A “structured clinical assessment” should be used to identify those at risk of asthma exacerbations, in the absence of a one simple test for the condition, according to updated national guidance.
Clinicians suspecting asthma should undertake a structured assessment using a combination of patient history, examination and tests to assess for probability, it said.
“We urge clinicians across the UK to refer to this guideline”
Patients should then be assigned into three groups based on the probability they have asthma –either high, intermediate or low, stated the new guideline published today.
If the probability of asthma is high, health professionals should start a carefully monitored trial of treatment, with the diagnosis confirmed if patients respond well.
However, health professionals should code their records as “suspected asthma” until a diagnosis is confirmed and should make a clear record on what basis the diagnosis was confirmed.
If the probability is low, further tests or referral to a specialist may be appropriate, according to the joint guidance from the British Thoracic Society and the Scottish Intercollegiate Guidelines Network.
“Asthma still remains a serious life threatening condition”
They said said the guideline’s “major focus” was on supporting health professionals to make accurate diagnoses and provide effective control and prevent life-threatening exacerbations.
It emphasised that there was “still no single test” that can definitively diagnose asthma and an individual’s asthma status can change over time.
Instead, it recommended an assessment that should include a history taking into account symptoms of cough, breathlessness, wheeze and chest tightness that have varied over time, personal or family history of allergic conditions, and evidence of variability over time in obstruction to airflow.
Spirometry by a trained clinician is recommended as the key frontline breathing test to be performed in most situations for adults and children over five years of age. If the test shows obstruction to airflow which reverses with treatment, it strongly supports a diagnosis of asthma.
But the guidance noted that a normal spirometry result did not always exclude an asthma diagnosis, especially if a patient had no symptoms at the time. It may be necessary to repeat spirometry when a patient had symptoms or use different tests, such as for fractional exhaled nitric oxide (FeNO).
“Nurses in particular can have a vital role in helping people to manage their condition”
In addition, the updated guideline includes new or revised recommendations on telehealth, supported self-management, non-drug and drug treatment – replacing the stepwise approach.
It highlighted that short-acting beta2 agonists were the key “rescue therapy” from symptoms or exacerbations, but should rarely be used on their own.
The guidance also emphasised the use of medication to prevent future asthma attacks, noting that inhaled corticosteroids remain the most effective “preventer” for all adults and children.
However, it warned that inhalers should not be prescribed generically to avoid patients being given an unfamiliar device that they may not know how to use properly.
If a patient had poor asthma control, the guidance said it was essential to check whether they were using their current drug treatment correctly and regularly, before stepping up treatment.
Each patient should be offered a written asthma action plan, as it is “key to the effective management of their asthma”, stated the guidance.
Additionally, it noted that weight loss initiatives could be offered for overweight or obese patients, which may improve asthma control.
It also advocated new electronic technologies that evidence showed could be at least as good as traditional methods, but noted outcomes varied.
Such approaches include games to encourage children to take medication, remote consultations, automated treatment reminders and computerised decision-support for health professionals.
Meanwhile, it added that pregnant women with asthma should be informed of the importance of continuing their medication “for the health of both mother and baby”.
Dr John White, a consultant at York NHS Foundation Trust and co-chair of the guideline development group, acknowledged that asthma diagnosis “isn’t always easy”.
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He said the guidance provided an “evidence-based but highly practical approach” to suspecting and confirming asthma diagnosis, as well as covering the most appropriate treatments and interventions.
It also reinforced previous messages that “remain vital”, he said, such as providing written action plans and only prescribing inhalers after patients demonstrated adequate technique following training.
He said: “We do hope that health, social care and education professionals can work together with people with asthma in using these guidelines to provide the best care possible.”
Sara Twaddle, director of evidence for Healthcare Improvement Scotland, of which SIGN is a part, added: “We urge clinicians across the UK to refer to this guideline for diagnosis and treatment.”
The Association of Respiratory Nurse Specialists and Royal College of Nursing both welcomed the updated guidelines.
ARNS chair Matt Hodson said: “We hope that this publication will again put a much needed focus on asthma care. Asthma still remains a serious life threatening condition with more than five million people affected in the UK.
“I encourage nurses and other healthcare professionals to familiarise themselves with this guidance and seek additional support or further education on asthma to enable them to give every patient the very best care,” he said.
Amanda Cheesley, the RCN’s professional lead for long-term conditions and end of life care, said: “These guidelines recognise that one size does not fit all, and good testing, advice and drug treatments must be available to everyone, even if they consider their condition mild.
“With the number of deaths rising, and concerns about the effects of air pollution, asthma must no longer be overlooked, and the doctors and nurses who treat it must have all the time and tools to treat it with the seriousness it deserves,” she said.
She added: “Nurses in particular can have a vital role in helping people to manage their condition, keep well and avoid hospital admissions. It is imperative that we have enough nurses with the right training to ensure that these guidelines are reflected in the experience of patients.”
Sonia Munde, Asthma UK’s head of helpline and clinical nurse manager, said: “Too often, when their symptoms get worse, people with asthma simply increase the amount they use their reliever inhaler to keep their symptoms under control.
Nurses urged to use new national asthma guidelines
“The guidance published today encourages clinicians to identify people with asthma who have become over reliant on their short-term reliever inhalers. This is a critical step to ensuring that people with asthma receive the treatment they need, rather than continuing to mask their worsening symptoms through increased use of their reliever inhaler,” she said.
“We want to see healthcare professionals putting this guidance into immediate effect by using the information already on their practice computer systems to audit their asthma patients and identify those at greatest risk,” she added.
- The updated guidance, plus a quick reference guide, and previous versions can be viewed on the BTS website