Difficult to treat asthma in adultsBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b494 (Published 24 February 2009) Cite this as: BMJ 2009;338:b494
All rapid responses
We congratulate Currie et al (1) for bringing this important area of
asthma care to a general audience in such a concise and accessible review.
We would like to emphasise four areas from our research and experience.
i) We have shown that in patients with BTS-defined severe asthma (2),
poor adherence, recognised in two thirds by not attending scheduled
appointments, is associated with worse symptom control and quality of
life, more rescue and exacerbation-related therapy, absenteeism, primary
care visits, A&E attendances and hospital admissions (3). Poor adherence
is also associated with anxiety, younger age, social deprivation and
adverse family circumstances. All of these may be reasons for poor
ii) Whilst depression is highlighted in the review, the relationship
between depression and asthma outcomes is complex and not only related to
adherence. We have shown that depression can predict poor outcomes
independently of self-management (4). In a recent study of Quality
Outcomes Framework (QOF) and prescribing data, a diagnosis of asthma
trumped both coronary heart disease and diabetes in predicting the highest
volumes of antidepressant prescribing (5). Doctors and nurses may not
always recognise the importance of the combination of severe asthma and
iii) We suspect the estimate that 5-10% of patients with asthma are
difficult to treat is an exageration. Noble et al (6) found 3% of their
patients with asthma were at risk of serious adverse outcomes.
iv) Tackling psychosocial problems with the aim of improving outcomes
in difficult asthma is complicated. Combined clinics with chest physicians
and psychiatrists can be very successful (7). However, those patients at
greatest risk often fail to attend hospital appointments (8). A primary
care-based study (6) which placed high risk patients onto an actively
managed electronic register reduced emergency treatments (oral steroid
courses, out of hours attendances and hospital admissions) and improved
attendance at planned appointments. This approach is being tested in a
randomised controlled multi-centre trial in Norfolk. Our experience is
that attendance at hospital clinics is more likely to be successfully
maintained once good engagement is achieved in primary care.
Identification of this high risk group by including relevant questions in
QOF would go a long way towards improving management in addition to the
development of specialist services in secondary care.
Brian Harrison, Professor of Respiratory Medicine, University of East
Michael Noble, GP, Acle, Norfolk.
Jane Smith, Lecturer in Health Psychology, University of East Anglia.
1 Currie GP, Graham Douglas J, Heaney LG. Difficult to treat asthma
in adults. BMJ 2009;338:593-7 (7 March).
2 British Thoracic Society and Scottish Intercollegiate Guideline
Network. British guidelines on the management of asthma. Thorax
3 Smith JR, Mildenhall S, Noble MJ, Mugford M, Shepstone L, Harrison
BDW. Clinician-identified poor compliance is useful in identifying,
amongst adults with severe asthma, patients with characteristics likely to
put them at risk of adverse outcomes. J Asthma 2005;42(6):437-45.
4 Smith JR. Psychological approaches for understanding and
influencing outcomes in severe asthma. PhD thesis 2009; University of East
5 Walters P, Ashworth M, Tylee A. Ethnic density, physical illness,
social deprivation and antidepressant prescribing: ecological study. B J
6 Noble MJ, Smith JR, Windley J. A controlled retrospective pilot
study of an at risk register in primary care. Prim Care Resp J
7 McAdam EK, Noble MJ, Harrison BDW. A combined clinic using a
medical and psychological approach in the management of poorly controlled
asthma. Asthma J 2000;5:71-9
8 Harrision BDW, Stephenson P, Mohan G, Nasser S. An ongoing
confidential enquiry into asthma deaths in the Eastern Region of the UK,
2001-2003. Prim Care Resp J 2005;14:303-13.
Competing interests: No competing interests
The clinical review entitled Difficult to Treat Asthma in Adults, published on 24 February 2009 by Graeme P Currie, J Gram. Douglas and Liam G Heaney was analyzed and discussed by our clinical staff at the Gustavo Aldereguía Hospital in Cuba. This review has been of great interest for all of us because of the broad and clear explanation presented in regards with the diagnostic and therapeutic management of Bronchial Asthma.
In our response to the article we offer the results of the experience of some Cuban doctors with in-patients who suffer from severe Asthma attacks at the Intensive Care Unit of the same institution. It gives medical assistance to about 400,000 inhabitants. The prevalence of Bronchial Asthma in this southern and central city of the Cuban island is 8.0%
Bronchial Asthma is a disease that presents in patients with greater etiopathogenic evidences. Bronchial hyper reactivity is still the most lethal combination of symptoms and signs in spite of all the medical efforts doctors carry out in the diagnosis and treatment of this entity either in the inter crisis period or in the exacerbation of the acute phase. As Cuban doctors from this hospital have devoted time to treat patients in such a condition, this summary shows some positive findings related to this Cuban experience.
In a series of 75 severely ill patients admitted at the Intensive Care Unit (ICU) in the year 2006 with a diagnosis of acute asthma attack , the treatment prior to admission was mainly directed to Hydration (89,3%), Theophyline (100%), IV Steroids (80,0%) and Beta stimulating aerosols (72%). After their admission at the ICU, there was an increase in the use of IV rehydration (100%), IV Steroid (89,3%), Antibiotics ( 49,3%)and I.V Betastimulating drugs were introduced for the first time in 76,6% of the patients.
The clinical classification used at this institution while determining he severity of the condition and its corresponding system of urgency is the classification established by Millar and green in 1994.
Other results from this experience are related to the mortality rate in a series of severely ill patient with Asthma crisis who were ventilated for 5 years (2002-2006). The mortality rate during that period was 12,5 % similar to the rate reported by Andersen in 1988 (12,3%) and higher than the mortality rate reported by Scoggine in 1977 (9,5%) and lesses to Sisald´s rate reported in 1969 (13,7%).
As can be seen, the mortality rates in ventilated asthmatic patients have not been reduced in the last 4 decades, although there are safer and more diverse mechanical ventilators and diverse therapeutical alternatives for the management of this pathology in order to face brochoconstriction. Therefore, strategies should be directed to the early treatment of the crisis and to the appropriate treatment as well as to the efficient management of patients in the inter crisis period if the aim is to diminish the appearance of severe asthma in the medical institutions.
1. Currie GP, Douglas JG, Heaney LG. difficult to treat asthma in adults. BMJ 2009; (338): b494.
2. Hall I, Genetics of asthma. Clin Asthma Rev 1997; (1): 39-44.
3. Burney PGJ, Britton JR, Chinn S. Is asthma correlate with salt intrake?. BMJ 1986: (292): 1483.
4. Van Schaychk CP, Dompleng E, Van Herwaarden C. Bronchodilatator treatment in moderate asthma or chronic bronchitis: continuous or demand? A randomized controlled study. BMJ 1991; (303): 1426-31.
Competing interests: No competing interests