An important update to national guidance on the management of asthma has been launched with a major focus on supporting health professionals to make accurate diagnoses and provide effective treatments to control asthma and prevent life-threatening asthma attacks.
The guideline, produced jointly by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) emphasises that there is still no single test that can definitively diagnose asthma and an individual’s asthma status can change over time.
It recommends that if a health professional suspects asthma, they should undertake a ‘structured clinical assessment’ using a combination of patient history, examination and tests to assess the probability of asthma. The history should include a review of the following:
- Symptoms of cough, breathlessness, wheeze and chest tightness that have varied over time
- Any history of recurrent attacks of symptoms
- Any wheeze previously recorded by a health professional
- A personal or family history of allergic conditions such as eczema and allergic rhinitis
- Objective evidence of variability over time in obstruction to a patient’s airflow (using the results of lung function tests)
- The absence of any pointers to an alternative diagnosis to asthma.
Quality assured spirometry is spotlighted as the key frontline breathing test to be performed in most situations with adults and children over five years of age. It is important that spirometry is quality assured i.e. professionals are trained and experienced in preparing and delivering the test as well as analysing the results. If the test shows obstruction to the patient’s airflow which reverses with treatment, this strongly supports a diagnosis of asthma. But a normal spirometry result does not always exclude an asthma diagnosis – especially if a patient has no symptoms at the time. It may be necessary for healthcare professionals to repeat spirometry when a patient has symptoms, and/or use different breathing tests – and observe over time.
One, often secondary, breathing test that can be carried out, involves measuring an individual’s fractional exhaled nitric oxide (FeNO) –a gas found in slightly higher levels in people with asthma. An increase suggests inflammation of the airways, and supports, but doesn’t prove, a diagnosis of asthma
The guideline helps health professionals to assign patients into three groups based on the probability they have asthma; either high, intermediate or low. It then summarises the key treatment and management actions to be taken for each group. The updated guideline also includes new or revised content in the following areas: asthma drug treatment (replacing the previous stepwise approach), non-drug treatments, supported selfmanagement, and the role of telehealthcare. Key highlights include:
- Short acting beta2 agonists are the key ‘rescue therapy’ from symptoms or asthma attacks and can form part of all treatment plans, but should rarely be used on their own.
- A key emphasis on medication to prevent future asthma attacks – inhaled corticosteroids remain the most effective ‘preventer’ drug for all adults and children
- If a patient has poor control of their asthma, it is essential to check whether they are using their current drug treatment correctly and regularly, before stepping up treatment.
- Each patient should be offered a written asthma action plan as it is key to the effective management of their asthma
- Women with asthma who are pregnant should be informed of the importance of continuing their asthma medication.
The ‘British guideline on the management of asthma’ (full version) and a ‘Quick Reference Guide’ summary is available to download from www.sign.ac.uk and www.brit-thoracic.org.uk
