Asthma is still a 'killer,' report warns

Health news today is dominated by the news that, as The Daily Telegraph reports, two in three asthma deaths "could have been prevented". The Daily Mail says that half of those who died were given the wrong medication.

The headlines follow the publication of a confidential enquiry report by the Royal College of Physicians into the public health impact of asthma. Currently, deaths in the UK caused by asthma are reported to be among the highest in Europe.

This review looks at 195 asthma deaths that occurred in the UK over the course of one year to try to identify avoidable factors and make recommendations for improvements in asthma care.

The report found that a lack of implementation of current guidelines on how asthma should be treated was a factor in just under half of these deaths. Asthma symptom-relieving medications were found to be over-prescribed by doctors, and not enough asthma-preventing medications were prescribed. The findings suggest that asthma was being poorly controlled in these people.

However, the blame for these preventable deaths cannot solely be attributed to health professionals. Patient factors that may have contributed to death were identified in 65% of cases. These included continued smoking or secondhand smoke exposure, not adhering to medical advice, and not attending review appointments.

The Royal College of Physicians has included recommendations to address the factors involved in these deaths to improve care for people living with asthma in the UK.

Where did the story come from?

The review was carried out by the Clinical Effectiveness and Evaluation Unit (CEEU) of the Clinical Standards Department at the Royal College of Physicians (RCP).

The RCP is an independent charity that provides doctors across all medical specialties with education, training and support throughout their careers. It plays a role in setting standards of medical practice.

What is asthma?

Asthma is a common long-term condition which affects the airways (bronchioles) that carry air in and out of the lungs. In people with asthma, the airways become tight and narrowed in response to certain triggers, such as exercise or infections. This makes it difficult for the person to breathe and leads to symptoms such as wheezing, coughing and shortness of breath.

Each person with asthma can have different symptoms, and the severity and different triggers make it difficult to have a firm diagnostic test for asthma.

Common triggers for asthma include pollen, dust mites, pet dander (dead skin shed by mammals) and certain medications, including non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen.

The severity of an asthma attack can vary greatly, and in some cases attacks can unexpectedly become life threatening or fatal.

The National Review of Asthma Deaths (NRAD) reports that the number of people affected by asthma in the UK is among the highest in the world, with up to 5.4 million people currently receiving asthma treatment.

The asthma fatality rate is said to have fluctuated over the past 50 years. Asthma deaths in the UK still remain among the highest in Europe, though comparable with Australia, New Zealand and the US.

The aim of the NRAD was to try to understand the circumstances surrounding asthma deaths in the UK, and therefore identify avoidable factors and make recommendations for changes to improve asthma care.

What to do in the event of an asthma attack

A severe asthma attack usually develops slowly, taking 6 to 48 hours to become serious. But for some people, asthma symptoms can get worse quickly. As well as symptoms worsening, signs of an asthma attack include:

you get more wheezy, tight-chested or breathless
the reliever inhaler is not helping as much as usual
there is a drop in your peak expiratory flow (see diagnosing asthma for more information)
if you notice these signs, do not ignore them – contact your GP or asthma clinic, or consult your asthma action plan, if you have one

Signs of a severe asthma attack include:

the reliever inhaler, which is usually blue, does not help symptoms at all
the symptoms of wheezing, coughing and a tight chest are severe and constant
you are too breathless to speak
your pulse is racing
you feel agitated or restless
your lips or fingernails look blue

Call 999 to seek immediate help if you or someone else has severe symptoms of asthma.

What did the RCP's review into asthma deaths find?

The review used data from the Office for National Statistics (ONS) for England and Wales, the Northern Ireland Statistics and Research Agency (NISRA), and the National Records of Scotland (NRS) to identify all asthma deaths recorded between February 2012 and January 2013.

They then carried out an in-depth review into each of these deaths using all relevant medical and post-mortem records. The reviewers analysed data for 195 people who were thought to die from asthma during this period.

Use of NHS services for asthma

The reviewers found that:

87 of the 195 people (45%) were known to have died without seeking medical assistance or died before emergency medical care could be provided.
More than half of those who died (112, 57%) did not appear to receive specialist medical care in the year before their death.
10% (19 of 195) died within 28 days of discharge from hospital after treatment for asthma
Almost a quarter (40 of 195, 21%) had attended a hospital emergency department with asthma at least once in the previous year.

Medical and professional care of asthma

The RCP's team found that:

Expert panels identified issues with the health professionals' use of asthma guidelines that could have helped to avoid death in 46% of deaths (89 of 195). This included lack of specific asthma expertise in 34 (17%) deaths, and a lack of knowledge of the UK asthma guidelines in 48 (25%) deaths.
Only around a quarter of those who died (44 of 195) had personal asthma action plans (PAAPs), which are known to improve asthma care.
For just under half (84 of 195), there was no evidence that they had an asthma review at their general practice in the year before death.
Exacerbating factors, or triggers, were documented in the records of almost half (95), including drugs, viral infections and allergy. A trigger was not documented in the other half.
Of 155 patients for whom severity could be estimated, 39% (61) appeared to have severe asthma, 49% (76) moderate asthma, and 9% (14) were being treated for mild asthma. It was considered that many patients who were treated as having mild or moderate asthma had poorly controlled under-treated asthma, rather than truly mild or moderate disease.

Prescribing and use of asthma medicines

The confidential enquiry found that:

There was evidence of excessive prescribing of reliever medication: 39% had been prescribed more than 12 short-acting reliever inhalers in the year before they died, which was considered likely to indicate poorly controlled asthma.
There was evidence of under-prescribing of preventer medication. According to current recommendations, most patients would usually need at least 12 preventer prescriptions per year: 80% had been issued with fewer than 12 preventer inhalers in the previous year.

Patient factors and perception of risk of poor control of asthma

The inquiry report found that:

Factors related to patients, their families and the environment could have helped to prevent death in 126 (65%) of those who died. These included smoking in 37 (19%), exposure to secondhand smoke in the home, not adhering to medical advice and not attending review appointments.
Poor recognition of the possibility of an "adverse outcome" (such as death) was an important avoidable factor in 7 of 10 (70%) children and 15 of 18 (83%) young people receiving care in general practice, and in two out of seven (29%) children and three out of nine (33%) young people receiving hospital care.
Psychosocial factors contributing to the risk of asthma death and its perception were identified by panels in just over a quarter of those who died (51), and included depression and mental health issues in 32 (16%) and substance misuse in 12 (6%).

What does the RCP recommend to prevent future asthma deaths?

The NRAD review makes extensive recommendations for the organisation of NHS services, medical and professional care, and prescribing and medicines use. These include:

Every NHS hospital and general practice should have a named clinical lead for asthma services who is responsible for formal training in the management of acute asthma.
Arrangements for follow-up must be made after every attendance at an emergency department or out-of-hours service for an asthma attack, and after every hospital admission.
Electronic surveillance of prescribing in general practice should be introduced to alert doctors to when patients are being prescribed too many short-acting reliever inhalers, or too few preventer inhalers.
All people with asthma should be given written guidance in the form of a personal asthma action plan (PAAP) that details their own triggers and current treatment, how to prevent relapse, and when and how to get help in an emergency.
People with asthma should have a structured review by a healthcare professional with specialist training in asthma at least once a year. People at high risk of severe asthma attacks should be monitored more closely.
All asthma patients who have been prescribed more than 12 asthma symptom-relieving inhalers in the past 12 months should have urgent review of their asthma control.
Health professionals must be aware of the factors that increase the risk of asthma attacks and death, including the importance of psychological and mental health issues.

The review also makes recommendations for patient-related factors, which include:

Patients should be encouraged to use self-management techniques to counteract their known triggers. These include increasing medication before the start of the hay fever season, avoiding non-steroidal anti-inflammatory drugs, or the early use of oral corticosteroids when the person has an exacerbation because of an allergy or viral infection.
People with asthma who smoke should be offered referral to a smoking cessation service. If a person with asthma has smoked in the past or is exposed to secondhand smoke, this should be noted in their medical records.
Children and their parents, carers and teachers should be educated about managing asthma.
The importance of minimising exposure to allergens and secondhand smoke should be emphasised, especially for young people with asthma.