Medically, you might be interested in…Asthma

Asthma
It is no harm to remind ourselves as doctors why we do this job, and the occasional dire consequences if due process is not followed. I begin this piece with an account of the coroner’s report on the death of a 10-year-old boy in England.1,2

William Gray, from Essex, died on May 29, 2021 from a cardiac arrest caused by respiratory arrest resulting from acute severe asthma. He had narrowly survived a previous near fatal attack in October 2020.

The Essex area coroner found that his death was contributed to by neglect and that he died ‘as a consequence of failures by healthcare professionals to recognise the severity and frequency of his asthma symptomology and the consequential risk to his life that was obvious’.

In a report aimed at preventing future deaths she added, “William’s death was avoidable. There were multiple failures to escalate and treat William’s very poorly controlled asthma by healthcare professionals that would and should have saved William’s life.”

Both patients and doctors all too often take asthma for granted. So, what should we do? Firstly, the excellent and easily followed Global Initiative for Asthma (GINA) pocket guideline3 is a must for every healthcare professional dealing with asthma.

The report stresses the need to assess the patient, adjust treatment and then review subsequently to ensure treatment is working. While it is not possible here to summarise the whole document here, it is worthwhile pointing out the simplified strategy of “Maintenance and Reliever Therapy” (MART) using an “Anti-inflammatory Reliever” (AIR).

This usually means treatment with an inhaler which combines both inhaled corticosteroid (ICS) and a rapid onset long-acting beta agonist (LABA) such as formoterol. This can be used for the first four steps of treatment in adults and adolescents. The beauty of this approach is that the confusion that often exists among patients around the difference between a reliever (B agonist) and preventer (also now called a controller) inhaler, which is usually an ICS, is lessened as both are used together.

The other advantage of this approach is that the anti-inflammatory meds are taken, and their dose increased, early on in the course of an attack. For children aged 6-11 years, the options are slightly different with low dose ICS being used whenever a short acting B agonist (SABA) is taken. Also, leukotriene receptor agonists (LTRA) are recommended in the early stages as a controller or preventer. GINA also give a helpful summary of the changes that have been made in the most recent guideline.4

At all stages and for every patient, it is vital to check concordance with recommended dosage and inhaler technique. Written asthma action plans are also lifesaving. These help the patient recognise when their control is deteriorating, giving them the vocabulary and understanding to seek help and ensure that the treatment they receive is working.

There is also helpful advice on step-down therapy when control is good for a period, usually around three months.

Membership of the Asthma Society5 should be encouraged for information and support.

A recent review in the NEJM on management of asthma in adults6 stressed the following points:

• Ensure that the diagnosis is correct.
• The three main goals of asthma management are control of symptoms, reduction in risk of exacerbations, and minimization of adverse effects of medications.
• Every visit should include a review of inhaler technique, medication adherence, coexisting conditions, ongoing exposures to environmental triggers, and confirmation of a correct diagnosis of asthma.
• In patients with mild asthma, the preferred treatment option is an inhaled glucocorticoid–formoterol combination as needed, and alternative options include the use of combination inhaled glucocorticoid–albuterol as needed or low-dose maintenance inhaled glucocorticoid plus a short-acting β2-agonistreliever as needed. Albuterol is the name given to salbutamol in the USA.
• Combination inhaled glucocorticoid–formoterol maintenance and reliever therapy is the preferred treatment for moderate-to-severe asthma as compared with an inhaled glucocorticoid with long-acting β2-agonist maintenance plus as-needed short-acting β2-agonist reliever therapy.

It is important to note that the treatment recommended in this NEJM review article is almost identical to the GINA guideline.

Finally, the importance of social factors and especially environment in the aetiology of asthma in children has been shown7. It is essential that tackling poverty and providing social equality becomes a health priority.

References

1. Hayes S. William Gray: Prevention of future deaths report. Courts and Tribunals Judiciary. Dec 2023. www.judiciary.uk/prevention-of-future-deathreports/william-gray-prevention-of-future-deaths-report.
2. Dyer C. Coroner warns of “multiple failures” that contributed to child’s death from asthma BMJ 2024;384:q641 http://dx.doi.org/10.1136/bmj.q641 Published: 13 March 2024.
3. Global Initiative for Asthma. A Pocket Guide for Asthma Management and Prevention for adults, adolescents and children aged 6-11. Updated 2023. https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/ (Accessed 19/04/2024).
4. GINA Guideline; What’s New in 2023 slide set. Available to download at: https://ginasthma.org/wp-content/uploads/2023/08/GINA-2023-Whats-New-Slides-WEBSITE.pptx.
5. Asthma Society of Ireland https://www.asthma.ie/home.
6. Mosnaim G. Asthma in Adults. N Engl J Med 2023;389:1023-31. doi: 10.1056/NEJMcp2304871.
7. Pollack C et al. Association of a Housing Mobility Program With Childhood Asthma Symptoms and Exacerbations. JAMA. 2023;329(19):1671-1681. doi:10.1001/jama.2023.6488.