A group of experts recommend measures to improve asthma treatment and say that asthma should be treated as an inflammatory condition. Nerys Hairon reports
Hairon, N. (2008) Experts call for urgent improvements in asthma treatment and management. Nursing Times; 104: 49, 21-22.
A group of respiratory specialists, GPs, paediatricians and patient representatives have called for an urgent change in asthma treatment and management (Holgate et al, 2008; University of Southampton, 2008).
The group's article (Holgate et al, 2008), published in the December issue of the European Respiratory Journal, identifies a need for improvement in a range of areas related to asthma including diagnosis, recognition of the nature of the disease, asthma control, the design of clinical trials, treatment for children, asthma research, and environmental conditions.
Launched in June 2007, the declaration was intended to draw attention to shortfalls in asthma management and to urge European policymakers to recognise that asthma is a public-health problem that should be a political priority.
The article reviews the evidence supporting the need for changes in asthma management, and summarises the 10 key points in the Brussels Declaration (see box). The authors make a range of recommendations for action. The article also highlights the Finnish Asthma Programme as a best-practice example of asthma management (Haahtela et al, 2006).
Box: 10 key points in the Brussels Declaration
Key points for European politicians, doctors, researchers and patients with asthma:
Source: Summarised by Holgate et al (2008)
Holgate et al (2008) say the prevalence of asthma has risen dramatically over the past 20 years and, each year, around 180,000 deaths worldwide are attributable to asthma.
While much work has been undertaken to improve the understanding of asthma, knowledge remains suboptimal. Diagnosis can be problematic; many diseases have similar presentations and no single measure or instrument proves that asthma is present.
In addition, once diagnosed, many patients receive inadequate information and education about treatment goals and many do not achieve asthma control. Children are a particular problem, as few clinical trials examine the efficacy and safety of asthma treatment for this group and the disease course in children is not well understood.
As asthma cannot yet be cured or prevented, the authors argue that more research is urgently needed to meet the remaining challenges.
Holgate et al (2008) highlight diagnosis as a key area for improvement.
Recent guidelines from a number of bodies recommend assessing symptoms and measuring lung function. However, the authors point out there is a poor relationship between symptoms and objective lung function, and asthma is often misdiagnosed. In addition, they say lung function tests can be insensitive and are particularly difficult to perform reliably in children.
Symptoms have therefore become the key factor for asthma diagnosis, although they tend to be non-specific and are shared by a number of other diseases.
The authors also point to evidence of a 'lack of diagnostic rigour' in primary care.
The importance of recognising inflammation as a key pathology in asthma is also highlighted. In the past, asthma was considered to be a simple disease involving reversible airflow obstruction that could be treated with bronchodilators. It is now clear the condition is much more complex, and a new appreciation of asthma as a respiratory manifestation of systemic inflammatory processes is emerging. The authors argue that a better understanding of the root cause of inflammation should lead to both curative treatments and effective prevention.
Poor asthma control
Understanding the causes of poor asthma control is highlighted as a key area for action. National and international asthma guidelines, such as the Global Initiative for Asthma guidelines (GINA, 2007), have set treatment goals for practitioners and patients.
Although targets differ slightly between guidelines, their overall aim is for patients to achieve and maintain control of asthma. However, many patients still have uncontrolled asthma. The authors say that the reasons are complex and involve clinical and behavioural factors, such as: poorly implemented guidelines; inadequate use of therapies; lack of adherence to regimens; lack of patient engagement with treatment plans; and disagreement between practitioners and patients on what constitutes asthma control.
Holgate et al (2008) recommend that, to address poor control, healthcare staff need to focus on controlling asthma, not simply on adherence. They argue that patients need routine tailored evaluation that can identify psychological and lifestyle factors that may lead to inadequate asthma control and poor outcomes. They say patient education focusing on risks and benefits of treatment is crucial, as is education for practitioners that stresses the importance of engaging patients.
Asthma in children
The recent increase in asthma prevalence is mainly due to the rise in childhood asthma. In Europe, asthma is now the major long-term illness of childhood - up to 20% of children are affected and asthma is the most common reason for hospital admission among children (Smyth, 2002).
However, Holgate et al (2008) state that treatment guidelines do not provide enough information on asthma in children, and that which is given is not followed. They highlight a clear need for clinical trials to look at the efficacy and safety of asthma medications in children. As asthma differs throughout childhood, studies should examine preschool children, school-age children and adolescents separately. The authors suggest that a sound evidence base in children is likely to lead to reduced hospital stays, fewer deaths and better quality of life.
Public health and best practice
Holgate et al argue that public-health initiatives are needed to promote asthma education for both patients and healthcare providers. Patient education should stress the need for regular anti-inflammatory therapy but also highlight that patients need to control their own asthma management. Healthcare staff need to acknowledge the individual nature of asthma and the need to reduce poor outcomes by identifying the factors responsible for them. Key public-health measures at EU level should include smoking cessation, dietary improvement and obesity reduction, and pollution control.
The Finnish Asthma Programme is given as an example of a successful public-health approach to asthma (Haahtela et al, 2006). This showed that early diagnosis, active treatment and guided self-management combined with patient education and decreases in smoking and environmental tobacco smoke, can improve outcomes and cut costs.
The national asthma programme in Finland took a public-health approach, focusing on disseminating new knowledge. Its main premise was that asthma is an inflammatory disease and requires anti-inflammatory treatment from the outset. Haahtela et al (2006) concluded that it is possible to reduce the morbidity of asthma and its impact on individuals and society. Holgate et al (2008) suggest that such programmes could be used across Europe.
Holgate et al (2008) conclude that the new understanding of asthma as a systemic inflammatory disease is not reflected in current guidelines or management strategies, and few treatments address the wider systemic inflammation. As a result, treatment choices are limited, patients with asthma do not receive tailored care and many have uncontrolled asthma.
The Brussels Declaration on Asthma calls for clinical and regulatory changes to be made in diagnosing and managing asthma. Nurses can contribute by improving patient education and understanding, and ensuring asthma treatment is tailored to individuals.
Global Initiative for Asthma (2007) Global Strategy for Asthma Management and Prevention . Updated 2007.
Haahtela, T. et al (2006) A 10-year asthma programme in Finland: major change for the better. Thorax; 61: 663-670.
Holgate, S. et al (2008) The Brussels Declaration: the need for change in asthma management. European Respiratory Journal; 32: 1433-1442.
Smyth, R.L. (2002) Asthma: a major pediatric health issue. Respiratory Research; 3: Suppl 1, S3-S7.
University of Southampton (2008) News release. Experts Urge Change in Asthma Management . 1 December 2008.