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Primary Care Respiratory

Update

Asthma Guidelines in Practice:

a PCRS consensus

Asthma Guidelines in Practice is a PCRS consensus-based article to provide clarity on aspects of

diagnosis, management and monitoring of asthma that are uncertain due to differences between

current national guidelines. The article has been written by Luke Daines (GP and Academic Clinical

Fellow, University of Edinburgh) in conjunction with GP colleagues Noel Baxter, Kevin Gruffydd Jones,

Steve Holmes, Duncan Keeley, nurse colleagues Val Gerrard and Carol Stonham and pharmacist

Deborah Leese. It is based on the recently published PCRS briefing paper (see https://www.pcrs-

uk.org/resource/btssign-british-asthma-guideline-update-july-2019).

Introduction

Asthma is a chronic respiratory condition affecting an estimated 5.4

million people in the UK.

Individuals with asthma suffer from wheeze,

shortness of breath, cough and chest tightness, limiting everyday

activities and fulfilment of roles at home and work.

In the UK, public sector spending for asthma exceeds £1.1 billion

each year, with the majority of costs (74%) arising from prescriptions

and the estimated 6.4 million primary care consultations that occur

each year.

Evidence-based management can maintain good day-

to-day control for most people with asthma and substantially reduce

the risk of asthma attacks.

However, knowing which evidence-based strategies to imple-

ment has been made confusing by the presence of multiple guide-

lines for asthma care. In the UK, the National Institute for Health and

Care Excellence (NICE) guideline (published 2017) concentrates on

diagnosis, monitoring and chronic management and incorporates

economic evaluation with interpretation from a multidisciplinary

guideline group.

The British Thoracic Society/Scottish Intercollegiate

Guideline Network (BTS/SIGN) guideline (updated 2019) covers all

aspects of asthma care and is led by a multidisciplinary clinical

group.

Whilst the evidence considered by the NICE and BTS/SIGN

guideline groups is broadly the same, the methodology used to pro-

duce the guidelines is different, and has resulted in different recom-

mendations.

Thankfully, following calls from PCRS (amongst others),

an agreement between BTS/SIGN and NICE has been reached,

meaning that future asthma guidelines will be jointly produced.

Asthma diagnosis

• Following a structured clinical assessment, weigh up the prob-

ability that an individual has asthma: use a monitored trial of

treatment if asthma is highly probable; conduct further inves-

tigations (spirometry, peak expiratory flow variability) if an

individual is at intermediate probability.

• Achieving an accurate diagnosis may take time and may

require the comparison of repeated measurements and clini-

cal assessments

• Objective evidence to support an asthma diagnosis should

be sought however likely the diagnosis appears to be.

• The basis for asthma diagnosis should be clearly documented

in medical records.

Asthma management

• Regular inhaled corticosteroid (ICS) is regarded as the foun-

dation of asthma pharmacological treatment.

• When prescribing ICS for children, the starting dose is usually

a ‘very low dose’ and the highest dose is classed as a

‘medium dose’.

• In line with the NICE recommendation, PCRS suggests a trial

of leukotriene receptor antagonists (LTRA) as the first line

add-on therapy to ICS with careful review.

• Maintenance and Reliever Therapy (MART) may be consid-

ered in adults who have a history of asthma attacks despite

medium dose ICS or ICS/LABA (long-acting beta-agonist).

Asthma monitoring

• A regular review of individuals with asthma provides the

chance to assess current symptom control and consider the

future risk of an asthma attack.

• Record asthma control, a measure of lung function, asthma

attacks, oral corticosteroids, absence from work/school and

smoking status at each review.

• Identify the future risk of an asthma attack in all individuals

with asthma: previous asthma attack, poor asthma control

and short-acting beta agonist (SABA) over-reliance increase

the risk substantially.

• Recognise individuals with severe asthma and refer for

specialist review

Key points

Having two UK asthma guidelines has led to conflicting advice and is confusing for clinicians. This article aims to bring

clarity on a number of issues and has been updated in line with the recently released BTS/SIGN 2019 guideline.

OCT+NOV 2019 issue.qxp_Layout 1 18/12/2019 12:30 Page 36

Primary Care Respiratory

Update

Clinical clue

Predominant cough with no lung function abnormality

Prominent dizziness, light-headedness or peripheral tingling

Recurrent severe ‘asthma attacks’ without objective evidence to confirm

Predominant nasal symptoms without lung function abnormality

Postural and food-related symptoms, predominant cough

Orthopnoea, paroxysmal nocturnal dyspnoea, peripheral oedema,

pre-existing cardiac disease

Crackles on auscultation

Significant smoking history (ie, over 30 pack-years), age of onset over 35 years

Chronic productive cough in the absence of wheeze or breathlessness

New onset in smoker, systemic symptoms, weight loss, haemoptysis

*May also be associated with non-obstructive spirometry.

Table 1:

Clinical features to suggest an alternative diagnosis to asthma in adults

Possible diagnosis

Chronic cough syndromes; pertussis

Dysfunctional breathing

Vocal cord dysfunction

Rhinitis

Gastro-oesophageal reflux disease

Cardiac failure

Pulmonary fibrosis

COPD

Bronchiectasis*, inhaled foreign body*, obliterative

bronchiolitis, large airway stenosis

Lung cancer*, sarcoidosis*

No airflow obstruction

With airflow obstruction

Rationale for PCRS consensus

We look forward to the joint guideline but, in the meantime, we want

to support primary care clinicians who are facing uncertainty due to

conflicting recommendations between the national guidelines. This

article, developed by PCRS members, aims to provide a clear, con-

cise and pragmatic view on the diagnosis, management and moni-

toring of asthma in primary care. It does not attempt to reproduce all

the details contained in each guideline, but instead focuses on the

areas that vary substantially between NICE and BTS/SIGN versions,

offering a workable solution.

Recommendations

Asthma diagnosis

Achieving a clear consensus for the best diagnostic strategy for

asthma is a particular challenge as, on top of economic and imple-

mentation considerations,

the definition of asthma is also evolving.

Traditionally a diagnosis of asthma was based on symptoms and

demonstration of variable obstructive airflow on lung function

testing.

2,7

Yet, more recent definitions of asthma include airway

inflammation and airway hyper-responsiveness to incorporate the

subtypes of asthma identified through recent research on genetics

and pathophysiological mechanisms.

This changing understanding

of asthma has delivered new ways in which to test and treat for

asthma subtypes and may in the future lead to asthma being ‘de-

constructed’ into distinct ‘treatable traits’.

7,8

Until then, a clear prag-

matic way forward is needed to guide clinicians in non-specialist

settings, where most asthma cases are diagnosed.

There is no definitive gold standard test which can categorically

confirm or refute the diagnosis of asthma. Therefore, the diagnosis

of asthma is made clinically following a structured clinical assess-

ment; a careful integration of evidence from a wide variety of

sources.

2,4

Key components of a structured clinical assessment in-

clude a detailed history, examination, review of the patient’s clinical

records and previously completed investigation results (for example,

peak expiratory flow, spirometry, blood eosinophils from a full blood

count).

When taking a history, ask about wheeze, shortness of breath,

cough and chest tightness, the most suggestive symptoms of

asthma.

2,4

Symptoms usually occur in episodes with no (or minimal)

symptoms between episodes.

Combinations of symptoms (partic-

ularly wheeze, cough and shortness of breath) occurring in episodes

are more useful for identifying asthma than individual symptoms, par-

ticularly in children.

Ask about variability in symptoms through the

day and between seasons. Clarify any triggers that provoke or

worsen symptoms

and, in adults, check specifically for work-related

factors. Remember to enquire about personal or family history of

other atopic conditions such as allergic rhinitis or eczema.

Informa-

tion from the patient clinical record, including previous respiratory

illnesses, treatments and responses and previous examination

findings (particularly wheeze heard on chest auscultation by a health

professional), can further build the clinical picture.

On auscultation of the chest, asthmatic wheeze tends to be end-

expiratory, scattered and polyphonic. Consider alternative diagnoses

if wheeze is never heard during symptomatic episodes (Table 1).

Remember that respiratory examination may well be normal in an

asymptomatic individual, so it is important not to exclude asthma

solely on examination findings.

In addition to a respiratory examina-

tion, check the throat for enlarged tonsils and look out for other signs

of atopic disease such as eczema or rhinitis.

Following a structured clinical assessment, the BTS/SIGN guide-

This table is reproduced from SIGN 158 (British guideline on the management of asthma) by kind permission of the Scottish Intercollegiate Guidelines Network

OCT+NOV 2019 issue.qxp_Layout 1 18/12/2019 12:30 Page 37

line recommends weighing up the probability that the individual has

asthma based on three categories: high, intermediate and low.

If a patient (whether adult or child) has all of the following typical

clinical features, they are considered to have a high probability of

asthma:

● Recurrent episodes of symptoms (‘attacks’)

● Wheeze confirmed by a healthcare professional

● A personal or family history of atopy

● A past record of variable airflow obstruction

● No features to suggest an alternative diagnosis (Table 1).

If there is any doubt, the diagnosis should be considered as inter-

mediate probability. Adults and children who have none of the typical

features of asthma or whose symptoms are suggestive of an alter-

native diagnosis have a low probability of asthma.

The probability of

asthma informs the next steps in the diagnostic work-up, as demon-

strated in Figure 1.

Even with a careful structured clinical assessment and diagnostic

work-up, the diagnosis of asthma can be challenging, particularly

due to the variable nature of symptoms and lung function over time

and the heterogeneity of presentation. Primary care is ideally placed

to collect, record and appraise the information required to make an

asthma diagnosis and provide continuity to allow repeated assess-

ments over time so that treatment response and natural variation can

be evaluated. Consequently, a diagnostic strategy based on repeated

clinical assessments, supported by objective clinical tests (including

peak expiratory flow monitoring) and sensitively using trials of initiating

and discontinuing therapy is recommended as a practical way

forward.

It is important to refer to specialist services in cases of doubt or

difficulty (Table 2).

Whilst investigating asthma, and until a diagnosis is confirmed,

use the code ‘suspected asthma’.

2,4

Once a diagnosis of asthma has

been made, record the basis for the decision in a single entry in the

person’s medical records, alongside the coded diagnostic entry. The

diagnosis of asthma should ideally be revisited and checked regularly

– especially when you first take over the care of a patient thought to

Primary Care Respiratory

Update

Figure 1 - Diagnostic algorithm for individuals presenting with symptoms suggestive of asthma

†

In children under 5 years and others unable to undertake spirometry in whom there is a high or intermediate probability of asthma, the options are

monitored initiation of treatment or watchful waiting according to the assessed probability of asthma

Presentation with respiratory symptoms: wheeze, cough, breathlessness, chest tightness

†

Adjust maintenance

dose. Provide self-

management. Arrange

on-going review

High probability of

asthma

Code as:

suspected asthma

Initiation of treatment

Good response

Other diagnosis

confirmed

Intermediate probability of asthma

Test for airway obstruction

spirometry + bronchodilator reversibility

Options for investigations are:

Test for variability

●

Reversibility

●

PEF charting

●

Challenge tests

Test for eosinophilic

inflammation or atopy:

●

FeNO

●

Blood eosinophils

●

Skin-prick test, IgE

Low probability of

asthma

Assess response

objectively

(lung function/validated

symptom score)

Poor

response

Investigate/treat for

other more likely

diagnosis

Other diagnosis

unlikely

Structured clinical assessment (from history and examination of previous medical records) look for:

●

Recurrent episodes of symptoms

●

Symptom variability

●

Absence of symptoms of alternative diagnosis

●

Recorded observation of wheeze

●

Personal history of atopy

●

Historical record of variable PEF or FEV

Poor

response

Suspected asthma:

Watchful waiting

(if asymptomatic) or

Commence treatment

assess response objec

tively

Good

response

Asthma

This figure is reproduced from SIGN 158 (British guideline on the management of asthma) by kind permission of the Scottish Intercollegiate Guidelines Network

OCT+NOV 2019 issue.qxp_Layout 1 18/12/2019 12:30 Page 38

Primary Care Respiratory

Update

have asthma. Good documentation is strongly recommended as the

variable nature of asthma can lead to individuals experiencing long

periods without symptoms, leading patients and clinicians to ques-

tion the original diagnosis.

Objective tests

Objective tests should be done in all patients old enough to perform

them, as part of an initial diagnostic assessment to support a confi-

dent diagnosis of asthma. Increasing the quality and availability of

objective testing across healthcare is an important policy priority.

Understanding that each diagnostic test available for asthma has

strengths and limitations is therefore valuable in order to use tests

most effectively to build up sufficient evidence so that a differential

diagnosis can be confirmed or refuted correctly.

Tests for demonstrating variability in airflow obstruction

A defining feature of asthma is variable airflow obstruction caused

by airway bronchoconstriction. Yet, demonstrating variable airflow

obstruction can be a challenge as airway physiology may be normal

when an individual with asthma is asymptomatic. This is reflected in

estimates for the negative predictive value of spirometry in adults and

children which varies between 18% and 54%,

indicating that more

than half of patients who have a negative result (non-obstructive

spirometry) will have asthma.

Therefore, relying on objective tests of airflow obstruction com-

pleted only at a single point of time risks missing asthma, particularly

if the patient is asymptomatic at the time of testing. Instead, testing

for variable airflow obstruction should be repeated over time.

In primary care, peak expiratory flow monitoring and spirometry

with bronchodilator reversibility testing are recommended mea-

sures to demonstrate variable airflow obstruction. When interpret-

ing spirometry, BTS/SIGN recommend the use of lower limit of

normal for FEV

/FVC ratio (instead of the fixed ratio of 70%) in

order to avoid the substantial under-diagnosis in children and over-

diagnosis of obstruction in older people.

2,5

Spirometry is a useful

diagnostic test in all patients with suspected asthma, yet if

resources are limited, prioritising those individuals who are consid-

ered intermediate probability is likely to be the best strategy.

Although sometimes undervalued, peak expiratory flow monitoring

can provide useful measurements. The value of peak expiratory

flow monitoring as an important initial test in the assessment of

asthma was discussed in the Spring 2017 edition of Primary Care

Respiratory Update (see https://pcrs-uk.org/peak-flow-and-mi-

crospirometry-support-diagnosis).

Tests for demonstrating eosinophilic inflammation

A positive fractional exhaled nitric oxide (FeNO) test indicates the

presence of eosinophilic inflammation, providing supporting (rather

than conclusive) evidence for an asthma diagnosis. A systematic re-

view of the accuracy of FeNO in diagnosing asthma in adults and

children reported a pooled sensitivity of 65% and specificity of 82%,

indicating that FeNO has a higher potential for ruling in – as opposed

to ruling out – the diagnosis of asthma.

In adults, a FeNO reading

of 40 ppb or more should be regarded as a positive test.

2,4

Accurate

Adults

Diagnosis unclear

Suspected occupational asthma (symptoms that improve when patient

is not at work, adult-onset asthma and workers in high-risk occupations)

Poor response to asthma treatment

Severe/life-threatening asthma attack

Prominent systemic features (myalgia, fever, weight loss)

Unexpected clinical findings (eg crackles, clubbing, cyanosis, cardiac

disease, monophonic wheeze or stridor)

Persistent non-variable breathlessness

Chronic sputum production

Unexplained restrictive spirometry

Chest X-ray shadowing

Marked blood eosinophilia

Table 2 Reasons for specialist referral

Children

Diagnosis unclear

Poor response to monitored initiation of asthma treatment

Severe/life-threatening asthma attack

Failure to thrive

Unexplained clinical findings (eg focal signs, abnormal

voice or cry, dysphagia, inspiratory stridor)

Symptoms present from birth or perinatal lung problem

Excessive vomiting or posseting

Severe upper respiratory tract infection

Persistent wet or productive cough

Family history of unusual chest disease

Nasal polyps

Referral for tests not available in primary care

‘Red flags’ and indicators of other diagnoses

Patient or parental anxiety or need for reassurance

This table is reproduced from SIGN 158 (British guideline on the management of asthma) by kind permission of the Scottish Intercollegiate Guidelines Network

OCT+NOV 2019 issue.qxp_Layout 1 18/12/2019 12:30 Page 39

interpretation of a FeNO result requires an understanding of the po-

tential confounding factors that may produce false positive and false

negative results (Box 1).

NICE (2017) recommendations for the role of FeNO in the diag-

nosis of asthma are different from those advocated by BTS/SIGN.

2,4

Given the limitations of FeNO, a central role in the diagnostic work-

up of all people suspected of asthma, as advocated by NICE, seems

over-emphasised and may lead to unintended consequences.

Currently, FeNO is not widely available in UK primary care so, if FeNO

is perceived as a required test, referrals to secondary care may

increase, adding to the workload in specialist settings and potentially

de-skilling clinicians in primary care. Cost may be a barrier for indi-

vidual practices adopting FeNO, as ongoing consumables are

required in addition to an initial investment. A future solution might

be for practices to pool resources and develop a locality-based

diagnostic service, as successfully implemented in the Netherlands

and currently being trialled in the UK.

4,15

Despite these concerns, there are clear benefits to be gained

from using FeNO, which could be realised if appropriately imple-

mented. For instance, if an individual has an intermediate probability

of asthma following a structured clinical assessment, a positive FeNO

test increases the probability of asthma, providing further supporting

evidence to confirm or refute a diagnosis. Therefore, in primary care,

PCRS recommend using FeNO as an optional investigation to test

for eosinophilic inflammation in individuals where diagnostic uncer-

tainty remains. Routine use of FeNO testing in adults and children is

not recommended except in specialist respiratory clinics. The

PCRS position statement on FeNO testing is available from

https://www.pcrs-uk.org/resource/feno-testing-asthma-diagnosis.

Diagnosis in children

Confirmation of variable airflow obstruction by objective demonstra-

tion of peak flow monitoring or spirometry with reversibility is desirable

in children old enough to perform these tests. However, the use of

spirometry is not well established in children in primary care and

additional training may be needed to ensure accurate results. If FeNO

is used in children aged 5–16 years, a result of 35 ppb or more is

regarded as a positive test.

2,4

In children under 5 years of age, a diagnosis of asthma is based

on establishing the probability of asthma after an initial structured

clinical assessment.

If the probability of asthma is high, a trial of

an inhaled corticosteroid (ICS) using a dosage of 400 μg/day

beclomethasone or equivalent may be considered.

2,16

If a child is

started on a trial of treatment, it should last for 6–8 weeks and be

stopped at the end of the trial.

2,16

If the child has had no response to

treatment and the medication has been taken, the diagnosis of

asthma is unlikely.

If symptoms improve with ICS but recur when

stopped, then settle again with reintroduction of treatment, a diag-

nosis of asthma can be made.

Where diagnostic doubt persists,

referral for specialist assessment should be considered (Table 2).

Asthma management

Management of asthma should be patient-centred, encouraging and

supporting self-management and making treatment decisions in

partnership with the individual. This should include promoting non-

pharmacological approaches including weight control, encouraging

physical activity and addressing tobacco dependency. Supported

self-management, which includes the provision of an asthma action

plan, improves individual asthma control whilst reducing visits to

unscheduled care.

ICS are regarded as the foundation of asthma pharmacological

treatment.

2,5

Therefore, a regular (low-dose) ICS with a short-acting

beta-agonist (SABA) as required is the recommended first-line main-

tenance treatment for adults. In children, once a diagnosis has been

made, the starting dose of ICS is ‘very low dose’ (200 μg/day

beclomethasone or equivalent). If the dose needs to be increased,

be aware that ‘medium dose’ (800 μg/day beclomethasone or equiv-

alent) represents a level of treatment to be used only if referring to

specialist care.

If asthma is well controlled there should be little or no need for

SABA.

Three or more doses of SABA per week may indicate poor

asthma control and a need to move up treatment. Over-reliance on

SABAs is well established as a risk factor for fatal asthma

(see

Monitoring section for further details), therefore anyone prescribed

more than one SABA a month should have their asthma urgently

assessed.

Prescribing inhalers by brand name and device ensures that

patients receive the inhaler that the prescriber intends for them.

Prescribing a generic inhaler or not specifying the device should be

avoided as it may result in a patient receiving an inhaler they have

not been taught to use. If prescribing a metered dose inhaler (MDI),

remember to issue with a spacer to increase the efficacy of drug

delivery.

A further consideration when prescribing inhalers is environmen-

tal impact. MDIs have a higher global warming potential than dry

powder inhalers (DPIs),

so if there is no obvious clinical reason to

Primary Care Respiratory

Update

Box 1 Factors that may confound the accuracy of

fractional exhaled nitric oxide (FeNO) in

making an asthma diagnosis

2,13,14

• Increased levels in men, tall people and those with a diet high

in nitrates (eg, spinach, broccoli)

• Increased levels in individuals with allergic rhinitis exposed

to an allergen (even without respiratory symptoms)

• Increased levels in those with rhinovirus infection (inconsis-

tent effect in those with asthma)

• Lower levels observed in children (N.B. accordingly a lower

reference range is used)

• Reduced levels in cigarette smokers

• Reduced levels by inhaled or oral steroids

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Primary Care Respiratory

Update

choose between inhaler types, opt for the lower carbon footprint

DPIs. Remember, however, that any decisions about inhaler choice

should be made on an individual basis between clinicians and patients,

so PCRS warn against any ‘blanket switching’ from MDIs to DPIs.

Add-on therapies

The choice of initial add-on treatment to low-dose ICS remains a

contentious issue and, therefore, was one of the key questions ad-

dressed by the BTS/SIGN 2019 update.

To understand why the two

guidelines continue to offer different advice, remember that the NICE

multidisciplinary guideline group considers an economic evaluation

in addition to clinical evidence

4,5

whilst BTS/SIGN make recommen-

dations based purely on a critical appraisal of the literature.

2,5

Adding long-acting beta-agonists (LABA) to ICS alone improves

symptoms, lung function and decreases asthma attacks in adults

and children.

In comparison to leukotriene receptor antagonists

(LTRA), LABA are more effective in reducing the number of exacer-

bations,

leading BTS/SIGN to recommend LABA as first-line add-

on treatment in adults.

If prescribing, LABA should always be issued

in combination inhalers with ICS, reducing the risk of harm from using

LABA as monotherapy

and improving the likelihood of adherence

to an additional medication. In children, BTS/SIGN state there is

insufficient evidence to choose between LABA or LTRA as initial add-

on therapy.

NICE recommends LTRA as the first-line add-on therapy in

adults and children because the marginal superiority in efficacy of

LABA (noted in adults)

is outweighed by its greater cost.

As an oral

medication, LTRA may offer an advantage for some for whom an

inhaler is impractical. LTRA also offer treatment benefit for those with

allergic rhinitis.

PCRS supports the value-based approach

that NICE used, and

therefore recommend LTRA as the first-line add-on therapy to ICS.

Effectiveness and tolerability should be reviewed in 4–6 weeks. If

LTRA is found ineffective it should be withdrawn, as adding a LABA

on top of a LTRA removes any cost advantage. In children, the use

of a paediatric low-dose ICS with LTRA as first-line add-on treatment

is recommended. If this combination is ineffective, then switch the

LTRA for a LABA.

Ultimately, the decision to opt for LTRA or LABA as initial add-on

therapy should be made after discussion between the clinician and

patient and should take consideration of other factors including

patient preference, adherence (including the potential for additional

prescription costs), concomitant diseases (eg, rhinitis) and risk of ex-

acerbation. Furthermore, there is no need to change the medication

of patients who are already well controlled on ICS/LABA.

Single combination inhaler for maintenance and reliever therapy

Particular types of ICS/LABA combination inhaler may be used to

provide both a regular daily dose and relief from symptoms when

needed, so-called Maintenance and Reliever Therapy (MART). In

comparison with the more traditional fixed daily dosing regimens,

MART may have advantages for some individuals as only one inhaler

is needed and every inhalation contains ICS, reducing the risk of

undertreated airway inflammation.

There are, however, important points to consider with MART.

Firstly, only those inhalers which contain formoterol as the LABA are

suitable for MART, as formoterol has a rapid onset of action. Sec-

ondly, the evidence to support MART is based on trials done on

adults, and whilst there was a reduction in asthma attacks (compared

with standard ICS/LABA treatment), there was no difference to quality

of life, asthma control, lung function or asthma medication use.

Thirdly, with limited evidence

and no licensed product for under-

12-year-olds, MART is not recommended in children.

In summary, MART may be considered as an option in adults

who have a history of asthma attacks despite medium-dose ICS or

ICS/LABA.

To become more widely used, there is a need for better

training and greater clarity on self-management instructions for

MART.

Asthma monitoring

A regular review of individuals with asthma provides the chance to

assess current symptom control and consider the future risk of an

asthma attack. Primary care is best placed to monitor asthma by

staff who are trained, competent and confident, and should be com-

pleted regularly (at least annually in stable patients with a definite

diagnosis) as a pre-planned appointment but also opportunistically.

A more frequent review may be necessary when a diagnosis is first

made, or for those with poor asthma control. At each review, asthma

control, lung function, asthma attacks, oral corticosteroids, absence

from work or school and smoking status should be recorded in the

notes. In children, growth (height and weight centile) should also be

measured.

Monitoring asthma symptom control

Asthma control should be assessed using the validated asthma con-

trol questionnaire or asthma control test and are recommended over

the Royal College of Physician’s three questions which has greater

value as a screening test for poor control.

Peak flow or spirometry

(or both) should be used to assess lung function. If asthma control is

sub-optimal, check for and address the common causes of poor

asthma control listed in Box 2. For more information on supporting

smokers to quit (be that individuals with asthma or parents/carers of

children with asthma), see the PCRS article on tobacco dependency

(https://www.pcrs-uk.org/sites/pcrs-uk.org/files/TobaccoDepend-

Flier_FINAL.pdf).

Currently there is insufficient evidence from real-life primary care

to support using FeNO routinely to monitor asthma control. However,

it may be an option to support asthma management in people who

are symptomatic despite using ICS as it can help to identify poor

adherence.

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Primary Care Respiratory

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As well as during a routine review, inhaler technique should be

observed and errors in technique corrected at every opportunity

when there is a deterioration in asthma control, when the inhaler is

changed and if the patient requests a check.

Predicting future risk of asthma attacks

In line with the delivery of personalised asthma care, identifying the

future risk of an asthma attack for children and adults should be

incorporated into any asthma review. In children aged 5–12 years

(Table 3), the factors associated with a greatly increased risk of

asthma attack are persistent asthma symptoms and past history of

asthma attack.

School-aged children are at moderately increased

risk if they are over-reliant on SABA, have a co-existing atopic dis-

ease, are vitamin D deficient or from a low-income family.

Additional

factors known to slightly increase the risk of asthma attack are

exposure to tobacco smoke, obesity, low parental education and

younger aged children (ie, closer to 5 than 12 years).

In adults (Table 4), having a history of previous asthma attacks

is associated with a greatly increased risk of asthma attack.

Poor

asthma control and SABA over-reliance are both associated with

a moderately increased risk of an asthma attack.

Smoking,

obesity, depression, older age, reduced lung function and female

gender are all associated with a slightly increased risk of a future

asthma attack.

Understanding the factors associated with an increased risk of

attack can help clinicians to know what to enquire about in consul-

tation, but should also lead to proactive care by identifying at-risk

individuals who do not consult regularly (for instance, by searching

the practice record to identify those individuals over-using SABAs).

At-risk individuals should receive targeted care by increasing the

frequency of review, optimising medication choice and adherence

and reviewing self-management strategies. For ideas and tools to

facilitate action on SABA over-reliance, see the work of the Asthma

Right Care Project (https://www.pcrs-uk.org/asthma-right-care).

Severe asthma

When monitoring individuals and weighing up future risk of attack,

have in mind the possibility of severe asthma as such patients require

referral for specialist review. BTS/SIGN define severe asthma as more

than two asthma attacks a year or persistent symptoms with SABA

use more than twice a week despite adequate adherence (>80%)

and therapies beyond initial or add-on controller treatments (ie,

‘specialist therapies’).

Severe asthma is increasingly regarded as a

distinct disease entity requiring specialist treatment and is the

subject of a PCRS pragmatic guide for clinicians (available at

Box 2 Common causes of poor asthma control

• Incorrect diagnosis, or co-morbidity that has been missed

• Lack of medication adherence

• Current treatment is unsuitable

• Under-use of ICS or overuse of SABAs

• Inappropriate inhaler technique

• Failure to use a spacer with ICS delivered by a metered dose

inhaler

• Smoking (active or passive) – ideally use a carbon monoxide

meter to monitor smoking

• Exposure to occupational triggers

• Seasonal or environmental factors

• Psychosocial reasons, including ideas and concerns about

asthma/treatment

Level of increased risk

Greatly increased risk

Moderately increased risk

Slightly increased risk

Unclear (evidence limited or equivocal)

Table 3 Factors associated with increased risk of future asthma attacks in school-aged children

Children

• History of previous asthma attacks

• Persistent asthma symptoms

• Suboptimal drug regimen (the ratio of the number of prescriptions for controller

medication to total number of prescriptions for asthma medication <0.5)

• Comorbid atopic/allergic disease

• Low-income family

• Vitamin D deficiency

• Younger age

• Exposure to environmental tobacco smoke

• Obesity

• Low parental education

• Reduced lung function

• Raised FeNO at routine interviews

• Positive skin prick tests

• History of allergen exposure

This table is reproduced from SIGN 158 (British guideline on the management of asthma) by kind permission of the Scottish Intercollegiate Guidelines Network

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Primary Care Respiratory

Update

https://www.pcrs-uk.org/resource/triggers-referral-poorly-controlled-

and-severe-asthma).

Conclusions

We look forward to the return of a single asthma guideline developed

through the collaboration of NICE and BTS/SIGN. In the meantime,

we have proposed clear guidance to address particular concerns

over conflicting aspects of asthma diagnosis, management and

monitoring that will support non-specialists to continue providing high

quality asthma care.

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Level of increased risk

Greatly increased risk

Moderately increased risk

Slightly increased risk

No increased risk

Unclear

(evidence limited or

equivocal)

Table 4 Factors associated with increased risk of future asthma attacks in adults

Children

• History of previous asthma attacks

• Poor control (assess review using objective patient reported control questionnaire such as ACT or ACQ)

• Inappropriate or excessive SABA use

• Older age

• Female

• Reduced lung function

• Obesity

• Smoking

• Depression

• Gender

• Urban residence

• History of anaphylaxis

• Comorbid gastro-oesophageal reflux

• COPD

• Raised FeNO at routine reviews

• Blood eosinophilia

• Poor adherence

This table is reproduced from SIGN 158 (British guideline on the management of asthma) by kind permission of the Scottish Intercollegiate Guidelines Network

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Primary Care Respiratory

Update

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