Two thirds of deaths from asthma are preventable, confidential inquiry finds
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3108 (Published 06 May 2014) Cite this as: BMJ 2014;348:g3108
All rapid responses
Until last year I had been a community consultant chest physician for 6 years and was not surprised at the frequency of preventable deaths from asthma in the UK.
The reasons for the inadequate management of both asthma and COPD in primary care are numerous but an important and neglected reason is the de-skilling of GPs that has resulted from a situation created by the chest experts.
As well as overcomplicating the process by which these conditions are diagnosed and managed, care of these patients has been largely delegated to nurses who follow the guidelines drawn up by these experts. Following guidelines is in keeping with the training of nurses but is antithetical to a medical training and not surprisingly doctors have difficulties with them and are pleased to be able to pass these patients to the nurses to look after.
Until GPs again take back the responsibility for the care of these patients the situation is unlikely to improve.
In order to help GPs to be able to do that they need a better understanding of airway symptoms and their management as occur in the common inflammatory conditions of the airways, asthma and COPD. I have attempted to do that. (1)
The additional advantage of this approach is its emphasis on symptoms--ie, it will necessarily have to be patient focused.
(1) The Paradox of Primary Care and the management of the common inflammatory conditions of the airways, Asthma and COPD. Understanding and managing airway symptoms. (Awaiting publication)
Competing interests: No competing interests
It would have been interesting to see what proportion of these patients had been sent a reminder for asthma review and their attendace. There is little a practitioner can do if the patient will not attend despite repeated reminders.
Competing interests: No competing interests
It is a pity that the photograph illustrating your news piece on the very important results of the National Review of Asthma Deaths should show a health professional carefully supervising the clearly ineffective use of a metered dose inhaler by a child with asthma. The child has her mouth wide open and is not using a spacer.
There is widespread ignorance by health care professionals about how to teach inhaler technique: a (correct) picture is worth a thousand words and the BMJ might perhaps take its educational duties more seriously , even in its news section.
Knowing how to use a spacer for making metered dose inhalers more effective when symptoms worsen is a key component in the effective self management of asthma. It is not fanciful to suggest that more effective teaching of this skill to and by health professionals might contribute to reducing the number of avoidable deaths.
References
Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013 Sep 13;9:CD000052. doi: 10.1002/14651858.CD000052.pub3.
Inhaler systems (devices) in children under the age of 5 years with chronic asthma
http://guidance.nice.org.uk/TA10
Inhaler devices for routine treatment of chronic asthma in older children (5-15 years)
http://guidance.nice.org.uk/TA38
Keeley D. Large volume plastic spacers in asthma. BMJ 1992; 305 doi: http://dx.doi.org/10.1136/bmj.305.6854.598 (Published 12 September 1992)
BMJ 1992;305:598
Competing interests: No competing interests
The MHRA proposal, which seems to have escaped attention, to allow inhalers to be supplied for schools to use in emergencies is a tangible improvement. That is a welcome development, which is being consulted on this month, and which should be supported.
Competing interests: No competing interests
In the news article stating that two thirds of deaths from asthma are preventable I was surprised to see a picture of a young girl using an MDI inhaler without a spacer device. BTS guidelines recommend the use of a spacer + MDI when treating asthma as lung deposition of the inhaled drug is so much better (1). Further, systemic and local side effects of inhaled steroids can be reduced. Surely the BMJ has a responsibility to illustrate correct inhaler technique instead of reinforcing the erroneous belief that an MDI alone can be used to treat asthma in children?
References
1. British Guideline on the Management of Asthma; British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network - SIGN, 2008 (latest revision May 2011)
Competing interests: No competing interests
Re: Two thirds of deaths from asthma are preventable, confidential inquiry finds
Dear Editor.
Since the invention of mouth-to-mouth artificial respiration and endotracheal intubation for respiratory arrest resuscitation in 1960, the previous Schafer method of chest compression was largely abandoned and this has been associated with a significant increase in deaths from asphyxic asthma 1, 2, 3,. The rise has never been explained. The problem persists and requires resolution.
If, after pulmonary arrest, chest compression is performed (Shafer’s method) there is immediate expulsion of air and resumption of breathing that frequently appeared to be normal by the time the patient reached hospital 4. This information has not reached individuals who are in a position to rescue these patients – usually family members or emergency personnel. Patients, particularly young patients, continue to die of acute asphyxic asthma because inflationary rescue procedures are used, either mouth to mouth lung inflation or endotracheal intubation and mechanical ventilation. In patients with acute asphyxic asthma after respiratory arrest, there are no reports in the literature of survival, except two cases of attempted mouth to mouth resuscitation in which no air could be forced into an already maximally extended chest wall. With the first chest compression (Shafer method) produced immediate expulsion of air from the mouth and resumption of respiration 4 and also, two cases in which endotracheal tubes and attempted inflation failed but chest compression produced immediate rescue 5,6. It appears that the fully extended chest wall prevented any inspiration in both cases until external chest compression had made inhalation possible.
The classical gross pathologic findings in asthma are of over distended lungs which do not collapse even when removed from the chest cavity.
I would like to recommend that relatives of asthmatics, paramedics and also physicians are taught this easy method of chest compression. A description can be found at http://www.firstaidinasthma.co.uk.
Replacing chest compression with the use of mouth-to-mouth resuscitation is causing the present continued incidence of acute asthma deaths.
Yours truly. Rex Harrison.
References:
1. Editorial, BMJ, February 10th 1968.
2. Speizer FE, Doll R, Heaf P, Observation on recent increase in mortality from asthma, BMJ, 1968; 1: 335-43.
3. Speizer FE, Doll R, Heaf P, et.al. , Investigation into the use of drugs preceding death from asthma, BMJ, 1968; 1; 339-43.
4. Harrison R, Chest compression first aid for respiratory arrest due to acute asphyxic asthma, EMJ Prehospital Care, 2001.16:3
5. Fisher MM, Whaley AP, Pye RR. External chest compression in the management of acute severe asthma—a technique in search of evidence. Prehospital Disaster Med. 2001; 16: 3
6. Alzetta M, Another case asthma near death averted by External Chest Compression
Competing interests: No competing interests