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In this article, we’ll explore what poor control means in respiratory conditions and how this can be improved. Professional Practice Consultant James Musk and career-long Primary Care Nurse and Respiratory Nurse Practitioner Carla Astles offer their thoughts, giving examples of poor control they’ve seen in respiratory care and the ways in which they’ve approached this critical issue.
Defining poor control in asthma and COPD
Ensuring effective control of asthma and COPD is essential to an individual being able to: suppress or minimise their symptoms; to prevent and reduce exacerbations; to avoid limitations in activities of daily living, and thus to enable someone to lead a normal, or nearly normal life.1,2, A lack of management of poor control is not only harmful to the individual, but also the healthcare system. One study of over 12,000 patients found that poorly controlled asthma increased the risk of exacerbations and the need for emergency medical attention, which was in turn associated with a three-fold to four-fold increase in care costs.2,
There are many ways in which poor symptom control can present in patients with respiratory conditions:3,4,
| Poorly controlled asthma | Inadequately controlled COPD |
| • symptoms three or more days per week
• need for short-acting B2-agonists (SABAs) to relieve symptoms on two or more days per week • waking up at night due to asthma one or more nights per week. |
• frequent exacerbations
• limitations in physical activity • hospitalisation. |
Of course, these are just some of the ways poor control may present or be identified, but there are many more. Keep reading for expert insights into the management of symptom control within respiratory care.
The impact of poor control in asthma and COPD
When asthma and COPD are not adequately controlled, this can severely impact a patient’s everyday life. In asthma, poor control can lead to overuse of a SABA, exacerbations, a considerable impairment on physical activities, a reduction in lung function and sleep disturbance.5, Similarly in COPD, poor control can lead to declined pulmonary function, exacerbations, a poorer quality of life and decreased exercise performance.6,
The impact of poor control can also have much wider and far-reaching consequences. Professional Practice Consultant at the University of Nottingham, James Musk explains that poor control can have a further knock-on impact for an individual too. “In general terms, poor control of asthma and or COPD can result in a vicious cycle of reduced exercise tolerance, decreased independence with respect to activities of daily living, and resultant deconditioning from a musculoskeletal system and lung function perspective. This often leads to a gradual decline in overall health and wellbeing.’’
Symptoms extend beyond respiratory issues and can have a knock-on effect to the patient’s life, impacting their ability to work and their quality of sleep. A reduced rate of productivity at work (presenteeism) as well as days lost (absenteeism) due to asthma affects approximately 21% of the UK workforce with asthma.7, Carla Astles, a career-long Primary Care and Respiratory Nurse Practitioner, agrees: ‘’Symptoms are not limited to respiratory symptoms and can include tiredness, weakness and a negative impact on mental health.’’
The same is true in COPD. There is a relationship of increasing absenteeism and increasing age and/or co-existing conditions in the COPD population. Poor control can lead to premature retirement and no longer being economically active. This can impact self-identity and worth as well as affecting social interaction and having financial implications.8,
Furthermore, both James and Carla elaborate on the impact of poor control on a patient’s sleep. ‘’Quantity and duration of sleep can be significantly affected particularly if the patient is struggling with heightened anxiety and stress; this may be a direct or indirect consequence of their persistent shortness of breath.’’ James explains.
Carla agrees, highlighting ‘’There is a bi-directional relationship between asthma and sleep.’’ Co-existing conditions such as nasal conditions, gastroesophageal reflux disease (GERD) and obstructive sleep apnoea are associated with asthma and can lead to sleep disturbances and poor sleep quality independent of asthma control.9, She concludes by emphasising ‘’essentially, asthma impacts sleep and poor sleep impacts asthma.’’
Nevertheless, poor control doesn’t just solely impact patients; it also impacts the broader healthcare system. The UK has been previously identified as an outlier with higher mortality and morbidity attributed to respiratory disease than other Western countries.10, The impact of poor control on the NHS includes the overall economic impact and use of resources, as well as environmental factors. Poorly controlled asthma and COPD can result in increased exacerbations along with higher rates of hospital admissions and emergency care. Consequently, this increases healthcare utilisation which can put a strain on NHS resources including outpatient services.
In the environmental context, we know that around 3% of all greenhouse gas emissions generated by the NHS come from inhalers prescribed for respiratory conditions.11, Poor disease control can also come from patient switching of devices, which is why environmentally driven switches to DPIs may offer temporary benefits to reduce the carbon footprint but can lead to long-term problems such as disease control.12,13,14,15,
Identifying poor control
Poor control can present in patients in several ways. These can be identified or captured during annual reviews, or in some more severe instances, following an attack, exacerbation or even hospitalistion. Identifying factors typically can include non-adherence to prescribed medication, poor inhaler technique and overuse of SABA.16, HCPs have a range of tools at their disposal to support in this identification, including:17,,18,,19,
- symptoms assessment e.g. asthma control questionnaire, asthma control test, COPD Assessment Test (CAT)
- lung function tests e.g. quality assured spirometry or peak flow
- history of exacerbations
- FeNO if available and in line with local/national policy.
There are more advanced, personalised, and innovative approaches which healthcare professionals (HCPs) can adopt with their patients too. James believes patients could benefit from a more individualised approach rather than the traditional annual recall and invite method. He explains:
‘’A deep dive into a patient’s ability to access healthcare may be required to remove barriers and promote engagement. Additionally, a population health management approach may be beneficial to target patients for a more intensive follow up.’’
Additionally, other factors such as pre-existing health inequalities, exacerbated by the cost of living crisis, means those on lower incomes suffer from worse respiratory conditions. In deprived communities, poor symptom control and frequent exacerbations can affect the type and frequency of care accessed. Limited access to healthcare can act as a barrier to proactively addressing disease control effectively in the context of the wider determinants of health.18,
Carla underscores the importance of HCPs understanding their patients. ‘’Understanding your local population immediately helps you consider the risk and needs of your respiratory population’’ says Carla. ’’Health inequalities related to socio-economic status, ethnicity, air pollution are all known to have significant or specific needs or relationships with lung health, disease, condition management and risk.’’
However, there are challenges and constraints to being able to address poor control at such scale, beyond even the time and financial pressures already being faced within the system. A lack of comprehensive recall is one challenge faced by HCPs at a practice level. James explains:
“One barrier to improving asthma and COPD control is the rigid recall processes in General Practice. As a specific example, young asthmatic patients who struggle to complete diagnostic testing may not subsequently appear on General Practice chronic disease registers. This presents the potential for a lack of routine follow up if recall processes are designed around the traditional Quality Outcomes Framework requirements for annual review. More comprehensive recall systems which include those with a queried or unconfirmed diagnosis would be extremely beneficial for relevant patients.”
Another challenging area is the access to funded education and crucially, availability of mentorship, support and networking for HCPs. Carla says:
‘’Currently, there are no unified national guidelines in the UK for asthma. Local guidelines (for asthma and COPD) often represent more recent published evidence and align with international reports that are updated annually. Dependent on the integrated care system (ICS)/integrated care board (ICB) networking, mentorship and delivery of local education sessions, this can contribute to poor understanding or confidence in the often-isolated primary care workforce.’’ For HCPs, she recommends finding networks through PCRS affiliated groups and contacting the long-term condition or respiratory lead at your ICB. ‘’Local meetings can integrate primary, community and secondary, helping to navigate those seeking clinical support and provide a voice at ICB level. Ways of working can be shared that will support delivery of respiratory care relevant to your practice population.’’
Improving poor symptom control in respiratory care
Improving poor control in respiratory care is essential in helping patients to manage their asthma and COPD effectively and involves a combination of approaches to improve and maintain condition control.
Improving control
| Inhaler choice and technique | Inhalation therapy can be useful in ensuring a patient reduces their symptoms and has better control over their asthma and COPD. The choice of inhaler should be tailored to the individual’s needs based on access, the prescriber’s clinical assessment and the patient’s ability and preference, with inhaler technique regularly assessed by a HCP to maintain good practice.20, |
| Shared decision making | Poor control is a term that can be understood differently by both patients and HCPs so a critical way to address this is for HCPs and patients to enter a shared dialogue on treatment and respiratory management.21,
James explains ‘’As a HCP advising patients, it is important to consider the patient’s ideas, concerns and expectations and incorporate these into a management plan to create shared ownership.’’ Carla agrees, she believes HCPs integrating themselves into the local community can have a positive effect on shared decision making. ‘’Speaking with your patient practice group (PPG) or local Breathe Easy group allows you to hear the voices of your respiratory population so you can collaborate to review services and accessibility.’’ |
| Patient education | Education plays a pivotal role in enhancing respiratory care by addressing inequalities and empowering HCPs to detect, diagnose and support their patients with chronic respiratory disease within their local contexts.22, Carla concludes ”It includes confidence and understanding when discussing therapies such as pulmonary rehabilitation.”
James says ‘’A patient’s understanding of their condition, and its predicted trajectory in the short and long term is a key component in promoting treatment adherence and optimising management. Education regarding triggers and rationale for treatment is essential for engagement.’’ |
Respiratory Nurse Consultant, Joanne King, explains the importance of ensuring patients are using the most suitable device.
Maintaining control
| Check ups, reviews and management | An annual review or check-up is a crucial moment to identifying poor control. James advises to ‘’begin consultations by giving the patient the opportunity to discuss their condition, how it affects their life, and if they have any concerns or questions regarding their health that they’d like to discuss’’. By approaching it this way it gives the patient the opportunity to discuss their respiratory condition and demonstrates to the patient that their needs are being heard. |
| Motivational interviewing | Defined as a collaborative conversation style for strengthening a person’s own motivation and commitment to change, motivational interviewing (MI) is thought to be an effective approach in disease management.23,24, Patients with respiratory conditions may be motivated to change their behaviour (mobilise, exercise, stop smoking) to improve their health but simultaneously lack confidence in their ability to succeed. MI seeks to create a supportive, empathic atmosphere whilst encouraging patients to verbalise their own motivations for change. For further support please visit the personalised centred institute. |
| Adherence monitoring | Adherence is crucial to achieving effective respiratory control. Continuous monitoring of adherence by both patient and HCP can ensure efficient disease control.25, Read more about how poor control is linked to adherence. |
What is being actioned to achieve better management at practice level?
The NHS Long Term Plan sets out ambitions for the NHS over the next ten years, identifying respiratory care as a clinical priority. Their aim is to improve the treatment and support of those with asthma and COPD, including:26,
- enable early and accurate diagnosis of respiratory diseases, by supporting the training of staff to deliver tests such as spirometry
- expand pulmonary rehabilitation services across the country so that patients who would benefit complete treatment in a good quality service
- improve appropriate prescribing of medicines and the way they are reviewed, and support patients to use their inhalers properly
- design and develop tools and programmes that will support patients to manage their condition themselves and receive personalised care.
Alongside the NHS long term plan, Core20PLUS5 is a national NHS England approach to inform action to reduce healthcare inequalities at both national and system level. The approach defines a target population – the ‘Core20PLUS’ – and identifies five focus clinical areas requiring accelerated improvement including chronic respiratory disease.27,
Visit our resource page to access further useful information for you and your patients.
Key takeaways
Tackling poor control in asthma and COPD is imperative to improving patient outcomes and reducing the burden on the NHS.
The NHS Long Term Plan and ambition is to identify respiratory disease as a clinical priority whilst improving treatment and support for those with respiratory conditions – especially as these conditions now affect 1 in 5 people in the UK.26,
Ultimately, a comprehensive approach that combines education, shared decision making, and health equality holds promise in tackling the ongoing issue of poor control in respiratory conditions.
