Feasibility and acceptability of using bronchial hyperresponsiveness to manage asthma in primary care: a pilot study

Abstract

Aims: To determine if indirect testing for bronchial hyperresponsiveness (BHR) to monitor inhaled corticosteroid (ICS) treatment in asthma is feasible and acceptable in primary care.Methods: Fourteen adult patients with asthma aged 22-70 years (4M:10F, forced expiratory volume in 1 s >70% predicted) taking ICS performed a test for BHR using mannitol on three visits 6 weeks apart. ICS dose adjustments were made based on the presence of BHR. The Asthma Quality of Life Questionnaire (AQLQ) and the Asthma Control Questionnaire were used at each visit. A semi structured interview at study exit assessed subject acceptability.Results: BHR did not return in those with no BHR at study entry (n=9) with decreasing ICS dose. Improvements in BHR with increasing ICS dose (n=5) were observed with clinically significant improvements in AQLQ (mean score increase >0.5, p=0.02). Feasibility and acceptability of BHR testing was demonstrated.Conclusions: It is feasible and acceptable to perform BHR testing using mannitol to help identify patients with asthma who would benefit from ICS dose increases and those with no BHR who could have a dose reduction.

Asthma monitoring in primary care: time to gather more robust evidence

“…Their qualitative analyses revealed increased understanding of the chronic nature of asthma and improved involvement in goal-setting between patients and their primary care health professional. Interestingly, these qualitative data 2 were gathered from BHR-positive patients, which casts some doubt on the external validity of the findings. As with many studies on asthma management in primary care, patients recruited into studies are already highly motivated and compliant.…”

“…In this issue of the PCRJ, Turton et al 2 have completed an important pilot study exploring the use of point-of-care indirect bronchial hyperresponsiveness (BHR) testing with mannitol in order to monitor and (importantly) adjust the ICS dose. Despite the small numbers, the authors found that there were improvements in Asthma Quality of Life Questionnaire (AQLQ) scores that correlated with improvements in BHR after increases in ICS dosage.…”

“…It is currently inappropriate to recommend that there be widespread adoption of a measurement technique that may lead to an increased use of medications such as ICS (with known increased risk of side effects) without clear and consistent evidence of improved outcomes for patients. As Turton et al comment,2 it is time to develop and implement larger trials based in primary care that utilise regular BHR testing to examine the long term health benefits of this monitoring.…”

“…Implementation will require the training of nursing or allied health staff to interact with patients -as Turton et al found. 2 Team-based primary care is the key to successful implementation of this type of ongoing asthma assessment. 6 In health systems where private practice dominates, a financial incentive may be required.…”

“…Anecdotally, this role expansion has not widely embraced an "integrated platform of asthma education". 2 Unless these financial incentives are established more broadly across primary care to actively foster team-based primary care with training and interest in comprehensive respiratory education, indirect BHR testing is unlikely to be widely implemented.…”