Asthma (adults)

Asthma guidelines

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

Updates

April 2025 MHRA Guidance on use of SABA : Short-acting beta 2 agonists (SABA) (salbutamol and terbutaline): reminder of the risks from overuse in asthma and to be aware of changes in the SABA prescribing guidelines - GOV.UK. Healthcare professionals should be aware of the change in guidance that no longer recommends prescribing SABA without an inhaled corticosteroid.

BTS/NICE/SIGN Asthma guidelines 

Overview | Asthma pathway (BTS, NICE, SIGN) | Guidance | NICE (1)

Clinical Knowledge Summaries Asthma guidelines 

Clinical Knowledge Summaries (2) has a summary of NICE Guidelines. 

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.

An objective test must be used to support a clinical suspicion of asthma. See NG245 Asthma: Algorithm A 27/11/2024

Access to spirometry should be available over the course of 24/25 in general practice.   There is some access to FeNO in general practice

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 5 years and older. This test may be available in some primary care practices. There is currently no routine access via secondary care referral in BNSSG. See FeNO - Help with your business case | Primary Care Respiratory Society to help construct your business case to enable sustainable adoption of FeNO in your practice.

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. Access to spirometry in general practice is still patchy but is part of the supplementary services basket so should be more widely available over the course of 2024/25. See also Spirometry page for updates.

Bronchodilator reversibility (BDR) - If asthma is not confirmed by eosinophil count or FeNO level, measure BDR with spirometry. Diagnose asthma if the FEV₁ increase is 12% or more and 200 ml or more from the pre-bronchodilator measurement (or if the FEV₁ increase is 10% or more of the predicted normal FEV₁). 

Variable peak expiratory flow (PEF) readings - If spirometry is not available or it is delayed, measure peak expiratory flow (PEF) twice daily for 2 weeks. Diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more.  Peak flow test - NHS (www.nhs.uk) - includes link to Peak Flow Diary from Asthma and Lung UK.

QOF indicator 2025/26 (AST012). 'The percentage of patients with a new diagnosis of asthma on or after 1 April 2025 with a record of an objective test between 3 months before or 3 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. All moderate-dose MART inhalers on the new BNSSG asthma guideline should be issued with an Emergency Steroid Card.

(Please also see the Managing glucocorticoid withdrawal (8) page for advice on managing withdrawal from glucocorticoids and how to avoid and manage glucocorticoid withdrawal syndrome.)

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:

• 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:

• Diagnostic uncertainty
• Exacerbation requiring hospital admission in the last 12 months
• Asthma remains uncontrolled after 3 months following treatment optimisation
• There is complicating multi-morbidity
• If ≥2 courses of oral corticosteroids in 12 months, despite optimising medication

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) Overview | Asthma pathway (BTS, NICE, SIGN) | Guidance | NICE

(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.

(8) Managing glucocorticoid withdrawal - Remedy page.

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.