Asthma Management and Visual Impairment — Free SCA Practice Case

1. Confirming the Diagnosis: Objective Testing is Mandatory

A clinical impression formed during an acute presentation — especially during a viral illness — does not constitute a confirmed asthma diagnosis. Under current NICE CKS and BTS-SIGN 2023 guidelines, asthma in adults must be supported by objective physiological evidence before a lifelong diagnosis is coded.

• ●FeNO (Fractional exhaled Nitric Oxide): Measures eosinophilic airway inflammation. A level ≥ 40 ppb in an adult is a positive result supporting an asthma diagnosis; 25–39 ppb is intermediate and should prompt further assessment rather than dismissal.
• ●Spirometry with bronchodilator reversibility (BDR): Demonstrates obstructive physiology. A positive BDR requires an improvement in FEV1 of ≥ 12% and ≥ 200 ml following inhaled Salbutamol.
• ●Both tests should be arranged before committing a patient to long-term treatment. Initiating interim therapy while awaiting results is appropriate — but the diagnostic question must remain open and explicitly communicated to the patient.
• ●If both tests are negative or equivocal, alternative diagnoses — including vocal cord dysfunction, cardiac cause, chronic rhinosinusitis with post-nasal drip, or inducible laryngeal obstruction — must be reconsidered before confirming a lifelong asthma label.

2. Assessing Asthma Control: The RCP 3 Questions

The Royal College of Physicians (RCP) 3 Questions are the validated primary care tool for quantifying asthma symptom burden. Ask at every asthma review:

1. ●Have you had difficulty sleeping because of your asthma symptoms (including cough)?
2. ●Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness, breathlessness)?
3. ●Has your asthma interfered with your usual activities (housework, work, school, sport)?

• ●A positive answer to any one question indicates suboptimally controlled asthma. Two or three positive answers indicate poor control requiring prompt escalation.
• ●In this case, Eleanor has nighttime waking 2–3 nights per week, daily chest tightness, and significant activity limitation — this is poorly controlled asthma requiring step-up of therapy.
• ●The diurnal pattern she describes — worst on waking, triggered by cold morning air — is characteristic of asthma physiology and adds weight to the provisional diagnosis while objective testing is awaited.

3. The SABA-Only Danger

• ●Treating symptomatic asthma with a Short-Acting Beta-Agonist (SABA) alone is clinically unsafe and contrary to both NICE CKS and BTS-SIGN 2023 guidelines.
• ●Asthma is a chronic inflammatory disease. Reliever-only treatment masks worsening inflammation, promotes beta-receptor downregulation, and significantly increases the risk of a severe or fatal attack.
• ●BTS/NICE/SIGN 2024 recommend initiating a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief (as-needed AIR therapy) to all children and adults above the age of 12.
• ●The ICS should be started at the time of the consultation as an interim measure, with a clear explanation that it treats the underlying airway inflammation rather than providing immediate relief.
• ●Do not conflate ICS preventers with MART (Maintenance and Reliever Therapy) regimens at this stage. MART uses a single fixed-dose combination ICS/LABA inhaler as both preventer and reliever and is a Step 3 strategy — it is not appropriate for a patient in whom the diagnosis is unconfirmed and baseline control is not yet established.

4. Inhaler Device Selection for Visually Impaired Patients

Standard pressurised metered-dose inhalers (pMDIs) require simultaneous canister depression and slow, deep inhalation — a coordination task that is inherently visual and extremely difficult without sighted instruction or physical demonstration.

• ●Dry Powder Inhalers (DPIs) — such as the Turbohaler, Nexthaler, or Ellipta — are often the device of choice for visually impaired patients. They require no hand-breath coordination: the patient primes the device and takes a fast, deep breath. Many DPIs provide tactile and auditory feedback (a distinct click on priming, a change in resistance when empty), enabling non-visual dose monitoring.
• ●Breath-Actuated Inhalers (BAIs) — such as the Autohaler or Easi-Breathe — are triggered automatically by inspiratory flow, removing the need for manual coordination. Check whether the dose counter on the specific BAI model is accessible by touch before prescribing.
• ●Large-volume spacers can eliminate the coordination barrier if a pMDI must be used for clinical reasons, though they introduce different practical challenges for a patient managing independently at home.
• ●Device choice must be a collaborative decision. Refer the patient to the asthma nurse or respiratory pharmacist for hands-on, tactile device training with multiple options before a final selection is made. Do not prescribe a replacement device over the phone without arranging this training.

5. Non-Visual Dose Monitoring: A Patient Safety Issue

An empty inhaler used during an acute attack delivers only propellant — no medication. For a patient who cannot read a dose counter, this is a significant and underappreciated safety risk.

• ●When prescribing any inhaler device to a visually impaired patient, explicitly confirm whether the dose indicator is accessible without sight.
• ●DPIs with tactile end-of-dose indicators (e.g., the Turbohaler empty indicator, the Ellipta counter with a raised tactile marker) are preferred.
• ●Advise the patient on pragmatic non-visual monitoring strategies: counting doses from a new inhaler, tracking usage by day, or asking a pharmacist to check remaining doses at each dispensing.

6. Personalised Asthma Action Plan (PAAP): Accessible Format

A written Personalised Asthma Action Plan significantly reduces hospital admissions and asthma deaths. NICE CKS and Asthma + Lung UK recommend that every asthma patient receives one.

• ●A standard paper PAAP is inaccessible to a severely sight-impaired patient. The plan must be provided in a format the patient can use independently.
• ●Options include: a verbal walkthrough with opportunity to ask questions, a digital version compatible with screen-reader software (Asthma + Lung UK provides accessible digital versions), an audio recording, or referral to a service that provides braille health materials.
• ●The PAAP for a patient with poorly controlled asthma should specify: what to do if symptoms worsen acutely, when to use the reliever, when to start a course of oral prednisolone (if prescribed), and when to call 999.
• ●Do not end a telephone consultation with a visually impaired patient by directing them to a website or written leaflet. Verbal confirmation of understanding is the minimum standard.

7. Comorbid Upper Airway Disease

The upper and lower airways are anatomically and physiologically linked. Allergic rhinitis and chronic rhinosinusitis are common comorbidities in asthma and can drive poor symptom control if untreated — a relationship explicitly recognised in the BSACI and NICE CKS rhinitis guidelines.

• ●Eleanor discloses persistent nasal blockage and a throat tickle when directly asked — features consistent with comorbid rhinitis contributing to her symptom burden.
• ●Per NICE CKS and BSACI guidance, untreated rhinitis impairs lower airway disease control. A trial of a topical intranasal corticosteroid (e.g., mometasone 50 mcg or fluticasone propionate 50 mcg nasal spray, 2 sprays each nostril once daily) is appropriate first-line management for persistent rhinitis.
• ●Post-nasal drip from rhinitis is also a recognised cause of chronic cough and throat irritation — symptoms Eleanor has attributed to her asthma and to the residual viral illness. Treating rhinitis may improve both her upper and lower airway symptoms.
• ●This can be initiated at the same consultation or deferred to the asthma clinic, but the symptom should be acknowledged and a management plan agreed rather than dismissed as a viral tail.

8. Red Flags in a New Adult Respiratory Presentation

Before attributing all symptoms to asthma in an adult with a new, unconfirmed respiratory diagnosis, exclude features that would suggest an alternative serious diagnosis:

• ●Haemoptysis — warrants urgent investigation to exclude malignancy or pulmonary embolism
• ●Significant unintentional weight loss — raises concern for malignancy
• ●Symptoms present for more than 3 weeks without clear viral trigger in a smoker or ex-smoker — consider lung malignancy and refer via the 2WW pathway
• ●Stridor or inspiratory wheeze — raises the possibility of upper airway obstruction or inducible laryngeal obstruction rather than asthma
• ●In a 42-year-old non-smoker with a clear post-viral onset and a classical diurnal pattern, these features are absent and the presentation is reassuring — but exclusion should be documented.

9. Safety Netting: Acute Asthma Deterioration

Safety netting must be specific and actionable. For a patient with poorly controlled asthma who cannot verify their inhaler dose, clear escalation guidance is particularly important.

• ●Call 999 or go to ED immediately if:
  • ●Breathlessness is severe and coming on rapidly
  • ●Unable to complete a sentence in one breath
  • ●Lips or fingertips turn blue (cyanosis)
  • ●The reliever inhaler provides no relief within 15 minutes, or relief lasts less than 4 hours
  • ●Symptoms are worsening rapidly despite using the inhaler
• ●Seek same-day GP or urgent care review if:
  • ●Nighttime waking increases in frequency
  • ●The reliever is being used more than 3 times a week
  • ●Breathlessness prevents normal daily activity
• ●Safety netting delivered verbally must be clear, jargon-free, and confirmed understood before the consultation ends. Direct the patient to a specific point of contact — do not leave escalation routes vague.

10. Common Candidate Mistakes in This Case

• ●Accepting the OOH diagnosis without question. The OOH assessment during an acute viral exacerbation was a working diagnosis only. Failing to arrange FeNO and spirometry means the patient may be committed to a lifelong label and long-term steroids without objective justification.
• ●Prescribing a replacement inhaler without checking dose accessibility. Swapping the pMDI for another device solves the coordination problem but replicates the dose-monitoring safety hazard unless the replacement device has a non-visual dose indicator.
• ●Continuing SABA monotherapy. Eleanor has multiple markers of poor asthma control. Failing to initiate an ICS preventer at this consultation is a clinically significant error — not a borderline one.
• ●Failing to identify the empty canister as a patient safety issue. Eleanor has been pressing the inhaler six or seven times daily and reports it now feels very light, with no way to check the dose counter. A candidate who does not directly ask how many doses have been used, or who prescribes a replacement without addressing how Eleanor will independently monitor remaining doses on any new device, leaves a recurring safety hazard unresolved.
• ●Failing to explore the nasal symptoms as a potential driver of the presentation. Eleanor volunteers a persistently blocked nose and post-nasal drip when specifically asked. Allergic rhinitis and upper airway disease are recognised contributors to cough and breathlessness, and in a patient whose diagnosis is unconfirmed, failing to consider upper airway disease as a differential or contributing factor represents an incomplete clinical assessment.

11. The MDT Role: Asthma Clinic and Respiratory Nurse

Referring Eleanor to the Practice Asthma Nurse or a specialist Respiratory Clinic serves several functions that cannot be delivered in a single telephone consultation:

• ●Performing FeNO and spirometry with bronchodilator reversibility testing in a controlled setting
• ●Tactile, hands-on device training with multiple inhaler types, allowing Eleanor to select the device she can manage most independently
• ●Constructing and delivering an accessible PAAP
• ●Assessing and addressing comorbid conditions including rhinitis
• ●Providing structured follow-up to monitor response to interim therapy and refine the long-term management plan

The referral should explicitly flag Eleanor's visual impairment so that the clinic can prepare accessible resources and allocate adequate appointment time for hands-on device education.