Clinical Focus

Asthma: assessment, diagnosis,

and treatment adherence
Gerri Kaufman

I n the UK, an estimated 5.4 million people currently

receive treatment for asthma. This includes
1.1 million children and 4.3 million adults (Kaufman,
Abstract
Asthma is a chronic inflammatory disorder of the airways that is
2011). Asthma has a significant impact on the quality of associated with a high level of morbidity. Evidence-based guidelines
life of patients and their families. Persistent symptoms and effective treatments are available for the management of
cause significant morbidity and absence from work or asthma, but achieving control can be difficult for the majority of
school, and poor control results in an increased rate of sufferers. A careful clinical history and objective measurement
hospital admissions (Haughey et al, 2008; Rees, 2010). of lung function are essential for diagnosis of the condition.
Mortality rates associated with asthma have declined Pharmacological therapy should follow a stepwise approach to
since the 1960s, but 1131 asthma-related deaths were treatment, and choice of inhaler device and inhaler technique are
reported in 2009 (Rees, 2010). Issues with inhaler central to symptom management. Partnership between asthma
technique, adherence, and response to treatment are patients and health professionals is essential to promote patient-
associated with poor asthma control (Haughey et al, centred care and adherence to medication.
2008). Addressing the causes of poorly controlled
asthma and improving care for disease sufferers could
prevent 75% of hospital admissions and up to 90% of airways, increased mucus secretion and constriction of
deaths (Greener, 2010). the smooth muscle in the airways (Mc Murray, 2010,
This article is intended to: Kaufman, 2011). These processes cause the airways to
■■ Define asthma and identify the airways affected by become narrow and irritated, which makes it difficult
the disease to breathe and causes one or more of the following
■■ Describe the key elements of the assessment and symptoms:
diagnosis of asthma ■■ Wheeze
■■ Describe the pharmacological treatments used in ■■ Breathlessness
asthma and discuss their adverse effects ■■ Chest tightness
■■ Explore the use of inhalers and the promotion of ■■ Cough (especially at night)
adherence to treatment. ■■ Variable airflow obstruction.

What is asthma? Diagnosis

There is no ‘gold standard’ definition of asthma, Taking a careful clinical history is essential if a diagnosis
but there is agreement on the main pathological, of asthma is suspected (British Thoracic Society (BTS)
physiological, and clinical features of the disease and Scottish Intercollegiate Guidelines Network
(Kaufman, 2011). Asthma is a chronic inflammatory (SIGN), 2011). It is important to establish the presence
disorder of the airways that is most commonly of symptoms such as cough, wheeze, breathlessness,
associated with allergic triggers. The disease can affect and chest tightness, and whether symptoms are
the trachea, the bronchi, and the bronchioles, which provoked by specific triggers (Kaufman, 2011). A key
form part of the lower respiratory tract. Asthma is indication of asthma is symptom variability; therefore,
associated with inflammation and swelling of the it is important to determine whether symptoms are
intermittent. Additionally, the severity of the symptoms,
how often they occur, and whether they cause nocturnal
Gerri Kaufman is a Lecturer in the Department of Health wakening or exercise limitation should be established.
Sciences at the University of York. It is essential to establish any medications the patient
is taking, including prescribed drugs, medications
Email: gerri.kaufman@york.ac.uk purchased over the counter, and herbal or homeopathic
remedies. Non-steroidal anti-inflammatory drugs, beta-
blockers, and aspirin can exacerbate asthma (Currie

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 Clinical Focus

et al, 2009). Chronic cough caused by angiotensin- SIGN, 2011). BTS and SIGN (2011) recommend that
converting enzyme inhibitors may also mimic less well- multiple PEF measurements are made over a minimum
controlled asthma (Currie et al, 2009). period of 2 weeks. This requires the patient to keep a
Exploring past medical or family history is diary of PEF measured in the morning and at night.
important, particularly any history of asthma or atopy. Additionally, patients should record medications taken,
Social history should include information about symptoms experienced, and factors perceived to trigger
hobbies and pets to ascertain if these may be triggers. asthma.
Occupational asthma may account for as much as
9–15% of adult-onset disease (BTS and SIGN, 2011); Treatment
therefore, asking patients about occupational exposure BTS and SIGN (2011) advocate a stepwise approach
to airway irritants may reveal a trigger. Although to asthma management. The stepwise approach helps
smoking and use of alcohol are not diagnostic markers guide the practitioner in the prescribing of treatment
for asthma, cigarette smoking is associated with and provides advice on drug classes and suitable
persistent asthma and higher risk of mortality if the doses. Patients should start treatment at the step most
individual experiences a near-fatal exacerbation (Currie appropriate to the initial severity of their asthma so that
et al, 2005). Similarly, alcohol misuse is associated with early control is achieved. Treatment should be stepped
fatal or near-fatal episodes (Currie et al, 2005). up when required and stepped down when control is
In addition to obtaining a clinical history, it is good. Practitioners should always revisit the diagnosis
important to obtain objective support for the diagnosis and check adherence to existing medication and inhaler
(BTS and SIGN, 2011). Confirmation of asthma technique before stepping up treatment (BTS and SIGN,
depends on demonstrating airflow obstruction that 2011).
varies over short periods of time (BTS and SIGN, 2011). Table 1 sets out the main medications used in asthma
This can be achieved through spirometry (Scullion, and their place in the stepwise approach to asthma
2005) or peak expiratory flow (PEF) measurement. management.

Spirometry Short-acting β2-agonists

Spirometry is the best way of identifying airflow BTS and SIGN (2011) recommend a short-acting beta2-
obstruction and making a definitive diagnosis of asthma agonist (β2-agonist), taken by inhalation, as the first-
(BTS and SIGN, 2011). Spirometry to measure forced line treatment for mild intermittent asthma. Examples
vital capacity (FVC) and forced expiratory volume in of short-acting β2-agonists that act on β2-adrenergic
1 second (FEV1) is conducted in the following way. receptors in bronchial smooth muscle are salbutamol
Following a maximum inspiration of air, the patient and terbutaline. These drugs produce bronchodilaton
uses maximum force to expel all the air from their and relieve the symptoms of chest tightness and
lungs—as hard and as fast as possible. The highest of at breathlessness (Kaufman, 2011).
least three reproducible measurements is recorded.
The ratio of FEV1 to FVC provides a useful measure of Inhaled corticosteroids
airway obstruction. Forced expiration normally results For patients who continue to experience symptoms
in FEV1:FVC ratios of more than 70%. Ratios less than while taking a short-acting b2-agonist, BTS and
70% indicate airway obstruction; the lower the ratio, the SIGN (2011) recommend the addition of an inhaled
more severe the obstruction (Kaufman, 2011). corticosteroid, such as beclometasone dipropionate,
Spirometry should only be performed by trained budesonide, and fluticasone propionate. Inhaled
professionals with accredited, up to date skills and the corticosteroids play an important role in reducing
ability to interpret results correctly (Worth et al, 2010). inflammation and are considered to be the most
Additionally, spirometers should be appropriately effective preventive therapy for asthma (Rees, 2010).
calibrated and serviced. Poor spirometry technique and
incorrect interpretation of results can lead to incorrect Long-acting β2-agonists
diagnosis and potentially inappropriate treatment If symptoms are not controlled with regular use of a
(Kaufman, 2011). short-acting b2-agonist and an inhaled corticosteroid,
BTS and SIGN (2011) recommend the addition of a
Peak expiratory flow long-acting b2-agonist. Long-acting b2-agonists, such
PEF is a simple test of lung function that calculates as salmeterol and formoterol, play a role in relaxing
the maximum flow of air achievable from a forced smooth muscle in the airways, enhancing mucociliary
expiration, starting from a position of maximum lung clearance, and reducing vascular permeability (Holgate
inflation (Booker, 2007). PEF can be a useful test for and Douglass, 2010). However, if there is no response,
the monitoring of variability, which is one of the main the long-acting β2-agonist should be discontinued and
features of asthma. Significant variability is present the dose of inhaled corticosteroid increased (BTS and
if peak flow readings vary by 20% or more (BTS and SIGN, 2011). Long-acting b2-agonists should not be

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 Clinical Focus

used as monotherapy and should only be introduced Seretide and Symbicort (Joint Formulary Committee,
for patients who are on inhaled corticosteroids, and the 2012).
inhaled corticosteroid should be continued (BTS and
SIGN, 2011). Leukotriene receptor antagonists
Inhaled long-acting b2-agonists and inhaled Leukotriene receptor antagonists, such as montelukast
corticosteroids can be given in a combination inhaler and zafirlukast, have a role to play in reducing
rather than separate inhalers once effectiveness is inflammation, mucus secretion, oedema, and the
established. Examples of combination inhalers include bronchoconstriction associated with asthma (Barnes,

Table 1. The main medications used in asthma, their mechanisms

of action, and their place in the stepwise approach to asthma
management
Step Medications Mechanism of action
Step 1: Treatment of mild intermittent Inhaled short-acting b2-agonist as Bronchodilation
asthma required (e.g. salbutamol or terbutaline)
Step 2: Regular preventive therapy Additional inhaled corticosteroid at dose Anti-inflammatory action and
of 200–800 μg/day; start with a dose that reduction of airway hyper-
is appropriate to the severity of disease responsiveness

Step 3: Initial add-on therapy Additional inhaled long-acting b2-agonist Bronchodilation and enhancement of
(e.g. salmeterol or fomoterol) mucociliary clearance
If response to long-acting b2-agonist is
good, continue this therapy
If there is benefit from long-acting b2-
agonist but control is still inadequate,
continue this therapy and increase the
dose of inhaled corticosteroid to 800 mg/
day (if patient is not already on this dose)
If control remains inadequate, introduce
a trial of other therapies (e.g. leukotriene
receptor antagonist or slow-release
theophylline)
Step 4: Treatment for persistent poor Consider trials of increasing the dose of
control inhaled corticosteroid to up to 2000 mg/
day
Additional fourth drug (e.g. leukotriene Leukotriene receptor antagonist:
receptor antagonist or slow-release anti-inflammatory action; reduction
theophylline) of airway hyper-responsiveness,
mucus secretion, and oedema; and
bronchodilation
Theophylline: Bronchodilation and
anti-inflammatory action
Step 5: Continuous or frequent use of Use daily steroid tablet in lowest dose to
oral steroids provide adequate control
Maintain high-dose inhaled steroid at
2000 mg/day
Consider other treatments to minimise the
use of steroid tablets
Refer patient for specialist care
From: BTS and SIGN (2011) and Kaufman (2011).

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 Clinical Focus

2008; Kuebler and Balkstra, 2008; Rees, 2010). The Committee, 2012).
addition of these agents can be considered for patients Paradoxical bronchospasm describes a situation
who experience persistent poor control of their asthma. in which the drug prescribed to treat tightening or
According to Barnes (2008), the leukotrienes can be narrowing of the airways has the effect of causing
effective in patients with aspirin- or exercise-induced bronchoconstriction. Treatment with an agonist can
asthma. Overall, the effects achieved with these drugs also lead to desensitization or tolerance and a reduced
are less than those achieved with inhaled corticosteroids responsiveness of the airways on continued or repeated
(Rees, 2010). exposure to the drug. (Hanania et al, 2002; Barnes,
2008).
Methylxanthines Inhaled corticosteroids have considerably fewer
The methylxanthine theophylline has a place in systemic effects than oral corticosteroids. There is a risk
the stepwise approach to asthma management. of oral candidiasis, but this can be reduced by using a
Theophylline is an effective bronchodilator that may spacer device with the inhaler and rinsing the mouth
also have anti-inflammatory properties (Rees, 2010). with water after inhalation of a dose (Joint Formulary
Comittee, 2012). However, the use of high doses of
Oral corticosteroids inhaled corticosteroids for prolonged periods can
For some patients with very severe asthma, in whom induce adrenal suppression and has been associated
control cannot be achieved with a combination of the with a small risk of glaucoma and lower respiratory
medicines described above, regular long-term oral tract infections, such as pneumonia. Bone mineral
corticosteroids may be required (BTS and SIGN, 2011). density can be reduced following long-term inhalation,
However, given the risk of systemic side effects, patients predisposing patients to osteoporosis. The most serious
with poorly controlled asthma should be referred for limitation of oral corticosteroid therapy is the risk of
specialist care before proceeding to these drugs (BTS significant long-term side effects, such as osteoporosis,
and SIGN, 2011). adrenal suppression, peptic ulceration, muscle wasting,
diabetes, weight gain, skin atrophy, and impaired
healing (Kaufman, 2010). Patients using oral steroids
Adverse effects of drug therapy and high doses of inhaled steroids should carry a
in asthma management steroid card (Joint Formulary Committee, 2012).
The beta receptors found in the lung are also found Churg–Strauss syndrome (increased symptoms of
in other tissues including the heart and blood vessels. asthma, sinusitis, and rhinitis; high eosinophil count in
Although the β2-agonists are relatively selective for the blood; and vasculitis that may affect several organs)
the lung, they can stimulate β1-receptors in the heart has occurred very rarely in association with the use of
and cause tachycardia and palpitations. β2-agonists leukotriene receptor antagonists (Schachter, 2010). In
increase the risk of adverse cardiovascular events in many of the reported cases, the reaction followed the
patients most at risk, such as individuals with pre- withdrawal of oral corticosteroid therapy. It is advised
existing risk factors for cardiac disease and myocardial that prescribers should be alert to the development of
hypoxia (Jordan, 2008). Patients with underlying heart eosinophilia, vasculitic rash, worsening pulmonary
disease (e.g. ischaemic heart disease, arrhythmias, or symptoms, cardiac complications, or peripheral
severe heart failure) should be advised to seek medical neuropathy (Joint Formulary Committee, 2012).
assistance if they experience chest pain or other It is important to exercise caution when prescribing
symptoms of worsening heart disease. β2-agonists can theophylline because the drug has a narrow therapeutic
also cause peripheral vasodilation and a drop in blood index, which means that the toxic dose is close to the
pressure as a result of activating the β2-receptors in therapeutic dose. Therefore, dosage considerations are
peripheral blood vessels (Simonsen et al, 2006). In important to ensure that the dose prescribed is effective
patients with comorbidities, the use of β2-agonists can and, at the same time, prevents adverse effects. The
worsen other long-term conditions (Jordan, 2008). Joint Formulary Committee (2012) highlights the need
Other systemic side effects of the β2-agonists include for caution when prescribing the drug for patients who
fine tremor, nervous tension, headache, and muscle are older or have heart failure, hepatic impairment, or
cramps. High doses of β2-agonists are associated with viral infection. Additionally, the plasma theophylline
hypokalaemia. This occurs mainly with parenteral concentration is decreased in smokers and after alcohol
and nebulized therapy. It is recommended that serum consumption. The plasma levels of theophylline must be
potassium levels are monitored in prolonged high-dose monitored carefully. Before introducing drugs such as
usage (Scullion and Holmes, 2010, Joint Formulary theophylline, it is important to revisit the diagnosis and
Committee, 2012). Severe paradoxical bronchospasm check compliance with treatment and inhaler technique
has been reported with the use of β2-agonists, and the (Kaufman, 2011). The adverse effects of theophylline
potential for its development should also be borne in are frequent and include nausea and vomiting, which
mind with inhaled corticosteroids (Joint Formulary can be minimized by modified release formulations.

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 Clinical Focus

Central nervous system symptoms are also common the inhaler, the drug, and the patient. Poor inhaler
and include tremor and anxiety. As with β2-agonists, technique can markedly reduce the proportion of drug
theophylline can cause hypokalaemia and is more likely that reaches the lung and is a well-documented cause of
to cause cardiac arrhythmias. High doses can also cause suboptimal asthma control (Chrystyn and Price, 2009).
convulsions (Schachter, 2010). A number of devices are available for the administration
Adverse effects of the drugs used in asthma of inhaled therapies (Kaufman, 2011). They include:
management are highlighted in Table 2. Further ■■ Spacers
discussion of the adverse effects of the drugs used ■■ Pressurized metered dose inhalers (MDIs)
in asthma management can be found in the British ■■ Breath-actuated devices
National Formulary (Joint Formulary Committee, ■■ Dry powder devices.
2012). The choice of drug is likely to determine the
choice of device. Different patients will have different
requirements, and it is unlikely that a single device will
Inhaler device and technique and satisfy the needs of all (Kaufman, 2011). It is important
adherence to treatment to discuss patient preferences, as the choice of device
The BTS and SIGN (2011) guideline gives advice on preferred by the patient can make a positive difference
drug classes and possible doses for the management of to disease control. If a patient cannot use a particular
asthma. However, information is not provided about device, another should be tried.
the choice of devices for inhaled therapy. According The different devices have advantages and
to Chrystyn and Price (2009), optimizing inhaler use limitations; for example, MDIs are quick to use and easy
requires a consideration of the interaction between to transport. However, two of the most crucial errors

Table 2. Adverse effects of drugs used in asthma

management
Bronchodilators Adverse effects
Short- and long-acting b2-agonists Tachycardia, palpitations, arrhythmias, myocardial ischaemia,
(e.g. salbutamol, terbutaline, hypokalaemia, muscle cramps, headache, anxiety, and insomnia
salmeterol, and formoterol)
Inhaled corticosteroids (e.g. Local effects: dyphonia, oropharyngeal candidiasis, and cough
beclometasone, budesonide,
ciclesonide, fluticasone, Systemic effects: adrenal suppression, growth suppression,
mometasone) bruising, osteoporosis, cataracts, glaucoma, metabolic
abnormalities (glucose, insulin, triglycerides), and psychiatric
disturbance
Oral corticosteroids Neuropsychological effects: depression, euphoria, paranoia,
insomnia, and psychological dependence
Opthalmic effects: cataracts, glaucoma, papilloedema, skin, purple
striae, moon face, acne, hirsutism, and thin skin and easy bruising
Gastrointestinal effects: peptic ulceration, dyspepsia, and
pancreatitis
Musculoskeletal effects: osteoporosis, proximal myopathy, and
tendon rupture
Endocrine and metabolic effects: hyperglycaemia, hypokalaemia,
salt and water retention, adrenal suppression, weight gain,
menstrual disturbance, and increased appetite
Leukotriene receptor antagonists Gastrointestinal symptoms, mild liver dysfunction, and Churg–
(e.g. montelukast and zafirlukast) Strauss syndrome
Methylxanthines (e.g. theophylline) Tachycardia, cardiac arrhythmias, nausea and vomiting, abdominal
pain, diarrhoea, headache, irritability and insomnia, seizures, and
hypokalaemia
From: Barnes (2008), Schachter (2010), Currie and Lipworth (2011), and Joint Formulary Committee (2012)

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 Clinical Focus

Correct inhaler technique is important for disease management and symptom control in patients with asthma

with MDIs are failure to coordinate inhalation with all of the devices available, to help patients review and
actuation of the device and inhaling the aerosol too improve their technique.
quickly (Corrigan, 2011). It is well recognized that pharmacotherapy and
Coordination difficulties can be overcome by using a adherence to medication is essential for the appropriate
breath-actuated device or a spacer, and the problem of management of chronic disease (Kaufman and Birks,
rapid inhalation can be improved by training (Corrigan, 2011a). Effective treatments are available for the
2011). For the best use of dry powder inhalers, very management of asthma, but achieving control can be
rapid and forceful inhalation is required. Failure to difficult for the majority of patients with this condition
inhale deeply and forcibly at the start of inhalation (Haughey et al, 2008).
results in the generation of drug particles that are too It is noted that patients in general have difficulty
big to enter the lungs. Additionally, if the patient does taking their medicines as directed, and non-adherence
not inhale fast enough or long enough, not all of the is believed to be responsible for considerable morbidity
dose is emitted (Haughey et al, 2008). It is essential and mortality (Kaufman and Birks, 2011a). There are
to provide practical training when a device is first a number of reasons why patients do not adhere to
prescribed, and inhaler technique should be reviewed at treatment or fail to take their medicines as prescribed.
every asthma consultation. Unless patients suffer with Patients who have difficulty adjusting to a diagnosis
significant cognitive impairment, the majority can learn of asthma and who cope by ignoring the problem or
to use an inhaler device correctly (Kaufman, 2011). playing it down may have difficulties in accepting and
Teaching and checking inhaler technique should be adhering to treatment. Patients who have incorrect
undertaken by competent professionals. This helps to perceptions about the nature of their disease or who
prevent the more subtle problems with technique going misunderstand prognosis and treatment are likely to
unnoticed, which can reduce the delivery of inhaled manage their medicines inappropriately (Kaufman and
drugs to the airways by as much as 90% (Corrigan, Birks, 2011a). Many negative and untrue perceptions
2011). Further information about inhaler devices and exist, particularly in relation to the use of steroids in
technique can be found at Asthma UK. Box 1 contains the management of asthma—for example, the beliefs
a web link to an animated demonstration, covering that inhaled steroids can cause addiction, weight gain,

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 Clinical Focus

and excessive hair growth (Cornforth, 2010). There are Box 1. Inhaler technique
patients who genuinely want to manage their illness but
motivational difficulties such as simple forgetfulness demonstration
prevent them from using their medicines consistently. http://www.asthma.org.uk/how-we-help/teachers-and-healthcare-
Some patients want control over their illness and professionals/health-professionals/interactive-inhaler-demo/
treatment while others are happy to play a passive role
(Kaufman and Birks, 2011a).
Issues with adherence are therefore multifaceted Table 3. Providing the correct amount
and challenging for health professionals (Chrystyn and type of information and aiding
and Price, 2009). However, the National Institute for
Health and Clinical Excellence (NICE) (2009) clinical
accurate recall and understanding
guidelines on medicines adherence is a reminder that Find out how much the patient already knows and how much more
non-adherence should not be viewed as the patient’s they want to know
problem. According to NICE (2009), non-adherence Giving information in small amounts
‘represents a fundamental limitation in the delivery of
healthcare, often because of a failure to fully agree the Checking the patient’s understanding before moving on to the next
prescription in the first place or to identify and provide section of information giving
the support that patients need later on’. Summarizing the key areas back to the patient
Patient-centred care, which involves working
in partnership with patients, is increasingly seen From: Kaufman and Birks (2011b)
as a means of delivering high quality, appropriate,
and cost-effective health care (Kaufman and Birks,
2011a). Involving patients with asthma in decisions Table 4. Encouraging patient
about their medicines, and providing appropriate involvement in decisions about
information about the disease, are strategies that can treatment and medicines
be used to promote patient-centred care and optimize
adherence to medicines. Patients need information Effective communication skills
about asthma and potential treatments if they are to Establishing a good rapport with the patient
make informed decisions about the use of medicines.
Patients need to know how asthma medications work Creating an atmosphere of trust
and how treatment will affect their condition in the Eliciting the patient’s ideas, concerns and expectations
short and long term. Elwyn et al (2003) point out that,
in consultations, the benefits of treatment are more Achieving a common interpretation of the problem
likely to be discussed than the risks. Yet, patients view Reaching a shared understanding of the problem
information about the risks as essential. Factors that
assist the practitioner with providing information and From: Kaufman and Birks (2011b)
aiding patient recall and understanding are summarized
in Table 3.
The practitioner’s ability to communicate effectively,
establish a rapport with the patient, and foster an Key Points
atmosphere of trust is central to patient involvement
(Moulton, 2007). Patients are likely to vary considerably ■■ Asthma is a disease of the airways characterized by
in their knowledge and ideas about asthma and the inflammation and associated with episodes of breathlessness,
different treatments. Encouraging them to express chest tightness, wheezing and cough
their ideas and concerns about the disease, their ■■ A careful clinical history and objective measurement of lung
expectations about treatment, and how they use their function is important in establishing a diagnosis of asthma
medicines is important to discover difficulties such as ■■ Clinical guidelines advocate a stepwise approach to drug
adjustment, negative and untrue perceptions about therapy, where treatment is stepped up when required, and
asthma, and issues of simple forgetfulness in taking stepped down when control is good
medicines. Sarver and Murphy (2009) remind us that ■■ Choice of inhaler device and inhaler technique are important
a partnership in which there is open dialogue is most in disease management and symptom control
influential in medication adherence, which is central ■■ Alongside pharmacological management of asthma,
to good asthma control. However, it is well known that partnership working between patients and health professionals
the power differential in many consultations favours the is critical to achieving optimal patient adherence with
practitioner, which can result in patients not presenting treatment and improving quality of life
their views (Kaufman and Birks, 2011a).
Failure to discover the patient’s perspective and

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 Clinical Focus

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in Health Care 12(Suppl 1): 33–6

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