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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

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

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 2017) NICE quality standard 25
Asthma: tiotropium (Spiriva Respimat) (2015) NICE evidence summary ESNM55
Thora-3Di for assessing asthma in children (2017) NICE medtech innovation briefing 122
Smartinhaler for asthma (2014) NICE medtech innovation briefing 90

Quality standards

Quality statements

Diagnosis

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 newly diagnosed asthma are diagnosed in accordance with NICE guidance.

Rationale

Making a diagnosis of asthma is a process which is different in adults and children and also varies among adults and among children. The diagnostic processes for adults and children are described in the NICE guideline on asthma. It is important the process followed is documented to ensure continuity in the diagnostic process. It is also important that the basis on which the diagnosis of asthma is made is clearly recorded because this process may have implications for the future management of the condition. Following the process should result in an accurate diagnosis and ensure the person receives appropriate treatment.
NICE is recommending objective testing with spirometry and FeNO for most people with suspected asthma; a significant enhancement to current practice. This 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.

Quality measure

Structure: Evidence of local arrangements to ensure people with newly diagnosed asthma are diagnosed in accordance with NICE guidance, and that the process is documented in their patient notes.
Process: Proportion of people with newly diagnosed asthma whose notes describe the process, as outlined in the NICE guidance, by which the diagnosis was made.
Numerator – the number of people in the denominator whose notes describe the process, as outlined in the NICE guidance, by which the diagnosis was made.
Denominator – the number of people with newly diagnosed asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people with newly diagnosed asthma to be diagnosed in accordance with NICE guidance.
Healthcare professionals ensure people with newly diagnosed asthma are diagnosed in accordance with NICE guidance.
Commissioners ensure they commission services for people with newly diagnosed asthma to be diagnosed in accordance with NICE guidance.
People with newly diagnosed asthma have a diagnosis made in line with NICE guidance.

Source guidance

Asthma: diagnosis, monitoring and chronic asthma management (2017) NICE guideline NG80, recommendations 1.1.1 to 1.1.6, 1.1.10, 1.2.1, 1.2.2, 1.3.14, 1.3.15, 1.3.18, 1.3.19, 1.3.21, 1.3.22 and section 1.4

Data source

Structure: Local data collection.
Process: Local data collection.

Definitions

Diagnostic process
The diagnosis and the process by which the diagnosis is made should be documented in the patient’s notes.
The diagnostic process is summarised in the NICE guideline on asthma, algorithms A, B and C, and consists of:
  • history and clinical examination
  • objective tests for asthma and
  • if diagnostic uncertainty remains but asthma is suspected, review of the response to treatment given in accordance with the NICE guidance.

Diagnosing occupational asthma

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

Adults with new onset asthma are assessed for occupational causes.

Rationale

Occupational asthma is the only form of asthma that can potentially be cured by removing the person from exposure to the trigger. Healthcare professionals need to be able to recognise symptoms that suggest occupational asthma so that they can ensure appropriate referral and treatment.

Quality measure

Structure: Evidence of local arrangements to ensure adults with new onset asthma are assessed for occupational causes.
Process: Proportion of adults with new onset asthma who are assessed for occupational causes.
Numerator – the number of people in the denominator assessed for occupational causes.
Denominator – the number of adults with new onset asthma.
Outcome: Incidence of occupational asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for adults with new onset asthma to be assessed for occupational causes.
Healthcare professionals assess adults with new onset asthma for occupational causes.
Commissioners ensure they commission services that assess adults with new onset asthma for occupational causes.
Adults who have recently developed asthma are assessed for causes linked to their place of work.

Source guidance

Asthma: diagnosis, monitoring and chronic asthma management (2017) NICE guideline NG80, recommendations 1.1.10 and 1.1.11

Data source

Structure: Local data collection.
Process: Local data collection.
Outcome: Local data collection.

Definitions

Adults
Adults are defined as 17 years and older.
New onset asthma
New onset asthma is defined as asthma developing in adults who have not had a previous diagnosis of asthma or a reappearance of childhood asthma in adults.
Assessing for occupational asthma
The NICE guideline on asthma lists the 2 questions to be asked when assessing for occupational asthma as:
  • Are symptoms better on days away from work?
  • Are symptoms better when on holiday?

Written personalised action plans

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 receive a written personalised action plan.

Rationale

Written personalised action plans, given as part of structured education, can improve outcomes such as self-efficacy, knowledge and confidence for people with asthma. For people with asthma who have had a recent acute exacerbation resulting in admission to hospital, written personalised action plans may reduce readmission rates.

Quality measure

Structure
Evidence of local arrangements to ensure people with asthma receive a written personalised action plan.
Process
a) Proportion of people with asthma who receive a written personalised action plan.
Numerator – the number of people in the denominator receiving a written personalised action plan.
Denominator – the number of people with asthma.
b) Proportion of people treated in hospital for an acute exacerbation of asthma who receive a written personalised action plan before discharge.
Numerator – the number of people in the denominator receiving a written personalised action plan before discharge.
Denominator – the number of people treated in hospital for an acute exacerbation of asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people with asthma to receive a written personalised action plan.
Healthcare professionals ensure they give people with asthma a written personalised action plan.
Commissioners ensure they commission services that give people with asthma a written personalised action plan.
People with asthma receive a written plan with details of how their asthma will be managed.

Source guidance

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.

Definitions

Personalised action plan
A personalised action plan should be tailored to the person with asthma, enabling people with asthma to recognise when symptoms are worse and setting out actions to be taken when asthma control deteriorates.

Equality and diversity considerations

A personalised action plan should be tailored to the person with asthma. The intent of the statement is for people with asthma to not just receive the information verbally but for it to be recorded. This allows people to refer back to the information at a later date. Other formats, such as braille, pictorial or digital, may be needed for particular groups.
For some people with asthma it may be appropriate for a parent or carer to be involved in the review of the written personalised action plan; particularly for children, older people and those with learning disabilities.

Inhaler technique

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 are given specific training and assessment in inhaler technique before starting any new inhaler treatment.

Rationale

People with asthma need to be able to use their inhaler correctly to ensure they receive the correct dose of treatment. There are several types of inhaler and it is important that training and assessment are specific to each inhaler.
Training and assessment need to take place before any new inhaler treatment is started, to ensure that changes to treatment do not fail because of poor technique.

Quality measure

Structure
Evidence of local arrangements to ensure people with asthma are given specific training and assessment in inhaler technique before starting any new inhaler treatment.
Process
Proportion of people with asthma who are given specific training and assessment in inhaler technique before starting any new inhaler treatment.
Numerator – the number of people in the denominator who have training and assessment in inhaler technique.
Denominator – the number of people with asthma starting a new inhaler treatment.

What the quality statement means for each audience

Service providers ensure systems are in place for people with asthma to be given specific training and assessment in inhaler technique before starting any new inhaler treatment.
Healthcare professionals ensure people with asthma receive specific training and assessment in inhaler technique before starting any new inhaler treatment.
Commissioners ensure they commission services that give people with asthma specific training and assessment in inhaler technique before they start any new inhaler treatment.
People with asthma are given training in using their inhaler before they start any new inhaler treatment.

Source guidance

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

During an assessment of inhaler technique the person with asthma should demonstrate that they can use the inhaler as specified in the manufacturer’s guidance.

Review

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 receive a structured review at least annually.

Rationale

A structured review can improve clinical outcomes for people with asthma. Benefits associated with structured review may include reduced absence from school or work, reduced exacerbation rate, improved symptom control and reduced attendance in accident and emergency departments.

Quality measure

Structure: Evidence of local arrangements to ensure people with asthma receive a structured review at least annually.
Process: Proportion of people with asthma who receive a structured review at least annually.
Numerator – the number of people in the denominator who had a structured review within 12 months of the last review or diagnosis.
Denominator – the number of people with asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people with asthma to receive a structured review at least annually.
Healthcare professionals ensure people with asthma receive a structured review at least annually.
Commissioners ensure they commission services that give people with asthma a structured review at least annually.
People with asthma have a review of their asthma and its management at least once a year.

Source guidance

Data source

Structure: Local data collection.
Process: Local data collection.

Definitions

Components of a structured review
The components of a structured review are set out in the BTS/SIGN guideline, paragraphs 4.3 and 4.4. The review will vary for adults and children.
Components of a structured review for children include:
  • assessment of asthma control
  • review of exacerbations, oral corticosteroid use and time off school or nursery as a result of asthma since last assessment
  • checking inhaler technique
  • assessing adherence
  • adjustment of treatment (consider stepping up if poor control or stepping down if good control since the last annual review)
  • possession and review of personalised action plan
  • exposure to tobacco smoke
  • measurement of growth centile (height and weight)
  • assessment of comorbidities.
Components of a structured review for adults include:
  • assessment of asthma control
  • review of exacerbations, oral corticosteroid use and time off work or study since last assessment
  • checking inhaler technique
  • assessing adherence
  • adjustment of treatment (consider stepping up if poor control or stepping down if good control since the last annual review)
  • bronchodilator reliance (which can be assessed by reviewing prescription refill frequency)
  • possession and review of personalised action plan
  • smoking status
  • assessment of comorbidities.
Assessment of asthma control
Monitor asthma control in adults, young people and children aged 5 and over using either spirometry or peak flow variability testing.
Consider using a validated questionnaire to assess asthma control in adults aged 17 and over.
[NICE’s guideline on asthma, recommendations 1.14.3 and 1.14.2]

Assessing 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 who present with respiratory symptoms receive an assessment of their asthma control.

Rationale

For people who present with respiratory symptoms between annual reviews, it is important to assess asthma control to identify those who need treatment. In some cases this may prevent admission to hospital for deteriorating symptoms.

Quality measure

Structure: Evidence of local arrangements to ensure people with asthma presenting with respiratory symptoms receive an assessment of their asthma control.
Process: Proportion of people with asthma presenting with respiratory symptoms who receive an assessment of their asthma control.
Numerator – the number of people in the denominator receiving an assessment of their asthma control.
Denominator – the number of people with asthma who present with respiratory symptoms.

What the quality statement means for each audience

Service providers ensure systems are in place for people with asthma who present with respiratory symptoms to receive an assessment of their asthma control.
Healthcare professionals assess asthma control in people with asthma who present with respiratory symptoms.
Commissioners ensure they commission services that assess asthma control in people with asthma who present with respiratory symptoms.
People with asthma who have symptoms have an assessment of how well their asthma is controlled.

Source guidance

Asthma: diagnosis, monitoring and chronic asthma management (2017) NICE guideline NG80, recommendations 1.14.2 and 1.14.3

Data source

Structure: Local data collection.
Process: Local data collection.

Definitions

Respiratory symptoms
Respiratory symptoms include cough, wheezing, breathlessness and chest tightness.
Assessment of asthma control
Monitor asthma control in adults, young people and children aged 5 and over using either spirometry or peak flow variability testing.
Consider using a validated questionnaire to assess asthma control in adults aged 17 and over.
[NICE’s guideline on asthma, recommendations 1.14.3 and 1.14.2]

Assessing severity

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 who present with an exacerbation of their symptoms receive an objective measurement of severity at the time of presentation.

Rationale

Severity of an exacerbation should be objectively measured as soon as a person presents with respiratory symptoms. Delays in measurement can result in symptoms deteriorating further. An accurate measurement can determine the level of severity of the attack and ensure appropriate treatment is started promptly.

Quality measure

Structure
Evidence of local arrangements to ensure people with asthma presenting with an exacerbation of their respiratory symptoms receive an objective measurement of severity at the time of presentation.
Process
Proportion of people with asthma presenting with an exacerbation of their respiratory symptoms who receive an objective measurement of severity at the time of presentation.
Numerator – the number of people in the denominator receiving an objective measurement of severity at the time of presentation.
Denominator – the number of people with asthma presenting with an exacerbation of their respiratory symptoms.

What the quality statement means for each audience

Service providers ensure systems are in place for people with asthma who present with an exacerbation of their respiratory symptoms to receive an objective measurement of severity at the time of presentation.
Healthcare professionals ensure people presenting with an acute exacerbation of asthma receive an objective measurement of severity at the time of presentation.
Commissioners ensure they commission services that give people with asthma who present with an exacerbation of their respiratory symptoms an objective measurement of severity at the time of presentation.
People with asthma who go to see a healthcare professional because their symptoms have worsened have their symptoms measured at the time of the appointment.

Source guidance

Consensus based on annex 3–7 and guidance in paragraph 8.2.3 in BTS/SIGN (2016) British guideline on the management of asthma. SIGN clinical guideline 153.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Respiratory symptoms
Respiratory symptoms include cough, wheezing, breathlessness and chest tightness.
Objective measurement of severity
The clinical signs to assess when determining the severity of an exacerbation differ for adults, children aged 2–5 years and children aged older than 5 years. The measurements are outlined below and in the BTS/SIGN guideline: table 12 or annex 3 for adults and table 14 or annex 5, 6 or 7 for children older than 2 years.
Children aged 2–5 years
Moderate asthma
Severe asthma
Life-threatening asthma
SpO2 ≥92%
Able to talk
Heart rate ≤140/minute
Respiratory rate ≤40/minute
SpO2 <92%
Too breathless to talk
Heart rate >140/minute
Respiratory rate >40/minute
Use of accessory neck muscles
SpO2 <92% plus any of:
  • silent chest
  • poor respiratory effort
  • agitation
  • confusion
  • cyanosis
Children older than 5 years
Moderate asthma
Severe asthma
Life-threatening asthma
SpO2 ≥92%
PEF ≥50% best or predicted
Able to talk
Heart rate ≤125/minute
Respiratory rate ≤30/minute
SpO2 <92%
PEF 33–50% best or predicted
Too breathless to talk
Heart rate >125/minute
Respiratory rate >30/minute
Use of accessory neck muscles
SpO2 <92% plus any of:
  • PEF <33% best or predicted
  • silent chest
  • poor respiratory effort
  • agitation
  • confusion
  • cyanosis
Adults
Measure peak expiratory flow (PEF) and arterial saturation
PEF >50–75% best or predicted
PEF 33–50% best or predicted
PEF <33% best or predicted
Moderate asthma
Acute severe asthma
Life-threatening asthma
SpO2 ≥92%
PEF >50–75% best or predicted
No features of acute severe asthma
Features of severe asthma
  • PEF<50% best or predicted
  • Respiration ≥25/minute
  • SpO2 ≥92%
  • Pulse ≥110 breaths/minute
  • Cannot complete sentence in 1 breath
  • SpO2 <92%
  • Silent chest, cyanosis, poor respiratory effort
  • Arrhythmia, hypotension
  • Exhaustion, altered consciousness

Treatment for acute asthma

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 or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation.

Rationale

Steroids are part of a range of treatment that can be given to people aged 5 years or older presenting with a severe or life-threatening exacerbation of asthma.
The use of steroids soon after presentation may contribute to reducing the need for hospital admission, preventing relapse in symptoms, reducing mortality and the need for beta2 agonist therapy.

Quality measure

Structure
Evidence of local arrangements to ensure people aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation.
Process
Proportion of people aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma who receive oral or intravenous steroids within 1 hour of presentation.
Numerator – the number of people in the denominator receiving oral or intravenous steroids within 1 hour of presentation.
Denominator – the number of people aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma to receive oral or intravenous steroids within 1 hour of presentation.
Healthcare professionals ensure people aged 5 years or older presenting to them with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation.
Commissioners ensure they commission services that give oral or intravenous steroids to people aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma within 1 hour of presentation.
People aged 5 years or older who see a healthcare professional with severe or life-threatening asthma are given oral or intravenous steroids within 1 hour.

Source guidance

BTS/SIGN (2016) British guideline on the management of asthma. SIGN clinical guideline 153, recommendations in paragraphs 9.3.3, 9.8.4 and 12.2 and guidance in annex 3–7

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Severe and life-threatening asthma
The BTS/SIGN guideline defines severe and life-threatening asthma in table 12 for adults and table 14 for children.

Specialist review

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 admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge.

Rationale

A structured review of clinical management and the written personalised action plan ensure people admitted to hospital receive appropriate treatment and in some cases may reduce readmission rates.

Quality measure

Structure
Evidence of local arrangements to ensure people admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge.
Process
Proportion of people admitted to hospital with an acute exacerbation of asthma who receive a structured review by a member of a specialist respiratory team before discharge.
Numerator – the number of people in the denominator receiving a structured review by a member of a specialist respiratory team.
Denominator – the number of people discharged from hospital after admission for an acute exacerbation of asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people admitted to hospital with an acute exacerbation of asthma to be reviewed by a member of a specialist respiratory team before discharge.
Healthcare professionals ensure people admitted to hospital with an acute exacerbation of asthma are reviewed by a member of a specialist respiratory team before discharge.
Commissioners ensure they commission services which give people admitted to hospital with an acute exacerbation of asthma a review by a member of a specialist respiratory team before discharge.
People admitted to hospital with a sudden worsening of asthma have a review by a member of a specialist team before discharge.

Source guidance

Consensus based on guidance from paragraph 5.3.2 in BTS/SIGN (2016) British guideline on the management of asthma. SIGN clinical guideline 153

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Structured review
A structured review should include:
  • an assessment of events leading up to the attack (including exposure to triggers, adherence and inhaler technique)
  • review of the written personalised action plan
  • review of regular treatment including considering whether this needs to be changed.
Specialist respiratory team
Specialist respiratory team is defined as a team in which the clinical lead is a respiratory consultant (adult or paediatric) or a specialist with an interest in respiratory disease (adult or paediatric) or a trained specialist nurse with expertise in managing asthma.

Equality and diversity considerations

A personalised action plan should be tailored to the person with asthma. The intent of the statement is for people with asthma to not just receive the information verbally but for it to be recorded. This allows people to refer back to the information later. Other formats, such as braille, pictorial or digital, may be needed for particular groups.
For some people with asthma it may be appropriate for a parent or carer to be involved in the review of the written personalised action plan, particularly for children, older people and those with learning disabilities.

Follow-up in primary 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 received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within 2 working days of treatment.

Rationale

For people treated for an exacerbation of asthma in hospital (both in accident and emergency departments and as inpatients) or through out-of-hours services, follow-up appointments are important to explore the possible reasons for the exacerbation and the actions needed to reduce the risk of further acute episodes.

Quality measure

Structure
a) Evidence of local arrangements to ensure people who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within 2 working days of treatment.
b) Evidence of local arrangements to ensure effective communication between secondary care centres (such as hospitals and out-of-hours services) and primary care.
Process
Proportion of people who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma who are followed up by their own GP practice within 2 working days of treatment.
Numerator – the number of people in the denominator followed up by their own GP practice within 2 working days of treatment.
Denominator – the number of people who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma to be followed up by their own GP practice within 2 working days of treatment.
Healthcare professionals follow up all people in their own practice who received treatment for an acute exacerbation of asthma in hospital or through out-of-hours services within 2 working days of treatment.
Commissioners ensure they commission services that specify effective communication between secondary care centres (such as hospitals and out-of-hours services) and primary care so that people who received treatment for an acute exacerbation of asthma in hospital or through out-of-hours services are followed up by their own GP practice within 2 working days of treatment.
People who received treatment in hospital or through out-of-hours services for a sudden worsening of their asthma see a healthcare professional in their own GP practice within 2 working days of treatment.

Source guidance

Consensus based on annex 3 and guidance from paragraphs 9.6.3 and 9.9.7 in BTS/SIGN (2016) British guideline on the management of asthma. SIGN clinical guideline 153

Data source

Structure
a) and b) Local data collection.
Process
Local data collection.

Definitions

People treated for an exacerbation of asthma in hospital
People who received treatment in hospital include both people treated in accident and emergency departments and those treated as inpatients.
Follow-up after an acute exacerbation of asthma
People admitted with an acute exacerbation should be followed up within 2 days of discharge; people not admitted but treated for an acute exacerbation should be followed up within 2 days of treatment.

Difficult asthma

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 difficult asthma are offered an assessment by a multidisciplinary difficult asthma service.

Rationale

People with difficult asthma need specialist assessment to accurately diagnose their asthma, exclude alternative causes of persistent symptoms, manage comorbidities, confirm adherence to therapy and ensure they are receiving the most appropriate treatment.

Quality measure

Structure: Evidence of local arrangements to ensure people with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service.
Process: Proportion of people with difficult asthma who receive an assessment by a multidisciplinary difficult asthma service.
Numerator – the number of people in the denominator receiving an assessment by a multidisciplinary difficult asthma service.
Denominator – the number of people with difficult asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people with difficult asthma to be offered an assessment by a multidisciplinary difficult asthma service.
Healthcare professionals offer people with difficult asthma an assessment by a multidisciplinary difficult asthma service.
Commissioners ensure they commission services that offer people with difficult asthma an assessment by a multidisciplinary difficult asthma service.
People with asthma that is difficult to control are offered an assessment by a team that specialises in managing ‘difficult asthma’.

Source guidance

BTS/SIGN (2016) British guideline on the management of asthma. SIGN clinical guideline 153, recommendations in paragraph 10.1

Data source

Structure: Local data collection.
Process: Local data collection.

Definitions

Difficult asthma
Difficult asthma is defined as asthma with symptoms despite treatment with high-dose therapies or continuous or frequent use of oral steroids as identified in the BTS/SIGN guideline.
Assessment
The BTS/SIGN guideline states a systematic evaluation should include:
  • confirmation of the diagnosis of asthma and
  • identification of the mechanism of persisting symptoms and
  • assessment of adherence with therapy.
Difficult asthma service for adults
The service requirements to be met by a difficult asthma service for adults are set out in NHS England’s specification for specialised respiratory services (adult) – severe asthma.
Difficult asthma service for children
The service requirements to be met by a difficult asthma service for children are set out in NHS England’s specification for paediatric medicine: respiratory.

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: December 2017

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