According to the Global Initiative for Asthma (GINA) asthma control is assessed in two domains: symptom control and risk of adverse outcomes.  Poor symptom control is budensome to patients and increases the risk of exacerbations, but patients with good symptom control can still have severe exacerbations.[1]

Asthma control should be assessed using the validated asthma control questionnaire(2) or asthma control test (3). The three questions recommended by the Royal College of Physician’s  is appropriate for use as a screening test for poor asthma control [4].  

Peak flow or spirometry (or both) should be used to assess lung function. If asthma control is suboptimal, check for and address the common causes as listed below:

• DIAGNOSIS. Is the diagnosis correct? Is there a previously unrecognised comorbidity?
• ADHERENCE. Is the patient adhering to their prescribed medication? Be particularly vigilant for underuse of ICS. Consider psychosocial reasons, including ideas and concerns about asthma of their prescribed treatment
• INHALER. Is the patients using their inhaler appropriately? Do they need a spacer with their metered dose inhaler
• SMOKING. Does the patient smoke or are they routinely exposed to tobacco smoke? A carbon monoxide meter can be used to monitor and demonstrate the effects of smoking
• TRIGGERS. Are they exposed to occupational triggers? Are there any seasonal or environmental factors that have not been addressed?

During a routine review, inhaler technique should also be observed and errors in technique corrected. Inhaler technique should be checked at every opportunity, including but not limited to, when there is a deterioration in asthma control, when the inhaler is changed and if the patient requests a check.

If asthma is well controlled there should be little or no need for SABA. Three or more doses of SABA per week may indicate poor asthma control and a need to step up treatment. Over-reliance on SABA is well established as a risk factor for fatal asthma [6], therefore anyone prescribed more than six SABA inhalers per year should have their asthma control urgently assessed[7].

References:

1. Global Initiatve for Asthma 2022. Global Strategy for Asthma maangement and Prevention https://ginasthma.org/wp-content/uploads/2022/07/GINA-Main-Report-2022-…

2.Juniper EF, O’Byrne PM, Guyatt GH, et al. Eur Respir J. 1999;14:902-907.https://erj.ersjournals.com/content/erj/14/4/902.full-text.pdf

3. Nathan RA, Sorkness CA, Kosinski M, Schatz M, Li JT, Marcus P, Murray JJ, Pendergraft TB. Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004 Jan;113(1):59-65. doi: 10.1016/j.jaci.2003.09.008. PMID: 14713908.

4. Royal College of Physicians 3 Questions for Asthma https://www.researchgate.net/figure/Royal-College-of-Physicians-3-Quest…;

5. Levy M, Andrews R, Buckingham R, et al. Why asthma still kills: The national review of asthma deaths (NRAD) confidential enquiry report. Royal College of Physicians, 2014. Available from: https://www.rcplondon.ac.uk/projects/outputs/why-asthmastill-kills (accessed Aug 2019). 

6. Network Contract Directed Enhanced Service Investment and Impact Fund 2022/23: Updated Guidance 30 September 2022. Page 78.  https://www.england.nhs.uk/wp-content/uploads/2022/03/B1963-iii-Network…