To our knowledge, this is the first study focusing on the quality and organization of acute asthma management in tertiary centres in Southeast Asia. The Asthma Insights and Reality in Asia-Pacific (AIRIAP) survey in 2000 is the only regional survey to date reporting asthma severity and management in the urban centres of eight areas of the Asia-Pacific regions.13–14 The survey highlighted only 13.6% of respondents were using ICS as a controller medication despite almost half of the respondents meeting the criteria for persistent asthma.13
The Asthma Insight and Management (AIM) study from 2009 to 2011 also reported a lack of knowledge and conviction for treatment recommendations across Asia-Pacific regions despite having persistent asthma.15 Amongst 413 Malaysians included in this study, 22% of patients reported daytime symptoms, 24% of patients reported night-time symptoms, and 42% required an emergency visit for treatment of acute asthma within the previous year.15
The presence of haze during the study period could be a confounding factor. This is a trans-boundary increase in air pollution caused mainly by forest and peatlands’ fire affecting countries in Southeast Asia that was particularly severe in the months of August and September 2019.16 The haze comprises of high concentration of particulate matter, predominantly less than 2.5 microns in size (PM2.5) that are sufficiently small enough to penetrate deep into the respiratory tract.17 Approximately 39.5% of patients developed an acute exacerbation triggered by haze. More than half of the admissions due to acute asthma were recorded in these two months. Increases in respiratory admissions have also been documented in Malaysia during the Southeast Asia haze in 2014 and 2015.18 Furthermore, neighbouring country Singapore documented a 20% increase in hospitalisations for asthma during the haze.19
GINA recommends assessment of clinical status and lung function one hour after commencement of treatment to guide the need for hospitalisation.20–21 These admission criteria includes pre-treatment FEV1 or PEF < 25% predicted or personal best; or post-treatment FEV1 or PEF < 40% predicted or personal best.22 For our cohort, the first PEF was only performed in 77.9%. The PEF measurement informs the decision to admit and is an objective variable in assessing a patient for severity and subsequent treatment. Further work is required in acute areas of busy tertiary hospitals to ensure that a simple PEF measurement is carried out as part of an acute asthma assessment.
Pre-discharge PEF was performed in all patients at both centres. GINA recommends discharge if post-treatment PEF is > 60% predicted or personal best. As an important indicator of stability prior to discharge, this figure reflects the quality of care at both centres.
Approximately 40.5% of patients on GINA treatment step 2–4 refused to comply with daily controller medications, which is a robust predictor of future risk of developing near fatal or fatal asthma. This is consistent with the findings of the AIRIAP study.14 Again, this highlights the importance of intervention with education and a clear asthma management plan on discharge emphasising the importance of ICS use.
Upon discharge, inhaler technique review was completed in only 69.8% of cases. From these, only 58% had good inhaler technique when reviewed. Studies have demonstrated that instruction by health care providers on correct metered-dose inhaler use is a modifiable factor for reducing incorrect inhaler technique.23
A clinic review appointment was scheduled in all patients at both centres at a mean duration of two weeks upon discharge. GINA recommends a follow-up appointment within two days of discharge with the patient’s usual health care provider to ensure continuity of treatment. Unfortunately, this is very difficult to achieve within the context of many Southeast Asian healthcare system. Malaysia differs from other countries in the region such as Indonesia and the Philippines in that it does not have an administratively decentralized public sector health care system.24 Most primary health care in urban areas are provided by the private sector.24 Thus, the scheduling of follow-up visits cannot reach guidelines recommendation due to inadequate capacity in the public primary care system whilst private primary care can be costly. More efforts need to be placed on decongesting specialist respiratory clinics at the tertiary level to allow more severe cases to be seen in a shorter timeframe.
There were limitations in this study. Firstly, only two tertiary centres were selected to be part of this study, which may not be fully representative of asthmatic care in the region. Secondly, this study also assessed documentation of care as a proxy for actual care, which could have led to an over-, or underestimation of the quality of care actually offered.