Asthma 2016 Guidelines: The 2016 update by the British Thoracic Society (free full text)

Today was published an important update to British Thoracic Society guidance on the management of asthma!

Diagnosing asthma

The guideline, produced jointly by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) emphasises that there is still no single test that can definitively diagnose asthma and an individual’s asthma status can change over time.

It recommends that if a health professional suspects asthma, they should undertake a ‘structured clinical assessment’ using a combination of patient history, examination and tests to assess the probability of asthma. 

The history should include a review of the following:

• Symptoms of cough, breathlessness, wheeze and chest tightness that have varied over time
• Any history of recurrent attacks of symptoms
• Any wheeze previously recorded by a health professional
• A personal or family history of allergic conditions such as eczema and allergic rhinitis
• Objective evidence of variability over time in obstruction to a patient’s airflow (using the results of lung function tests)
• The absence of any pointers to an alternative diagnosis to asthma.

Quality assured spirometry is spotlighted as the key frontline breathing test to be performed in most situations with adults and children over 5 years of age.  It is important that spirometry is quality assured i.e. professionals are trained and experienced in preparing and delivering the test as well as analysing the results.

If the test shows obstruction to the patient’s airflow which reverses with treatment, this strongly supports a diagnosis of asthma.

But a normal spirometry result does not always exclude an asthma diagnosis – especially if a patient has no symptoms at the time. It may be necessary for healthcare professionals to repeat spirometry when a patient has symptoms, and/or use different breathing tests - and observe over time.

One, often secondary, breathing test that can be carried out, involves measuring an individual’s fractional exhaled nitric oxide (FeNO) - a gas found in slightly higher levels in people with asthma. An increase suggests inflammation of the airways, and supports, but doesn’t prove, a diagnosis of asthma.

The guideline helps health professionals to assign patients into 3 groups based on the probability they have asthma; either high, intermediate or low.  It then summarises the key treatment and management actions to be taken for each group.

If the probability of asthma is high, health professionals should start a carefully monitored trial of treatment. If patients respond well, according to lung function tests or symptom questionnaires, this will confirm the diagnosis.   Health professionals should code their records as ‘suspected asthma’ until a diagnosis is confirmed and should make a clear record on what basis the diagnosis was confirmed. If the probability is low, further tests or immediate referral to a lung specialist may be appropriate.

Treating asthma

The updated guideline also includes new or revised content in the following areas: asthma drug treatment (replacing the previous stepwise approach), non-drug treatments, supported self-management, and the role of telehealthcare.

Key highlights include: 

• Short acting beta2 agonists - a group of drugs that can provide quick relief of asthma symptoms - are the key ‘rescue therapy’ from symptoms or asthma attacks and can form part of all treatment plans, but should rarely be used on their own
• A key emphasis on medication to prevent future asthma attacks - inhaled corticosteroids remain the most effective ‘preventer’ drug for all adults and children
• Asthma inhalers should not be prescribed generically to avoid patients being given an unfamiliar device that they may not know how to use properly
• If a patient has poor control of their asthma, it is essential to check whether they are using their current drug treatment correctly and regularly, before stepping up treatment
• Weight loss initiatives – including dietary and exercise programmes – can be offered for overweight or obese adults and children with asthma and may improve their asthma control 
• Each patient should be offered a written asthma action plan as it is key to the effective management of their asthma
• The use of new electronic technologies can help in the delivery of asthma care, and evidence shows they can be at least as good as traditional methods, although outcomes do vary

Approaches include; games to encourage children to take their medication, remote consultations, automated treatment reminders, and computerised decision-support systems for health professionals. The guideline says they can be considered according to local need

• Women with asthma who are pregnant should be informed of the importance of continuing their asthma medication during pregnancy for the health of both mother and baby

Dr John White, British Thoracic Society member and Consultant Respiratory Physician, York NHS Foundation Trust, who co-chaired the group that delivered the updated BTS/SIGN Guideline, said:

‘Asthma is a complex disease and symptoms can vary over time.  In addition, evidence shows there’s still no single ‘magic bullet test’ for asthma. This all means that diagnosis isn’t always easy.

This update should be really valuable as it gives healthcare professionals an evidence-based but highly practical approach to suspecting and confirming a diagnosis of asthma, as well as giving the latest guidance on the most appropriate treatments and interventions to combat the disease.  

The guideline also reinforces previous messages that remain vital in the battle against asthma. It is critical, for example, that everyone with the condition is offered a written personalised action plan and review, and that inhalers are only prescribed after patients have received training in using them and demonstrate adequate technique.

We do hope that health, social care and education professionals can work together with people with asthma in using these guidelines to provide the best care possible.’   

SIGN is part of Healthcare Improvement Scotland.

Sara Twaddle, Director of Evidence for Healthcare Improvement Scotland, said:

“Over 5 million people are currently being treated for asthma in the UK and 1,468 people died from asthma attacks in the UK in 2015 – the highest level for 10 years. It’s important that we diagnose and treat people to the best of our ability, hence the reason we update this guideline for clinicians every two years using the most up-to-date evidence. This new updated guideline underlines that there is still no single diagnostic test for asthma, and emphasises the importance of preventive therapy. We urge clinicians across the UK to refer to this guideline for diagnosis and treatment. By doing so, they will help to improve the care that people with asthma receive.”

The BTS/SIGN asthma guideline is a ‘living guideline’ updated biennially.  Following a scoping exercise, key sections are selected for updating based on availability of new evidence. 

Free full text:

https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/