The first confidential enquiry report from the Royal College of Physicians (RCP), Why Asthma Still Kills, published today, found nearly half (45%, 87 patients) of those included in this study who died from asthma did not have any medical help during the final asthma attack.
Dr Shuaib Nasser, consultant allergist and respiratory physician at CUH and Fellow of The Royal College of Physicians, contributed to the report. He said: “Triggers for asthma attacks had not been documented in more than half the asthma deaths and few had seen an asthma specialist in the year before death.
“The asthma deaths reported by this confidential enquiry are a call to action for health professionals to better understand why asthma kills and to work together with people who suffer with asthma. The report highlights the variability of asthma in every individual and this requires improved documentation of triggers and severity."
He continued: “Patients want to understand their asthma better and to know the triggers for their asthma symptoms. If these are identified early, people with asthma will become much better at managing their condition and be able to predict when to increase their treatment or call for help. If the key recommendations are implemented asthma deaths will be substantially reduced.”
Dr Nasser started his asthma clinic 15 years ago at Addenbrooke’s, part of CUH, and was one of the first clinicians in the UK to investigate the cause of asthma deaths. He led a coalition of chest and asthma specialists, paediatricians, asthma nurses, as well as GPs, from across the Eastern region to examine the causes of asthma deaths and whether there were preventable factors. The Eastern regional confidential inquiry into asthma deaths, as it was called, circulated its reports widely and attracted the attention of the Chief Medical Officer at the time Liam Donaldson, who recommended that the inquiry was taken to a national level.
Dr Nasser said: “At CUH, and across the East of England, we had, and continue to have, some of the best care in the UK, the lowest death rates and some of the lowest hospital admission rates for any city in UK.”
The key to successful treatment is identification of individual triggers for asthma, called phenotypes. Dr Nasser explained: “Asthma is not one disease, rather a range of phenotypes. In each person with asthma we attempt to identify the underlying mechanism allowing better targeted treatment.”
In 2007 Dr Nasser published a paper on ‘thunderstorm asthma’. He said: “On one day in summer 2002 we suddenly had more than 50 people attend A&E with acute severe asthma, normally we might see one patient a day suffering from such acute symptoms. When we studied these cases, it emerged from my research that almost all of the patients were allergic to Alternaria, which is a type of fungal spore growing on cereal crops such as wheat and barley. A thunderstorm spreads this fungal spore widely. We were able to tackle this phenotype of asthma by increasing medication levels before the Alternaria season. This method was very successful and the following year no one came back into hospital in late summer when Alternaria levels can be very high.”
The report found nearly half (45 per cent, 87 patients) of those included in this study who died from asthma did not have any medical help during the final asthma attack. For 33 per cent of people (65 patients) there was no record of them seeking medical assistance and for 11 per cent (22 patients) help was not given in time. The NRAD found that 80 per cent of the children under 10 (8 out of 10), and 72 per cent of young people aged 10 – 19 (13 out of 18) died before they reached hospital.
NOTES
The NRAD was commissioned by the Healthcare Quality Improvement Partnership (HQIP) and managed by the Royal College of Physicians (RCP) in collaboration with professional and patient organisations including The Royal College of Pathologists. The NRAD looked at the circumstances surrounding death from asthma in order to identify patterns and trends in the care received by patients.
Findings from the NRAD include:
· The standard of care received was less than satisfactory in a quarter of those who died and there was ‘room for improvement’ in the care received by 83% of those who died.
· Triggers for asthma attacks had not been documented in more than half of the cases and 57 per cent were not recorded as being under specialist supervision in the year before death.
· There were deficiencies in both routine care and in the treatment of attacks.
· There was widespread under-use of preventer inhalers and excessive over-reliance on reliever inhalers.
· Ten per cent of those who died did so within one month of discharge from hospital following treatment for asthma; at least 21 per cent had attended an emergency department at least once in the previous year.
· Over half of those who died were being treated for mild or moderate asthma at the time; experts concluded that this was mostly because neither doctors nor patients themselves recognised how serious their asthma really was.
· Nineteen per cent of those who died were smokers and others, including many children, were exposed to second-hand smoke in the home.
· Some patients had not collected their prescriptions for preventative treatment or did not attend regular asthma check-ups.
Recommendations made by the NRAD include:
· Every hospital and GP practice should have a designated, named clinician for asthma services.
· Better monitoring of asthma control; where loss of control is identified, immediate action is required including escalation of responsibility, treatment change and arrangements for follow-up.
· Better education is needed for doctors, nurses, patients and carers to make them aware of the risks. They need to be able to recognise the warning signs of poor asthma control and know what to do during an attack.
· All patients should be provided with a personal asthma action plan (PAAP), which can help them to identify if their asthma is worsening and tell them how and when to seek help.
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PR & Communications
Adrian Ient, Media Relations Manager,
Communications Department, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ
Tel: 01223 274433 Email: adrian.ient@addenbrookes.nhs.uk
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