Reviewing your patient
For patients to manage a variable condition like asthma, it’s important that they’re able to recognise and act on symptoms and know when their control is slipping. Asthma reviews are key to give your patient the education and information they need for effective self management.
Asthma reviews in primary care should take place at least yearly, or within 48 hours of an exacerbation, asthma attack or admission to hospital.
Reviews should ideally be a 20- to 30-minute face-to-face consultation which covers all aspects of your patient’s asthma care.
Asthma reviews should only be carried out by healthcare professionals who have completed training in asthma management.
For advice on asthma training, see our Professional Development page
10 top tips for asthma reviews
1. Check the diagnosis is correct
30% of asthma diagnoses are estimated to be incorrect. Check that the diagnosis of asthma is supported by clinical assessment and objective testing. If there is any uncertainty, you can repeat objective testing.
2. Explain the diagnosis
In order for self management to work, first of all your patient needs to understand what asthma is, how their medications work and how they can tell when their asthma's getting worse. This will help improve their confidence and increase adherence to their treatment regime. Consider showing your patient this video.
3. Assess asthma control
Assessing how well your patient’s asthma is controlled is fundamental to the asthma review process. The Asthma Control Test (ACT) uses a series of questions for patients to assess their asthma control.
Some HCPs send the ACT electronically and use the results to prioritise which patients they will bring for a face-to-face appointment. It’s important to remember that the ACT is designed to support the asthma review consultation rather than as a risk-stratification tool to help you identify patients with uncontrolled asthma.
It is really important to look at how your patient is taking their medication. Poor adherence to inhaled corticosteroids is an important reason why asthma becomes uncontrolled and increases the risk of asthma attacks.
Are they taking their preventer medication as prescribed? If not, ask what they are struggling with.
Do they forget? Try suggesting
- Setting a reminder on their phone
- Downloading an app or
- Keeping their inhaler next to their toothbrush.
Do they have worries or concerns about their medication? Discuss these with your patient.
How often are they requesting short acting bronchodilator inhalers?
- People with well-controlled asthma should be using no more than 3 SABA inhalers a year
- If your patient is requesting more, this should trigger a review to find out why
- SABA prescriptions should not be limited until you have helped your patient regain asthma control.
For your patients on MART or AIR regimes, ask how often your patient is using extra doses of their inhaler. More than 3 times a week or regularly using extra doses most days indicates poor control.
If your patient's asthma has been well controlled for 3 months or longer, consider stepping down therapy. Click here for guidance on stepping down treatment
If they are poorly controlled, think about the factors which can affect asthma control before you consider stepping up therapy.
4. Check the number of flare-ups in last 12 months, or since last review
Look through the notes to find any flare-ups, admissions to hospital or attendances at A&E/urgent treatment centres.
Refer your patient to secondary care if there is poor control despite moderate dose therapies (link to managing asthma page) or if they have required 2 or more courses of corticosteroid tablets (Prednisolone) in the past 12 months.
5. Check peak flow
It is important that your patient knows their usual peak flow so that they can use this as a measure of whether their asthma is getting worse. Make sure you check their peak flow technique and correct if necessary. Their best peak flow should be recorded in their notes for future reference.
6. Review inhaler technique and consider if patient would benefit from and be willing to switch to a lower carbon inhaler.
It is essential that patients are shown how to use their inhalers and are prescribed a device that is suitable for them. Qof also requires that an HCP observes their patients using their inhalers. Click here for guidance on inhaler techniques
Offer your patient a lower carbon alternative if they are using a pressurised-Metered Dose Inhaler (pMDI). See our page on choosing the right inhaler device for your patient for details on how to do this.
7. Review triggers and factors which affect asthma control
If your patient understands and recognises their triggers, you can work out how to reduce exposure to them and limit their impact. Check your patient’s occupation for signs of occupational asthma. Ask about the indoor and outdoor air quality and how it affects their asthma.
See here for more information about finding and managing factors which affect asthma control such as gastric reflux, nasal symptoms, rhinitis and medications (both prescribed and over-the-counter).
8. Check smoking status
Explain that smoking not only harms the lungs, but it also makes inhaled corticosteroids less effective. Offer smoking cessation support. Suggest Asthma + Lung UK's Stopping Smoking leaflet
9. Check vaccination status
Explain to your patient that people living with asthma are more likely to develop potentially serious complications from influenza.
Click here for information for your patients on the flu vaccine
10. Review asthma action plan
Asthma action plans are an essential part of your patient’s self management. They should be developed and reviewed together with your patient, to make sure that they understand their day-to-day treatment, know what to do if their symptoms are worsening and what to do in an emergency.
Find our asthma personal asthma action plans and a step by step guide to filling them out here