Desktop Helper No. 2 - A practical guide to improve difficult-to-manage asthma in primary care - online version

April 2024

This is an online version of Desktop Helper No. 2 - A practical guide to improve difficult-to-manage asthma in primary care. Visit the linked page for a PDF, translations, more information and related resources. References are available at the bottom of this page.

Difficult-to-manage asthma occurs either when the person or their clinician finds control and treatment challenging, despitethe (apparent) best possible treatment. This leads to the person facing difficulties dealing with some of the following:

Daytime asthma symptoms, more than twice/week
Any night awakening due to asthma-related symptoms
More than two exacerbations per year requiring rescue systemic corticosteroids (1)
Frequent use of SABA (≥3 canisters per year or ≥3 times per week)
Poor control despite prescription of high-dose ICS often in combination with LABA/LAMA or use of OCS (1)
Frequent primary care out-of-hours contacts (one or more per month)

ICS Inhaled corticosteroid, SABA short-acting beta-agonist, LABA long-acting beta-agonist, LAMA long-acting muscarinic antagonist, OCS oral corticosteroid

Asthma: a problem that can be managed

Studies estimate that in primary care about one out of every six people living with asthma have difficult-to-manage asthma, and of those, between a quarter and a half will have severe asthma. (2,3) Having difficult-to-manage asthma puts people at higher risk of exacerbations and even death, which are preventable with effective management. Similarly, they are at greater risk of steroid-related adverse effects (if treated with high-dose ICS or avoidable courses of OCS or low-dose OCS over a period of time), and their morbidity and health costs are disproportionately higher. People with well-controlled asthma have a better quality of life, reduced symptoms and exacerbations, reduced hospital visits and admissions and lower risk of premature death. (4-7) But most importantly, difficult-to-manage asthma can be managed using a structured approach. (8)

People with asthma and clinicians should collaborate to improve asthma control, especially those with difficult-to-manage asthma, supporting the individual to take an active role in setting goals and targets, self-monitoring, and adopting a healthier lifestyle. This guide provides practical support to primary care and other community healthcare professionals to improve the care of people with difficult-to-manage asthma and to avoid unnecessary referrals of patients who could be better managed in primary care.

How to identify a person with difficult-to-manage asthma?

Ensure that the diagnosis is correct
Over one-third of people living with asthma have an incorrect diagnosis. (9-13) Confirm that the person really has asthma before stepping up treatment as a surprising number of people diagnosed and treated for asthma (from 12 to 50%)(14) either do not have the disease or have it in association with other conditions causing persistent symptoms (see below). (15,16)

Potential confounding factors for the diagnosis of asthma or its severity are dysfunctional breathing, anxiety, exercise-induced laryngeal obstruction (EILO), vocal cord dysfunction (VCD), obesity and low level of fitness (deconditioning) (Figure 1). All of which may also co-exist with asthma.

Diagnosis can be achieved by reviewing clinical history; the diagnostic probability is significantly increased using a lung function test (DTH15). Testing for biomarkers of inflammation such as blood eosinophils, specific IgE and/or FeNO, where available, may assist in making the diagnosis and predicting response to ICS.

More information on diagnosis

Find and manage comorbidities

In people with daily symptoms and/or two or more exacerbations per year, investigate whether these symptoms are caused by asthma alone or if there are comorbidities causing similar symptoms, potentially leading to an incorrect diagnosis of asthma or aggravating their asthma. Identifying and managing these comorbid conditions may also improve asthma symptom control. The interaction between asthma and its comorbidities is bidirectional, with the potential to exacerbate or alleviate the clinical manifestations and treatment responses of both. If needed, refer for further evaluation or treatment of these conditions.

A regular and planned structured review (22,23) is the only way to improve the detection and care of people living with difficult-to-manage asthma. Review periodically, depending on level of control and the person’s needs and preferences, until control and treatment goals are achieved. Review patients in community-based clinics through remote telephone or video consultations if face-to-face review is not possible.

More information on comorbidities

What should you check when conducting a structured review?

Control of asthma

ASK THE PERSON WITH ASTHMA (in the past 4 weeks…)

Have you had daytime asthma symptoms more than twice a week?
Have you had any night awakening due to asthma?
Have you used SABA reliever for symptoms more than twice a week?
Have you had any limitation of activities due to asthma?

No to all questions – well controlled; Yes to 1 or 2 – partly controlled; Yes to 3 to 4 uncontrolled
(GINA Box 2.2, p38²⁴).

REMEMBER

Monitoring asthma control regularly is crucial to ensuring optimal outcomes.
Use a validated questionnaire to assess asthma control: ACT, RCP3 or CARAT.

Information and resources