Asthma - Monitoring/ Annual Review Guidance

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.


This guidance refers to:

  • Monitoring and annual review of patients with asthma

This guidance does not cover:

  • Acute presentation of Lower Respiratory Tract Infection.
  • Patients presenting with potential exacerbation of Asthma without prior diagnosis who should be managed as per Asthma (Acute) - Management Care Pathway
  • Children 12 years or under

Routine Management

All practices should have a named healthcare professional Asthma Lead with an appropriate Asthma Management qualification e.g Asthma or Respiratory Diploma
Staff should have access to ongoing training and educational support.
The effectiveness and efficiency of care and management processes should be regularly reviewed using clinical audit and evaluation of outcomes


  • The use of a comprehensive template will support the delivery of a structured and proactive review
    • associated with reduced exacerbation and days lost from normal activity
      • The local asthma review template can be accessed via SystmOne (Wakefield only) click here for example screenshot
      • For information about how to add the template to your clinical tree click here
  • A Telephone review has been shown to be a suitable option for those patients who fail to attend for routine reviews
    • The telephone interview template can be accessed via SystmOne (Wakefield only) click here for example screenshot
    • For information about how to add the template to your clinical tree click here

Primary care asthma Review

  • Aim: To identify if asthma is CONTROLLED or UNCONTROLLED and take action.
  • Offer: at least annual review to all those on the asthma register.
  • Time taken: approximately 20 -30 minutes.
  • Conducted by healthcare professional with appropriate education

Prioritise those at greatest risk of attack

  • Identification via computer searches and reviews of medical records (see section below re: identifing those at risk)
  • Placement on an 'At risk' register for Asthma.
  • System devised to 'flag up' risk and prioritise attendance.

Prioritisation of care

  • Proactive recruitment to attend for asthma assessment.
  • Telephoning resistant 'DNA' (Did Not Attend) patients to assess control and encourage attendance.
  • Review by suitably qualified Health care professional for all patients within 2 working days of acute treatment, including discharge from the Emergency Department.
  • Priority / same-day appointments for those with deteriorating symptoms who are 'At risk'.
  • Consider telephone review using appropriate templates (see reviews section above)
  • Liaison with community pharmacists, schools, school nurses & community colleagues e.g. community nurses.

Identifying those at risk

SIGN Definition of those at risk

  • Previous near-fatal asthma
  • Previous admission for asthma in the past year (including emergency department)
  • Requiring three or more classes of medication
  • Heavy use of short acting B2 agonist
  • 'Brittle asthma'

Identifying those at greatest risk - computer searches

  • Previous near-fatal asthma
  • Hospital attendance with asthma attack in past 2 months (including Emergency Department attendances).
  • Presentation with asthma attack in primary care in past 2 months
  • Two or more courses of oral steroids and/or antibiotics in past 12 months.
  • Medication safety concerns
    • B2 agonist (>12 relievers in 12 months)
    • Less than 12 ICS in 12 months
    • LABA without ICS
  • DNA asthma clinic or excepted from QOF.
  • Repeated days off school or work with Asthma
  • 'Brittle asthma'.

Annual Review


  • Number of Asthma exacerbations in past 12 months, including last oral steroid use, emergency department or out of hour's attendance
  • Emergency asthma admission
  • Work days lost since last seen in clinic (Is there any suggestion of occupational asthma?)
  • Flu vaccination recorded in last 12 months, if appropriate
  • Smoking status recorded : stop smoking advice given and referral to stop smoking service if appropriate - See smoking care cessation pathways

Assessment of Control

  • The following Royal College of Physicians 3 Questions is the minimum QOF requirement
    • Have you had difficulty sleeping because of your asthma symptoms (including cough)?
    • Have you had your usual asthma symptoms during the day (cough, wheeze chest tightness)?
    • Has your asthma interfered with your usual activities (work, sex, housework, exercise) Asthma Control Test
  • The asthma control test is an excellent tool for use with adult patients and is included in the local template as the locally recommended assessment tool

Physical assessment/examination

  • Height, Weight, Body Mass Index,
  • Consider need for blood tests
    • eg. IgE RAST if appropriate & will change management of condition.
  • Spirometry
    • Record at each review record FEV1 and FVC, as % predicted and FEV1/FVC ratio.
    • If spirometry not available record Peak Expiratory Flow PEF where possible using patients own peak flow meter.
  • Peak Expiratory Flow, Record actual PEF, predicted PEFR, best PEF (as value and % predicted)

Medication review

  • Discuss and record current medication
    • Assess concordance and understanding
  • Assess inhaler technique at every review
    • Is device appropriate?
    • Is there a need for spacer or spacer replacement (how long in use)?
  • Step up/down treatment as needed in response to assessment.
    • If control is achieved and maintained, after 12 weeks inhaled cortico steroid therapy should be reduced (dose decreased by 25-50%) to the lowest step that maintains control
  • Drug side-effects (current) and potential risks (eg. Steroid-induced osteoporosis).
  • Consider referral to Community Pharmacist for further support with medication either through a New Medicines Service assessment or a Targeted Medicines Use Review.
  • Assess and record use of 'over the counter' medications and herbal medications

Asthma Self Care

  • Assess patient's understanding of how to recognise worsening asthma
  • Assess and address patients' need for education (symptoms and *PEF) and what action to take.
  • Assess understanding of action to take in an emergency.
  • Provide and support all patients to develop and maintain a personalised asthma control plan
  • Consider referral to Expert Patients Programme.
  • Agree interval for asthma follow-up

See Primary Care Asthma Monitoring/Annual Review for summary overview

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Please support the development of a personalised Asthma Control Plan to support shared decision making and self care

Patient information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 09.2017
  • Publication Date: 09.2017
  • Review Date: 03.2019
  • Ref No: RS10 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to:
Only the electronic version is maintained, once printed this is no longer a controlled document


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