The findings from this study demonstrate an approach to practice that is in line with the Clinical Reasoning Cycle19, where paramedics instinctually collect information about their patients and use both existing guidelines, patient demographics and their own clinical experience to inform their clinical decision-making. The Clinical Reasoning Cycle19 illustrates the cognitive processes of acquiring and processing information, from perception to reasoning and demonstrates how medical professionals can effectively treat patients with various contradictory or worsening conditions. Ritz et al. 26 discuss this challenge, suggesting that healthcare is not an exact science, and it is not always possible to label patients by their presenting medical condition19.

The analysis found that paramedics effectively followed the guidelines while responding to changes in the patient’s condition and relevant medical history. Participants highlighted this when referring to the older population where the presence of asthma is often complicated by other respiratory conditions such as COPD, or other compounding factors, such as those caused by a cardiac history. Additionally, participants reported that patients often experience side effects such as arrhythmias, tremors and headaches, but these are often accepted as part of the treatment process and only considered problematic when levels are reached that overshadow the presenting asthma exacerbation.

Similarly, the influence of psychological factors can also directly affect the current condition and cause its deterioration. When treating exacerbations, paramedics try to address anxiety and prevent it from becoming a contributing factor. This is discussed by Stubbs et al. 27 who note the impact that anxiety and associated depression can have on the control of asthma, often resulting in poorer health outcomes. These views and subsequent approaches demonstrate a more holistic understanding of the presenting complaint where clinicians look at common linking and underlying factors that may be present. This was reinforced with reference to diabetes as a significant comorbidity, strengthened with discussion of shared risk factors such as weight control and mobility, something Stubbs et al. 27 also note and which is commonly discussed within literature relating to the two conditions28. The way paramedics treat patients is based on the clear understanding that no two patients are the same, and depending on the patient’s current situation, paramedics will objectively decide on a treatment plan that may involve an adaptive application of guidelines. Despite three clinical grades of paramedics participating in this study, their roles did not appear to influence their perception or decision-making when managing asthma patients. The reason may be as one participant stated, because ‘the algorithm ….. is pretty straightforward,’ meaning they simply follow this until treatment needs to be escalated or deescalated, or when contributory factors such as comorbidity require attention.

Despite the lack of homogeneity in asthma patients, the priority in patient management is to ensure airway patency before providing further treatment. Although all participants in this study shared this view, their deeper understanding that the respiratory system does not function independently was apparent and supported by Sarkar et al. 10 who discussed the importance of homoeostasis in maintaining a suitable V/Q balance. Participants often referenced the possibility that cardiac changes could affect the patient’s breathing and corresponding mechanisms. Further consideration showed that these effects may be due to other medical conditions or drug side effects. However, it is unclear at what level these changes become problematic.

Consistent with current literature7,8 and clinical expectations, a general acceptance that cardiac-related side effects may occur when managing asthma patients with β₂ agonists is shown. However, in this instance despite a clinical reasoning approach, clinicians may overlook them as a potential problem, which would not be the case if the effects presented outside of this specific treatment. The reflective component of the Clinical Reasoning Cycle24 can help conceptualize this, as each asthma patient cared for is exposed to a greater variety of systemic changes, thereby increasing understanding and expectations for the next patient.

Knowing that a patient has a comorbidity which may impact the presenting condition is important. However, surreptitiously replicating those same effects through the use of treatment brings an added risk7,8,9,10. The participants demonstrated an awareness of contributing factors present when asthma patients experience an exacerbation of their condition, a point considered by Boulet29 who outlines that underlying conditions can impact the severity of asthma in several ways, from changing the phenotype to altering presentation.

Patient-centred care heralds the view that patients are individuals, a concept Entwistle and Watt30 supported when discussing communication and patient empowerment, suggesting that clinicians should also be mindful not to manage patients according to a set list of expectations. Chouchane et al. 31 further advocate this view when citing human factors as key to effectively managing patients, explaining that sometimes the most effective drug may not be suitable for all patients.

Participants clearly demonstrated that they consider the complexity of patient’s individual needs and individual treatment needs, especially when conditions such as stroke, pregnancy, diabetes, and even anxiety are identified. This level of awareness suggests that paramedics and other clinicians may consider varied physiological, psychological and behavioural changes, but as Rosendal32 Pizzorno33 and Richens et al. 34 suggest, if we are only treating the presence of symptoms without identifying the causes, these may present themselves as larger problems in the patient’s future. An example drawn from these data is: If administration of salbutamol causes reciprocal changes, including an increase in blood glucose levels, how do clinicians know if their patient is also hyperglycaemic at the time of treatment if they do not routinely assess Capillary Blood Glucose levels for asthma patients35.

The findings suggest that the level of understanding demonstrated by all paramedics regarding causation, treatment and compounding factors shows a preference to manage their patients on a ladder of escalation, as opposed to a scripted ‘one-size-fits-all’ approach. The data suggests varying degrees of acceptance that other medical conditions may be present, or that treatment may result in physiological changes that affect the patient’s health status. However, a pre-emptive approach to compensate for this is not always demonstrated. Future research could investigate the specific comorbidities and/or side effects experienced by asthma patients and ascertain the point at which clinicians perceive non-therapeutic effects to be clinically significant for patients, both in the short and long term.

The study recruited at a time when the UK was starting to recover from the COVID-19 pandemic, meaning there were still a number of effects impacting how patients were managed. This was both from the patients’ and clinicians’ perspective and included not only the clinical complications associated with COVID-19, but also a reduction in calls to milder and more moderate asthma exacerbations36,37. Paramedics may have seen fewer asthma patients during this time compared to the previous two years, and when they did their considerations with these patients would have been complicated by consideration of the COVID-19 infection.

The COVID-19 pandemic further meant we undertook all interviews online. Although this approach may have had benefits, we accept that in-person interviews are preferred to build a rapport between interviewers and interviewees. However, this is not thought to have significantly impacted the data collected for this study.

Although 15 interviews may seem like a small number on the surface, the literature suggests that the number of participants in such studies should not be considered in isolation, but rather as part of the larger element of data adequacy which looks at the quality, richness and level of commonality or differences between data20,21. We therefore believe that the data collected and presented is suitably representative of the views/actions of paramedics across the participating Trust.

In conclusion, asthma is an inflammatory disease with diverse phenotype characteristics. Recognising the factors present during an exacerbation allows paramedics to respond effectively to individual complexities through consideration of changing phenotypes, compounding comorbidities and response to pharmacological treatment. Consideration of the various physiological (e.g. blood glucose level), psychological (e.g. anxiety) and behavioural changes (e.g. sedentary time) experienced by patients allows paramedics to improve their level of clinical reasoning and dynamically adapt their management to provide optimised care in the short-term and potentially reduce any long-term health implications. These underlying considerations are often based on experience and developmental reflection, influencing drug selection and interpretation of the relevance/impact of any observed side effects or comorbidities.