma attacks requires a thorough understanding of asthma pathophysiology, prompt assessment, and effective management strategies. For nursing students preparing for the NCLEX exam, mastering these skills is essential. By recognizing the signs of a severe asthma attack, administering appropriate interventions, and educating patients on long-term management, you can provide high-quality care and improve patient outcomes.

Prepare diligently, stay informed, and approach each case study with confidence. Your knowledge and skills can make a significant difference in the lives of patients with asthma.

Case of Acute Severe Asthma

Kane guthrie.

• Dec 2, 2022

A 25-year-old lady Miss. Poor Compliance is rushed into your Emergency Department as a Priority 1. She is a brittle asthmatic and has been given 3x 5mg salbutamol nebs, and 0.5mg of adrenaline IM prehospital. On arrival Miss PC is sitting forward in the tripod position , using her accessory muscles to breath. She is tachypnoeic, agitated and unable to talk.

Vital signs: Pulse 143, BP 138/95, RR 42, Sp02 91% on neb, GCS 14/15.

Past Medical and Medication History

• Smoker. Severe asthmatic. Intubated twice in past 2 years
• Currently taking seritide 250/50mg, salbutamol MDI PRN and prednisolone 50mg PRN

Asthma Epidemiology

• Over 2.2 million Australians have currently diagnosed asthma
• 406 deaths attributed to asthma in 2006
• Highest risk of dying from asthma is in the elderly over 70
• The emergency clinician’s goal in treating acute severe asthma is preventing intubation
• Severe/Critical asthma is a life threatening condition

Asthma Pathophysiology

• Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells.
• Smooth muscle hypertrophy and hyperplasia
• Inflammatory cell infiltration and oedema
• Goblet cell and mucous gland hyperplasia with mucous hypersecretion
• Protein deposition including collagen
• Epithelial desquamation
• Most common, responsible for 80-85% of all fatal events is characterised by eosinophilic inflammation associated with gradual deterioration over days-weeks occurring in patients with severe or poorly controlled asthma, and is slow to respond to therapy.
• The second phenotype, with neutrophilic inflammation, has both rapid onset and response to therapy.

Markers of severe asthma:

• Inability to speak in full sentences
• Use of accessory muscles or tracheal tugging
• Cyanosis and sweating
• Pulsus paradoxus (>15mmHg decreased with inspiration). With severe muscle fatigue might be absent
• Quiet chest on auscultation (The “Silent Chest”)
• Confusion or decreased level of consciousness
• Hypotension or bradycardia
• FEV 1<40% predicted
• PEF <40% of predicted or best (<25% in life threatening asthma)
• Oxygen saturation <90-92%
• PaO2 <60mmHg
• PaCO2 >45mmHg

Complications of Asthma :

• Pneumothorax, Pneumomediastinum, Pneumopericardium and Pneumoretroperitoneum
• Cardiac Arrhythmias, Myocardial ischaemia or infarction
• Electrolyte disturbances (hypokalaemia, hypomagnesaemia, hypophosphataemia)
• Lactic Acidosis
• Hyperglycaemia

Conditions that may mimic acute asthma:

• Upper airway obstruction
• Foreign-body aspiration
• Vocal cord dysfunction syndrome
• Pulmonary oedema
• Acute exacerbations of COPD
• Hysterical conversion reaction
• Munchausen syndrome

Diagnostic Test:

• Hyperinflation 5-10%
• Infiltrate 5%
• Pneumothorax <1%
• Pneumomediastinum <1%
• Respiratory alkalosis typical
• Inaccurate predictor of outcome
• Will seldom alter your treatment plan
• An objective measure of lung function
• Useful to assess response to treatment
• Impossible to obtain in the dying patient
• <25% Severe
• 25-50% Moderate
• 50-70% Mild
• >70% Discharge Goal
• Simple, and less painful than ABG
• Provides continuous oxygenation measurements
• Needs to placed on well-perfused site, difficult to obtain readings if global hypoperfusion or peripheral vasoconstriction present.
• Aim to keep sp02 >92%

Management of Acute Severe Asthma

• Hypoxia is the main cause of death in asthma
• Oxygen should be given to keep Sp02 above 92%
• A slight Pco2 rise may occur with oxygen therapy but this is of no clinical significance.

Beta-agonists:

• Rapid acting inhaled beta-agonists (bronchodilators) are the first line therapy for acute asthma.
• Nebulisers should generally be used in acute severe asthma, as provide easier delivery of medication to patient, multi dose inhalers have a role in mild to moderate asthma.
• IV salbutamol gives you the advantage of hitting the beta 2 receptors from the back door, while continuing nebulizer treatment, and should be trialed in patients not responding to nebulisers.
• Continuous nebuliser therapy appears to be more effective than intermittent nebulisers for delivering beta-agonist drugs to relieve airway spasm in acute severe asthma.  (Cochrane Review, 2009)
• Salbutamol toxicity can caused a lactic acidosis which is often unrecognized in asthma patients, the lactic acidosis has been hypothesized to adversely affect ventilation by increasing ventilatory demand, increasing dead space ventilation, worsening dynamic hyperinflation and intrinsic PEEP. Management is to discontinue salbutamol at the earliest opportunity.
• Dose:  Salbutamol Nebuliser Ampoule 5mg
• Dose: Salbutamol IV 5mg in 500mL of 0.9% sodium chloride or 5% dextrose start at 30mL/hr titrating up to 120mL/hr

Anticholinergics:

• Anticholinergics agents block muscarinic receptors in airway smooth muscles, inhibit vagal cholinergic tone and result in bronchodilation.
• Dose: Ipratropium bromide (Atrovent) 500ug to second dose of salbutamol via neb, can be repeated every 4hours
• Use of corticosteroids within 1 hour of presentation to an ED significantly reduces the need for hospital admission in patients with acute asthma. Benefits appear greatest in patients with more severe asthma, and those not currently receiving steroids
• Dose: Prednisolone 50mg PO
• Dose: IV Hydrocortisone 100-200mg
• Note: Parenteral route is indicated in ventilated patient or patient unable to swallow, eg. Vomiting

Adrenaline:

• Can be give either intravenously or via nebulizer
• Bronchoconstriction is the major pathology in asthma; airway oedema might also make a significant contribution. Both the a-agonist and B-agonist effects of adrenaline might be beneficial, with the alpha effect decreasing oedema and the beta effect responsible for bronchodilation.
• Dose:  IV 6mg in 100mls 5% dextrose start at 1-15mLs/hour
• Dose: Nebulizer 1mg in 3ml normal saline

Aminophylline:

• The popularity of aminophylline in asthma exacerbations has diminished in recent years.
• Systematic reviews have shown that IV aminophylline in severe acute asthma does not produce additional bronchodilation above that achieved with beta-agonist and corticosteroids.
• Side effects; cardiac arrhythmia’s, vomiting, toxicity.
• Dose : 5mg/kg over 20min followed by infusion of 500mg aminophyline n 500mL of 5% dextrose at 0.5mg/kg per hour

Magnesium Sulphate:

• Magnesium potential role is asthma may involve a combination of smooth muscle relaxation, inhibition of histamine release and acetylcholine release from nerve endings.
• Most evidence to support the use of magnesium in asthma is in the acute severe asthmatic were it has been shown to be safe and beneficial.
• Dose : IV 2-4g over 30-60mins
• Heliox Mixture 80% helium/20% oxygen
• There is evidence that helium and oxygen mixtures (heliox) may provide additional benefits to patients with acute asthma.
• Heliox mixtures have the potential to decrease airway resistance, and therefore decrease the work of breathing for the severe acute asthma patient.

Antibiotics:

• Antibiotics are not indicated in the management of severe acute asthma.
• Antibiotics should only be used in the setting of an underlying pneumonia, respiratory tract infection or to aid in the prevention of ventilator-associated pneumonia in ICU.

Airway Management

Non-Invasive Positive Pressure Ventilation:

Good quality evidence and trails to support the use of NPPV in asthma are lacking, however it is worth trying when intubation is not immediately indicated. Remember the goal of the emergency clinician’s in treating asthma is to prevent intubation.

• Positive pressure is generally less than 15cmH2O
• Benefit between CPAP vs BiPAP is unknown
• Tachypnea caused by severe asthma can make it difficult for the patient to coordinate they’re breathing with machine making BiPAP uncomfortable
• Need a large randomised control trial to determine the effectives properly of NIV, in acute severe asthma.

“Asthmatic on BiPAP before being Intubated”

Mechanical Ventilation:

1-3% of acute severe asthma requires intubation. Prevention of intubation and mechanical ventilation are the goals of managing acute severe asthma, this can be achieved by maximising pre-intubation therapy, however you don’t want to wait too long or let the severe asthmatic tire before trying to intubate them. Once an asthmatic is intubated and ventilated their morbidity and mortality increasing dramatically, and it can be difficult to wean from the ventilator.

Criteria for Intubation:

• Cardiac or Respiratory arrest
• Altered mental status
• Progressive exhaustion
• Severe hypoxia despite maximal oxygen delivery
• Failure to reverse severe respiratory acidosis despite intensive therapy
• pH <7.2, carbon dioxide pressure increasing by more than 5mmHg/hr or greater than 55 to 70mm/Hg, or oxygen pressure of less than 60mm/Hg.

Challenges:

• Effective pre-oxygenation impossible
• No margin for error or delay
• Need to be intubated by most experienced person available
• High intrathoracic pressure after RSI

Recommendations:

• Fluid bolus before intubation if possible
• RSI preferred
• Ketamine for bronchodilator effects
• Permissive hypercapnea essential

Initial Ventilator settings in paralysed patients:

• FiO2 1.0, then titrate to keep SpO2 >94%
• Tidal Volume 5-6ml/kg
• Ventilator rate 6-8 breaths/min
• Long expiratory time (I:E ratio >1:2)
• Minimal PEEP < 5cmH2O
• Limit peak inspiratory pressure to <40cmH2O
• Target plateau pressure <20cmH2O
• Ensure effective humidification

• Brenner, B. Corbridge, T. & Kazzi, A. (2009). Intubation and mechanical ventilation of the asthmatic patient in respiratory failure. The Journal of Emergency Medicine. 37(2s), s23-s34.
• Camargo, C. Rachelefsky, G. & Schatz, M. (2009). Managing Asthma Exacerbation in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbation.The Journal of Emergency Medicine. 37 (2S), S6-S17.
• Camargo, C. Spooner, C. & Rowe, B. (2009). Continuous versus intermittent beta-agonist for acute asthma (Review). http://www.thecochranelibrary.com.
• Chua, F. & Lai, D. (2007). Acute severe asthma: Triage, treatment and thereafter. Current Anaesthesia & Critical Care. 18, 61-68.
• Creagh-Brown, B. & Ball, J. (2007). An under-recognized complication of treatment of acute severe asthma. American Journal of Emergency Medicine. 26, 513-515.
• Hodder, R. et al. (2009). Management of acute asthma in adults in the emergency department: nonventilatory management.  CMAJ. 182(2), E55-E67.
• Holley, A. & Boots, R.(2009). Review article: Management of acute severe and near-fatal asthma. Emergency Medicine Australasia, (21) 259-268.
• Jones, L. & Goodacre, S. (2009). Magnesium sulphate in the treatment of acute asthma: evaluation of current practice in adult emergency departments. Emergency Medicine Journal. 26, 783-785.
• Melnick, E. & Cottral, J. (2010). Current Guidelines for Management of Asthma in the Emergency Department.  http://www.ebmedicine.net. 2(2). 1-13.
• Morris, F. & Fletcher, A. (Ed). (2009). ABC of Emergency Differential Diagnosis. Oxford: Blackwell Publishing
• National Asthma Council of Australia. Asthma management handbook: 2006. Accessed http://www.nationalasthma.org.au/cms/images/stories/amh2006_web_5.pdf, 12/02/2010
• Nowak, R. Corbridge, T. & Brenner, B. (2009). Noninvasive Ventilation. The Journal of Emergency Medicine. 37(2S), S18-S22.
• Peters, S. (2007). Continuous Bronchodilator Therapy. Chest. 131(1),1-5.
• Phipps, P. & Garrard, C. (2003). The pulmonary physician in critical care. 12: Acute severe asthma in the intensive care unit. Thorax. 58, 81-88.
• Ram, F. Wellington, S. Rowe, B. & Wedzicha, J. (2009). Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma (Review)
• Rodrigo, G. Pollack, C. Rodrigo, C. Rowe, B. (2010). Heliox for non-intubated acute asthma patents (Review).
• Rowe, B. Spooner, C. Ducharme, F. Bretzlaff, J. Bota, G. (2008). Early emergency department treatment of acute asthma with systemic corticosteroids (Review). http://www.thecochranelibrary.com.
• Rowe, B. et al. (2009). Magnesium sulfate for treating exacerbations of acute asthma in the emergency department (Review). http://www.thecochranelibrary.com.

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• Volume 55, Issue 12
• Case-control study of severe life threatening asthma (SLTA) in adults: demographics, health care, and management of the acute attack
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• J Kolbe a , b ,
• W Fergusson a ,
• M Vamos c ,
• J Garrett a
• a Department of Respiratory Medicine, Green Lane Hospital, Auckland, New Zealand, b Department of Medicine, University of Auckland, Auckland, New Zealand, c Department of Psychiatry, John Hunter Hospital, Newcastle, NSW, Australia
• Dr J Kolbe, Respiratory Services, Green Lane Hospital, Auckland, New Zealand jkolbe{at}ahsl.co.nz

BACKGROUND Severe life threatening asthma (SLTA) is important in its own right and as a proxy for asthma death. In order to target hospital based intervention strategies to those most likely to benefit, risk factors for SLTA among those admitted to hospital need to be identified. A case-control study was undertaken to determine whether, in comparison with patients admitted to hospital with acute asthma, those with SLTA have different sociodemographic and clinical characteristics, evidence of inadequate ongoing medical care, barriers to health care, or deficiencies in management of the acute attack.

METHODS Seventy seven patients with SLTA were admitted to an intensive care unit (pH 7.17 (0.15), Pa co 2 10.7 (5.0) kPa) and 239 matched controls (by date of index attack) with acute asthma were admitted to general medical wards. A questionnaire was administered 24–48 hours after admission.

RESULTS The risk of SLTA in comparison with other patients admitted with acute asthma increased with age (odds ratio (OR) 1.04/year, 95% CI 1.01 to 1.07) and was less for women (OR 0.36, 95% CI 0.20 to 0.68). These variables were controlled for in all subsequent analyses. There were no differences in other sociodemographic features. Cases were more likely to have experienced a previous SLTA (OR 2.04, 95% CI 1.20 to 3.45) and to have had a hospital admission in the last year (OR 1.86, 95% CI 1.09 to 3.18). There were no differences between cases and controls in terms of indicators of quality of ongoing asthma specific medical care, nor was there evidence of disproportionate barriers to health care. During the index attack cases had more severe asthma at the time of presentation, were less likely to have presented to general practitioners, and were more likely to have called an ambulance or presented to an emergency department. In terms of pharmacological management, those with SLTA were more likely to have been using oral theophylline (OR 2.14, 95% CI 1.35 to 3.68) and less likely to have been using inhaled corticosteroids in the two weeks before the index attack (OR 0.69, 95% CI 0.47 to 0.99). While there was no difference in self-management knowledge or behaviour scores, those with SLTA were more likely to have inappropriately used oral corticosteroids during the acute attack (OR 2.09, 95% CI 1.02 to 4.47).

CONCLUSIONS In comparison with those admitted to hospital with acute severe asthma, patients with SLTA were indistinguishable on sociodemographic criteria (apart from male predominance), were more likely to have had a previous SLTA or hospital admission in the previous year, had similar quality ongoing asthma care, had no evidence of increased physical, economic or other barriers to health care, but had demonstrable deficiencies in the management of the acute index attack. Educational interventions, while not losing sight of the need for good quality ongoing care, should focus on providing individual patients with better advice on self-management of acute exacerbations.

• life threatening asthma
• socioeconomics
• health care
• acute attack

https://doi.org/10.1136/thorax.55.12.1007

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Successful Benralizumab Treatment in Acute Near-Fatal Asthma with ECMO Support: A Case Report

Affiliations.

• 1 Institute of Respiratory Disease, Department of Translational Biomedicine and neuroscience, University "Aldo Moro", Bari, Italy.
• 2 Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari Aldo Moro.
• PMID: 38949856
• DOI: 10.1080/02770903.2024.2375287

Introduction: Near-fatal asthma (NFA) is a severe condition that can lead to respiratory arrest or high carbon dioxide levels, often requiring mechanical ventilation. Biologics have revolutionized the management of severe asthma, significantly improving symptom severity, reducing the number of exacerbations and hospitalizations, and decreasing the need for oral corticosteroids. However, their effectiveness in acute settings, particularly for ICU patients experiencing severe respiratory failure, is not well-studied. More research is needed to determine if biologics can improve recovery during severe asthma exacerbations.Case Study: We report a case of NFA in a patient with severe allergic eosinophilic asthma, who experienced global respiratory failure necessitating hospitalization, intubation, and veno-venous extracorporeal membrane oxygenation (VV-ECMO). Given the severity of the clinical condition, compassionate administration of Benralizumab, which targets the IL-5 receptor, was attempted.

Results: Five days from anti-IL5 receptor treatment start, the patient was extubated and the ECMO stopped. After the stepdown to the respiratory intensive care unit (RICU), the patient was weaned from oxygen therapy and subsequently discharged from hospital.

Conclusion: Benralizumab demonstrated rapid effectiveness in improving respiratory failure leading to successful weaning from VV-ECMO and subsequent extubation.

Keywords: Asthma; ECMO; IL-5; respiratory failure.

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• DOI: 10.1002/clt2.12377
• Corpus ID: 270388473

Embedding patients' values and preferences in guideline development for allergic diseases: The case study of Allergic Rhinitis and its Impact on Asthma 2024

• R. J. Vieira , B. Sousa‐Pinto , +10 authors Holger J. Schünemann
• Published in Clinical and Translational… 1 June 2024

37 References

Patients' values and preferences for health states in allergic rhinitis-an artificial intelligence supported systematic review., allergic rhinitis and its impact on asthma (aria) guidelines—2016 revision, next-generation allergic rhinitis and its impact on asthma (aria) guidelines for allergic rhinitis based on grading of recommendations assessment, development and evaluation (grade) and real-world evidence., development and application of health outcome descriptors facilitated decision-making in the production of practice guidelines., patient values and preferences regarding vte disease: a systematic review to inform american society of hematology guidelines., application of a mapping function to estimate utilities for ragweed allergy immunotherapy trials, measuring preferences for cost-utility analysis: how choice of method may influence decision-making., development and use of health outcome descriptors: a guideline development case study, a systematic review of how patients value copd outcomes, academic productivity of young people with allergic rhinitis: a mask-air® study., related papers.

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Effect of Antidiabetic Medication on Asthma Attacks: A UK Self-Controlled Case Series and Population-Based Cohort Study

49 Pages Posted: 28 Jun 2024

University of Edinburgh - Asthma UK Centre for Applied Research

Kenneth KC Man

University College London - UCL School of Pharmacy

Imperial College London - National Heart & Lung Institute

Imperial College London - Department of Metabolism, Digestion and Reproduction

Aziz Sheikh

University of Edinburgh - Usher Institute

Chloe I. Bloom

Background: Elevated body mass index and type-2 diabetes are prevalent in asthma and increase the risk of severe asthma attacks. In experimental studies, the antidiabetic medications, metformin and glucagon-like peptide-1 receptor agonists (GLP-1RA), have been found to mitigate airway inflammation, hyperresponsiveness and remodelling. Methods: To estimate the effectiveness of metformin (first-line antidiabetic medication) and synergistic effects of add-on antidiabetic medications (GLP-1RA, dipeptidyl peptidase-4 inhibitors, sulphonylureas, sodium-glucose co-transporter-2 inhibitors and insulin) to reduce asthma attacks, we adopted a triangulation approach: applying different methodologies each with different biases. Methods included self-controlled case series (SCCS), metformin new-user cohort with inverse-probability of treatment weighting (IPTW cohort), and negative control exposure and outcome analyses. Our data source was UK, nationwide, primary care healthcare records and hospital admissions and mortality data. Asthma attacks were defined as a short course or oral corticosteroids or unscheduled asthma-related hospital attendance or death. To evaluate the effect of metabolic phenotypes (body mass index, glycaemic control) and asthma phenotypes (type-2 inflammation, asthma severity) we conducted interaction analyses. Findings: From over 2 million adults with asthma, we identified eligible new-users of metformin, with diabetes or polycystic ovary syndrome, for the SCCS (4,395 patients) and IPTW cohort (8,625 patients). Metformin was found to be associated with lower asthma attacks, of similar magnitude in both approaches (SCCS: adjusted incidence rate ratio, IRR 0.69, [95%CI 0.62-0.76]; IPTW: weighted-hazard ratio, HR 0.77 [0.68-0.86]). Negative control analyses did not find evidence of significant bias. HbA1c, BMI, blood eosinophil count and asthma severity did not modify the association (p>0.05). The only add-on antidiabetic medication to have an additive effect was GLP-1RA (SCCS: IRR 0.61 [95%CI 0.46-0.81]). Interpretation: Metformin lowered asthma attacks by approximately 30%. This appeared to be mediated by mechanisms other than through glycaemic control or weight loss and occurred across asthma phenotypes. GLP-1 had a further additive effect of around 40%. Funding: This research was supported by Asthma+Lung UK (WADR22\100003). Declaration of Interest: CIB reports grants from Asthma+Lung UK and the National Institute for Health Research Imperial Biomedical Research Centre. BL reports grants from Asthma+Lung UK. All other authors declare no competing interests. Ethical Approval: This study used anonymised electronic health records, Clinical Practice Research Datalink (CPRD) obtained under license from the UK Medicines and Healthcare Products Regulatory Agency. Predetermined statistical analysis plan was approved by CPRD (protocol 22_002086).

Keywords: Asthma attack, metformin, GLP1-RA, diabetes, PCOS

Suggested Citation: Suggested Citation

Bohee Lee (Contact Author)

University of edinburgh - asthma uk centre for applied research ( email ).

Edinburgh United Kingdom

University College London - UCL School of Pharmacy ( email )

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• v.26(1); 2023 Feb

Patient views on asthma diagnosis and how a clinical decision support system could help: A qualitative study

1 Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh UK

Eddie Donaghy

Victoria murray, leo campbell, carol stonham.

2 NHS Gloucestershire Clinical Commissioning Group, Gloucester UK

3 Primary Care Respiratory Society (PCRS), Knowle UK

Andrew Bush

4 Imperial Centre for Paediatrics and Child Health and National Heart and Lung Institute, Imperial College, London UK

5 Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London UK

Brian McKinstry

6 Centre for Population and Health Sciences, Usher Institute, University of Edinburgh, Edinburgh UK

Heather Milne

7 South East GP Unit, NHS Education for Scotland, Edinburgh UK

Hilary Pinnock

Luke daines, associated data.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Introduction

Making a diagnosis of asthma can be challenging for clinicians and patients. A clinical decision support system (CDSS) for use in primary care including a patient‐facing mode, could change how information is shared between patients and healthcare professionals and improve the diagnostic process.

Participants diagnosed with asthma within the last 5 years were recruited from general practices across four UK regions. In‐depth interviews were used to explore patient experiences relating to their asthma diagnosis and to understand how a CDSS could be used to improve the diagnostic process for patients. Interviews were audio recorded, transcribed verbatim and analysed using a thematic approach.

Seventeen participants (12 female) undertook interviews, including 14 individuals and 3 parents of children with asthma. Being diagnosed with asthma was generally considered an uncertain process. Participants felt a lack of consultation time and poor communication affected their understanding of asthma and what to expect. Had the nature of asthma and the steps required to make a diagnosis been explained more clearly, patients felt their understanding and engagement in asthma self‐management could have been improved. Participants considered that a CDSS could provide resources to support the diagnostic process, prompt dialogue, aid understanding and support shared decision‐making.

Undergoing an asthma diagnosis was uncertain for patients if their ideas and concerns were not addressed by clinicians and were influenced by a lack of consultation time and limitations in communication. An asthma diagnosis CDSS could provide structure and an interface to prompt dialogue, provide visuals about asthma to aid understanding and encourage patient involvement.

Patient and Public Contribution

Prespecified semistructured interview topic guides (young person and adult versions) were developed by the research team and piloted with members of the Asthma UK Centre for Applied Research Patient and Public Involvement (PPI) group. Findings were regularly discussed within the research group and with PPI colleagues to aid the interpretation of data.

1. INTRODUCTION

Asthma is a chronic respiratory disease accounting for at least 6.4 million primary care consultations each year in the United Kingdom. 1 Although a common condition, making a diagnosis of asthma is not always straightforward for clinicians and estimates from primary care suggest that asthma is often misdiagnosed. 2 , 3 , 4 Overdiagnosis can lead to costly, potentially harmful treatment and may affect job and lifestyle decisions; whilst underdiagnosis risks inadequate treatment and avoidable morbidity and mortality. 5 , 6

Asthma is a variable condition with different phenotypes meaning that individuals with asthma can experience and present with a range of symptoms of varying severity. 7 The aim is to demonstrate objective evidence of variability over time, and investigations such as spirometry and fractional exhaled nitric oxide (FeNO) can increase or decrease the likelihood of a diagnosis of asthma. However, in primary care, timely access to tests is not guaranteed and false positive and false negative results are common. 5 Consequently, it may take months before a clinician feels able to confirm (or refute) a diagnosis of asthma. 8 The potentially long timescale can lead to frustration and uncertainty amongst patients 9 and needs to be handled confidently and accurately by clinicians. 10

In addition to increasing the availability and use of objective tests, 11 clinical decision support systems (CDSS) could provide a solution for improving the accuracy of an asthma diagnosis and may help improve the patient experience. CDSS are usually designed to aid the decision‐making of clinicians 12 but may be utilized to facilitate shared decision‐making with patients. For instance, CDSS can be used to collect, calculate and present information about the likelihood of a diagnosis or treatment benefit. For example, AsthmaTuner, a self‐management system which collects lung function and symptom data via Bluetooth spirometer and patient app, respectively, provides automated treatment recommendations for patients and an interface for health professionals. 13 For diagnosis, a CDSS could be used to calculate the likelihood of a particular condition, and present the probability and options for confirming a diagnosis. In a Norwegian study, a web‐based CDSS designed to aid the diagnosis and classification of chronic obstructive pulmonary disease (COPD) in primary care was found to reduce misdiagnosis and increase the number of patients receiving smoking cessation advice but did not improve the prescription of pharmacological treatment. 14

Having derived and validated a clinical prediction model for asthma diagnosis, 15 , 16 we plan to implement the model in primary care as a CDSS. Being aware that a previous systematic review found that CDSS for asthma were infrequently utilized, 17 we wanted to understand patient views on asthma diagnosis and how a CDSS could help to maximize the potential value of a future CDSS for patients. Therefore, to inform the development of the CDSS, this study aimed to explore patient experiences regarding asthma diagnosis and to understand how a CDSS could also be used to improve the diagnostic process for patients.

To inform the development of an intervention (the CDSS), the study design was guided by the Medical Research Council (MRC) framework for developing and evaluating complex interventions. 18 To understand which design features would be most important for an asthma diagnosis CDSS, the experiences and views of patients (and parents of children) who had undergone an asthma diagnosis were sought using qualitative methods. We undertook interviews with young people, adults and the parents of children, who had a recent diagnosis of asthma (ideally within the past 5 years). Interviews took place between 1 October 2020 and 31 January 2021. All participants provided informed consent before interviews were conducted.

2.1. Recruitment and sampling

Participants were recruited from general practices across four regions within the United Kingdom (Greater Glasgow and Clyde, Lothian, West Midlands, Yorkshire and Humber). Participating practices identified adults and young people (≥12 years) and parents of children (≥5 years) who had ‘active asthma’ and a diagnosis of asthma coded in the electronic health records within the last 5 years. ‘Active asthma’ was defined as a coded diagnosis of asthma and having had a prescription for any asthma treatment within the previous year. 19 Children below 5 years of age were excluded as viral‐associated wheeze is common in this age group and can complicate asthma diagnosis. Based on the age of legal consent, we offered young people aged ≥12 years the chance to take part in an interview themselves. A clinician from each practice screened the list of selected patients for eligibility and excluded individuals who had COPD, were unable to give informed consent (e.g., due to cognitive impairment) or for social/clinical reasons (e.g., significant co‐morbidity, recently bereaved or on a palliative care register).

Potential participants were mailed an information sheet and an expression of interest form which included questions about age, gender, age at diagnosis, how asthma was confirmed (i.e., symptoms, examination, tests) and the confidence they had in their asthma diagnosis (agree, not sure, do not agree with diagnosis). Responses to these questions were used to purposively sample individuals to represent a range of participants in terms of age, gender, length of time since asthma diagnosis, confidence in the diagnosis and who made the diagnosis.

2.2. Data collection

Semistructured in‐depth interviews were conducted by telephone (to comply with social distancing during the COVID‐19 pandemic). Interviews were conducted by a male (E. D.) or female (V. M.) postdoctoral researchers, both of whom have experience in health services research. Interviews lasted between 30 and 45 min and were audio recorded, transcribed verbatim and redacted of identifiable information. No repeat interviews were necessary. Transcripts were not returned to participants for comment.

2.3. Topic guides

Prespecified semistructured interview topic guides (young person and adult versions) were developed by the research team (see Supporting Information). To consider the validity and reliability of the topic guides, we conducted pilot interviews with members of the Asthma UK Centre for Applied Research Patient and Public Involvement (PPI) group. Topic guides mapped to the study objectives and were designed to allow a focused yet flexible approach 20 that facilitated exploration of experiences of asthma diagnosis; perceptions and expectations of patient involvement in the diagnostic process and how a computer system/CDSS could have helped or hindered their experiences.

2.4. Data analysis

We used a thematic approach to data analysis. 21 Using Nvivo 10 (QSR International), transcripts were read and manually coded using overarching themes. In an attempt to maximize reliability, after the initial transcripts had been coded, three researchers (V. M., L. D., H. P.) conducted a thematic analysis with selected transcripts during this iterative process. Emerging themes were discussed before deciding on an initial coding framework. Transcripts were coded on an ongoing basis concurrently with interviews and revisited as the study progressed so that new themes could be included, and the coding framework refined. The final coding framework was thus a combination of themes proposed in advance together with other themes generated during the analysis, 21 which represents both a deductive and inductive approach to qualitative analysis. 22 The consolidated criteria for reporting qualitative research was used to guide reporting (see Supporting Information). 23

2.5. Interpretation

We took a critical‐realist perspective when interpreting the data, 24 which helped when considering the experiences, motivations and meanings of participants' lived realities. 21 To aid interpretation, findings were regularly discussed within the research group and with PPI colleagues. The concept of medical dominance emerged as relevant, and we used this to guide interpretation. 25 , 26 Medical dominance is based on the view that in relation to health and illness, medical professionals hold power and control which shape and influence health professional/patient interactions and experiences. 27 , 28 , 29

We received 53 expressions of interest within the study period and using purposive sampling, 27 individuals were invited to take part. 17 participants contributed to interviews, including 14 individuals with asthma and 3 parents of children with asthma (Table  1 ). All participants had been diagnosed with asthma before the COVID‐19 pandemic. Of the 26 individuals not invited, 23 had been diagnosed several years before and 3 children had been diagnosed before 5 years of age.

Patient demographics

3.1. Overview of themes

Analysis of data sought to answer two key research questions: patient experiences during an asthma diagnosis and patient views and experiences of a CDSS. Four subthemes were identified regarding patient experiences during the diagnostic process; knowledge and understanding of asthma, communication, receiving and retaining information and self‐management. An additional four themes emerged in relation to patient experiences and views of a CDSS; patient experiences of screen sharing, online health information use, patient views on an asthma CDSS and barriers and facilitators to a CDSS being used. Topics are reported in this order.

3.2. Key theme 1: Diagnosis: The patient experience

3.2.1. knowledge and understanding of asthma.

Several participants recalled being uncertain about what asthma was or how it might present. For instance, participant adult/1 (female, age 41–50, site 1), recalled that she ‘didn't know that coughing was a sign of asthma’, despite having a sister and a best friend who had been diagnosed with the condition as teenagers. Other participants believed asthma always started in childhood:

It was a bit weird 'cause I'd never had it before and [obviously it] was … like, I thought it was quite late. I thought it was one of those things you just had as a kid and then, like, you had it from the beginning and that was that. (P/young person/1, female, 16–30, site 5)

Participants often had their own ideas about the cause of symptoms, and without prior knowledge or experience of asthma, some individuals worried about what they viewed as the worst‐case scenario such as cancer:

Somehow you associate it (asthma) with really sick people. I don't know. I didn't sort of think of it as a kind of a manageable issue. Sort of, these people who had maybe asbestos poisoning to their lungs or something like that. A very dramatic thing. (P/adult/6, male, 41–50, site 1)

In a similar vein, some participants, held a lack of familiarity with asthma symptoms leading them to assume their symptoms were a consequence of lifestyle choices or personal stresses so achieving a diagnosis was a relief:

We bought a house which we then discovered had a lot of hidden mould issues and I think that's been a contributor to all of this [….] The asthma diagnosis really helped. (P/adult/6, male, 41–50, site 1)

For some participants, an asthma diagnosis came as a surprise and was made co‐incidentally during an appointment for another problem:

I was actually diagnosed accidentally, but I was glad I was diagnosed at the time. I was actually meant to go about my toe because I was arguing with my son when he was about five years old and I got my toe jammed under the door and it was bruised. So anyway, I went to the doctor about it and he noticed that I was a bit wheezy so he decided that he would do a test. And he turned round and said, yeah, you're asthmatic. (P/adult/4, female, 41–50, site 2)

3.2.2. Communication

The importance of communication during the assessment for an asthma diagnosis was a common theme arising from interviews. Some participants were surprised that being diagnosed with asthma had taken a long time, and another participant remained unsure if they had asthma:

Cause all along they're like, oh there's no official test so this might not be, so you'll just need to try this and try that and see if it works or not. So, it's quite a … like, unsure and quite a long process sometimes. (P/young person/1, female, 16–30, site 5)

There was never any concrete diagnosis, so I don't know whether I have a pre‐existing condition now or not. (P/adult/9, male, 41–50, site 4)

However, many patients were satisfied with the step‐by‐step processes they experienced and the principles of parsimony by problem‐solving through the simplest means available to enable an accurate diagnosis:

‘It took a while. It was sort of an ongoing thing over … well, I'd had sort of recurring colds and kind of persistent things like that, with kind of wheezing and coughing and so on. And […] my GP, I think was quite methodical about this so there were various tests and eliminations and so on. So, it had come over a couple of years’. Yeah, but I think it's the right way to do it. I was very happy with it. (P/adult/6, male, 41–50, site 1)

A lack of communication about the variable nature of asthma during the early stages of the diagnostic process left some respondents unsure if they had asthma or not. P/young person/2, reported feeling ‘a wee bit shocked’ when diagnosed with asthma because she considered herself to be ‘the fittest I'd ever been’. Participant adult/8 (male, 61–70, site 3) was told he had asthma but said ‘it wasn't explained how my lungs work or anything’. Participant young person/2, felt disappointed with the support she had received, explaining she had been ‘just told and then left with that information’:

You sometimes feel that people are just giving you a decision but not explaining it in enough detail. [….] Even like when my mum's been there with me, it's just been, kind of […] like none of us have fully understood how I have asthma. (P/young person/2, female, 16–30, site 2)

A perceived lack of time and the use of complex language were reasons participants gave for communication being poor. Participants generally understood why time may be an issue. For instance, P/adult/6 (male, 41–50, site 1), who had been diagnosed for 1 year, felt that ‘the system is congested’. Similarly, P/adult/2 (adult, female, 21–30, site 1), talked about General Practitioners (GP) as being ‘obviously very busy’ and her GP did not have time to explain the diagnostic process or use language that the patient understood. Consequently, she preferred to see the asthma nurse who provided ‘more of an understanding about what's going to happen’:

I think the thing about the nurses are … especially the asthma nurses, they, kind of, already […] I mean, they only see you once a year but they know you a bit better so they can, kind of, explain things in a bit more user‐friendly way, I guess. (P/adult/2, female, 21–30, site 1)

Parents of children undergoing the diagnostic process felt communication was particularly problematic, and reported feeling frustrated and helpless during a lengthy and often inconclusive testing process:

You know, I was really annoyed because, you know, like every second week she was ill and [had a] high temperature. And like even, you know, we went to emergency hospital appointment, and nobody could say nothing. And I thought because she was … she has a twin sister, and they were born two weeks before due. Yeah, and […], another problem, like, because she is the second twin, she's the youngest one. And when she had cough and the doctor said, because (twin 1) has asthma, (twin 2) probably has asthma as well. And for me it's like, she never had a test. (P/parent of child/2, female, age 9, site 2)

3.2.3. Receiving and retaining information

Whilst one participant (P/adult/4, female, 41–50, site 2) reported her diagnosis was explained to her satisfaction and she remembered everything she was told, most respondents reported leaving their appointment(s) with little information or not being able to recall the information later. For some respondents, much of the asthma information received was new to them and felt overwhelming. One individual felt relief at finally having a label for their condition. Others suggested they had appeased their GP by pretending to follow the conversation:

It takes me sometimes a while to cotton on to things. And I may say, ‘yes, I understand’ at first. I suppose I'm fairly typical of most people in that way. I say ‘yes, I understand’ but I don't think I've got a full grasp of it, you know? (P/adult/3, male, 61–70, site 1)

The provision of paper handouts to support asthma information during consultations was useful for some, met with indifference by others, and received poorly by one or two participants. Handouts were unlikely to be kept and the information on them was not well retained:

I probably got a leaflet or something like that, that had two or three pages in it, then, and then, well, a leaflet, you put it down and then it disappears. (P/adult/7, female, 51–60, site 1)

I'm a digital person. I hate bits of paper, 'cause I lose bits of paper. (P/adult/10, male, 61–70, site 4)

3.2.4. Self‐management

In keeping with the perceived lack of information provided at the time of diagnosis, some individuals felt underconfident in managing their asthma after they had been diagnosed, for example, taking their inhaler correctly:

The only problem, if it could be said to be a problem, was I didn't know how to use the inhalers correctly. I don't believe, I don't remember being told how to use an inhaler. (P/adult/3, male, 61–70, site 1)

Although some participants talked about their personal asthma action plan (a key component of asthma self‐management), 5 several respondents said they had not been provided with one, and others did not know what they were:

I know everybody talks about their asthma plan, but mine is not like … I've not got any asthma plan written down, but I mean […] I know myself and I've got an oximeter in the house as well now that I will test on these various things. (P/adult/13, female, 41–50 site 4)

3.3. Key theme 2: CDSS: Patient experience and views

Participants spoke about a range of topics relating to how a computer, the internet or a CDSS could be used to enhance a consultation for a possible asthma diagnosis. Four subthemes were identified: patient experiences of screen sharing, online information use, patient views of an asthma CDSS and barriers and facilitators to CDSS use.

3.3.1. Patient experiences of screen sharing

Respondents were asked about their experiences of using the screen alongside their clinician during appointments. 30 One or two participants talked about screen sharing with their asthma nurse, but most could not recall being invited to look at the computer screen during a GP consultation. Few participants realized that they could be invited to look at the screen, or even understood why they might want to see it:

GPs certainly not, I don't think they ever share screens. The asthma nurse … I think they have like, they've shown us, but they are just graphs, not really to do with asthma necessarily. They are to do with like height and weight and where you should be and then your peak flow, that stuff. (P/parent of child/1, male, age 14, site 4)

Well, I don't really think like that is a nice thing to do … Aye, I'm just thinking that (screen) was a bit private, you know, would that not be a bit private to them? (P/adult/12, male, age 51–60, site 6)

That said, some participants had experience screen sharing during clinical consultations:

Certainly, in the hospital in most sessions. I'm quite curious as an individual anyway, and dangerous because I have a little bit of knowledge, so I've been looking at the numbers they were copying down. I think in the consultant conversation he was definitely pivoting the monitor so we could look at it. I can't remember what was on it, but I do remember that seating arrangement to both look at it. (P/adult/9, male, 41–50, site 4)

Some respondents felt that a CDSS which allowed them to see how the clinician worked through their diagnosis, might have helped them to understand more about the variability of asthma and other aspects to help understand the condition.

So, yes anything that provides better, broader information from a multitude of directions, so not just ‘Here is a piece of writing for you’. Like you are seeing with visuals, you know, I think is only going to make it better. (P/parent of child/1, male, age 14, site 4)

3.3.2. Online health information use

When asked about accessing health information online pre‐diagnosis, a lack of trust in the quality of information online alongside patient perceptions of GP dislike of the practice, meaning that most respondents avoided using the internet to try and self‐diagnose.

I think I'm of the generation that what the doctor tells me I believe him. I tend not to look up illnesses myself. (P/adult/11, female, 61–70, site 4)

I don't go online so much […] because I work for a health organisation. And I know that doctors get annoyed with, sort of, patients looking up symptoms online before actually going to see them; and then thinking they've got something when they've not actually got it. So, that's maybe one of the reasons I don't tend to sort of go online to look out for health problems and things like that. (P/adult/1, female, 41–50, site 1)

However, participants noted that they accessed information online post‐diagnosis to expand their knowledge or define their condition better:

I looked it up, which I never normally do, asthma symptoms. And it's because I was still coughing and I'm … the thing I says to my brother and sister, I'm not convinced I've got asthma. I think it's a chest infection […] So … what I read on the Internet, sadly […] confirmed what I was feeling [was asthma]. (P/adult/8, male, 61–70, site 3)

There was a perception that negative clinical attitudes existed towards patients exploring online information before a GP diagnostic appointment (P/adult/1, female, 41–50, site 1). Conversely, some held the view that ‘Dr Google’ was useful particularly in terms of searching for groups to exchange views and experiences of asthma.

Everything seems to be online, and everybody seems to have an opinion and so easily accessible […] information that you need, and you know, you've got your asthma, you know, groups online. (P/adult/13, female, 51–60, site 4)

3.3.3. Patient views on an asthma CDSS

The most popular output for the CDSS was the ability to provide the probability of an asthma (ideally visually) during diagnostic consultations. Moreover, respondents agreed that being able to see the factors which could lead towards an asthma diagnosis would be useful alongside further information to improve treatment management:

And he could say, I don't know, let's say there's various fields on your screen, if five out of these ten fields are ticked, the chances are, that you've got asthma or whatever disease and as you can see you've got seven of them ticked; you know, something like that. A visual representation. (P/adult/10, male, 61–70, site 4)

In keeping with the lack of confidence that individuals had about their understanding of asthma, participants suggested that incorporating an educational section within the CDSS which could be used during the consultation to show a visual representation of how asthma affects the lungs would be of interest and could assist communication and their understanding:

I actually think that kind of thing would be really helpful for children and young people…. because it's very abstract, and especially if it's just something that you think is just how your body is, you never question it, you never really think about it in terms of the actual physiological processes that are happening, you are just like, ‘Oh I've got asthma, right’. (P/parent of child/1, male, age 14, site 4)

If there's a simulation or something like that, ‘Here's how it looks when it's really bad’ and ‘Here's how, what’, ‘Here's how an inhaler, what it does to your lungs’, ‘Here's what specific medication does’ and stuff like, yeah, I think that would be very interesting […] just looking at it on a piece of paper, is not the best. I think seeing some kind of simulation would be much more helpful. (P/adult/7, female, 51–60, site 1)

Respondents also noted that it would be beneficial to understand where they fit into an overall picture of asthma severity, with P/adult/9 (male, 41–50, site 4), two years since diagnosis asking, ‘What's normal and where am I versus normal?’ Some participants felt that understanding the significance of their diagnosis could have helped them take the diagnosis more seriously from the beginning. Participants also suggested that a website associated with the CDSS which could be used after the consultation would be more beneficial to them in the long run than the traditional handouts:

I think it's a good idea. I think it would help quite a lot 'cause the big problem I had was that I wasn't using my inhaler correctly and then I wasn't seeing an improvement on … kind of, on my, like, lung capacity essentially. So, I think if I'd, kind of, had that understanding earlier on then I would have been more dedicated to using my inhaler the way that I'm meant to. (P/adult/2, female, 21–30, site 1)

There were others who were sceptical, believing their diagnosis would not have been speedier or different with the aid of a CDSS.

I mean, I have to say that on these indicators alone, my family history was ‘no none’. At that point I didn't really have any allergies, they have come on since. Also, my coughing had, ironically, stopped by the time … after the first episode my coughing had stopped because of the operation. Also, I didn't have a wheeze. (P/adult/13, female, 51–60, site 4)

3.3.4. Barriers and facilitators to a CDSS being used

Respondents expressed interest in the potential role of the CDSS and could see areas where the CDSS might improve the diagnostic experience. However, respondents also highlighted that whether the potential was realized depended on how the CDSS was used:

So, I think this system would be good but if it's just the system and then a very overworked GP that doesn't make eye contact, it's not really going to work. It would be, kind of … you know, you'd have to have the right person who was interacting in … on it with you. (P/adult/2, female, 21–30, site 1)

To this end, most respondents viewed the CDSS as an avenue through which communication between patients and clinicians could be facilitated:

Between yourself and the health professionals, this might be a little bit of a focal point for the conversation. So, I think that's likely to work well. (P/adult/6, male, 41–50, site 1)

The ability to aid understanding between clinicians and patients was viewed as the most important aspect of the CDSS, especially for those respondents who found the initial diagnosis ‘daunting’ (P/adult/7, female, 51–60, site 1). Moreover, screen‐sharing was viewed as an opportunity to be ‘treated like an intelligent adult’ (P/adult/6, adult male, 41–50, site 1). Using the CDSS could provide a framework for clinicians and patients to use together to provide a better‐shared understanding of potential routes to diagnosis.

4. DISCUSSION

Being diagnosed with asthma could feel like an uncertain process for participants in this study, who felt that limited consultation time or poor communication made it difficult to understand how and why the diagnosis had been made. Some participants felt they retained information about asthma diagnosis poorly and considered online or digital resources more useful than paper handouts. Participants felt possible advantages of a CDSS for asthma diagnosis may be prompting dialogue, improving understanding and encouraging a shared diagnostic process between patients and clinicians.

4.1. Interpretation

The hallmark of asthma is variability. Symptoms vary over time and in severity and making a diagnosis of asthma can require time or repeated investigations to build up the information required. 5 , 8 , 9 For patients, preconceived concepts about what asthma is, and who is at risk of developing the condition influence the credibility of an asthma diagnosis. For clinicians, weighing up the probability of an asthma diagnosis, differentiating between asthma and other conditions and excluding red flags can all influence how a consultation is conducted. 8 , 10 Thus, the perceptions of both clinician and patient can shape a consultation and a mismatch in these perceptions may lead to dissatisfaction. 30 Involvement of patients in consultations to allow shared decision‐making is widely accepted in medical practice and may lead to better asthma control, quality of life, adherence to medication and patient satisfaction. 31 Yet for shared decision‐making to occur, clinicians need to have time and resources to provide information on the pros and cons of a particular course and patients need to feel able to understand and question the medical explanations while contributing what is important for them. 32 , 33 , 34

Amongst the diagnostic experiences recalled in this study, there were instances where participants felt their diagnosis was a fait accompli or did not feel empowered to ask questions or engage in meaningful interactions, believing the professional opinion was final. Additionally, and often because of perceived time constraints during GP appointments, patients were reluctant to ask for clarification or explore their diagnosis further, even though they were often dissatisfied with the information provided. One patient deliberately refrained from seeking further asthma information online, believing that doing so would be annoying for their GP. These examples may indicate a mismatch in the perceptions of health between patients and clinicians during the consultation. One influencing factor may be patient/clinician power imbalance, whereby the health professional was perceived to hold power within the consultation. 26 , 27 , 28 A perceived superiority of clinicians in the eyes of patients can impact their willingness to share their opinions, 34 and engage in consultation because they trusted that the clinician knew best. 35 On the other hand, some patients may prefer a more direct consulting style and not be actively involved in decision‐making. 36

Consequently, strategies/interventions to support a more egalitarian partnership between patient and professional may encourage more supportive patient care, an increased understanding of individual illness and facilitate patient empowerment. 28 , 29 In this study, there were a few examples of reduced medical dominance; participants described screen sharing and the layout of seating in the consultation room. In keeping with a prior study 30 ; screen sharing did contribute to patients feeling involved in the consultation, yet few participants had direct experience of it occurring. Whilst the theory of medical dominance extends beyond doctors to allied health professionals and nurses, 28 , 29 some participants in this study preferred to see their asthma nurse (compared to a GP) because they found the consultation more understandable. Other factors such as the length of the appointment may also have influenced this view.

To promote shared decision‐making, Agoritsas et al. 33 suggested clinicians need ‘skills and tools’ while patients require ‘information and support’. CDSS has traditionally been seen as technology to support clinicians, but can also promote patient‐focussed practice 37 through the involvement of patients in decision‐making about their health and well‐being. 38 , 39 In this study, participants liked the idea of visualizing the probability of asthma, seeing simulations of lung physiology and being able to see how the clinician worked through their diagnosis. However, some participants had reservations, explaining there would be no point in a CDSS if the clinician did not have time to engage. In keeping with this view, some have argued that the barriers to using CDSS set them up for failure. 40 , 41 , 42 For instance, with a lack of guidance on how decision support systems could be used, clinicians were more likely to rely on their training and experience than on new technologies. 43 Additionally, a lack of appointment time could result in reduced patient involvement, as the clinician focuses on the CDSS rather than inviting the patient to become part of the decision‐making. 40

4.2. Implications for research and practice

The importance of diagnostic tests was noted by participants in this sample, and the lack of access to tests is a source of frustration and uncertainty for patients and health professionals alike. 10 In Germany and Sweden, spirometry can be achieved at the time of presentation, or within 2 weeks, respectively. 10 Yet in other health systems, including the United Kingdom, the time between the first presentation and achieving spirometry or FeNO can be months. Therefore, in the United Kingdom, one implication of this work is to improve capacity and timely access to diagnostic tests for asthma. 44 , 45 Digital solutions, such as the AsthmaTuner self‐management system, could transform the diagnosis and management of asthma. 13 , 46 The use of connected technologies such as wearable sensors, Bluetooth spirometers and digital peak expiratory flow devices could increase access to diagnostic information and allow measurements to be performed when a patient is symptomatic. 13 , 46 CDSS which collates data from such devices and supports interpretation could lead to improvements in the diagnostic accuracy of asthma though further high‐quality studies are needed.

In situations where testing remains difficult to achieve, where the outcome of tests makes the diagnostic process protracted (i.e., false negatives), or variable symptoms occur over an extended timescale, considering how best to achieve shared diagnosis‐making through explanation of the current situation and deciding on the most appropriate next steps may help patients remain involved. The role that an asthma diagnosis CDSS may have in engaging patients through the diagnostic process is planned to be evaluated during a feasibility pilot study.

4.3. Strengths and limitations

The study was designed and piloted using input from a multidisciplinary advisory group and PPI members to develop topic guides and trial interviews which ensured that the topics covered were important to those with asthma and the study team. We sought views from a wide range of individuals who had been recently diagnosed with asthma from different areas across England and Scotland. Despite invitations being sent to those who had a diagnosis of asthma coded in the electronic health records within the last 5 years, we received many expressions of interest from individuals who had been diagnosed over 5 years before, and from individuals over 50 years of age.

Recruitment was severely hampered by the COVID‐19 pandemic for the following reasons: non‐COVID studies (such as ours) were paused to prioritize urgent research which meant the planned study period was restricted; GP practices faced high workload and reduced staffing which made it more difficult to recruit practices; it took longer for clinical research network staff to gain access to GP practices and send out invitations to patients. Despite these challenges, we managed to recruit parents of children with asthma, young people and older adults, with a range of diagnostic experiences. Having interviewed 14 participants, we considered that with respect to adults over 30 years, no new information was being collected and no new codes were developed. 47 In line with our purposive sampling approach, we chose to complete further interviews to enhance the diversity of the sample, specifically parents of children and young people. Before the study period closed, we were able to include more parents of children and one participant in the 16–30 age group. 47 Overall, we felt that data saturation had been achieved because the themes had been fully described with no new information being obtained in the later interviews. However, we acknowledge that had we been able to recruit more males, participants aged 16–30 years and individuals from rural GP practices we may have heard about different experiences.

This study sought views on a proposed CDSS being developed by the research team. Regarding reflexivity, we acknowledge the desire to create a successful CDSS may have influenced data collection and interpretation by being eager to pick up on positive aspects during interviews and identifying favourable opinions when analysing the data. We attempted to minimize the influence of any one individual by having two researchers conduct interviews and several team members (including a steering group) contribute to the interpretation of results.

5. CONCLUSIONS

The process of diagnosing asthma was uncertain for patients if their ideas and concerns were not addressed by clinicians and were often related to a perceived lack of consultation time and limitations in communication. A CDSS designed with patients' needs in mind could encourage a more shared diagnostic process between patients and clinicians, and improved communication relating to the nature of the condition and its management, including the patient's role in self‐management.

AUTHOR CONTRIBUTIONS

Luke Daines and Hilary Pinnock conceived the idea and achieved funding. Victoria Murray and Eddie Donaghy conducted patient interviews. Anne Canny, Eddie Donaghy, Luke Daines, Hilary Pinnock and Victoria Murray wrote the first draft and Leo Campbell, Carol Stonham, Andrew Bush, Brian McKinstry and Heather Milne were involved in the interpretation of data, revising it critically. All authors gave final approval for the article to be published.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS STATEMENT

The study received ethical approval from London Stanmore Research Ethics Committee (ref: 19/LO/1722).

Supporting information

Supplementary information.

ACKNOWLEDGEMENTS

We are grateful to Optimum Patient Care and Tactuum, our collaborators on the Asthma + Lung UK/Innovate UK‐funded research grant to develop an asthma diagnosis clinical decision support system. We thank the Asthma UK Centre for Applied Research Patient and Public Involvement team for their help during the study. This study was funded by Asthma + Lung UK/Innovate UK grant number: AUK‐PG‐2018‐404. L. D. was supported by a clinical academic fellowship from the Chief Scientist Office (CAF/17/01).

Canny A, Donaghy E, Murray V, et al. Patient views on asthma diagnosis and how a clinical decision support system could help: a qualitative study . Health Expect . 2023; 26 :307‐317. 10.1111/hex.13657 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT