Dr Steve Holmes (pictured) and Jane Scullion discuss revised advice on asthma management, clarification of recommendations for clinicians, and PAAPs to help patients control their asthma

holmes steve

Independent content logo

Read this article to learn more about:

  • the updated advice from BTS/SIGN on the management of asthma
  • how implementation of supported self-management and personalised asthma action plans can improve quality of life and reduce symptoms and emergency treatment for asthma
  • the importance of ensuring patients receive adequate instruction in the use of inhaler devices and that they can demonstrate effective use.

Key points

GP commissioning messages

 

 
27/02/2015 CORRECTION

Paragraph 3 of this article, first published in January 2015, has been adapted in the following ways:

Original text:  ‘…the NRAD report considered mortality figures from more sources than the ONS and had stricter inclusion and exclusion criteria (for example deaths in people over 75 years of age were excluded).’

Correction: ‘(for example deaths in people over 75 years of age were excluded)’ has been deleted as some individuals over 75 years of age were included if certain criteria were met.*

Original text:The NRAD identified 3544 people who had asthma mentioned on their death certificate. The review team excluded approximately 2600 as not having died from asthma.

Correction:The review team excluded approximately 2600 as not having died from asthma’ has been changed to‘Of these, 900 met the overarching inclusion criteria for the NRAD and were screened for consideration by the confidential enquiry panel.’ This change was made as we cannot conclude that the approximately 2600 excluded did not die from asthma; therefore we have now focused on the number included for further review.*

Original text: ‘…leaving a detailed review in 276 cases. Of these cases, 195 (29%) were actually considered to have died from asthma.’

Correction: The percentage figure ‘29%’ is wrong and has been deleted.

We are sorry for any confusion we may have caused.

*To access the NRAD full report, click here

In October 2014, the British Thoracic Society (BTS) and Scottish Intercollegiate Guideline Network (SIGN) published the updated British guideline on the management of asthma 1—a timely update in view of publication of the May 2014National review of asthma deaths (NRAD) from the Royal College of Physicians (RCP). 2

The NRAD suggested that complacency on the part of both healthcare professionals and patients remains a significant reason for fatalities from asthma.2 This complacency is supported by research into people with asthma and their significant symptoms that persist despite good therapeutic options. 3 It is worth evaluating this in more detail.

First, we know from well-designed asthma trials that for most people who achieve control by taking regular treatment it can be maintained,4 and that our patients' expectations can often be low;3 however, this study also showed that patient satisfaction levels dropped when patients were shown guideline examples of what they should expect from good asthma care.3 The NRAD report highlighted a variety of issues around monitoring, use of medication, inappropriate review, and failure to address risk factors.2

The NRAD review does, however, challenge our view on annual mortality data that is produced. Whereas the Office for National Statistics (ONS) highlights around 1300 deaths per year from asthma, 5 the NRAD report considered mortality figures from more sources than the ONS and had stricter inclusion and exclusion criteria (for example deaths in people over 75 years of age were excluded). The NRAD identified 3544 people who had asthma mentioned on their death certificate. 2 The review team excluded approximately 2600 as not having died from asthma—and looked in more detail at the remaining 900 cases: review was not possible for 272 (because of failure to obtain records/notes); 352 were deemed not to have asthma or asthma was unlikely to have been the cause of death; leaving a detailed review in 276 cases. Of these cases, 195 (29%) were actually considered to have died from asthma and the NRAD focused on these deaths.

Guidance from BTS/SIGN

The first British guideline for the management of asthma in adults was published by the BTS in 1990,6 well before further guidance from NICE and SIGN. A combined guideline between the BTS and SIGN was first published in 2003. The British guideline on the management of asthma was updated annually between 2004 and 2012, and beginning with the current update (October 2014) updates are now planned to be biennial.

Overview of the 2014 updates

Every chapter in the BTS/SIGN guideline has now been updated, but no amendments were made to the diagnosis and monitoring section this time. (NB NICE anticipates publishing guidance on diagnosis and monitoring of asthma in June 2015.) The areas that have been updated since 2012 include:

  • supported self-management (which has been significantly rewritten)
  • non-pharmacological management
  • pharmacological management
  • inhaler devices
  • management of acute asthma
  • difficult asthma
  • asthma in pregnancy
  • occupational asthma.

This article will concentrate mainly on supported self-management and the non-pharmacological and pharmacological sections of good asthma care.

The guidance has made a key change in terminology, using the phrase 'asthma attack' now rather than 'asthma exacerbation'. This fits in with trying to use terminology that our patients understand and use instead of more complex medical phrases.

Diagnosis

Before we move on to look at new areas highlighted in the guideline, it is worth briefly considering the importance of diagnosis. It may seem obvious to suggest that the foundation for any management guideline is to ensure that a good diagnosis has been established prior to commencing treatment. Asthma is a more complex area than many, in that the diagnosis is based on clinical skills and a pattern rather than a single test; the concepts of high, intermediate, and low probability have been used in the BTS/SIGN guidance since 2008.

For children, it is recommended that the diagnosis is made based on a good suggestive history, confirmatory examination, and careful consideration of alternative diagnoses.

In the case of adults, we would ideally again look for a good suggestive history and confirmation at examination, but demonstrating reversibility (by peak expiratory flow [PEF] readings or, preferably, spirometry, which is a more robust screening tool) is also strongly recommended. Clinicians should note that serial peak flow measurements are not recommended because these measurements are so often inaccurate as they may not show asthma variability within this time frame and do not reliably rule the diagnosis of asthma in or out.1

Monitoring

The BTS/SIGN guideline does not provide advice for monitoring adults with asthma in specialist care, although it should be expected that specialists in secondary care would undertake a more complex review than that carried out in primary care.

Recommendations in primary care are for monitoring and recording of:

  • symptomatic asthma control
  • lung function (using spirometry or PEF)
  • asthma attacks, use of oral corticosteroids, and time off work or school since the previous review
  • inhaler technique
  • adherence to treatment
  • use of bronchodilators
  • possession and use of a self-management plan/Personalised asthma action plan (PAAP).

It is salutary to reflect on how poorly these aspects were managed for those patients who died as a result of asthma (see Table 1, below).

Table 1: Monitoring during the year prior to death of patients who died from asthma (adapted from the National review of asthma deaths)2
Recorded assessment criteria in previous 12 monthsPrimary care follow up (n=195) (%)Patients with secondary care follow up (n=83) (%)
Peak flow rate 105 (54) 15 (18)
Spirometry 40 (21) 17 (20)
Inhaler technique checked 96 (49) 14 (17)
Assessment of asthma control using RCP three questions or similar during last review 37 (19) 5 (6)
Assessment of the person's adherence to medical advice 57 (29) 9 (11)
Provided with a personal asthma action plan (ever) 33 (17) 12 (14)
  • RCP=Royal College of Physicians
  • The above table is extracted from 'Why asthma still kills' report, published by the National review of asthma deaths (NRAD) in 2014. NRAD was commissioned by the Healthcare Quality Improvement Partnership as part of the Clinical Outcome Review Programmes. The full report can be found at: www.hqip.org.uk

Supported self-management

The chapter in the guideline that has probably undergone the most significant change is on the exploration of supported self-management—there is a large body of evidence regarding this and the chapter has been moved to a more prominent position, after diagnosis and before nonpharmacological and pharmacological management.

Supported self-management sounds straightforward, but when we look at how infrequently clinicians currently check adherence and inhaler device use, and how frequently patients do not comply with medication, it is clear that the basics of good care are being forgotten. The guideline presents substantial evidence that shared decision-making, alongside a structured review and education, as well as a PAAP:1

  • reduces the incidence of:
    • hospitalisation
    • emergency department attendance
    • unscheduled consultations
  • improves patient symptoms
  • reduces days off work
  • improves quality of life.

The guideline evidence for PAAPs in asthma is strong, with 22 systematic reviews of 261 randomised controlled trials covering evidence in a wide range of demographic, clinical, and healthcare contexts, including preschool children, ethnic minorities, and in both primary care and secondary care.

One example of a PAAP is illustrated in Table 2 (below), but there are a number of good quality PAAPs available, including one from Asthma UK (see here). However, for there to be any chance that the PAAP will be used, we need to work with our patients and understand their ideas, concerns, and expectations, both about the disease and about their therapeutic options. It is also important to assess medicine adherence carefully. Based on a calculation of how long an inhaler will last (remembering that some have 60, some 120, and some 200 doses), it is quick and easy, using a computerised record system, to evaluate the number of inhalers a patient has requested and how long they should last. Doing this does not let us know, however, whether the medication is dispensed by the pharmacist, nor indeed, even if dispensed, whether it is used by the patient according to the advised dose (and we know that not all patients collect their prescriptions, nor use their medication as we expect).

The closer we can align our shared understanding (the patient's views and beliefs and our own as their clinician), the more likely we are to move forward with shared decision-making and start to improve outcomes for our patients.

Table 2: Components of a Personalised Asthma Action Plan
ComponentNotes
Trigger for action is based on PEF measurement or symptoms (PEF based on percentage of patient's best peak flow) Either peak flow or symptoms or both is fine
Standard written instructions Beneficial in the evidence (although some management plans are now trying pictorial imagery rather than writing)
Traffic light configuration (red, amber, green) No better than standard written instructions
Action plans usually include two to four parameters. Commonest:
  • increased use of short-acting beta agonist
  • initiation of oral corticosteroid
  • seeking medical advice if symptoms worsen
-
  • PEF=peak expiratory flow.

Non-pharmacological interventions

Non-pharmacological interventions for asthma have always been debated, and many of our patients would wish to try these interventions rather than rely on medication. The latest updated guideline from BTS/SIGN is more direct and clear in its advice. It recommends only suggesting an intervention if its benefits are clear from the medical evidence. For the primary prevention of asthma, the guideline:1

  • does not recommend allergen avoidance (single or multiple, animals, house dust mite, or food)
  • recommends:
    • that breastfeeding should be encouraged 'for its many benefits, including a potential protective effect in relation to early asthma' (although it highlights that the research on this is conflicting)
    • weight reduction in obese patients to promote general health and to reduce subsequent respiratory symptoms consistent with asthma
    • that parents and parents-to-be do not smoke—again because of the general health benefits, but also because of evidence that smoke exposure increases wheeze in infancy and creates a greater risk of asthma persisting in childhood.

The section on secondary prevention is more extensive, exploring a wide range of non-pharmacological interventions that have had varied support over time:1

  • relating to a Cochrane review published in 2008 (after the update to the guideline was published), the guidance has changed significantly, suggesting that physical and chemical methods of reducing house dust mite levels in the home (including vacuum cleaning, heating, ventilation, air filtration, ionisers, acaricides) are ineffective and should not be recommended by healthcare professionals
  • recommendations relating to immunisation (influenza/ pneumococcal) are not as direct as national guidance from the Chief Medical Officer that chronic diseases such as asthma (that require inhaled or tablet steroid treatment or have led to hospital admission in the past) should receive immunisation (see here). The BTS/SIGN guideline suggests that there is little evidence as yet for use of pneumococcal vaccination and only a small benefit to improved quality of life with influenza immunisation. The overarching advice in the guideline is to immunise 'independent of any consideration of asthma', and that high-dose inhaled corticosteroids (ICS) can be used to attenuate responses to vaccines
  • the guideline supports weight reduction in overweight patients with asthma as this 'may lead to improvement in asthma symptoms'
  • it recommends that breathing exercises can be offered (including physiotherapist-taught methods) as an adjunct to pharmacotherapy to reduce symptoms and improve quality of life
  • based on identification in a Cochrane review of two small trials (even though these only included 55 patients in total), the guideline says there may be a role for family therapy for children with difficult asthma.

A list of the non-pharmacological approaches that are not recommended in asthma is summarised in Table 3 (below).

Table 3: Non-pharmacological interventions that are not recommended in asthma by the BTS/SIGN guideline1
InterventionComment
Acupuncture Evidence appears subject to publication bias and in general does not demonstrate benefit
Air ionisers Evidence is strong that clinicians should not recommend
Air pollution No evidence at present (asthma is more common in less polluted parts of the UK)
Allergens (pets) Mixed evidence—often after pets are removed, no benefit is found and some patients appear to gain tolerance to the allergen from exposure
Antioxidants No evidence at present of benefit from introduction or supplementation
Electrolyte supplementation Limited studies and more research needed before any recommendation can be given
Fish oil/lipids Limited evidence and none to support these supplements at present
Herbal/traditional Chinese medicine Weak evidence and a need for some randomised controlled trials
Homeopathy Weak evidence with poor methodology
House dust mite No evidence and healthcare professionals should not recommend reducing exposure
Hypnosis and relaxation therapy Weak evidence and poor methodology
Manual therapy including massage and spinal manipulation No evidence at present
Physical exercise training Cochrane review has shown no benefit on lung function parameters, but an overall healthy active lifestyle is recommended (no evidence). While some people may experience exercise-induced asthma, the numbers are relatively low and many top class athletes have asthma, but control it
Probiotics No evidence of benefit

Pharmacological management

The pharmacological management section has been updated in line with more recent research (although no articles published after August 2012 were included in the guideline update) and highlights, initially, the guideline definition of complete control of asthma (see Box 1, below). However, it recognises that there is always a balance between symptom control and potential side-effects or inconvenience of taking medication.

Box 1: The BTS/SIGN guideline definition of complete control of asthma1

  • No daytime symptoms
  • No night-time awakening due to asthma
  • No need for rescue medication
  • No asthma attacks
  • No limitations on activity including exercise
  • Normal lung function (in practical terms FEV1 and/or PEF>80% predicted or best)
  • Minimal side-effects from medication.
  • FEV1 =forced expiratory volume in 1 second; PEF=peak expiratory flow
  • British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 141. Edinburgh: 2014. Available at: www.sign.ac.uk/pdf/SIGN141.pdf Reproduced by kind permission.

As in previous updates, the 2014 BTS/SIGN guideline takes a stepwise approach to treatment (see Figure 1 below).

Step 1: mild intermittent asthma

Step 1 involves use of a short-acting bronchodilator, such as inhaled short-acting beta 2 agonists (e.g. salbutamol), and recommends that this should be used as needed. It would be expected that with good control, a patient would need a maximum of two puffs of their short-acting reliever twice a week; four puffs a week over a year is marginally more than one inhaler per year.

As clinicians, we should challenge ourselves to consider adapting treatment if our patients require more than this amount. The guideline also highlights that any person who requires more than one short-acting reliever inhaler a month should be reviewed urgently1 (which fits in with the increased risk identified in the NRAD report2).

Step 2: regular preventer therapy

Step 2 involves the initiation of regular preventer therapy (low dose ICS). The guideline says that there is little evidence in adults of short-term detrimental effects other than local dysphonia and oral candidiasis at doses <800 μg of beclometasone diproprionate (BDP); however, it raises the possibility of longterm longterm effects on bone, although one study has indicated no effect on bone density at doses <1000 μg.7

An ICS is suggested by BTS/SIGN for anyone who has experienced an asthma attack in the previous 2 years, anyone who is symptomatic or using a shortacting reliever three times or more a week, and anyone waking once a week with their asthma.

The recommendation is that ICS should be prescribed initially at a dose appropriate to the severity of disease; a reasonable starting dose for most adults is 400 μg of BDP equivalent (200 μg in children). In mild to moderate asthma, starting at a high dose of ICS and gradually reducing it does not confer any benefits.

The impact of smoking is often overlooked and the guideline recommends smoking cessation. It notes that people who have smoked or who continue to smoke often require higher doses of ICS to gain a therapeutic response.

There are three important areas to consider when prescribing ICS:1

  • not all products are dose-equivalent to BDP:
    • prescribing clinicians should check if they are in any doubt about the amount of ICS they are prescribing
  • ICS (except ciclesonide once daily) are usually used twice daily as the research suggests they are slightly more effective at that dose. The guideline suggests, however, that once-daily use may be sufficient for patients with milder asthma once they have good or complete control of the disease
  • the ICS should be titrated down to the lowest possible dose that controls symptoms (a reduction of 25%–50% of the ICS dose is recommended after a minimum of 3 months' stability).

Step 3: initial add-on therapy

Step 3 is recommended if there is failure to control a patient's asthma at step 2. Prior to stepping up treatment, it is important to consider whether the diagnosis is right, whether there is anything else contributing to the symptoms, whether the patient is taking their current medication as expected, and whether they are able to use the prescribed inhaler device effectively.

The guideline recommends that for people taking up to 400 μg bd (adults) of BDP it is worth considering addition of an inhaled long-acting beta2 agonist (LABA) as first choice (this improves lung function and symptoms as well as decreasing asthma attacks). Certainly, if ICS at doses between 400 μg and 800 μg fail to achieve control, a LABA is recommended at step 3. Other suggestions for add-on therapy at step 3 are: leukotriene receptor antagonists; theophyllines; and slow-release beta2 agonists. However, the guideline recognises that side-effects are common with the latter two treatments.

If the addition of a LABA does not improve symptoms, the guideline recommends that the dose of BDPequivalent ICS should be increased to 800 μg daily (if not on that dose already).

The recommendation that a LABA should not be prescribed alone remains unchanged in the guideline. This was picked up in the NRAD report where 14% of people who died from asthma were being prescribed LABA alone. The BTS/SIGN guideline clearly recommends that in asthma, a LABA should only be used in combination with an ICS.

Figure 1: Summary of stepwise management of asthma in adults1
Summary of stepwise management of asthma in adults
  • * beclometasone dipropionate or equivalent
  • British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 141. Edinburgh: 2014. Available at: www.sign.ac.uk/pdf/SIGN141.pdf Reproduced by kind permission.

Step 4: addition of a fourth drug

Moving to steps 4 or 5 should be considered a significant step in primary care as very few people with asthma require treatment at this level. It is therefore vital that clinicians re-evaluate the diagnosis, compliance, concordance, avoidance of triggers, and the patient's ability to use inhaler devices before stepping up treatment again ('stepping back before stepping up').

The evidence in the guideline becomes much more consensus-based at this level, but recommends that if control in adults is still inadequate at 800 μg BDP/day or equivalent (400 μg in children) and a LABA, one of the following interventions should be considered:

  • increase ICS to 2000 μg BDP/day (800 μg BDP/day in children 5–12 years, with a spacer if necessary)
  • leukotriene receptor antagonist
  • theophyllines
  • slow-release beta2 agonist tablets (with caution if the patient is already on a LABA).

A new alternative is the possible use of long-acting muscarinics, such as tiotropium, as an addition at step 4. This drug is very familiar in the management of chronic obstructive pulmonary disease, but has recently been licensed for use in asthma. However, the use of tiotropium in asthma has not been fully reviewed by the current SIGN/BTS guideline.

Step 5: oral steroids

Step 5 involves a step up to frequent or continuous use of oral corticosteroids, and referral to specialist care is recommended. 1,2

At this level a careful evaluation of the diagnosis again needs to be made, and consideration of potential co-morbidity involvement with symptoms. There is a range of treatments that might reduce the need for oral steroids and lessen the risk of long-term side-effects.

Anti-IgE monoclonal antibodies (omalizumab) are now more commonly used in specialist care, as, at times, are immunosuppressants (methotrexate, ciclosporin, and oral gold), which can be given as a 3-monthly trial. There will also be some patients for whom sublingual or subcutaneous immunotherapy or bronchial thermoplasty in specialist centres is suitable.

Inhaler devices

The section on inhaler devices in the 2014 BTS/SIGN guideline has also been updated. There is a strong recommendation that clinicians should only prescribe a device if the patient has been taught to use it and has subsequently demonstrated satisfactory technique. 1 The patient needs to be confident and able to manage the device themselves.

There is plenty of evidence that patients are not using their inhaler devices appropriately in many situations. One study demonstrated that although 74% of patients who had been using their inhaler for, on average, 2–3 years reported they were using it correctly, on checking only 10% demonstrated correct technique.8 What is even more alarming is that many clinicians themselves, even when teaching about the devices regularly, are unable to use them correctly. This is especially true for pressurised metered dose inhalers (pMDI). 9

For mild and moderate asthma attacks, the guideline makes a strong recommendation that in children (aged 5–12 years) a pMDI and spacer is as effective as a nebuliser; and in adults the same is true, although some patients may prefer some types of dry powder devices.

Spacers

It is still clinically common to see patients making basic errors in the use of spacer devices. The guideline presents some sensible advice on their use and care that is clear and that encourages appropriate and simple use (see Box 2, below).

Box 2: Top tips for using and cleaning spacer devices1

  • Ensure the pMDI and spacer are compatible
  • The drug should be administered by repeated single actuations of the pMDI into the spacer, each followed by inhalation
  • There should be minimal delay between pMDI actuation and inhalation
  • Tidal breathing is as effective as single inhalations
  • Clean the spacer device every month (and not more frequently), washing in detergent and allowing it to dry in the air—wipe the mouthpiece before use
  • Drug delivery varies according to static charge (metal and other antistatic spacers are not affected)
  • Plastic spacers should be replaced at least every 12 months (but some may need changing at 6 months).
  • pDMI=pressurised metered dose inhaler.

Conclusion

The latest update of the British guideline for the management of asthma addresses the challenges arising from the National review of asthma deaths to improve care and reduce mortality from asthma. The guidance has strong evidence to support use of PAAPs as part of a supported self-management programme, and there have been updates to the non-pharmacological intervention recommendations, which are clearer on areas that are no longer recommended.

The guideline reinforces the importance of a good asthma diagnosis, which is the cornerstone of subsequent management, and of checking adherence and inhaler device technique, carefully stepping up therapy but equally stepping down when good control is achieved.

It will be interesting to see whether we can manage to improve the quality of care and reduce morbidity and mortality further with the implementation of this updated guideline from BTS/SIGN.

Key points

  • Asthma still kills
  • Most asthma deaths are seen as preventable
  • Complacency in people with asthma and healthcare professionals with regard to symptoms is seen as fundamental to causing asthma deaths
  • Inhaler devices are poorly used by people with asthma
  • Use of inhaler devices is poorly taught by healthcare professionals
  • There is lack of adherence to a stepwise approach to asthma
  • There is an over reliance on reliever medication
  • Good asthma reviews are essential
  • Secondary prevention may have a part to play in controlling symptoms
  • Supported self management is recommended
  • Personalised asthma action plans (PAAPs) should be given to all people with asthma.

Back to top

GP commissioning messages

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • This updated guideline places a special emphasis on guided self-management for asthma
  • Practices should ensure that enough time is allowed for them or for the local pharmacy to educate patients about inhaler use at the point of prescription
  • Patients' inhaler technique and usage should be reviewed and monitored regularly:
    • this is an ideal role for pharmacy, which could be funded through a medication use review or local enhanced service
  • Clinical commissioning groups:
    • could find rates of asthma reviews and admissions in QOF data and hospital admission data, and target support for practices with low rates of asthma reviews or high rates of asthma admissions
    • should encourage the use of PAAPs and consider providing a local template
  • Combination LABA/ICS inhalers are often one of the highest prescribing cost items for CCGs but generic equivalents are beginning to become available and so CCGs should evaluate these for inclusion in formularies.

QOF=quality and outcomes framework; PAAP=personalised asthma action plan;
LABA=long-acting beta2 agonist; ICS=inhaled corticosteroids; CCG=clinical commissioning group

Back to top

References

  1. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 141. Edinburgh: 2014. Available at: www.sign.ac.uk/pdf/SIGN141.pdf
  2. Royal College of Physicians of London, British Thoracic Society and British Lung Foundation. Why asthma still kills: The national review of asthma deaths (NRAD). Confidential enquiry report. London: Healthcare Quality Improvement Partnership, 2014. Available at: www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf
  3. Haughney J, Barnes G, Partridge M, Cleland J. The Living & Breathing Study: a study of patients' views of asthma and its treatment. Prim Care Respir J 2004; 13 (1): 28–35.
  4. Bateman E, Bousquet J, Busse W et al on behalf of the GOAL Steering Committee and Investigators. Stability of asthma control with regular treatment: an analysis of the Gaining Optimal Asthma controL (GOAL) study. Allergy 2008; 63: 932–938.
  5. Office for National Statistics (ONS). Mortality statistics: deaths registered in England and Wales (Series DR) . Available at: www.ons.gov.uk/ons/rel/vsob1/mortality-statistics--deaths-registered-in-england-and-wales--series-dr-/index.html (accessed 14 January 2015).
  6. The British Thoracic Society, The National Asthma Campaign, London. TRCoPo, in association with the General Practitioner in Asthma Group, the British Association of Accident and Emergency Medicine, the British Paediatric Respiratory Society, et al. The British Guidelines on Asthma Management 1995 Review and Position Statement. Thorax 1995; 52: S1–S20.
  7. Fay J, Jones A, Ram F. Primary care based clinics for asthma.Cochrane Database of Systematic Reviews 2002, Issue 1.
  8. Basheti I, Armour C, Bosnic-Anticevich S, Reddel H. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Education and Counseling 2008; 72: 26–33.
  9. Baverstock M, Woodhall N, Maarman V. Do healthcare professionals have sufficient knowledge of inhaler techniques in order to educate their patients effectively in their use? Thorax 2010; 65: A117–A118 doi:10.1136/thx.2010.150979.45.