Improving the management of asthma in adults in primary care.

Studies in adult patients have suggested that 30% of those diagnosed with asthma do not have the condition and it is likely that the diagnosis is missed in many others. Initial clinical assessment should explore symptoms of wheeze, breathlessness, chest tightness and cough. The probability of asthma is increased if more than one of these symptoms is present and particularly if symptoms are worse at night and in the early morning or are exacerbated by triggers such as exercise, allergen exposure, cold air or drugs. The BTS/SIGN guideline advocates spirometry after taking the history. If airflow obstruction is present, a trial of treatment can commence, but a firm diagnosis also requires a symptomatic response and an improvement in the measured airflow obstruction. The FeNO level correlates well with airway inflammation, and is therefore a good indicator of asthma and in particular of the likely response to inhaled corticosteroids. The test is especially useful for patients with suggestive symptoms but normal spirometry. The cornerstone of asthma monitoring is a structured clinical review conducted in primary care on at least an annual basis. Health outcomes are improved by education in self-management, incorporating written personalised asthma action plans. Checking concordance with existing therapies and inhaler technique before escalating treatment is an important part of improving the pharmacological management of asthma. Any patient prescribed more than one short-acting bronchodilator device a month should be identified and have their asthma assessed urgently and measures taken to improve overall control.