How can primary care professionals reduce the burden of asthma exacerbations and improve asthma control in the real world?
An expert commentary by Dr Sara Núñez Palomo
and Dr Miguel Román-Rodríguez, Spain
The main objective in the management of patients with asthma is present and future control.1
12082022 
05 min read 
English Asthma exacerbations are clear examples of poor control, and result in high economic and personal costs.1 Although mild asthma could be considered free of serious complications, patients are still at risk of moderate or severe exacerbations.
A systematic review found that up to 22% of patients with mild asthma had been hospitalised or had experienced a severe exacerbation in the previous year.2 In a major study of asthma mortality in the UK, it was found that 9% of deaths from asthma occurred in patients diagnosed with mild asthma.3
Little is known about factors associated with an increased risk of moderate and severe exacerbations and poor disease control in patients with mild asthma. We know that a high percentage of these patients are treated exclusively with short-acting bronchodilators (SABA) on demand. This is despite latest guideline recommendations to use inhaled corticosteroids (ICS) in all patients with asthma, including mild asthma.1
We present here two studies that attempt to identify factors associated with a higher risk of poor asthma control and exacerbations, some of which can be managed in primary care settings.
Real-life observational study - Predictors of Asthma Control and Exacerbation
The first is a real-life observational study conducted on 738 patients with moderate to severe asthma; data were collected from a hospital asthma care center in Quebec.4 In this study, it was shown that psychological distress and smoking, as well as advanced age (>65 years old), have a large impact on poor asthma control.4
The strongest predictor of future exacerbations was the number of asthma exacerbations during the previous year. Other factors such as lower FEV1 (50%-80%), older age (>65) and frequent SABA use (>7 doses per week vs 4 doses per week) were also associated with an increased risk of exacerbations.4
Modifiable risk factors such as psychological distress and smoking could be beneficially addressed through tailored behavioral interventions in the primary care setting. However, asthma exacerbations were associated with several unmodifiable factors, mostly related to the severity of asthma.4
Real-life observational study - Predictors of Asthma Control and Exacerbation
The first is a real-life observational study conducted on 738 patients with moderate to severe asthma; data were collected from a hospital asthma care center in Quebec.4 In this study, it was shown that psychological distress and smoking, as well as advanced age (>65 years old), have a large impact on poor asthma control.4
The strongest predictor of future exacerbations was the number of asthma exacerbations during the previous year. Other factors such as lower FEV1 (50%-80%), older age (>65) and frequent SABA use (>7 doses per week vs 4 doses per week) were also associated with an increased risk of exacerbations.4
Modifiable risk factors such as psychological distress and smoking could be beneficially addressed through tailored behavioral interventions in the primary care setting. However, asthma exacerbations were associated with several unmodifiable factors, mostly related to the severity of asthma.4
In summary, prevention and correction of asthma exacerbations is key to achieving good asthma control, even in patients with mild asthma.2,4
Systematic follow-up of asthma patients should assess inhalation technique, therapeutic compliance as well as control of comorbidities. Additionally, SABA overuse and exposure to allergens and irritants should be avoided.1,6
Key takeaways:
- Asthma patients with mild to moderate disease who suffer an exacerbation could benefit from regular follow-ups, given the relationship of exacerbation risk with previous exacerbations.1
- Smoking cessation in asthmatic smokers and early detection and treatment of psychological distress at primary care level could improve asthma control and reduce exacerbations.4
- Likewise, identifying elevated eosinophilia in peripheral blood could allow for earlier intensification of treatment and would help identify patients with a higher risk of severe exacerbations.5
ABBREVIATION:
FEV1, forced expiratory volume (in the first second); ICS, inhaled corticosteroids; SABA, short-acting bronchodilators.
REFERENCES:
- GINA 2022. https://ginasthma.org/wp-content/uploads/2022/05/GINA-Main-Report-2022-FINAL-22-05-03-WMS.pdf. Accessed 6 September 2022
- Fitzgerald J M, et al. The burden of exacerbations in mild asthma: a systematic review. ERJ Open. 2020;6(3):00359-2019.
- Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential enquiry report. London, UK; 2014. Accessed 6 September 2022.
- Racine G, et al. Predictors of Asthma Control and Exacerbations: A Real-World Study. J Allergy Clin Immunol Pract. 2021;9(7):2802-2811.e2. doi: 10.1016/j.jaip.2021.04.049.
- Tran T N, et al. Persistence of Eosinophilic Asthma Endotype and Clinical Outcomes: A Real-World Observational Study. J Asthma Allergy. 2021;14:727-742. Published 2021 Jun 25. doi: 10.2147/JAA.S306416.
- Kaplan A. The Myth of Mild: Severe Exacerbations in Mild Asthma: An Underappreciated, but Preventable Problem. Adv Ther. 2021 Mar;38(3):1369-1381. doi: 10.1007/s12325-020-01598-2. Epub 2021 Jan 20. PMID: 33474708; PMCID: PMC7816833.
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Dr Sara Núñez Palomo
Dr Miguel Román-Rodríguez
Dr Sara Núñez Palomo
Dr Miguel Román-Rodríguez
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