Asthma. Key messages: SIGN/BTS asthma guidelines. Learning from asthma deaths. Abbreviations. Diagnosis of asthma. Topic

Transcription

1 Key messages: SIGN/BTS asthma guidelines The key messages from the 2016 BTS/SIGN guidelines on asthma are: A good history is key there are no perfect tests. When considering the diagnosis, consider the likelihood that this is asthma. If the likelihood is high, then proceed straight to a trial of treatment tests are not necessary. Use tests (usually spirometry and reversibility) when the diagnosis is less certain (intermediate probability of asthma). Aim for total control: no regular symptoms, no limitations of activity/exercise, no need for rescue medication, no attacks and normal lung function. When teaching inhaler technique, use TIDAL breathing (normal breaths not great gasps!). Use short-acting beta-agonists alone only if intermittent short lived wheeze. If using 3x a week or more, then add in a regular preventer. Whatever level of treatment, step up if using SABA 3x a week or more. Step down when symptoms are controlled. When reducing ICS, reduce by 25-50% every 3m, aiming to be on the lowest dose of ICS that controls symptoms. Exercise-induced asthma is an expression of poorly controlled asthma in the vast majority, and treatment should be stepped up. There is a heavy emphasis on Personalised Action Plans, so that patients have written information to help them know when to seek help. In acute asthma, peak flows of 75% or below should be treated with oral steroids. Doubling of ICS is not used in this setting, although regular treatments should be reviewed, and, if necessary, stepped up. When measuring PEFR, best PEFR is preferred to predicted PEFR (so make sure you capture this data when they are well!). SIGN/BTS reiterated the key messages from the National Review of Deaths (summarised below). Learning from asthma deaths These learning points are from the National Review of Deaths (UK) (2014). The number of asthma deaths in the UK is higher than in other European countries: 1300 in 2015 (ONS). Most deaths occur before admission to hospital. Most deaths occur in those with chronically severe asthma however, a minority occur suddenly in those with a background of mild or moderate disease. Most who die have not been given adequate doses of inhaled or oral steroids OR have not had objective assessment/monitoring of their asthma (peak flows, etc.). Some patients are still dying because they have an attack triggered by NSAIDs or beta-blockers. In those who died, there was a severe underuse of written Personalised Action Plans (PAAPs). Heavy or increasing use of beta-agonists was associated with asthma deaths (patients and doctors missing a vital cue). Behavioural and adverse psychosocial factors were present in the majority of patients who died (e.g. frequent DNAs/selfdischarge from hospital, social isolation, unemployment/low income, obesity, severe relationship or legal stress). Those who have had a near fatal asthma attack should be under specialist monitoring indefinitely. Those who have had a severe asthma attack should be under specialist care for at least a year. Abbreviations The following abbreviations are used throughout this article: SABA Short-acting beta-agonist e.g. salbutamol LABA Long-acting beta-agonist e.g. salmeterol, formoterol ICS Inhaled corticosteroids e.g. beclometasone, fluticasone (propionate/furoate), budesonide LAMA Long-acting muscarinic antagonist e.g. tiotropium LTRA Leukotriene receptor antagonist e.g. monteleukast Diagnosis of asthma Page 1 of 17

2 Interpreting lung function tests Page 2 of 17

3 Page 3 of 17

4 Differential diagnoses to consider in adults and children Referral criteria for adults and children Page 4 of 17

5 Management Page 5 of 17

6 Inhaled corticosteroid strengths Page 6 of 17

7 Acute severe asthma I have presented this in the form of a protocol. Feel free to photocopy and use in your own practice. Page 7 of 17

8 Page 8 of 17

9 Monitoring asthma Page 9 of 17

10 Testing understanding of Personalised Action Plans (PAAPs) This bit is ENTIRELY anecdotal! I have found the best way to test people s understanding of how to manage their asthma is to run two scenarios by them. The conversations normally go something like this: Tell me what you would do if your asthma had been pretty good for some months, but you wake in the middle of the night and your asthma is really bad, your chest feels really tight and you are struggling to breathe. What would you do? Take my inhaler? The blue one I d probably take 2 puffs? You don t feel any better. What do you now? Take another few puffs? I don t really know doctor Can you have more than 4 puffs? Well, in situations like this, you can have up to 10 puffs, but if things are not getting better, you should be thinking about calling 999. But doctor, isn t 999 just for emergencies? This IS an emergency! You can t breathe and your inhaler isn t helping!!! Let s try another scenario: over the past 5 6 days, your asthma has been getting a bit worse, you are getting breathless when you climb the stairs, but you are OK walking around. You have taken your blue and brown inhaler as you normally do, but it doesn t seem to be improving, in fact things are getting a little bit worse. What would you do? I d ring you! Excellent! Right now let s write all this down in what we call a PAAP! Preventing asthma Page 10 of 17

11 Primary prevention: to reduce the risk of developing asthma SIGN 2016, 153 Allergen avoidance: for children at risk of developing asthma, complex multifaceted interventions targeting multiple allergens may be considered, if the family is able to meet the costs, demands and inconvenience of such a demanding programme. However, avoiding specific single things in pregnancy or early life is not recommended to reduce the risk of developing asthma (e.g. house dust mite reduction measures, avoiding single food allergens, or pets). Food avoidance during pregnancy and lactation is NOT recommended to reduce the risk of asthma in the infant. Breast-feeding should be encouraged as it may be protective. Obese and overweight children should be offered a weight loss programme to reduce the likelihood of respiratory symptoms suggestive of asthma. Discourage smoking by parents. Secondary prevention: measures to reduce the impact of the disease Smoking cessation (patient and parents of children with asthma). Weight loss may improve asthma control if overweight or obese. Breathing exercise programmes (as an adjunct to drug therapy) may improve quality of life and reduce symptoms. House dust must reduction and air ionisers are NOT effective/recommended. Prognosis for children with wheeze Parents often ask Will my child grow out of it?. SIGN offer the following advice: Prognosis: will my child grow out of it? SIGN 2016, 153 The following affect the chance of children growing out of their asthma: Age at onset: the earlier the onset of wheeze, the better the prognosis most children who present with wheeze before the age of 2y will be asymptomatic by mid-childhood. However, if a child has atopy, this is a risk factor for having long-term wheeze, regardless of age at presentation. (Clearly this applies to children who are well between episodes of wheeze not those who also have features of other diseases such as cystic fibrosis.) Sex: boys are more likely to grow out of asthma than girls. Frequency/severity of attacks: those with frequent/more severe episodes have less chance of growing out of their asthma. Family history: a strong family history of atopy, especially maternal atopy, reduces the risk of growing out of asthma. Adolescents and asthma in adolescents (10 19y) SIGN 2016, 153 In adolescents, underreporting of symptoms is common. Most will have normal lung function when well. Advise adolescents and their parents not to smoke. Choose the inhaler they are most likely to use. Ask about issues using it at school/other settings. Discuss avoiding long-term career options that might increase the risk of occupational asthma. In children with exercise-induced breathlessness, an exercise test is helpful to rule out asthma. Panic attacks and anxiety disorders are more common in adolescents and make asthma symptoms more common. The Control Test and the Control Questionnaire (ACQ) (see Useful websites box) have been validated for use in adolescents. Quality of life scales may be useful. SIGN/BTS suggest AQLQ12+ (apply for access at Pregnancy and asthma in pregnancy SIGN 2016, 153 FEV1 and peak flow rates do not change significantly as a result of pregnancy, and so can still be used for assessing severity (NEJM 2009;360:1862). Good control of asthma in pregnancy is important for mother and baby. Advise women not to smoke, for their own and the baby s sake. SABA, LABA, ICS, sodium cromoglicate, nedocromil and oral and intravenous theophyllines can be used safely in pregnancy and breast-feeding. Use oral steroids whenever indicated in pregnancy. Use LTRA if they are needed to get good control. Treat severe asthma in hospital (continuous foetal monitoring is indicated). Women on >7.5mg/day of prednisolone for more than 2w before the onset of labour should have iv hydrocortisone cover in labour. is not an indication for caesarean section. Page 11 of 17

12 Occupational asthma or rhinitis Occupational asthma or rhinitis Do your symptoms improve when away from work, or deteriorate when at work? Ask everyone with asthma or rhinitis about their job, and the materials they work with. Consider occupational asthma if new onset asthma in adulthood or re-emergence of asthma in someone who had grown out of their asthma. About 1 in 10 people who meet these criteria will have occupational asthma. High-risk occupations include: Food processing, especially baking/pastry making. Laboratory work. Metal work, especially welding/soldering. Chemical processing. Farming and other jobs with exposure to dust/fumes. Spray painting. Health/dental care. Woodwork. Textiles/plastics/rubber manufacture. Diagnosis and management 4x daily serial peak flows aid diagnosis, showing a dip on starting work and improvements when away from the workplace. Early referral to a chest physician/occupational physician is recommended. A history of rhino-conjunctivitis can precede the diagnosis of occupational asthma the risk of developing occupational asthma is highest in the first year after developing the rhinitis. Early avoidance of the cause is important: once diagnosed, the person should be moved away from working in the environment that triggers their asthma. Difficult to control asthma Difficult to control asthma SIGN 2016, 153 Review diagnosis. Review triggers and adherence to medication. Review psychological well-being, as co-morbidity common. In children, review family psycho-social wellbeing. Refer for specialist assessment. Consider monitoring sputum eosinophil count to guide steroid treatment. This BMJ clinical review is old, but I have included it here because it helpfully reminds us what to consider when we see an adult with asthma that is difficult to control. Clearly, you are also likely to refer! (BMJ 2009;338:b494). Do they really have asthma? Review history and examination findings; consider investigating for other causes (see end of this section). Are they taking the drugs? Are they taking them properly? Are lifestyle or occupational factors exacerbating the asthma? Obesity and smoking are two important contributory factors. Is this occupational asthma (see above)? Is it drug-induced? NSAIDs, aspirin and beta-blockers can all make asthma worse. The chronic cough from ACE inhibitors can mimic an asthmatic cough. Do they have asthma and another co-existing condition? Bronchiectasis. Sinusitis. Allergic rhinitis. Psychological distress. Vocal cord dysfunction. Reflux. Investigate for other causes (which tests you do depends on clinical features): Possible blood tests: Eosinophil count Aspergillus serology/rast Theophylline levels for compliance Alpha 1 antitrypsin Immunoglobulins and functional antibody tests Anti-neutrophil cytoplasmic antibody. Pulmonary function: Complex lung function tests (e.g. flow volume loops, lung volumes, transfer factors). Page 12 of 17

13 Radiology: CXR Chest CT (bronchiectasis or interstitial lung disease?). Other tests: Nasal endoscopy (polyps, rhinosinusitis?) Bronchoscopy (tumour, foreign body?) Laryngoscopy (vocal cord dysfunction?) Echo (failure?) Psychiatric assessment. Treating difficult to control asthma A DTB review reiterated the need to review the diagnosis, assess compliance and triggers. They also considered the treatment options (DTB 2016;54(11):126): Steroid sparers: limited evidence of benefit, and this should only be carried out by a specialist. Anti-IgE monoclonal antibodies (e.g. omalizumab): beneficial in people with severe asthma that is IgE-mediated (about 50% of people with poorly controlled asthma). Given by subcutaneous injection every 2 4w. Reduces admissions and the need for ICS, but the evidence in those with more severe disease is less clear than in mild moderate disease. Anti-eosinophil therapies (e.g. mepolizumab): another monoclonal antibody therapy, this time useful in those with airway eosinophilia. Given subcut every 4w; however, a Cochrane review of the evidence found all but one of the trials used intravenous versions! Subsequent trials using subcut versions have been small and relatively short (just over 300 patients in total). Expensive: /y. Continuous beta-agonists infusions: lack of evidence. Immunotherapy: not licensed for asthma, but some trials have shown that slowly increasing the exposure to a dose of an allergen sublingually may improve some aspects (such as lung function). However, data on important outcomes like admissions and exacerbations are missing, and what data there is usually relates to those with mild moderate asthma. Bronchial thermoplasty: this is discussed in the step diagram. Drug dilemma: tiotropium in asthma The SIGN/BTS guidance says: LABA+ICS (for which there is good evidence), is preferred to using ICS+LAMA (for which there is insufficient evidence). There is not enough evidence to suggest using tiotropium at earlier stages in asthma management (for example, instead of increasing the dose of ICS). Note that: Tiotripium is licenced for asthma in ADULTS only. Only the Respimat (mist) device is licensed for use in asthma. The Handihaler (dry powder) device is NOT. The recommended dose in asthma is 2 puffs (5mcg) daily. What is the evidence? The DTB concluded that (DTB 2015:53(9):102): The evidence is based on small, short term studies showing statistically significant improvements in things like FEV1 BUT these changes usually did not meet the criteria set by the European Medicines Agency for being CLINICALLY significant. For example, a minimum patient perceivable improvement is defined as 230ml whereas these trials demonstrated improvements of ml. Patient reported asthma control and quality of life improvements were demonstrated, but again did not reach the criteria for being clinically important. On this basis, the DTB did not support the use of tiotropium in asthma. Drug dilemma: beta-blockers in asthma In 2002, a Cochrane review concluded that, in patients with mild moderate asthma, cardioselective beta-blockers should not be withheld from those with heart disease (Cochrane 2002, CD002992). The Cochrane study was a meta-analysis of only 548 adults in 32 studies (so small numbers/study, and small numbers overall). Treatment with beta-blockers was for 1 7d only, so very short term. An updated meta-analysis was published in 2014 and gave a more cautious interpretation of the data (Chest 2014; 145(4):779): In asthmatics, cardioselective beta-blockers had the following effects: Reduced FEV1 (mean drop 7%, although 1 in 8 had a drop of 20% or more). Reduced response to beta-agonists by an average of 10% (suggesting it would be harder to treat an asthma attack). 1 in 33 had worsening of their asthma. The responses were all dose related, with higher doses more likely to cause more problems. Page 13 of 17

14 With non-selective beta-blockers: The mean drop in FEV1 was 10% (1 in 9 had a drop of 20% or more). Response to beta-agonists reduced by 20%. 1 in 13 had worsening of their asthma symptoms. On this basis, some have concluded that cardioselective beta-blockers may be used cautiously in those with mild moderate asthma. However, it is important to bear in mind: SIGN says that beta-blockers, including beta-blocker eye drops, are contraindicated in asthma. The BNF says beta-blockers, including those considered to be cardioselective, should usually be avoided in patients with a history of asthma. However, when there is no alternative, a cardioselective beta-blocker can be given to these patients with caution and under specialist supervision. In such cases the risk of inducing bronchospasm should be appreciated and appropriate precautions taken. The National Review of Deaths (2014) reminds us that some patients in the UK are still dying because they have an attack triggered by beta-blockers. Beta-blockers can be, and are, used in those with COPD. Drug dilemma: LABAs in asthma IMPORTANT SAFETY ISSUE: LABA in asthma (e.g. salmeterol, formoterol) LABAs (salmeterol, formoterol, etc.) should NEVER be used in asthma without inhaled steroids because of an increased risk of death (this is not the case in COPD). One trial quantified this risk as 1 death/700 patient years of treatment (NEJM 2009;360:1671). This also applies to children. SIGN, the MHRA and the National Review of Deaths (2014) recommend the use of combination ICS/LABA inhalers to prevent patients stopping their ICS and remaining on a LABA alone. (A BJGP editorial reminded us that about 1 in 5 of those prescribed separate inhalers ended up taking LABA without inhaled steroids (BJGP 2013;63:627).) The MHRA advice around LABAs is: NEVER use LABAs without inhaled steroids in asthmatics (although this is fine in COPD). NEVER use LABAs in children under 5y (with or without steroids). Do NOT initiate LABAs in those with rapidly deteriorating asthma. Ensure patients have had a trial of inhaled steroids alone before stepping up to combination steroid/laba use. Step down from LABAs as soon as possible. Action: have you reviewed those currently taking LABA for asthma: could they be stepped down? So are LABAs safe when combined with inhaled steroids? Because of the above concerns, the FDA required a study of LABA plus ICS vs. ICS alone to prove safety of LABA when used with ICS. A large RCT randomised over patients over the age of 11y to either fluticasone alone or salmeterol and fluticasone as a combined inhaler, and followed them for 26w (too short, we think!). All the patients had had a severe exacerbation in the past 12m. The trial was run by the manufacturers (NEJM 2015;374:1822). There were no differences in asthma-related adverse events between the groups, suggesting LABAs combined with inhaled steroids are safe. There was no difference in rates of hospitalisation for an exacerbation. There was a slightly lower risk of the primary endpoint in those on ICS and LABA than those on ICS alone (8% vs. 10%), but this was a composite endpoint (an exacerbation needing 3d of oral steroids or hospitalisation) (we don t like composite endpoints see the statistics chapter (Online Handbook) for an explanation of why!). A similar study in children aged 4 11y also showed no harms when LABA+ICS was compared with ICS alone over 26w (NEJM 2016;375:840). A trial of budesonide plus formoterol vs. budesonide alone in those aged over 11y, run over 26w, also showed no harms (NEJM 2016;375:850). What does this mean in practice? These trials offer some reassurance that LABAs, when used with ICS, are safe. However, as the editorial points out, those with a history of life-threatening or unstable asthma were excluded. This vulnerable group is the one in which we most want to use combination therapy! (NEJM 2016;374:1887). Do NOT use LABAs alone in asthma because of the increased risk of death (although they can be used alone in COPD). SIT: Single Inhaler Therapy for maintenance and relief Page 14 of 17

15 Many of you will be familiar with SMART regimens using Symbicort (Symbicort for Maintenance And Reliever Therapy): the idea is that asthmatics have a single inhaler containing a steroid and a LABA (in the case of Symbicort, budesonide and formoterol), and use it for daily maintenance, but can use additional doses of the same inhaler to manage exacerbations. As alternatives to Symbicort have become available, the preferred name is now SIT (Single Inhaler Therapy). SIT can be used with formoterol-containing inhalers, as it has a fast onset of action (similar to salbutamol). Salmeterol LABA CANNOT be used in SIT regimens, as its onset of action is too slow. As far as I am aware, vilanterol is not currently recommended for SIT therapy (lack of evidence), although it may have a faster onset of action than salmeterol. SIT regimens are NOT recommended in those under the age of 18y. A Cochrane review concluded that (Cochrane 2013;CD007313): SIT reduces the number of exacerbations requiring oral steroids. Although promoted as a means to reduce hospitalisations, the evidence for this is weak. More people stopped SIT because of minor adverse events, although there was no increase in serious adverse events. Antibiotics in exacerbations The 2016 SIGN/BTS guidance does not recommend routine antibiotics for exacerbations, unless there is evidence of infection. A small trial of azithromycin vs. placebo in asthmatics presenting with an exacerbation, confirmed there was no significant benefit, but those in the antibiotic arm had more GI side-effects. Of note, the researchers were only able to recruit half the patients they identified because the rest had been given antibiotics already! (DTB 2016;54(12)134). How often do you give antibiotics for exacerbations of asthma? Schools providing salbutamol Twenty school-age children die of asthma each year in England and Wales, usually before reaching hospital. From October 2014, schools have been allowed to purchase a stock of salbutamol inhalers and spacers from pharmacies for emergency use. This follows a survey by UK that showed that 64% of children with asthma did not have access to salbutamol because they had left it at home/it was broken/run out, etc. (DTB 2014;52(10):110). Whether this will have any impact on asthma deaths in children is not yet known. Growth and inhaled steroids in children In children with asthma, the guidelines recommend annual measurement of height and weight centiles to monitor growth. We know that while using inhaled steroids, growth rate is slowed, but do children catch up? This cohort study followed 1000 children who had been in a study where they had been randomised to inhaled steroids (budesonide), nedocromil or placebo during childhood (5 13y at randomisation) (NEJM 2012;367:904). Mean adult height was 1.2cm lower in those using budesonide (CI cm lower) than those using placebo/nedocromil. Most of this impact on growth appears to have occurred in the first 2y of treatment, with prolonged treatment not having a greater effect on growth. Vitamin D and asthma prevention In this RCT, 800 women at high risk of developing asthma were randomised at between 10 and 18w gestation to receive high dose vitamin D (4400IU) or normal dose (400IU) for the duration of the pregnancy (the VDAART trial, JAMA 2016;315:362). 3 years later there were no differences in rates of asthma between the 2 groups. However, when the trial looked at women with higher levels of serum vitamin D vs. lower levels of serum vitamin D it did suggest a reduction in asthma in the children. Longer larger studies are needed! Paracetamol vs. ibuprofen and risk of asthma exacerbations Can the use of paracetamol increase the risk of asthma exacerbations? The ideal study would look at whether paracetamol vs. ibuprofen vs. placebo affected rates of asthma exacerbation. Unfortunately, no such study exists. However, a USA-based double blind RCT enrolled 300 children with mild asthma (on low dose regular inhaled steroids) aged between 1 and 5y. It randomised them to receive either ibuprofen or paracetamol for pain or fever on an as needed basis and followed them up for 48w. The number of asthma exacerbations requiring steroids was the primary outcome. There was no placebo arm because it would be unethical to deny children analgesia for pain or antipyretics for fever (NEJM 2016;375:619). There was no significant difference in the number of asthma exacerbations between the two groups (0.81 Page 15 of 17

16 (paracetamol) vs (ibuprofen). There was no difference in SABA use or unplanned healthcare use. So paracetamol does not increase the risk of asthma exacerbations. Remember that 5% children and 20% adults with asthma have a direct reaction to NSAIDs/aspirin and use of these drugs triggers a worsening of their asthma. Osteoporosis and oral steroids The SIGN asthma guidance recommends that if oral steroids are used continuously, or more than 3 4 courses are given over a 12m period, you should monitor for systemic side-effects: Monitor BP, screen for diabetes and check for dyslipidaemia. Monitor bone mineral density, and, if a significant reduction occurs, offer long-acting bisphosphonates. The SIGN osteoporosis guideline suggests following the RCP guidance, which means (SIGN 2015, 142): Start bone protection without further assessment on anyone aged >65y or with a history of fragility fracture. Do a DXA in everyone else and start bone protection if T-score < 1.5 S.D. Ensure all get lifestyle advice. Alendronate, risedronate, etidronate, zoledronate and teriparatide are licensed for the prevention of glucocorticoid-induced osteoporosis. Diagnosis History is the key to the diagnosis of asthma: there are no perfect tests. When considering the diagnosis, consider the likelihood that this is asthma. If the likelihood is high then proceed straight to a trial of treatment tests are not necessary. Use tests (usually spirometry and reversibility) when the diagnosis is less certain (intermediate probability of asthma). Drug therapy Aim for total control: no regular symptoms, no limitations of activity/exercise, no need for rescue medication, no attacks and normal lung function. Use short-acting beta-agonists alone only if intermittent, short-lived wheeze. If using 3x a week or more, then add in a regular preventer. Whatever level of treatment, step up if using SABA 3x a week or more. Step down when symptoms are controlled. When reducing ICS, reduce by 25 50% every 3m, aiming to be on the lowest dose of ICS that controls symptoms. NEVER use long-acting beta-agonists (e.g. salmeterol, formoterol) without inhaled steroids in asthma (risk of death). In the vast majority exercise induced asthma is an expression of poorly controlled asthma, and treatment should be stepped up. In acute asthma, peak flows of 75% or below should be treated with oral steroids. Doubling of ICS is not used in this setting, although regular treatments should be reviewed, and, if necessary, stepped up. Concordance and self-management There is a heavy emphasis on Personalised Action Plans (PAAPs) so that patients have written information to help them know when to seek help. PAAPs improve asthma control and reduce emergency use of health services (GPs, A&E, admissions). Checking inhaler technique is crucial: use a device to do this. TIDAL breathing is now recommended for those using a spacer (several normal breaths rather than one long/fast intake of breath is preferred). Page 16 of 17

17 Do all your asthmatics have a PAAP? If not, how about ensuring that over the next year you develop one with each patient with asthma? Do you check inhaler technique as part of your asthma reviews? Do you have a device to do this? Do you record all the things suggested in an asthma review on your asthma template? Are any of your patients on a LABA without inhaled steroids or on separate LABA and steroid inhalers? More than 1 salbutamol inhaler/month suggests poor control. Have a look at salbutamol use in the next 5 asthmatics you see. How many have used than more than 12 salbutamol inhalers in the past 12m? Do they need their asthma care reviewing (or do they just have multiple unused inhalers scattered around their house!). In our practice, when salbutamol scripts are on repeat, the receptionists will ask the patient to make an asthma review if they have had more than 3 SABA inhalers in the past 12m. For professionals: Inhaler technique: The technique needed for each type of inhaler is described in a leaflet from the National Council Australia, and is available at: Inhaler technique can be checked using devices such as the In-check DIAL from Clement Clarke ( Don t forget, you also need appropriate mouthpieces (oneoff inspiratory). (We don t make any money from recommending these!) PAAPs These can be downloaded from UK: symptom control questionnaires: Royal College of Physicians 3 Question test: Ask In the last week/month: Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? Have you had difficulty sleeping because of your asthma symptoms/cough? Has your asthma interfered with your usual activities (housework, work, school)? No to all 3 suggests good control. Take action if Yes to any questions. Tip: I remember this as day/night/life. Control Test: Control Questionnaire: apply for access at Children s Control Test: For patients: has an interactive demonstration of inhaler technique and downloadable self-management cards, along with many other useful resources. Page 17 of 17