Asthma treatment guidance is essential - but only if it’s not contradictory, explains Natalie Harper, the respiratory advanced nurse practitioner at Dorset County Hospital.
To paraphrase the Spice Girls “two really should have become one”. What are we talking about; it is of course the dilemma of BTS/SIGN versus NICE guidance on asthma for both diagnosis and chronic management.
NICE published their guidance on the 29th November whilst BTS/SIGN updated theirs in September of 2016.
Wouldn’t it be good, I hear you say, to have more guidance to help us in clinical practice and in principle the answer may be yes, but in practice it’s not helpful when guidance is contradictory.
“This confusion could lead to decisions that are detrimental to patient care”
Differences begin with how we diagnose asthma, with NICE suggesting that the first choice for adults should be FeNO whereas BTS/SIGN still state spirometry is the gold standard and there is also conflicting advice on pharmacological treatment.
Position statements from organisations such as the Primary Care Respiratory Society (PCRS) and Asthma UK have been very helpful in aiding us to understand the differences between the documents, but do not solve the problem that two sets of guidance will inevitably cause confusion for clinicians who do not regularly management people with asthma. This confusion could lead to decisions that are detrimental to patient care.
No one would argue that the process up until this point has been perfect.
Of course, any guidance that improves either the diagnostic process or the management of patients is welcomed, but we have to ask the question why both BTS/SIGN and NICE did not all gather around a table and produce a comprehensive one-stop-shop for any clinician to refer to.
“We should never forget to use our judgements and clinical expertise.”
Unfortunately, although this was suggested on many occasions during the writing and consultation process this did not occur and we are where we are. The question we now have to consider is how to deal with these two sets of guidelines in practice?
Whatever your stance on the guidelines and when and how to use them, our main focus now has to be on our patients.
We must ensure that our patients are all treated as individuals and that we assess them holistically with a thorough, comprehensive history as well as objective tests to support the diagnosis of asthma and tailor their treatment to meet their needs.
This could be done by referring to both sets of guidance and not just one. It would also be advisable and good practice to seek opinion from a specialist or even refer onwards if despite following guidelines your patients are not responding to the treatment plan you have them on.
We are all trained clinicians and should remember that at the end of the day guidelines are just guidelines and we should never forget to use our judgements and clinical expertise.
Natalie Harper, respiratory advanced nurse practitioner, Dorset County Hospital Foundation Trust & Asthma lead for ARNS