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Asthma

About

What is covered

This interactive flowchart covers diagnosing, monitoring and managing asthma in children, young people and adults. It aims to improve the accuracy of diagnosis, help people to control their asthma and reduce the risk of asthma attacks.

Phased implementation

NICE is recommending objective testing with spirometry and FeNO for most people with suspected asthma. This is a significant enhancement to current practice, which will take the NHS some time to implement, with additional infrastructure and training needed in primary care. New models of care, being developed locally, could offer the opportunity to implement these recommendations. This may involve establishing diagnostic hubs to make testing efficient and affordable. They will be able to draw on the positive experience of NICE's primary care pilot sites, which trialled the use of FeNO.
The investment and training required to implement the new guidance will take time. In the meantime, primary care services should implement what they can of the new guidelines, using currently available approaches to diagnosis until the infrastructure for objective testing is in place.

Updates

Updates to this interactive flowchart

19 September 2018 Asthma (NICE quality standard 25) updated.
28 November 2017 Updated on publication of asthma: diagnosis, monitoring and chronic asthma management (NICE guideline NG80). Asthma (NICE quality standard 25) updated to bring it in line with the new guideline.
3 October 2017 Reslizumab for treating severe eosinophilic asthma (NICE technology appraisal guidance 479) added to difficult and severe asthma.
24 January 2017 Mepolizumab for treating severe refractory eosinophilic asthma (NICE technology appraisal guidance 431) added to difficult and severe asthma.
1 April 2014 Measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO, NIOX VERO and Nobreath (NICE diagnostics guidance 12) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing, monitoring and managing asthma in children, young people and adults in an interactive flowchart

What is covered

This interactive flowchart covers diagnosing, monitoring and managing asthma in children, young people and adults. It aims to improve the accuracy of diagnosis, help people to control their asthma and reduce the risk of asthma attacks.

Phased implementation

NICE is recommending objective testing with spirometry and FeNO for most people with suspected asthma. This is a significant enhancement to current practice, which will take the NHS some time to implement, with additional infrastructure and training needed in primary care. New models of care, being developed locally, could offer the opportunity to implement these recommendations. This may involve establishing diagnostic hubs to make testing efficient and affordable. They will be able to draw on the positive experience of NICE's primary care pilot sites, which trialled the use of FeNO.
The investment and training required to implement the new guidance will take time. In the meantime, primary care services should implement what they can of the new guidelines, using currently available approaches to diagnosis until the infrastructure for objective testing is in place.

Updates

Updates to this interactive flowchart

19 September 2018 Asthma (NICE quality standard 25) updated.
28 November 2017 Updated on publication of asthma: diagnosis, monitoring and chronic asthma management (NICE guideline NG80). Asthma (NICE quality standard 25) updated to bring it in line with the new guideline.
3 October 2017 Reslizumab for treating severe eosinophilic asthma (NICE technology appraisal guidance 479) added to difficult and severe asthma.
24 January 2017 Mepolizumab for treating severe refractory eosinophilic asthma (NICE technology appraisal guidance 431) added to difficult and severe asthma.
1 April 2014 Measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO, NIOX VERO and Nobreath (NICE diagnostics guidance 12) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Reslizumab for treating severe eosinophilic asthma (2017) NICE technology appraisal guidance 479
Mepolizumab for treating severe refractory eosinophilic asthma (2017) NICE technology appraisal guidance 431
Omalizumab for treating severe persistent allergic asthma (2013) NICE technology appraisal guidance 278
Bronchial thermoplasty for severe asthma (2012) NICE interventional procedures guidance 419
Asthma (2015 updated 2018) NICE quality standard 25
Asthma: tiotropium (Spiriva Respimat) (2015) NICE evidence summary ESNM55
OxyMask for delivering oxygen therapy (2018) NICE medtech innovation briefing 160
Thora-3Di for assessing asthma in children (2017) NICE medtech innovation briefing 122
Smartinhaler for asthma (2017) NICE medtech innovation briefing 90

Quality standards

Quality statements

Objective tests to support diagnosis (developmental)

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice for asthma and should be read in full.
Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

People aged 5 years and over with suspected asthma have objective tests to support diagnosis.

Rationale

Asthma can be misdiagnosed, which means that people with untreated asthma are at risk of an asthma attack, and people who do not have asthma receive unnecessary drugs. Following taking an initial history and assessment, objective tests can help healthcare professionals to diagnose asthma correctly in people over 5 years. There is no single objective test to diagnose asthma and the correct initial test may identify the need for further tests. The basis on which a diagnosis of asthma is made should be documented. Children under 5 are unable to perform objective tests, and treatment should be based on observation and clinical judgement until the child is old enough for objective testing.

Quality measures

Structure
a) Evidence of local arrangements or referral pathways to asthma diagnostic hubs to ensure that people aged 5 years and over with suspected asthma have objective tests to support diagnosis.
Data source: Local data collection, for example, service protocol or referral pathways.
b) Evidence of local arrangements to ensure that healthcare professionals are trained and competent to carry out and interpret objective tests to support diagnosis of asthma.
Data source: Local data collection, for example, training records and competency assessments.
c) Evidence of local processes to ensure that the basis for a diagnosis of asthma is documented.
Data source: Local data collection, for example, service protocol.
Process
a) Proportion of adults aged 17 years and over with newly diagnosed asthma who have a record of a fractional exhaled nitric oxide (FeNO) test to support diagnosis.
Numerator – the number in the denominator who have a record of a FeNO test to support diagnosis.
Denominator – the number of adults aged 17 years and over with newly diagnosed asthma.
Data source: Local data collection, for example, audit of patient health records.
b) Proportion of people aged 5 years and over with newly diagnosed asthma who have a record of a spirometry test to support diagnosis.
Numerator – the number in the denominator who have a record of a spirometry test to support diagnosis.
Denominator – the number of people aged 5 years and over with newly diagnosed asthma.
Data source: Local data collection, for example, audit of patient health records.
c) Proportion of people aged 5 years and over with newly diagnosed asthma who have a record of the objective tests used to support diagnosis.
Numerator – the number in the denominator who have a record of the objective tests used to support diagnosis.
Denominator – the number of people aged 5 years and over with newly diagnosed asthma.
Data source: Local data collection, for example, audit of patient health records.
Outcome
Prevalence of asthma.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as GP practices, community health services and hospitals) ensure that processes are in place for people aged 5 years and over with suspected asthma to have objective tests to support diagnosis. Depending on local arrangements, this may involve referral to a local asthma diagnostic hub. Service providers ensure that healthcare professionals are trained and competent in performing and interpreting objective tests, and that processes are in place to record the basis for a diagnosis of asthma (for example, see NICE's asthma diagnosis implementation data collection sheet).
Healthcare professionals (such as doctors, nurses and pharmacists) are aware of local arrangements for accessing objective tests for asthma and ensure that people aged 5 years and over with suspected asthma have objective tests to support diagnosis. Healthcare professionals record the basis for a diagnosis of asthma.
Commissioners (clinical commissioning groups and NHS England) commission services that ensure that people aged 5 years and over with suspected asthma have objective tests to support diagnosis. Commissioners consider whether local diagnostic hubs for asthma would optimise investment in equipment and staff training.
People aged 5 years and over with suspected asthma have tests to confirm if they have asthma. An accurate diagnosis will make sure they get the treatment they need.

Source guidance

Asthma: diagnosis, monitoring and chronic asthma management (2017) NICE guideline NG80, recommendations 1.1.2 and 1.3.22

Definitions of terms used in this quality statement

Objective tests to diagnose asthma
Tests carried out to help determine whether a person has asthma, the results of which are not based on the person's symptoms, for example, tests to measure lung function or evidence of inflammation. There is no single objective test to diagnose asthma. Objective tests should be performed in accordance with the algorithms in the NICE guideline.
The initial test for children and young people aged 5 to 16 years is spirometry. A bronchodilator reversibility (BDR) test should be considered if spirometry shows an obstruction. If diagnostic uncertainty remains after spirometry and BDR, consider a FeNO test. If diagnostic uncertainty remains after FeNO, monitor peak flow variability for 2 to 4 weeks.
The initial tests for adults aged 17 years and over are FeNO followed by spirometry. A BDR test should be carried out if spirometry shows an obstruction. If diagnostic uncertainty remains after FeNO, spirometry and BDR, monitor peak flow variability for 2 to 4 weeks. If diagnostic uncertainty remains after measuring peak flow variability, refer for a histamine or methacholine direct bronchial challenge test.
[NICE’s guideline on asthma, terms used in this guideline and algorithms B and C]
Suspected asthma
A potential diagnosis of asthma based on symptoms and response to treatment that has not yet been confirmed with objective tests.
[NICE’s guideline on asthma, terms used in this guideline]

Equality and diversity considerations

If a child is unable to perform objective tests when they are 5 years, healthcare professionals should continue treatment based on observation and clinical judgement and should try doing the tests again every 6 to 12 months until the child is able to perform the tests. If it is decided that a child, adult or young person with symptoms suggesting asthma cannot perform a particular test, healthcare professionals should try to perform at least 2 other objective tests and diagnose suspected asthma based on symptoms and any positive objective test results.
Some people with learning disabilities or mental health problems may need additional support to help them to perform objective tests to diagnose asthma.

Written personalised action plan

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice for asthma and should be read in full.

Quality statement

People aged 5 years and over with asthma discuss and agree a written personalised action plan.

Rationale

Involving people with asthma (including their families and carers as appropriate) in developing a written personalised action plan can help them to respond to changes in their symptoms, enabling them to self-manage their asthma and reduce the risk of serious asthma attacks and hospital admission. Regular reviews of the action plan with a healthcare professional can help to prevent complications arising.

Quality measures

Structure
a) Evidence of a local framework and guidance for healthcare professionals on providing asthma education and developing a written personalised action plan for people aged 5 years and over with asthma.
Data source: Local data collection, for example, service protocol.
b) Evidence of local arrangements to ensure that people aged 5 years and over with asthma discuss and agree a written personalised action plan with their healthcare professional.
Data source: Local data collection, for example, service protocol.
Process
a) Proportion of people aged 5 years and over with asthma who have a record of a discussion to agree a written personalised action plan.
Numerator – the number of people in the denominator who have a record of a discussion to agree a written personalised action plan.
Denominator – the number of people aged 5 years and over with asthma.
Data source: Local data collection, for example, audit of patient health records.
b) Proportion of people aged 5 years and over with asthma who have a documented written personalised action plan.
Numerator – the number of people in the denominator who have a documented written personalised action plan.
Denominator – the number of people aged 5 years and over with asthma.
Data source: Local data collection, for example, audit of patient health records.
Outcome
a) Rate of hospital attendance or admission for an asthma attack.
Data source: NHS Digital’s Hospital Episode Statistics includes data on admissions and A&E attendances for asthma attack.
b) Satisfaction of people with asthma aged 5 years and over and their family and carers (as appropriate) that they are able to self-manage their condition and their asthma is well controlled.
Data source: Local data collection, for example, patient and carer surveys.

What the quality statement means for different audiences

Service providers (such as GP practices, community health services and hospitals) ensure that processes are in place to involve people aged 5 years and over with asthma, and their family and carers as appropriate, in developing a written personalised action plan and to provide education to help them self-manage their asthma. Service providers ensure that written personalised action plans are reviewed regularly, including after an asthma attack.
Healthcare professionals (such as doctors, nurses, healthcare assistants and pharmacists) involve people aged 5 years and over with asthma, and their family and carers as appropriate, in developing a written personalised action plan and provide education to help them self-manage their asthma. Healthcare professionals regularly involve people with asthma in reviewing and updating their written personalised action plan, including after an asthma attack.
Commissioners (clinical commissioning groups and NHS England) commission services that involve people aged 5 years and over with asthma, and their family and carers as appropriate, in developing and reviewing a written personalised action plan and provide education to help them self-manage their asthma. Commissioners should ensure consistency by providing a local framework and guidance to healthcare professionals on developing and reviewing written personalised action plans and providing education for people with asthma.
People aged 5 years and over with asthma have their own asthma care plan, which helps them take their asthma medicines and know what to do if the medicines are not working (with support from their family and carers as appropriate). Their healthcare professional gives them (and their family and carers as appropriate) information about asthma, involves them in developing the plan and helps them to use it. The care plan is reviewed regularly with the person’s healthcare professional and also reviewed after an asthma attack.

Source guidance

Asthma: diagnosis, monitoring and chronic asthma management (2017) NICE guideline NG80, recommendation 1.10.1

Definitions of terms used in this quality statement

Written personalised action plan
A written personalised action plan (such as Asthma UK’s asthma action plan) should be tailored to the person with asthma, enabling them to recognise when symptoms are worse. The plan should set out actions to be taken if asthma control deteriorates and who to contact.
[British Thoracic Society and Scottish Intercollegiate Guidelines Network’s (BTS/SIGN) guideline on management of asthma, recommendation 5.2.2, and expert opinion]

Equality and diversity considerations

Healthcare professionals should have a discussion with family or carers of children under 5 years with symptoms of asthma to agree if a written personalised action plan would be helpful.
The personalised action plan should be provided in an accessible format and tailored to meet individual needs, taking into consideration a person’s capacity and their ability to care for themselves. Additional support may be needed for people with learning disabilities to ensure that they can be involved in the discussion and are able to understand how to use their plan.

Monitoring asthma control

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice for asthma and should be read in full.

Quality statement

People with asthma have their asthma control monitored at every asthma review.

Rationale

Monitoring of asthma control at every asthma review will identify if control is suboptimal. If suboptimal asthma control is identified, the person should have an assessment to identify possible reasons for this, including adherence and inhaler technique, before their treatment is adjusted. Support and education can be provided to improve adherence and inhaler technique. Monitoring asthma control and addressing any problems identified will improve quality of life and reduce the risk of serious asthma attacks and hospital admissions.

Quality measures

Structure
a) Evidence that tools, such as a validated questionnaire, are used locally for monitoring asthma control in adults.
Data source: Local data collection, for example, service specifications.
b) Evidence that spirometry or peak flow variability testing are used locally for monitoring asthma control in people aged 5 and over.
Data source: Local data collection, for example, service specifications.
c) Evidence of local arrangements to ensure that people with asthma have their asthma control monitored at every asthma review.
Data source: Local data collection, for example, service protocol.
Process
a) Proportion of people with asthma who had an asthma review within the past 12 months.
Numerator – the number in the denominator who had an asthma review within the past 12 months.
Denominator – the number of people with asthma.
Data source: Local data collection, for example, audit of patient heath records.
b) Proportion of asthma reviews that include monitoring of asthma control.
Numerator – the number in the denominator that include monitoring of asthma control.
Denominator – the number of asthma reviews.
Data source: Local data collection, for example, audit of patient heath records.
Outcome
a) Proportion of people with asthma prescribed more than 12 short-acting beta agonist (SABA) reliever inhalers within the past 12 months.
Data source: Local data collection, for example, electronic prescribing data. The community pharmacy quality payments scheme collects data on referrals for an asthma review for people with asthma dispensed more than 6 short-acting bronchodilator inhalers without any corticosteroid inhaler within a 6-month period.
b) Rate of hospital attendance or admission for asthma attack.
Data source: NHS Digital’s Hospital Episode Statistics includes data on admissions and A&E attendances for asthma attack.

What the quality statement means for different audiences

Service providers (such as GP practices, community health services and hospitals) ensure that processes are in place for people with asthma to have their asthma control monitored at every asthma review. Service providers ensure that if asthma control is suboptimal, processes are in place for adherence and inhaler technique to be assessed before treatment is adjusted. Service providers ensure that staff are trained to use the tools and tests needed to monitor asthma control and to assess adherence and inhaler technique.
Healthcare professionals (such as doctors, nurses, healthcare assistants and pharmacists) monitor asthma control at every asthma review. If control is suboptimal they assess adherence and inhaler technique before adjusting treatment.
Commissioners (clinical commissioning groups and NHS England) commission services that monitor asthma control at every asthma review. Commissioners ensure that tools, such as a validated questionnaire, and spirometry or peak flow variability testing, are available for monitoring asthma control.
People with asthma have their asthma control checked when they have a review of their asthma. If their asthma is not well controlled, they get support to make sure they are using their medicines correctly, for example, a check of how they are using their inhaler. If this doesn’t help, they may have their medicines or inhaler changed to help prevent asthma attacks.

Source guidance

Asthma: diagnosis, monitoring and chronic asthma management (2017) NICE guideline NG80, recommendations 1.14.1 and 1.14.3

Definitions of terms used in this quality statement

Monitoring asthma control
Consider using a validated questionnaire, such as the Asthma Control Questionnaire or Asthma Control Test, to monitor asthma control in adults. Asthma control should be monitored in people aged 5 and over using either spirometry or peak flow variability testing.
[NICE’s guideline on asthma, recommendations 1.14.2 and 1.14.3]
Asthma review
Any asthma review, including review after an asthma attack and annual asthma review.
[Expert opinion]

Equality and diversity considerations

Healthcare professionals using a validated questionnaire to monitor asthma control should ensure it is provided in a suitable format to meet individual needs. People with a learning disability or low literacy levels may need additional support to ensure that they understand what is being asked and can take part in the discussion. 

Follow-up by general practice after emergency care

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice for asthma and should be read in full.

Quality statement

People who receive treatment in an emergency care setting for an asthma attack are followed up by their general practice within 2 working days of discharge.

Rationale

People who have recently had emergency care for an asthma attack may be at risk of another attack. Timely follow-up in general practice after discharge from emergency care allows healthcare professionals to check that the asthma is responding to treatment, to explore the possible reasons for the attack and to give support and advice about reducing the risk of further attacks.

Quality measures

Structure
a) Evidence of local arrangements to ensure that emergency care settings notify the person’s general practice following treatment for an asthma attack.
Data source: Local data collection, for example, service protocols.
b) Evidence of local arrangements to ensure that general practices follow-up people treated in an emergency care setting for an asthma attack within 2 working days of discharge.
Data source: Local data collection, for example, service protocol.
Process
a) Proportion of cases of asthma attack treated in an emergency care setting notified to the person’s general practice.
Numerator – the number in the denominator notified to the person’s general practice.
Denominator – the number of cases asthma attack treated in an emergency care setting.
Data source: Local data collection, for example, audit of patient health records. Data on follow up requests is included in the National Asthma and COPD Audit Programme (NACAP) adult asthma audit and children and young people asthma audit as an element of the patient’s discharge.
b) Proportion of notifications of asthma attack treated in an emergency care setting followed up by a general practice within 2 working days of discharge.
Numerator – the number in the denominator that are followed up by a general practice within 2 working days of discharge.
Denominator – the number of notifications of asthma attack treated in an emergency care setting.
Data source: Local data collection, for example, audit of patient health records.
Outcome
a) Rate of re-attendance within 7 days of a previous attendance in emergency care for asthma.
Data source: Local data collection, for example, audit of patient health records. Data on A&E re-attendance is included in NHS Digital’s Accident and Emergency Quality Indicators.
b) Rate of hospital attendance or admission for asthma attack.
Data source: NHS Digital’s Hospital Episode Statistics includes data on admissions and A&E attendances for asthma attack.
c) Mortality rate for people with asthma.
Data source: Local data collection, for example, audit of patient health records. National data on the under 75 mortality rate from respiratory disease is included in NHS Outcomes Framework – indicator 1.2 available from NHS Digital’s Clinical indicators.

What the quality statement means for different audiences

Service providers (such as A&E departments, out-of-hours services, walk-in centres and general practices) ensure that processes are in place to notify the person’s general practice when treatment for an asthma attack has been provided in an emergency care setting. Once notified, general practices ensure follow-up takes places within 2 working days of discharge. General practices ensure that staff who follow-up people who have had an asthma attack are trained in asthma care.
Healthcare professionals (such as doctors, nurses, pharmacists and healthcare assistants) notify the person’s general practice when they provide treatment in an emergency care setting for an asthma attack. Healthcare professionals in general practices ensure that follow-up takes place within 2 working days of discharge from emergency care.
Commissioners (clinical commissioning groups and NHS England) commission emergency care services that have processes in place to notify the person’s general practice when treatment is provided for an asthma attack. Commissioners ensure that there is sufficient capacity for general practice to follow-up within 2 working days of discharge. Commissioners could consider introducing a local quality improvement scheme to encourage the pathway to be established.
People who have emergency treatment for an asthma attack are checked by a healthcare professional at their GP surgery within 2 working days of discharge. This is to check that their treatment is working and help them to understand why their asthma got worse and how to stop it happening again.

Source guidance

Management of asthma (2016) British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) clinical guideline 153, recommendations 9.6.3, 9.9.7, and annexes 3 and 6

Equality and diversity considerations

Healthcare professionals in emergency care should ensure that alternative follow-up arrangements are made for people who are not registered with a general practice, for example, because they are homeless. 

Suspected severe asthma (developmental)

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice for asthma and should be read in full.
Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

People with suspected severe asthma are referred to a specialist multidisciplinary severe asthma service.

Rationale

People with suspected severe asthma need specialist assessment to confirm a diagnosis of severe asthma. Specialist assessment is important to revisit adherence to treatment, exclude other causes of persistent symptoms and ensure the most appropriate treatment. Specialist care can help to improve asthma control, prevent asthma attacks and reduce harmful long-term dependence on oral corticosteroids.

Quality measures

Structure
a) Evidence that specialist multidisciplinary severe asthma services are available for people with suspected severe asthma.
Data source: Local data collection, for example, service specifications for children and young people, and adults.
b) Evidence of local arrangements to ensure that people with suspected severe asthma are referred to a specialist multidisciplinary severe asthma service.
Data source: Local data collection, for example, service protocols and referral pathways.
Process
Proportion of people with suspected severe asthma who are referred to a specialist multidisciplinary severe asthma service.
Numerator – the number in the denominator who are referred to a specialist multidisciplinary severe asthma service.
Denominator – the number of people with suspected severe asthma.
Data source: Local data collection, for example, audit of patient health records.
Outcome
a) Rate of hospital attendance or admission for an asthma attack.
Data source: NHS Digital’s Hospital Episode Statistics includes data on admissions and A&E attendances for asthma attack.
b) Proportion of people with asthma who have 2 or more courses of high-dose oral corticosteroids per year.
Data source: Local data collection, for example, electronic prescribing data.

What the quality statement means for different audiences

Service providers (such as hospitals) ensure that processes are in place to identify people with suspected severe asthma so that they can be referred to a specialist multidisciplinary severe asthma service. Service providers ensure that a diagnosis of asthma is made, and adherence and comorbidities are addressed before a referral is made.
Healthcare professionals (such as doctors and nurses) are aware of local referral pathways for severe asthma and refer people with suspected severe asthma to a specialist multidisciplinary severe asthma service. Healthcare professionals ensure that a diagnosis of asthma is made, and adherence and comorbidities are addressed before making a referral. Healthcare professionals ensure that people with suspected severe asthma know what to expect when they are referred.
Commissioners (NHS England) commission specialist multidisciplinary severe asthma services for adults and children and young people and ensure referral pathways are in place. Commissioners ensure that providers identify people with suspected severe asthma so that they can be referred. Commissioners ensure that specialist services have sufficient capacity to meet the demand for assessments for people with suspected severe asthma.
People with suspected severe asthma are referred to a service that specialises in managing severe asthma so that the reasons for their asthma and their treatment can be reviewed.

Source guidance

Management of asthma (2016) British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) clinical guideline 153, recommendation 10.1

Definitions of terms used in this quality statement

Severe asthma
When a diagnosis of asthma is confirmed and comorbidities have been addressed, severe asthma is defined as asthma that needs treatment with the medicines suggested for steps 4 to 5 in the Global Initiative for Asthma (GINA) guideline (a high-dose inhaled corticosteroid [ICS] with a long-acting beta 2-agonist [LABA] or leukotriene modifier or theophylline) for the previous year or systemic corticosteroids for 6 months or more of the previous year to prevent it from becoming ‘uncontrolled’ (that is, controlled asthma that worsens on tapering of these high doses of ICS or systemic corticosteroids [or additional biologics]) or that remains ‘uncontrolled’ despite this therapy. ‘Uncontrolled’ is defined as at least 1 of the following:
  • Poor symptom control: Asthma Control Questionnaire consistently greater than 1.5 or Asthma Control Test less than 20.
  • Frequent severe exacerbations: 2 or more bursts of systemic corticosteroids in the previous year.
  • Serious asthma attacks: at least 1 hospitalisation, ICU stay or mechanical ventilation in the previous year.
  • Airflow limitation: after appropriate bronchodilator withhold FEV1 less than 80% predicted (in the face of reduced FEV1/FVC defined as less than the lower limit of normal).
[Global Initiative for Asthma Global strategy for asthma management and prevention, European Respiratory Society/American Thoracic Society International guidelines on definition, evaluation and treatment of severe asthma, and expert opinion]
Specialist multidisciplinary severe asthma service
A dedicated multidisciplinary service with a team experienced in the assessment and management of severe asthma. The service requirements for adults are set out in NHS England’s specification for specialised respiratory services (adult) – severe asthma. The service requirements for children are set out in NHS England’s specification for paediatric medicine: respiratory with additional information provided in the 2016/17 Prescribed Specialised Services Commissioning for Quality and Innovation (CQUIN) scheme for difficult to control asthma assessment in 12 weeks.

Equality and diversity considerations

Healthcare professionals should ensure that people with learning disabilities are referred to a specialist service if severe asthma is a possibility but it has not been possible to assess all relevant criteria.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

If an adult, young person or child with symptoms suggestive of asthma cannot perform a particular test, try to perform at least 2 other objective tests. Diagnose suspected asthma based on symptoms and any positive objective test results.
Record the basis for a diagnosis of asthma in a single entry in the person's medical records, alongside the coded diagnostic entry.

Clinical history

Take a structured clinical history in people with suspected asthma. Specifically, check for:
  • wheeze, cough or breathlessness, and any daily or seasonal variation in these symptoms
  • any triggers that make symptoms worse
  • a personal or family history of atopic disorders.
Do not use symptoms alone without an objective test to diagnose asthma.
Do not use a history of atopic disorders alone to diagnose asthma.

Physical examination

Examine people with suspected asthma to identify expiratory polyphonic wheeze and signs of other causes of respiratory symptoms, but be aware that even if examination results are normal the person may still have asthma.

Initial treatment and objective tests for acute symptoms at presentation

Treat people immediately if they are acutely unwell at presentation, and perform objective tests for asthma (for example, FeNO, spirometry and peak flow variability) if the equipment is available and testing will not compromise treatment of the acute episode.
If objective tests for asthma cannot be done immediately for people who are acutely unwell at presentation, carry them out when acute symptoms have been controlled, and advise people to contact their healthcare professional immediately if they become unwell while waiting to have objective tests.
Be aware that the results of spirometry and FeNO tests may be affected in people who have been treated empirically with inhaled corticosteroids.

Positive test thresholds for objective tests for children and young people (aged 5 to 16)

Test
Positive result
35 ppb or more
Obstructive spirometry
FEV1/FVC ratio less than 70% (or below the lower limit of normal if this value is available)
BDR test
Improvement in FEV1 of 12% or more
Peak flow variability
Variability over 20%

Positive test thresholds for objective tests for adults (aged 17 and over)

Test
Positive result
40 ppb or more
Obstructive spirometry
FEV1/FVC ratio less than 70% (or below the lower limit of normal if this value is available)
BDR test
Improvement in FEV1 of 12% or more and increase in volume of 200 ml or more
Peak flow variability
Variability over 20%
Direct bronchial challenge test with histamine or methacholine
PC20 of 8 mg/ml or less
Risk stratification is a process of categorising a population by their relative likelihood of experiencing certain outcomes. In the context of this guideline, risk stratification involves categorising people with asthma by their relative likelihood of experiencing negative clinical outcomes (for example, severe exacerbations or hospitalisations). Factors including non-adherence to asthma medicines, psychosocial problems and repeated episodes of unscheduled care can be used to guide risk stratification. Once the population is stratified, the delivery of care for the population can be targeted with the aim of improving the care of the strata with the highest risk.
Do not offer the following as diagnostic tests for asthma:
  • skin prick tests to aeroallergens
  • serum total and specific IgE
  • peripheral blood eosinophil count
  • exercise challenge (to adults aged 17 and over).
Use skin prick tests to aeroallergens or specific IgE tests to identify triggers after a formal diagnosis of asthma has been made.
Offer spirometry to adults, young people and children aged 5 and over if a diagnosis of asthma is being considered. Regard a forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio of less than 70% (or below the lower limit of normal if this value is available) as a positive test for obstructive airway disease (obstructive spirometry).
The following recommendations are from NICE technology appraisal guidance on inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and over.
For adults and children aged 12 years and older with chronic asthma in whom treatment with an ICS is considered appropriate, the least costly product that is suitable for an individual, within its marketing authorisation, is recommended.
For adults and children aged 12 years and older with chronic asthma in whom treatment with an ICS and LABA is considered appropriate, the following apply.
  • The use of a combination device within its marketing authorisation is recommended as an option.
  • The decision to use a combination device or the two agents in separate devices should be made on an individual basis, taking into consideration therapeutic need and the likelihood of treatment adherence.
  • If a combination device is chosen then the least costly device that is suitable for the individual is recommended.
These recommendation should be read in conjunction with the recommendations in inhaler devices.
The following recommendations are from NICE technology appraisal guidance on inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12 years.
For children under the age of 12 years with chronic asthma in whom treatment with an ICS is considered appropriate, the least costly product that is suitable for an individual child (taking into consideration technology appraisal guidance 38 and 10), within its marketing authorisation, is recommended.
For children under the age of 12 years with chronic asthma in whom treatment with an ICS and LABA is considered appropriate, the following apply.
  • The use of a combination device within its marketing authorisation is recommended as an option.
  • The decision to use a combination device or the two agents in separate devices should be made on an individual basis, taking into consideration therapeutic need and the likelihood of treatment adherence.
  • If a combination device is chosen then the least costly device that is suitable for the individual child is recommended.
These recommendation should be read in conjunction with the recommendations in inhaler devices.

Uncontrolled asthma

Uncontrolled asthma describes asthma that has an impact on a person's lifestyle or restricts their normal activities. Symptoms such as coughing, wheezing, shortness of breath and chest tightness associated with uncontrolled asthma can significantly decrease a person's quality of life and may lead to a medical emergency. Questionnaires are available that can be quantify this.
This guidance uses the following pragmatic thresholds to define uncontrolled asthma:
  • 3 or more days a week with symptoms or
  • 3 or more days a week with required use of a SABA for symptomatic relief or
  • 1 or more nights a week with awakening due to asthma.

Measuring fractional exhaled nitric oxide concentration

The following recommendation is an extract from NICE diagnostics guidance on measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO, NIOX VERO and NObreath.
FeNO testing is recommended as an option to help diagnose asthma in people:
  • who, after initial clinical examination, are considered to have an intermediate probability of having asthma (as defined in the British guideline on the management of asthma 2012) and
  • when FeNO testing is intended to be done in combination with other diagnostic options according to the British guideline on the management of asthma (2012).
Further investigation is recommended for people whose FeNO test result is negative because a negative result does not exclude asthma.

Glossary

bronchodilator reversibility
dry powder inhaler
(a wheeze is a continuous, whistling sound produced in the airways during breathing. It is caused by narrowing or obstruction in the airways; an expiratory polyphonic wheeze has multiple pitches and tones heard over different areas of the lung when the person breathes out)
fractional exhaled nitric oxide
forced expiratory volume in 1 second
forced vital capacity
(any longer time away from work than usual breaks at weekends or between shifts)
inhaled corticosteroid
immunoglobulin E
long-acting beta-2 agonist
long-acting beta-2 agonists
leukotriene receptor antagonist
leukotriene receptor antagonists
(maintenance and reliever therapy is a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required; only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol))
(tests carried out to help determine whether a person has asthma, the results of which are not based on the person's symptoms, for example, tests to measure lung function or evidence of inflammation; there is no single objective test to diagnose asthma)
provoking concentration to induce a 20% reduction in forced expiratory volume in 1 second
pressurised metered dose inhaler
parts per billion
title: Obstructive spirometry
FEV1/FVC ratio less than 70%
short-acting beta-2 agonist
short-acting beta-2 agonists
(suspected asthma describes a potential diagnosis of asthma based on symptoms and response to treatment that has not yet been confirmed with objective tests)

Paths in this pathway

Pathway created: March 2014 Last updated: October 2018

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