Assessing the risk of attack in the management of asthma: a review and proposal for revision of the current control-centred paradigm

Abstract

Asthma guidelines focus on day-to-day control of symptoms. However, asthma attacks remain common. They continue to cause mortality and considerable morbidity, and are a major financial burden to the UK National Health Service (NHS) and the wider community. Asthma attacks have chronic consequences, being associated with loss of lung function and significant psychological morbidity. In this article we argue that addressing daily symptom control is only one aspect of asthma treatment, and that there should be a more explicit focus on reducing the risk of asthma attacks. Management of future risk by general practitioners is already central to other conditions such as ischaemic heart disease and chronic renal impairment. We therefore propose a revised approach that separately considers the related domains of daily control and future risk of asthma attack. We believe this approach will have advantages over the current 'stepwise' approach to asthma management. It should encourage individualised treatment, including non-pharmacological measures, and thus may lead to more efficacious and less harmful management strategies. We speculate that this type of approach has the potential to reduce morbidity and healthcare costs related to asthma attacks.

Figure 1. Deaths from asthma, road accidents, and epilepsy in 2000 and 2010. Data from UK National Statistics and the Department for Transport

Figure 2. Schematic to illustrate the risk of asthma attack for populations of asthma patients with good, partial, and poor asthma control

Figure 3. (A) An example of the proposed coordinates system to inform asthma management. Ongoing poor daily control results in escalation along the y axis and ongoing risk of severe asthma attack leads to escalation along the x axis. LAAC=long-acting anticholinergic, LABA=long-acting β₂-agonist, SABA=short-acting β₂-agonist, ICS=inhaled corticosteroid. Phenotype-specific anti-inflammatory relates to oral treatment (e.g. prednisolone or macrolide). The letters on the chart relate to example patients and are discussed in the text and panel (B). (B) Treatment received by example patients A, B, and C under existing and proposed guideline structures. Patient identifying letters relate to panel (A). Smoking cessation advice is not explicitly included above but is evidently a key aspect of management

Figure 4. Example of communication following an asthma risk assessment. This approach has the potential to improve understanding of the rationale for an asthma treatment, facilitate shared decision-making, and may improve concordance