Clinical risk reduction - asthma

ASTHMA is a common condition in both general practice and in secondary care. Most patients with asthma are easily diagnosed and the management is usually straightforward. The SIGN/BTS guideline is widely read and contains sound advice on the diagnosis and management. However it is easy to become complacent about the disease and to forget that there are around 1000 deaths per year which are attributed to asthma. Because it is such a well-recognised condition with clear guidelines, any failure to diagnose or manage the condition appropriately can become the subject of litigation and the courts will expect a higher standard of care from ‘a competent doctor acting with reasonable care’ than in rare conditions. Medico-legal problems can arise both from incorrect diagnosis and inappropriate treatment.

Making the diagnosis

Just as all that glisters isn’t gold, all that wheezes isn’t asthma. It is important to get the diagnosis right since problems can arise if other possibilities are ignored. In the case of adults the diagnosis is relatively straightforward and is suggested by the presence of more than one of the following:

● wheeze
● breathlessness
● cough
● chest tightness.

It is useful but not always possible to demonstrate reversible airways obstruction. If an increase in FEV1 of 12% or more can be demonstrated then the diagnosis is clear. However, some people have intermittent symptoms and it can be difficult to ‘catch them’ for spirometry when they have symptoms.

In children under five, spirometry is unlikely to be feasible and the diagnosis has to be made on clinical grounds. Once again, cough and wheeze are pointers towards the diagnosis, particularly if the symptoms are recurrent, worse in the morning, precipitated by exercise and associated with a family history of atopy.

Sometimes the diagnosis remains unclear and the best option is a therapeutic trial of a beta adrenergic or steroid inhaler. In this case it is easy to fall into the trap of assuming the diagnosis is asthma if the patient improves. It is necessary to withdraw the treatment and confirm the diagnosis. After all, upper respiratory infections do get better with the passage of time regardless of what treatment is used. If there is a poor response to treatment, the diagnosis may still be asthma, but it is important to review the diagnosis in this situation and not to be afraid to send the patient for further assessment and investigations by a respiratory physician.

Long-term management

It is important to use the minimum doses of drugs which will keep the patient symptom-free and to step up and step down treatment accordingly. Regular follow-up is necessary to ensure that the management is appropriate. It is vital to deal with acute exacerbations expeditiously, to detect warning signs that the exacerbation is becoming severe and to safety net by agreeing an action plan with the patient based on symptoms or peak flow rates. Patients at particular risk of fatal or near fatal exacerbations are those with a history of hospital admissions, on multiple therapy and with high betaagonist use. In addition, the risk is increased by behavioural factors such as denial, noncompliance with treatment, alcohol or drug problems, and social isolation.

Medico-legal issues

No doctor is infallible and the courts recognise this. For litigation to succeed it has to be demonstrated that no competent doctor, acting with reasonable care, would have acted in the same way. Some of the medico-legal issues are unique to asthma whereas others are more generally applicable.

Keep proper records. In many cases the patient’s recollection of events will differ from that of the doctor. If the doctor makes adequate contemporaneous notes then the court is highly likely to accept this version of events. In my experience of GMC and civil litigation I have lost count of the number of times I have heard doctors say: “I did it but I didn’t write it down”, “I don’t record negative findings”, or “I always instruct patients when to seek a review of their condition”. In the case of a patient with, for example, an asthma exacerbation, it is essential to record something along the lines of: “not breathless at rest, PEF =400, Chest some exp wheeze, resp rate 14, no cyanosis, PO2 97. Given 50mg prednisolone for 5 days, review urgently if PEF goes below 300 or if significant deterioration in symptoms”. This doesn’t take long and provides good evidence of appropriate assessment and management.

Be alert to other possible diagnoses. Many conditions can be mistaken for asthma (see below).It is not always possible to get the right diagnosis first time around but we must try to avoid developing a fixed idea of the diagnosis and be ready to rethink the situation.

CASE STUDY A 35-year-old man developed intermittent cough and breathlessness. He was treated for asthma and improved to some extent but his symptoms recurred. Spirometry was normal. The patient continued to complain of breathlessness in the absence of any abnormal findings on examination. Review by a cardiologist did not produce any diagnosis. Chest X-ray was normal. After two years of intermittent symptoms the patient collapsed and died suddenly. What do you think the diagnosis was? The post mortem diagnosis was recurrent pulmonary emboli. Although in the view of the author the patient’s management did not fall below acceptable standards, clearly if the diagnosis had been considered the outcome might have been better.

Be careful with repeat prescriptions. Many patients will be on repeat prescriptions for their asthma drugs. This is fine but it is important to check on a regular basis that the patient is taking the correct drug in the correct quantities. Situations have occurred where patients have continued on oral steroids or high-dose inhaled steroids long after the need for these has stopped. The results of this can be serious and include osteoporotic fractures and adrenal failure.

Watch out for inappropriate concomitant therapy. We are all aware that beta-blockers are contra-indicated in asthma but the occasional prescription does slip through the net and would be difficult to defend. Many patients with asthma can safely take aspirin or non steroidal anti-inflammatory drugs but some patients will have an adverse reaction. It is important to explain this possibility and advise accordingly.

Maintain good communications with the patient. Ideally every patient should have an agreed action plan which would include when to step up or step down medication and when to seek medical help. This is of particular value in ‘brittle asthma’ but would be good practice in all asthma patients.

Reflective practice. Regular audit of asthma care, looking at the number of patients being hospitalised or requiring emergency treatment for exacerbations, will help to identify systematic problems in asthma management. Significant event analysis of hospital admissions will identify issues with the management of individual patients. Although not essential from a medicolegal point of view, such activities will be necessary for successful revalidation and will minimise the risk of litigation.

Conclusion

Asthma is a condition where the diagnosis is usually clear and treatment is straightforward but it is essential to be vigilant and not to adopt a casual approach. The presence of well-recognised guidelines makes the condition easier to manage but also makes inadequate management difficult to defend.

MISTAKENLY DIAGNOSED AS ASTHMA

●Hyperventilation syndrome
●Reflux disease
●Pulmonary fibrosis
●Inhaled foreign body
●Rhinitis
●Heart failure
●Bronchiectasis
And the list goes on…

Dr Malcolm Campbell is Senior Lecturer in General Practice in the Faculty of Medicine at the University of Glasgow