Asthma
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Last updated on 5 September 2024

Asthma Care Protocol will be implemented from January 2025 – HSG GPs may refer to updates from AIC for details on the implementation of these protocols.


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Asthma is a chronic respiratory condition commonly encountered in primary care and primary care providers play a key role in delivering asthma care. The lifetime prevalence of asthma in Singapore has been reported to be around 10.5%1. Hospital admissions for asthma are largely avoidable and often used as an international benchmark for quality and access to primary care2. In Singapore, asthma admission rates from 2003 to 2019 were approximately 80 per 100,0003. The economic burden of asthma in Singapore is high, with most of this cost attributed to poorly controlled asthma4. Measures to improve asthma care in primary care, including early detection, accurate diagnosis and appropriate medication management, will have significant impact on reducing the health and economic burden of asthma in Singapore. ​

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1.      In patients with no formal diagnosis of asthma:

  1. Assess patients with suspected features of asthma (history of recurrent, episodic respiratory symptoms of wheeze, shortness of breath, chest tightness and cough) using tests that measure expiratory airflow limitation, and response to bronchodilator challenge or variability in lung function (e.g. spirometry^ or peak expiratory flow ).

  2. Check if the patient is on any medications that can cause bronchospasm. 

  3. Exclude common cardiac, gastroenterological, respiratory, or infective differentials for symptoms of chronic cough, breathlessness, chest tightness, and wheeze.

  4. When indicated and where available, bronchodilator reversibility testing or other confirmatory testing for asthma should be carried out and documented before starting treatment with preventer (controller) therapy.

     

2.      In patients diagnosed with asthma:

  1. Assess asthma control by using symptom control questionnaires (e.g. Global Initiative for Asthma (GINA) symptom control tool). 

  2. Assess their future risk of exacerbations and poor asthma outcomes. 

  3. Optimise asthma control with the regular use of inhaled corticosteroid (ICS) as the foundation of asthma therapy.

  4. Treat modifiable risk factors and comorbidities (e.g. allergic rhinitis, obesity, gastroesophageal reflux disease (GERD)).

  5. Promote non-pharmacological therapy such as trigger avoidance, avoiding environmental tobacco smoke and smoking cessation.

  6. Promote relevant vaccinations. 

  7. Provide asthma self-management education and skills training including appropriate inhaler use and correct inhaler technique. #


^Spirometry services are available at selected PCN HQs. GPs should check with their respective PCNs if spirometry is offered.

#Asthma nurse counselling services are available at PCN HQs. GPs should contact their respective PCNs if they wish to refer their patients for this service.

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The management goal for persons with asthma is to prevent or minimise symptoms and reduce the risk of poor outcomes.5

Chronic Management

Asthma assessment5

Regular care reviews should be arranged with patients with asthma to assess:

  1. Asthma symptom control and

  2. Risk of exacerbation and poor asthma outcomes. ​

Asthma symptom control assessment includes:

  1. Frequency and intensity of daytime and night-time symptoms.

  2. Frequency of reliever use for symptom relief.

  3. Ability to carry out daily activities.

Use of questionnaires to assess asthma symptom control such as the GINA Asthma Symptom Control tool6 are recommended.

Risk of exacerbations^ and poor asthma outcomes5,6 

Risk factors for exacerbations and poor asthma outcomes that are independent of symptom control should be assessed. Patients with good symptom control can still be at risk of future severe exacerbations or asthma-related deaths.  

^Exacerbations refer to worsening of asthma symptoms beyond those typically experienced by the patient, sometimes requiring urgent actions, including unscheduled clinic visits, use of oral corticosteroid, emergency department visits, and hospital admissions. Asthma exacerbations may lead to mortality in some cases.


Pharmacotherapy

1.      Use a stepwise approach when starting treatment for a patient newly diagnosed with asthma.

2.      Asthma is a chronic condition with chronic airway inflammation being a characteristic feature. Hence, inhaled corticosteroids are the mainstay of long-term asthma management.4,5

3.      Use a stepwise approach also in the long-term management of asthma.

Refer to the Agency for Clinical Effectiveness (ACE) guidelines for Asthma – Optimising Long-term management with inhaled corticosteroids (published 15 October 2020) 5:

Stepwise Approach to Asthma Pharmacological Treatment



LABA, long-acting beta2 agonist; LTRA, leukotriene receptor antagonist; MART, maintenance and reliever therapy; OCS, oral corticosteroid


BREATHE factors


4.      Oral beta-2 agonist, e.g. oral salbutamol should not be used for patients with asthma, inhaled beta-2 agonist should be used instead as a reliever. For patients aged 6 years and older, inhaled short-acting beta agonist (SABA) (e.g. salbutamol) should not be used alone without a preventer to treat asthma long-term, even in patients with mild or intermittent symptoms.5

5.      Monitor the use of SABA to avoid overuse (defined as ≥3 pressurised metered dose inhaler (pMDI) canisters utilised per year).3

6.      When prescribing an inhaler, consider the patient's ability to use the inhaler correctly, concerns about using ICS, and inhaler cost; choose an inhaler that the patient is most likely to use regularly to enable long-term successful asthma control and consider prescribing the use of a spacer device/aerochamber when patients are unable to demonstrate correct inhaler technique.5

7.      Use a stepwise approach, tailoring the treatment regimen to the level of asthma symptom control.5

8.      Before stepping up the medication dose, check medication adherence, inhaler technique, look for triggers, check for co-morbidities (e.g. rhinosinusitis, GERD).

9.      Oral corticosteroids should not be administered regularly as long-term treatment of asthma. Those who require 2 or more short courses of OCS over 12 months, for treatment of asthma exacerbations, require optimisation of asthma management. It is important to optimise asthma management to reduce the risk of asthma exacerbations and the need to use OCS6.

 

Asthma Education & Skills training

1.      All asthma patients should be provided with education and skills training to enable them to self-manage their asthma well. Adherence to inhaled corticosteroids and inhaler technique should be checked regularly (e.g. at least annually) and whenever there is suboptimal asthma control.

2.      Key components of asthma education are:

  1. Inhaler technique training.

  2. Importance of using inhaled corticosteroid regularly to achieve and maintain long term asthma control self-management.

  3. Symptom recognition and what to do in an asthma attack.

  4. Trigger avoidance.

3.      Provide all asthma patients with a Written Asthma Action Plan (WAAP) (available in vernacular languages at the resource section). 

4.      Self-monitoring with peak flow is useful in some patients.  These patients should be encouraged to monitor their peak flow, preferably using a chart.

5.      Education is best done in a language the patient is proficient in.​


Smoking Cessation

  1. Check smoking history regularly, and advise smoking cessation if the patient is a smoker. Refer for smoking cessation counselling and offer smoking cessation medicines.

 

Preventive Care

  1. Ensure that influenza, pneumococcal and COVID-19 vaccinations are up to date. Please refer to the table on Recommended Care Components below for further details on vaccinations for patients with Asthma.

  2. Advise on haze precautions when appropriate.  ​

 

Considerations for Specialist Referral

  1. Difficulty confirming asthma diagnosis.

  1. Suspected occupational asthma.

  2. Persistent uncontrolled asthma or frequent exacerbations despite being on medium to high-dose ICS treatment or patients who may need biologic agents (Step 4 or 5 of pharmacological treatment approach).

  3. Uncontrolled asthma with risk factor(s) for poor asthma outcomes. 

  4. Evidence of significant treatment side effects.

  5. Symptoms suggesting complications or subtypes of asthma (e.g. allergic bronchopulmonary aspergillosis, eosinophilic asthma).

  6. Specific patient groups with asthma such as pregnant patients and athletes.

  7. Patients with features of both asthma and COPD (Recommendation 7 in ACE Clinical Guidance on COPD – Diagnosis and Management)

Management of Asthma Exacerbations 6,7

Asthma exacerbations represent a loss of chronic asthma control. The underlying inflammatory response can last up to 2 weeks, during which the there is a risk of further exacerbations.

All patients with asthma and their caregivers should be provided with guided self-management asthma education3.

Patients should seek medical attention immediately if their asthma continues to deteriorate despite following their written asthma action plan or if their asthma suddenly worsens3.


Management of Asthma Exacerbations in Primary Care6,7

Assess patients presenting with symptoms and signs of an asthma exacerbation in primary care as soon as possible to determine the severity of the asthma exacerbation.

Patients with severe or life threatening asthma exacerbation should be transferred to the emergency department as soon as possible, preferably via ambulance.

While awaiting transfer, administer inhaled SABA, ipratropium bromide, oxygen (if available) and systemic corticosteroid.

Patients with mild or moderate asthma exacerbation should be treated with inhaled SABA [4-10 puffs by pMDI + spacer] repeated every 20 minutes for 1 hour; oral prednisolone 30-50mg stat and controlled oxygen (if available) to be administered to keep oxygen saturation (SpO2) above 93%.

Monitor patients closely in the clinic. Transfer patients with worsening condition to the emergency department, preferably by ambulance, for further management.

Re-assess the patient within an hour of starting bronchodilator therapy. Patients whose condition have improved with SABA treatment (symptoms improved, SpO2 ≥95% on room air) and have adequate resources to be cared for at home may be discharged home with SABA (to be used as needed), inhaled preventer therapy (start/ step up) and short course of oral corticosteroid eg oral prednisolone 30mg/ day for 5 days.

Follow-up within 1-2 weeks is recommended.

 

Recommended Care Components ​

Recommended Care Components

Minimum Frequency*

Remarks

Asthma Control Assessment (GINA symptom control tool score)

Twice a year

After an exacerbation -Follow-up within 1 to 2 weeks

After starting or adjusting treatment- Follow-up within 1 to 3 months

Patients at higher risk of poor outcomes - Follow-up every 1 to 3 months

Smoking Assessment

Annually

Assessment on smoking habits (estimated sticks/day; zero for non-or ex-smoker) and provide smoking cessation counselling 

Self-management education

At diagnosis, and whenever there is a change of medication

GPs may refer patients to PCN nurses for asthma counselling and provide a written asthma action plan

Spirometry

When clinically indicated

Spirometry services are available at selected PCN HQs. GPs should check with their respective PCNs if spirometry is offered

Influenza vaccination

​Annually or per season for:

  • patients with asthma aged 18 to 64 years; and

  • ​all persons aged 65 years and older​

As recommended under the NAIS 

Pneumococcal Vaccination

 

18 to 64 years of age:

  • 1 dose of PPSV23

  • For patients with certain other medical conditions (e.g. immunocompromising conditions), PCV13 may be recommended before PPSV23.

 

All persons aged 65 years and older:

  • 1 dose of PCV13

  • 1 dose of PPSV23 at an appropriate interval after PCV13 (and any previous PPSV23 dose)​​

For further details on dose schedule for PCV13 and PPSV23 based on age and medical conditions, please refer to NAIS  ​

COVID-19 Vaccination 

Two initial COVID-19 vaccine doses at an interval of eight weeks apart.

An additional dose in 2024, around one year (and not earlier than five months) after the last dose received, is recommended for all persons aged 60 years and older, medically vulnerable individuals (e.g. chronic lung conditions) and residents of aged care facilities. ​

As recommended in MOH Circular No. 12/2024 dated 29 February 2024.

*More frequently if clinically indicated​

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The following data fields should be documented in GPs' case notes as part of good clinical practice for all patients enrolled to their practice. Submission of data fields marked with asterisks* is required for subsidy claims and Healthier SG payments.

 

Diagnosis

  1. Diagnosis*

  2. CDMP condition(s)*

  3. Diagnosis Year


Asthma Control Assessment

  1. GINA Score*

  2. Date*


Asthma Counselling

  1. Date of asthma counselling

  2. Date of Written Asthma Action Plan (WAAP) done

 

Spirometry

  1. Date of spirometry

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Smoking History​

  1. Smoking status (Never smoker, Ex-smoker, Current smoker)*

  2. Year starting smoking (if smoker)

  3. No. of sticks smoked/day (if smoker) (For never smoker or ex-smoker, input 0)*

  4. Stage of Change – (i) Pre-contemplation, (ii) Contemplation, (iii) Preparation, (iv) Action, or (v) Maintenance

  5. Fagerstrom Test Score – For patients who are prepared to quit and are actively participating in a structured smoking cessation counselling programme, GPs can consider administering the Fagerstrom test  to determine degree of nicotine dependence

  6. Date of Smoking Assessment


Vaccination

  1. SDD code*

  2. Date*

  3. Due Date of Next Dose

  4. I acknowledge that I have reviewed the results and care delivery provided, that the vaccinations done are clinically indicated as per MOH's prevailing guidelines

  5. Vaccination Exception Condition(s) (if applicable)*

  6. COVID-19 Vaccination Dose Type*

  7. COVID-19 Vaccination Condition(s)*


 Medical Therapy

  1. I have reviewed that patient is on regular preventer(s) as clinically appropriate

  2. The patient needed rescue therapy

  3. Date

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CHAS/PG/MG cardholders who are Healthier SG enrollees can opt to use the Healthier SG Chronic Tier at their enrolled clinics, which provides percentage-based subsidies for selected chronic medications sold within the stipulated price caps. When making claims for these medications, GPs will need to submit the quantities and selling prices for the drug product prescribed. 

 

Details on the GP Annual Service Fee for enrollees with Asthma can be found in the Healthier SG Enrollment Programme Agreement. 

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  1. Ministry of Health (Singapore). National Health Survey 2010 report. Singapore: Epidemiology & Disease Control Division, Ministry of Health, 2011. (accessed 30 June 2024).

  2. Rosano A, Loha CA, Falvo R, van der Zee J, Ricciardi W, Guasticchi G, et al. The relationship between avoidable hospitalization and accessibility to primary care: a systematic review. Eur J Public Health. 2013;23(3):356–360.

  3. Lim LHM, Chen W, Amegadzie JE, Lim HF. The increasing burden of asthma acute care in Singapore: an update on 15-year population-level evidence. BMC Pulm Med. 2023;23(1):502.

  4. Finkelstein EA, Lau E, Doble B, Ong B, Koh MS. Economic burden of asthma in Singapore. BMJ Open Respir Res. 2021;8(1):e000654.

  5. Agency for Care Effectiveness (ACE). Asthma – optimising long-term management with inhaled corticosteroid. ACE Clinical Guidance (ACG), Ministry of Health, Singapore. 2020. 

  6. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2024. Updated May 2024.​ 

  7. Thomas M, Kay S, Pike J, et al. The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J 2009; 18: 41-49.

  8. Fanta CH, Dixon AE, Zachrison KS. (2023). Acute exacerbations of asthma in adults. UptoDate. Retrieved August 17, 2023, from https://www.uptodate.com

  9. ​Agency for Care Effectiveness (ACE) Chronic obstructive pulmonary disease – Diagnosis and management. ACE Clinical Guidance (ACG), Ministry of Health, Singapore. 2024​