WHAT IS
ASTHMA?
Lynne Powell RN, MSc., IP, PgCEd
BTS/SIGN (2012)
‘Asthma is a common condition which
produces a significant workload for general
practice, hospital outpatient clinics and
inpatient admissions. It is clear that much of
this morbidity relates to poor management
particularly the under use of preventative
medicine.’
British Thoracic Society, Scottish Intercollegiate Guidelines Network, British Guideline on the
Management of Asthma A national clinical guideline May 2008. Revised January 2012.
NICE
QS25 Quality standard for asthma
 Asthma is a long-term condition that affects the airways in the
lungs in children, young people and adults.
 Classic symptoms include breathlessness, tightness in the chest,
coughing and wheezing.
 The goal of management is for people to be free from symptoms
and able to lead a normal, active life.
 This is achieved partly through treatment, tailored to the person,
and partly by people getting to know what provokes their
symptoms and avoiding these triggers as much as possible.
 The causes of asthma are not well understood, so a cure is not
usually possible, although this can sometimes be achieved in
occupational asthma.
NICE
QS25 Quality standard for asthma
 Occupational factors account for about 1 in 6 cases of asthma in
adults of working age[1].’
 In the UK, 5.4 million people are currently receiving treatment for
asthma, 1.1 million of whom are children[2].
 Asthma is the most common long-term medical condition, and 1
in 11 children has it.
 There are around 1000 deaths a year from asthma, about 90% of
which are associated with preventable factors. Almost 40% of
these deaths are in people under 75.
 Asthma is responsible for large numbers of accident and
emergency department attendances and hospital admissions.
Most admissions are emergencies and 70% may have been
preventable with appropriate early interventions[3].’
Diagnosis
 The diagnosis of asthma is a clinical one; there is no
standardised definition of the type, severity or
frequency of symptoms, nor of the findings on
investigation.
 The absence of a gold standard definition means that it
is not possible to make clear evidence based
recommendations on how to make a diagnosis of
asthma.
Diagnosis
 Central to all definitions is the presence of symptoms
(more than one of wheeze, breathlessness, chest
tightness, cough) and of variable airflow obstruction.
 More recent descriptions of asthma in children and in
adults have included airway hyper-responsiveness and
airway inflammation as components of the disease.
 How these features relate to each other, how they are
best measured and how they contribute to the clinical
manifestations of asthma, remains unclear.
Diagnosis
 Although there are many shared features in the
diagnosis of asthma in children and in adults there
are also important differences.
 The differential diagnosis, the natural history of
wheezing illnesses, the ability to perform certain
investigations and their diagnostic value, are all
influenced by age.
What causes an asthma
attack?
 It can start at any time.
 Two-thirds of people get symptoms in childhood.
 More likely if there is a family history. It often runs in families,
especially if the related allergic conditions of eczema and hay fever are
present.
 Nasal problems such as polyps.
 Environmental factors, poor air quality if you already have asthma.
 Modern lifestyles, central heating, double glazing, carpeting and
upholstered furniture.
 Not all asthma attacks/exacerbations are the same
 Some are worse than others
 There are 4 contributory factors to an exacerbation
4 contributory factors for
an exacerbation of asthma
 Hypersensitivity – Once the airways have been exposed
to a trigger, they become easily irritated with repeated
exposure.
 Bronchospasm – The muscles around the airways
tighten up & make the airways smaller.
 Inflammation – The airways become swollen & irritated.
This also makes the airways smaller & makes breathing
more difficult.
 Mucus production – Inflamed airways produce excess
mucus which clogs the already narrowed openings.
Symptoms of an
exacerbation of asthma
 Cough
 Shortness of breath at rest or with exercise
 Trouble exhaling
 Wheezing
 Chest tightness
 Productive cough usually white & frothy
 Night-time waking with shortness of breath
Asthma Triggers
 Strong emotions (laughing or crying)
 Hot or cold air
 Odors (perfume, cleansers, air
freshener, etc)
 Exercise
 Exposure to animals (cats, dogs,
horses, etc)
 Dust mites, cockroaches
 Smog
 Pollens, weeds, grasses
 Smoke
Atopy & allergy
 Atopy is the predisposition of an individual to produce
high quantities of IgE in response to allergens in the
environment.
 This predisposition is inherited from your mother, father
or both.
 Only atopic people develop sensitivity to one or more
allergens.
 Atopy is silent; atopic people do not necessarily display
symptoms of allergy.
 The only way to identify atopy is through allergy testing
(IgE/RAST; skinprick testing).
Atopy & allergy
 Allergy means that the person develops symptoms
upon contact with an allergen to which he/she has
become sensitive.
 You need to be atopic to become allergic
 but if you are atopic you will not necessarily
progress to allergy.
Allergen
exposure
Early and Late phase response
Overview of
allergic
response
Types of allergies
Many asthmatics show
signs of allergy such as:
 Eczema
 Allergic/perennial rhinitis
 Foods allergies such as dairy
products
 Angio-oedema
 Anaphylaxis
Allergic/non allergic
If evidence of allergy is insisted upon for a diagnosis
of asthma, then this will exclude non-allergic
individuals who have exactly the same symptoms and
signs, and who respond to anti-asthma therapy.
It is therefore perfectly reasonable to classify asthma
as:
 non-allergic ('intrinsic')
 allergic ('extrinsic').
Quality and Outcome Framework guidance for
GMS Contract Wales 2013/14
Indicator
Points
Achievement
thresholds
Records
AST001. The contractor establishes and maintains
a register of patients with asthma, excluding
patients with asthma who have been prescribed no
asthma-related drugs in the preceding 12 months
4
Initial diagnosis
AST002W. The percentage of patients aged 8 or
over with asthma (diagnosed on or after 1 April
2006), on the register, with measures of variability
or reversibility recorded between 3 months or
anytime after diagnosis.
15
45-80%
AST003W. The percentage of patients with
asthma, on the register, who have had an asthma
review in the preceding 15 months that includes an
assessment of asthma control using the 3 RCP
questions
NICE 2011 menu ID: NM23
20
45-70%
AST004W. The percentage of patients with asthma
aged 14 or over and who have not attained the age
of 20, on the register, in whom there is a record of
smoking status in the preceding 15 months
6
45-80%
Ongoing management
Asthma
(AST)
QOF
Asthma (AST) QOF
Quality and Outcome Framework guidance for GMS Wales 2013/14
 Asthma is a common condition which responds well to
appropriate management and which is principally
managed in primary care.
 One of the main difficulties in asthma is the variability
 Some symptoms of asthma are shared with diseases of
other systems
 A proportion of patients with COPD will also have asthma
 It is inappropriate to monitor symptom-free patients on no
therapy or minimal symptoms
AST indicator 003W
(NICE 2011 menu ID;NM23)
RCP questions
In the last month:
 Have you had difficulty sleeping because of your
asthma symptoms (including cough)?
 Have you had your usual asthma symptoms during
the day (cough, wheeze, chest tightness or
breathlessness?
 Has your asthma interfered with your usual
activities (for example, housework, work/school,
etc.)?
Asthma Annual Review
‘If asthma appears to be uncontrolled, the following
are to be managed appropriately before increasing
asthma therapy:’
AST indicator 003W (NICE 2011 menu ID;NM23) RCP questions
 Smoking behaviour
 Poor inhaler technique
 Inadequate adherence to regular preventative
asthma therapy
 Rhinitis
Asthma Annual Review
AST indicator 003W (NICE 2011 menu ID;NM23)
During an asthma review the following takes place:
 Assess symptoms (using the 3 RCP questions)
 Measure peak flow
 Assess inhaler technique
 Consider a personalised asthma plan
Asthma myths
 Asthma can be cured
 You can be infected with asthma by someone who has it
 A change in environment may help treat your asthma
 Patients with asthma shouldn’t exercise
 Asthma medications are addictive
 You don’t die from asthma
 Asthma symptoms are the same for everyone
 You grow out of asthma as you get older
 Asthma only presents in children
Is asthma serious?
http://www.asthma.org.uk/asthma-facts-and-statistics
 Imagine being paralysed by fear as you struggle to breathe,
unable to speak, unable to ask for help. That’s what an
asthma attack feels like.
 There are 5.4 million people with asthma in the UK, which
means asthma affects one in five households. Asthma is not
just an excuse to skip PE. For a quarter of a million people
with severe asthma, even climbing the stairs can feel like a
marathon, never mind going outside their home.
 Three people die every single day because of asthma. But
most of these deaths could have been avoided. Asthma UK
is the charity dedicated to changing this.
Key facts
 5.4 million people in the UK are currently receiving treatment
for asthma: 1.1 million children (1 in 11) and 4.3 million adults
(1 in 12).
 Asthma prevalence is thought to have plateaued since the late
1990s, although the UK still has some of the highest rates in
Europe and on average 3 people a day die from asthma.
 There were 1,143 deaths from asthma in the UK in 2010 (16 of
these were children aged 14 and under)
 An estimated 75% of hospital admissions for asthma are
avoidable and as many as 90% of the deaths from asthma are
preventable.
Asthma across the UK

In Northern Ireland 182,000 people are currently receiving treatment for asthma. This
includes 36,000 children and 146,000 adults.

In Scotland, 368,000 people are currently receiving treatment for asthma. This includes
72,000 children and 296,000 adults.

In Wales 314,000 people are currently receiving treatment for asthma. This consists of
59,000 children and 256,000 adults.

One in 11 children has asthma and it is the most common long-term medical condition.
On average there are two children with asthma in every classroom in the UK.

The UK has among the highest prevalence rates of asthma symptoms in children
worldwide.

Every 18 minutes a child is admitted to hospital in the UK because of their asthma.

The NHS spends around £1 billion a year treating and caring for people with asthma.

In 2008/09 up to 1.1 million working days were lost due to breathing or lung problems.