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AsthmaXchange provides learning resources and up-to-date information for healthcare professionals in primary and secondary care on asthma diagnosis, treatment and management.

Find out more about asthma by completing the case-based e-learning modules and accessing the latest featured content.

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Asthma Resources

Access and download the latest featured asthma content, resources and tools for use in daily clinical practice

Resources

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Anticholinergics in asthma e-learning module
Learn about the use of anticholinergics in asthma in this interactive e-learning module
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Long-acting anticholinergics mechanism of action video
Learn about the mechanism of action of long-acting anticholinergics in asthma in this short animation
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Expert opinion: long-acting anticholinergics in asthma 
Watch Professor David Halpin explain the use of long-acting anticholinergics in the treatment of asthma
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www.spirivaglobal.com/asthma
Click here to learn more about tiotropium Respimat® in asthma
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Anticholinergics in asthma e-learning module
Learn about the use of anticholinergics in asthma in this interactive e-learning module
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IPCRG smoking cessation guide
Access the smoking cessation desktop helper, developed by IPCRG, to help engage your patients in conversations on smoking cessation  
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IPCRG spirometry guide
Access the spirometry guide, developed by IPCRG and PCRS-UK, to provide practical information on how to perform spirometry tests  
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IPCRG SIMPLES document    
Access the SIMPLES desktop helper document, developed by IPCRG; a practical guide to improve the care of adults with difficult-to-manage asthma  
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HCP-Patient consultation guide
Learn about the key actions for you and your patients to cover before, during, and after asthma reviews  
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Anticholinergics in asthma e-learning module
Learn about the use of anticholinergics in asthma in this interactive e-learning module
link
Long-acting anticholinergics mechanism of action video
Learn about the mechanism of action of long-acting anticholinergics in asthma in this short animation
link
Expert opinion: long-acting anticholinergics in asthma 
Watch Professor David Halpin explain the use of long-acting anticholinergics in the treatment of asthma
link
www.spirivaglobal.com/asthma
Click here to learn more about tiotropium Respimat® in asthma
link
IPCRG smoking cessation guide
Access the smoking cessation desktop helper, developed by IPCRG, to help engage your patients in conversations on smoking cessation  
Open

FAQs

Explore FAQs in the diagnosis, treatment, and overall management of asthma, with answers provided by primary care experts
  • How can I correctly diagnose asthma, particularly in young patients?

    Current guidelines1, 2 advise that healthcare professionals (HCPs) can diagnose asthma based on a clinical history suggestive of reversible and variable airway narrowing, supported by objective tests. Reversibility can be demonstrated using diagnostic trials of short-acting bronchodilators and inhaled or oral steroids. 
    It is ideal to have a measure of airflow obstruction, either with a peak flow meter, a microspirometer, or full spirometry before and after any test of reversibility; if this is not possible, a well-documented change in symptoms may suffice. 
    As asthma is variable over time, any diagnostic test has to be interpreted within the clinical context; a negative test on a day when the patient is asymptomatic cannot exclude the possibility of asthma. Tests of airflow limitation are specific but not sensitive,1 meaning that an abnormal test result is more helpful than a normal test result. Assessment of airway responsiveness or eosinophilic airway inflammation using exhaled nitric oxide (FeNO) are more sensitive, with FeNO having the additional advantages of being easy to measure and identifying corticosteroid-responsive disease.2
    Objective testing cannot be performed in children younger than 5 years.1 After 5 years of age, it becomes increasingly possible to obtain a measure of airway obstruction. For those children where testing is not yet an option, a process of regular re-assessment and use of inhaled therapies when the diagnostic suspicion is high is appropriate.1 HCPs should actively look for evidence of improvement, or none, and refer the patient to secondary care if usual treatment does not stop the symptoms. Objective testing should be performed, if possible, as soon as a child is old enough.1

    References
    1.    Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org (accessed July 2016).
    2.    British Thoracic Society/Scottish Intercollegiate Guideline Network. British Guideline on the Management of Asthma, 2016. Available from: http://sign.ac.uk/guidelines/fulltext/141/index.html (accessed July 2016).

     

  • How can I correctly diagnose asthma in people with suspected exercise-induced asthma?

    It is possible to test the response to exercise (or any other trigger for asthma) using symptoms or measures of airflow obstruction. In the case of exercise, where spirometry testing is possible, the test should be performed before and after a level of activity that causes symptoms to see if there is a significant difference in pre- and post-test results. A fall in forced expiratory volume in one second (FEV1) of >10% and >200 mL from baseline is suggestive of exercise-induced asthma in adults.1

    Reference
    1.    Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org (accessed July 2016).

  • What are the key points to consider when interpreting spirometry readings and data in asthma?

    A negative spirometry result does not exclude asthma. Indeed, a study in a primary care population showed that only approximately a quarter of those subsequently shown to have asthma had obstructive spirometry at the time of assessment.1 The clinical history, repeated objective measures over time, and response to treatment trials will help establish confidence in both HCP and patient regarding the diagnosis of asthma. 
    An FEV1/forced vital capacity (FEV1/FVC) ratio of <70% suggests airway obstruction.2,3 Asthma is one condition that causes airway obstruction. A clinical history of episodic symptoms, triggered by allergens or an upper respiratory tract infection, in the context of a non-smoking patient with atopy increases the probability of the diagnosis being asthma. 

    References
    1. Schneider A, et al. BMC Pulm Med 2009;9:31.
    2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org (accessed July 2016).
    3. British Thoracic Society/Scottish Intercollegiate Guideline Network. British Guideline on the Management of Asthma, 2016. Available from: http://sign.ac.uk/guidelines/fulltext/141/index.html (accessed July 2016).

  • What tools should I use to rule out asthma in a person with a persistent cough?

    The predictive value of isolated signs or symptoms is poor. Asthma is one cause of chronic cough, but most people with an isolated symptom of cough do not have asthma.1 Treatment with corticosteroids, either orally for 1–2 weeks or inhaled for 6 weeks will treat an asthma-related cough in most people.1,2 It is important to ask about the severity and frequency of cough using a visual analogue scale before and after treatment to help objectively assess the response. 
    References
    1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org (accessed July 2016).
    2. British Thoracic Society/Scottish Intercollegiate Guideline Network. British Guideline on the Management of Asthma, 2016. Available from: http://sign.ac.uk/guidelines/fulltext/141/index.html (accessed July 2016).

  • What factors should be considered when selecting an inhaler device for adults with asthma?

    The choice of inhaler device is defined by the choice of drug, device availability and any relevant reimbursement restrictions.1 Consideration of the patient’s age or ability to use an inhaler may further help in choosing the device. If the patient is unable to use a certain device, then HCPs should offer an alternative.
    Even with training, not all patients can use their inhalers correctly or maintain good inhaler technique, as patients may:

    • be unable to handle the inhaler
    • have strong negative preferences towards particular devices
    • have natural breathing patterns that do not match their prescribed inhaler.

    Matching the device to the patient can be a better course of action than training and retraining a patient to use a specific inhaler.2 Ensuring the patient is given an inhaler they can use may prevent the need for increased therapy.
    References
    1. Dolovich MB, et al. Chest 2005;127:335–371.
    2. Haughney J, et al. Respir Med 2010;104:1237–1245.

  • What are ‘add-on therapies’, and what data and information are available on them?

    Most patients with asthma can achieve control by taking a single daily controller medicine and occasionally using a reliever inhaler. This is usually enough to manage the condition. 
    However, some people with asthma may require extra treatments in order to help them manage their asthma. These are called 'add-on treatments' or 'add-on therapies' because they are always added on to ICS treatment.1
    Add-on therapies for patients with severe asthma may be considered when patients have persistent symptoms and/or exacerbations despite optimised treatment with moderate-dose controller medications (usually a high-dose ICS) and treatment of modifiable risk factors (refer to the GINA strategy for further information).2

    References
    1. Asthma UK. Other medicines and treatments. Available from: https://www.asthma.org.uk/advice/inhalers-medicines-treatments/other/ (accessed July 2016).
    2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org (accessed July 2016).

  • How can both good and poor inhaler technique be identified and how can I ensure good inhaler technique?

    Poor inhaler technique leads to poor asthma control, an increased risk of exacerbations and increased adverse events. Most patients (up to 70–80%) are unable to use their inhaler correctly.1
    Unfortunately, many HCPs are unable to correctly demonstrate how to use the inhalers they prescribe. Most people with incorrect inhaler technique are unaware that they have a problem with their technique. There is no ‘perfect’ inhaler – patients can have problems using any inhaler device.1
    The Global Initiative for Asthma (GINA) strategy suggests some approaches to ensure effective use of inhaler devices.1 These include choosing the most appropriate inhaler for the patient before prescribing, checking inhaler technique at every opportunity, showing the patient how to use the device correctly with a physical demonstration, and rechecking inhaler technique as frequently as possible, as errors often surface soon (4–6 weeks) after initial training.1
    Reference
    1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org (accessed July 2016).

  • Why do people with asthma often not take their regular controller medication and what can I do about it?

    Patient adherence to medication is influenced by a number of factors, such as forgetting doses or financial constraints, as well as how the individual judges the necessity of their treatment relative to their concerns and symptoms.1
    Intentional non-adherence derives from the balance between the patient’s beliefs about the personal necessity of taking a given medication relative to any concerns about taking it.2
    A patient’s adherence to their medication is often influenced by:

    • their perceptions of illness (i.e. expectations, aspirations and goals)
    • their beliefs and concerns about treatments and cultural perceptions of asthma
    • their perceived need and the level of control they want to achieve
    • contextual issues, such as past experiences, the influence of others and practical difficulties.3

    HCPs must be prepared to work in an on-going partnership with patients to ensure they are offered a clear rationale as to why inhaled corticosteroids (ICS) are necessary, and to address patient concerns about potential adverse effects. This approach, based on a detailed examination of the patient’s perspectives on asthma and its treatment, and with an open, non-judgmental manner on the part of the HCP, is consistent with the idea of concordance.2 This, of course, means accepting that sometimes patients will choose not to take regular medication; the HCP’s role is to ensure that this is an informed decision.

    References
    1. Horne R. Chest 2006;130(1 Suppl):65S–72S.
    2. Horne R, et al. National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO). 2005. Available from: http://www.nets.nihr.ac.uk/__data/assets/pdf_file/0009/64494/FR-08-1412-076.pdf (accessed July 2016).
    3. Horne R, et al. BMC Pulm Med 2007;7:8.

  • What should I do if an adult with asthma is uncontrolled on ICS/LABA treatment?

    Diagnostic error is one of the most common reasons for failure to achieve asthma control; the first thing to do is to reassess the diagnosis using the approaches discussed in the Diagnosis section of these FAQs. If the diagnosis is confirmed, an attempt should be made to understand the reasons for poor control using the SIMPLES approach to difficult-to-manage asthma, developed by the International Primary Care Respiratory Group (IPCRG) and it is available in several languages (accessible from this link).1
    GINA has also developed an approach to investigate patients with poor symptom control and/or exacerbations despite treatment (refer to Box 2-4 in the GINA strategy).2
    After reassessing the diagnosis and dealing with the reasons for poor control, if needed, the physician should discuss with the patient the need to step up treatment to a step 4 option.
    If the patient was on low-dose ICS/long-acting β2-agonist (LABA) (step 3), the preferred next step is medium-/high-dose ICS/LABA in a single inhaler. As an alternative, if there is a history of exacerbations, the physician can agree with the patient to add tiotropium by soft mist inhaler, while keeping a low-dose ICS/LABA in a single inhaler. Tiotropium by soft mist inhaler is an add-on treatment for patients (≥12 years old) with a history of exacerbations.2
    If the patient was on medium-/high-dose ICS (step 3), the next logical option would be to add-on a LABA by switching to a medium-/high-dose ICS/LABA in a single inhaler (step 4).2

    References
    1. Ryan D, et al. Prim Care Respir J 2013;22:365–373.
    2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org (accessed July 2016).

  • How and when should regular medication be stepped down or stopped?

    There are some reasons to step down asthma regular medication.
    Consider stepping down controller treatment until symptoms recur, to help confirm the diagnosis of asthma as suggested in the GINA strategy.1
    After starting initial controller treatment, it is advisable to review the patient’s response after 2–3 months, or earlier, depending on clinical urgency, and step down treatment once good control has been maintained for 3 months.1
    Consider stepping down regular asthma treatment once good asthma control has been achieved and maintained for about 3 months to find the lowest level of treatment for the patient that controls both symptoms and exacerbations. As part of this process it is important to:
    provide the patient with a written asthma action plan, monitor closely, and schedule a follow-up visit
    not completely withdraw ICS unless this is needed temporarily to confirm the diagnosis of asthma.1
    Any step down of asthma treatment should be considered as a therapeutic trial, with the response evaluated in terms of both symptom control and exacerbation frequency. Prior to stepping down treatment, the patient should be provided with a written asthma action plan and instructions for how and when to resume their previous treatment if their symptoms worsen.1

    References
    1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org (accessed July 2016).

  • What is the current guidance on referral to pulmonologists for adults with asthma, and what can I expect them to do? 

    Referrals to specialists are made for a number of reasons as outlined below.1,2

    • Diagnostic uncertainty

    Asthma is a clinical diagnosis and it is often possible to make the diagnosis in primary care based on a good clinical assessment, corroborated with objective tests available in primary care (such as peak flow varying over time or spirometry with reversibility). If the diagnosis is not clear and/or other diagnoses need to be excluded, a referral may be needed to arrange investigations that require specialist facilities (such as challenge tests, full lung function assessment and tests of eosinophilic airway inflammation). However, sometimes just discussing a complex case with a specialist may be helpful for a primary care physician. 

    • Occupational asthma

    If an occupational cause is suspected, the patient should be referred promptly for tests to confirm the diagnosis, and manage the challenge of eliminating work-related exposure and the medicolegal aspects of compensation. The key feature is a history of occupational worsening of asthma, often after an asymptomatic period (latency). Bakers, laboratory animal handlers, spray painters, solderers and plastic workers are at particular risk of occupational asthma.

    • Poor control

    Despite following a structured approach (such as SIMPLES)2, it is sometimes not possible for a primary care physician to help patients bring their asthma under control, and referral may be considered. A pulmonologist is likely to go back to the beginning and reconsider the diagnosis, reassess practical issues such as adherence and inhaler technique, and address smoking cessation, trigger avoidance, and comorbidities before advising stepping up to more specialised treatment. They are also more likely to have access to more diagnostic tests and other specialist team members, such as a respiratory physiotherapist. Most guidelines recommend specialist advice before commencing a third controller medication, high-dose inhaled steroids, regular oral steroids, omalizumab or mepolizumab.

    • At-risk asthma

    A few patients are at high risk of very severe or fatal asthma attacks and should be under specialist care. These at-risk asthma patients may be identified by their past history of life-threatening asthma, often require high doses of treatment to control troublesome symptoms, and many have psychosocial problems that make it difficult for them to look after their asthma. 

    • Concerned or anxious patient

    It may be helpful to request a specialist consultation to reassure concerned or anxious patients. The specialist may not say anything different to the family doctor, but sometimes it helps patients to have the advice reinforced by a pulmonologist.3

    Further information on referrals can be found in the feature article ‘Shared care in asthma: a role for primary and secondary healthcare professionals’.

    References
    1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org (accessed July 2016).
    2. Ryan D, et al. Prim Care Respir J 2013;22:365–373.
    3. Agusti A, et al. Eur Resp J 2016;47:410–419.

  • What are the key points to include in a referral letter from primary care?

    Clearly, the referral letter needs to be tailored to individual circumstance, but in general the letter should contain the information below.1
    •    Introduce the patient, with relevant details about demography, social circumstances, and occupation. 
    •    Summarise the past history of asthma and other related conditions.
    •    Explain the problem in diagnosing or managing the patient and the help needed.
    •    Provide a summary of what has been done so far. 
    •    Provide copies of any results (for example spirometry, blood tests including eosinophil count) and detail treatments tried previously and whether (or not) they have helped.

    Reference

    1. Ryan D, et al. Prim Care Respir J 2013;22:365–373.

  • How can I best help smokers with asthma quit?

    As there have been no studies specifically looking at treating nicotine dependency in people with asthma, it is recommended that the same guidelines are followed as for the general smoking population. It is known from studies in people with severe and very severe chronic obstructive pulmonary disease that 6-month smoking cessation rates of almost 50% can be achieved when the right medications and right level of behavioural support are provided.1
    People with asthma who smoke may have higher levels of dependency and higher chances of relapse, so ensuring medicine adherence and high enough doses of nicotine replacement therapy (NRT) are important. People are often under-dosed with NRT due to concerns about potential harm from higher doses, and may fail in their attempt to stop smoking. Dual prescription of multiple NRT choices, according to situation and need, and smoking cessation drugs such as varenicline (varenicline may not be available in all regions and countries) can be combined, and evidence suggests this leads to a higher likelihood of smoking cessation.2
    Encourage people with asthma who smoke to quit by advising that symptoms, asthma attacks, and hospitalisations are all reduced if they do not smoke tobacco. It is also likely that they will be able to reduce the dose of ICS, as low doses are more effective in non-smokers than smokers.3

    References
    1. Jiménez Ruiz CA, et al. Nicotine Tob Res 2012;14:1035-1039.
    2. Koegelenberg CN, et al. JAMA 2014;312:155–161.
    3. Tomlinson JEM, et al. Thorax 2005;60:282–287.

  • What effects do e-cigarettes have on asthma versus normal cigarettes?

    If your patient is using an electronic cigarette regulated in your country as a medicine, then the constituents will have been assessed as with other nicotine replacement products for potential harm. In this case you can be certain that use of an e-cigarette will be less harmful than tobacco smoke.1
    It is not known if nicotine delivery through an e-cigarette is harmful in patients with asthma as the studies that can answer this question have not yet been performed. 
    Non-medicinal e-cigarettes and unregulated versions will not have been through the same, or indeed possibly any quality control or safety testing. While it is likely that even these products are less harmful than tobacco smoke in patients with asthma, it is again hard to be certain about the level of harm.1
    A pragmatic approach would be to recommend smoking cessation with medicinal products and specialised support of sufficient intensity to support the level of the patient’s dependence. 

    Reference
    1.    Public Health England. E-cigarettes: an evidence update. 2015. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf (accessed July 2016).