New asthma guidance places emphasis on preventing attacks

The need for a stronger focus on preventing asthma attacks is among key features of the updated guidelines produced by the British Thoracic Society and Scottish Intercollegiate Guidelines Network.

“The advice on how to predict an individual’s future asthma attack risk will support the NHS”

John White

Other core recommendations include the need to refer people whose asthma cannot be controlled using standard methods to specialist care.

The guidance includes new or updated advice on many aspects of asthma care including monitoring the condition, drug treatments and treatments that do not involve drugs, and environmental issues such as the impact of different types of inhalers on global warming.

New recommendations include the fact every regular asthma check should include a risk assessment for future asthma attacks alongside standard breathing tests and investigations.

Health professionals should look at key factors that could put people at “greatly increased risk” of an asthma attack such as a history of previous attacks, whether a patient is currently struggling to control their asthma and over-use of medication such as inhalers to tackle symptoms.

Under the guidance, nurses and others should also be aware of factors that can “moderately” or “slightly” increase the risk of attacks.

In children, this could include having allergies on top of asthma, being obese and exposure to cigarette smoke.

In adults, factors that may elevate risk somewhat include old age, being female, reduced lung function, obesity, smoking and depression.

“We do hope that the guidelines will help a range of health and care professionals”

John White

The guidance underlines the importance of asthma reviews taking place at least once a year when future asthma attack risk, current symptoms and treatment should all be assessed.

The section on monitoring asthma has been completely revised and also advises against the routine use of certain tests.

For example, the guidelines do not recommend routine use of FeNO testing in adults or children except in specialist asthma clinics.

The test, which measures levels of fractional exhaled nitric oxide, may suggest inflammation of the airways.

This can support but does not prove a diagnosis of asthma, according to the guidance, which said there was not enough evidence to show it helped improve asthma control.

The guidance also advises against using a sputum eosinophilia test – which assesses “biomarkers” of inflammation in patient’s spit – in order to monitor asthma in children or adults.

The revised guidelines re-emphasise the need for personalised action plans for asthma patients and stress the need to address inequalities by reaching out to those less likely to already be accessing support, such as vulnerable groups and people from poorer backgrounds.

When it comes to drug treatment for asthma, health professionals drawing up action plans for adults are advised to consider quadrupling the level of inhaler medication at the onset of an attack.

If necessary this enhanced level of inhaled corticosteroids can be continued for up to 14 days in order to head off the attack and avoid the need for ongoing oral steroids, according to the guidance.

However, it stresses clinicians needed to weigh up the benefits and risks of this strategy for people already on a high dose of inhaled corticosteroids.

The guidance goes on to advise on the next steps in asthma care if inhalers are not proving to be effective but also stresses that for a small number of patients standard therapies will not work.

It now recommends that all patients whose asthma is not adequately controlled using recommended initial and add-on treatments should be referred to specialist care.

The guidance advises on non-drug treatments, such as breathing exercises that can be used in conjunction with medication to reduce symptoms and improve patients’ quality of life.

Meanwhile, it states people with asthma who smoke should be warned of the dangers and offered support to quit. In particular parents or carers of children with asthma should be informed about the risks of exposure to second-hand smoke.

“The guideline also underlines previous messages that are pivotal to combating asthma”

John White

Dr John White, aonsultant respiratory physician and British Thoracic Society member, who co-chaired the group that developed the updated guidelines, said a key goal was to deliver more personalised care that helped people manage their asthma more effectively.

“The advice on how to predict an individual’s future asthma attack risk will support the NHS to identify those most likely to face potentially life-threatening attacks and deliver specific strategies to prevent this,” he said.

He said this would support the NHS Long Term Plan’s aim to reduce health inequalities and variations in care across different communities and parts of the country.

“The guideline also underlines previous messages that are pivotal to combating asthma, for example, it is critical that all asthma patients have a personalised action plan and their symptoms, medication and inhaler technique are monitored on an appropriate basis,” said Dr White, who works at York NHS Foundation Trust.

“We do hope that the guidelines will help a range of health and care professionals to work together with people with asthma to provide the best possible treatment and care,” he added.

At the same time as the document was launched, it was revealed that future UK-wide guidance for the diagnosis and management of chronic asthma in adults, young people and children will be jointly produced by the British Thoracic Society, Scottish Intercollegiate Guidelines Network and the National Institute for Health and Care Excellence (NICE).

Together, the three bodies will work on developing a range of guidance and resources to create a new “asthma pathway”, it was announced.