Asthma (adults)

Asthma guidelines

The following page focuses on the diagnosis and management of adults with chronic asthma.

BTS/SIGN Asthma guidelines 

BTS/SIGN Guidelines (1)were last updated in July 2019.

NICE Asthma guidelines 

Clinical Knowledge Summaries (2) has a summary of NICE Guidelines which were last updated in April 2022. 

Air pollution and Health in Primary Care

Please see the Remedy page on Air pollution and health which has information for professionals and also a patient information leaflet.

Acute asthma in adults

See CKS guidelines on acute exacerbation of asthma. Also summarised in the BNF guidelines.

Asthma in children

For advice on management of asthma in children please see the following pages:

• Paediatric Asthma (acute) including wheeze
• Asthma in children (chronic)

Diagnosis

NICE guidelines advise that asthma should be considered in patients with the presence of more than one variable symptom of wheeze, cough , breathlessness and chest tightness.

Diagnosis should be confirmed by one or more of the following methods which are summarised below (see Clinical Knowledge Summaries for full guidelines):

Fractional exhaled nitrous oxide (FeNO) testing - if available. Should be used where possible to confirm eosinophilic airway inflammation to support an asthma diagnosis in people aged 17 years and older and can also be used in children where diagnostic uncertainty (see CKS). This test may be now available in some primary care practices but there is currently no routine access via secondary care referral in BNSSG. 

Spirometry - should be offered to all symptomatic people over the age of five years. The FEV₁/FVC ratio is normally greater than 70%. Any value less than this suggests airflow limitation. However, a normal spirometry result when the person is asymptomatic does not rule out asthma. There are currently difficulties in performing spirometry in primary care. See Spirometry page for updates.

Bronchodilator reversibility (BDR) - can also help to confirm a diagnosis of asthma, and should be offered, where available, to adults (aged 17 and over), and considered in children and young people (aged 5 to 16 years) with obstructive spirometry (FEV1/FVC ratio less than 70%):

• In adults, an improvement in FEV₁ of 12% or more, together with an increase in volume of at least 200 mL in response to beta-2 agonists or corticosteroids is regarded as a positive result. An improvement of greater than 400 mL in FEV₁ is strongly suggestive of asthma.
• In children, an improvement in FEV₁ of 12% or more is regarded as a positive result.

Variable peak expiratory flow (PEF) readings - can support an asthma diagnosis if there is diagnostic uncertainty. A value of more than 20% variability after monitoring at least twice daily for 2-4 weeks is regarded as a positive result (3) Peak flow test - NHS (www.nhs.uk) - includes link to Peak Flow Diary from Asthma and Lung UK.

QOF indicator (AST006). QOF requires that an initial diagnosis of asthma in a patient aged 6 and over should be confirmed by recording of spirometry and one other objective test (FeNO or reversibility or variability) between 3 months before and 6 months after diagnosis.

Red Flags

Red-flag signs and symptoms in adults that suggest an alternative diagnosis and should prompt immediate referral to a respiratory physician for additional investigations include (2):

• Prominent systemic features (such as myalgia, fever, and weight loss).
• Unexpected clinical findings (such as crackles, finger clubbing, cyanosis, evidence of cardiac disease, monophonic wheeze, or stridor).
• Persistent, non-variable breathlessness.
• Chronic sputum production.
• Unexplained restrictive spirometry.
• Chest X-ray shadowing.
• Marked blood eosinophilia.

Prescribing

BNSSG prescribing guidelines

There are local Asthma Prescribing Guidelines for Adults on the BNSSG formulary which give advice on management of chronic asthma and include key principles of prescribing and patient monitoring.

Emergency Steroid Card Update (28.5.21)

The BNSSG Adult Asthma guidelines have been updated to include information regarding the introduction of the Steroid Emergency Card issued by the joint National Patient Safety Alert to support early recognition and treatment of adrenal crisis in adults. To support consistent implementation, the Society for Endocrinology, the Specialist Pharmacy Service (SPS), and the British Association of Dermatology (BAD) have produced more detailed guidance. Table 3 in this guidance relates to which inhaled glucocorticoid doses should be issued with an Emergency Steroid Card. These inhalers have now been highlighted with a ▲ symbol on the BNSSG asthma guidelines to help quickly identify whether an Emergency Steroid Card is required.

Environmental Considerations

Metered-dose inhalers (MDIs) contribute to an estimated 3.9% of the carbon footprint of the NHS. The BNSSG respiratory system formulary page has information about the environmental impact of inhalers and can help inform choices about which inhalers should be used.

Please see the Planetary Health and Sustainable Practice guidelinesfor further information.

Monitoring

Patients with asthma should have an annual review that includes (7):

• an assessment of asthma control using a validated asthma control questionniare (5)
• a record of the number of exacerbations
• an assessment of inhaler technique
• a written personalised action plan (6)
• a record of smoking status (either personal or second hand)

Referral

The BNSSG asthma guidelines advise referral in to secondary care in the following scenarios:

• If there is diagnostic uncertainty
• Admission to hospital for poorly controlled asthma
• Asthma remains uncontrolled after 3 months following treatment optimisation
• There is complicating multi-morbidity
• Consideration of monoclonal antibody therapy
• Patient has complicating lung conditions (e.g. vasculitis, allergic bronchopulmonary aspergillosis or bronchiectasis)
• If despite medication being optimised, is still requiring ≥2 courses of oral corticosteroids in 12 months

Secondary care clinics are available at UHBW, NBT and RUH (Bath) via e-RS.

There are also Respiratory HOT clinics available at UHBW and NBT for patients where more urgent assessment of a patient is needed.

Steroid Sick Day Rules

Patients on long term steroid medication may be at risk of adrenal crisis. Please see the following guidelines on management:

• Adrenal crisis | Society for Endocrinology - Advice about managment of adrenal crisis. A NHS steroid card can also be downloaded from this site.
• BNSSG Sick Day Rules guidelines are available in the Formulary section.

Resources

(1) BTS/SIGN Guidelines 

(2) Asthma - Clinical Knowledge Summaries

(3) Peak flow test - NHS (www.nhs.uk)

(4) Asthma + Lung UK | Asthma home

(5) Asthma Control Test

(6) Asthma action plans | Asthma + Lung UK

(7) MidYorksNHS - YouTube - video guide to self management of asthma in 11 different languages.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance 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, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.