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Identifying severe asthma patients in primary care 

Severe asthma is usually managed and treated in a secondary care setting. However, the initial assessment in primary care is critical to ensure that the patient receives appropriate care and referral as required.

Assessing a patient for specialist referral

When presented with a patient whose asthma is uncontrolled, the disease severity level may not be immediately clear. The following actions are first recommended when investigating uncontrolled asthma in primary care: 1

  • Investigate the patient’s inhaler technique and adherence to medication
  • Confirm the diagnosis of asthma by excluding alternative conditions. If lung function is normal when the patient is symptomatic, consider halving the ICS dose and re-testing lung function after 2–3 weeks
  • Remove potential risk factors and triggers, and check that comorbidities are correctly diagnosed and treated. Significant asthma comorbidities to consider include:
    • Rhinosinusitis
    • Gastroesophageal reflux disease
    • Obesity
    • Sleep apnoea
    • Depression
    • Anxiety

Consider stepping treatment up to the next level. Ensure that this involves shared decision-making and balances potential benefits with risks.

Reassessment after follow-up

If the above steps are not successful and the patient’s asthma is still uncontrolled after 3–6 months on Step 4 treatment, then the patient should be referred to a specialist or severe asthma clinic. This can be done earlier if symptoms are severe or uncertainty remains over the diagnosis. 1

Measuring asthma control

Accurately recording asthma control during follow-up can help monitor response to treatment. The ACT and ACQ are two commonly used methods of measuring asthma control.

ACT

ACQ

  • A patient-administered, five-item tool 2
  • Can help identify poorly controlled asthma if a patient scores 19 or lower 2-4
  • Can help familiarise clinicians with asthma management goals, to identify poorly controlled patients and evaluate the effects of treatment 56
  • A patient-administered, validated five- or seven-point questionnaire 56
  • Mainly based on symptom intensity or impact 6
  • Designed to be brief and easy to complete in the clinic 5

ACQ, Asthma Control Questionnaire; ACT, Asthma Control Test.

Measuring asthma severity

Degree of severity is not usually a progression from mild to severe disease over time. 7The ERS/ATS Task Force 2014 published guidelines on severe asthma, including an updated definition:

When a diagnosis of asthma is confirmed and comorbidities have been addressed, severe asthma is defined as ‘asthma that requires treatment with high-dose ICS plus a second controller (and/or systemic corticosteroids) to prevent it from becoming ‘uncontrolled’ or which remains ‘uncontrolled’ despite this therapy.

Chung, et al. 2014. 8

The 2016 update of the GINA guidelines recommends assessing asthma severity retrospectively from the level of treatment required to control symptoms and exacerbations. 1This differs from previous GINA definitions, which subdivided asthma by severity based on the level of symptoms, airflow limitation and lung function variability.

When a patient has been correctly diagnosed with severe asthma and remains uncontrolled despite the appropriate investigations, they should be referred for specialist care. 18

Differential diagnosis

In 12–30% of patients, non-asthmatic conditions are misdiagnosed as uncontrolled severe asthma. 8This is because there are numerous diseases that can masquerade as severe asthma in adults:

  • Dysfunctional breathlessness/vocal cord dysfunction
  • COPD
  • Hyperventilation with panic attacks
  • Bronchiolitis obliterans
  • Congestive heart failure
  • Adverse drug reaction (e.g. ACE inhibitors)
  • Bronchiectasis/cystic fibrosis
  • Hypersensitivity pneumonitis
  • Hypereosinophilic syndromes
  • Pulmonary embolus
  • Herpetic tracheobronchitis
  • Endobronchial lesion/foreign body (e.g. amyloid, carcinoid, tracheal stricture)
  • Allergic bronchopulmonary aspergillosis
  • Acquired tracheobronchomalacia
  • Churg-Strauss syndrome

References

  1. GINA 2016 © 2016 Global Initiative for Asthma, all rights reserved.  Use is by express license from the owner. www.ginasthma.org (Last accessed December 2016).
  2. Asthma Control Test. Available at: www.asthmacontroltest.com. Last accessed November 2016.
  3. Nathan RA, et al. J Allergy Clin Immunol 2004;113:59–65.
  4. Thomas M, et al. Prim Care Respir J 2009;18:41–9.
  5. Juniper EF, et al. Eur Respir J 1999;14:902–7.
  6. O’Byrne PM, et al. Eur Respir J 2010;36:269–76.
  7. Chanez P, et al. J Allergy Clin Immunol 2007;119:1337–48.
  8. Chung KF, et al. Eur Respir J 2014;43:343–73.