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Asthma management

A NICE pathway brings together all NICE guidance, quality


standards and materials to support implementation on a specific
topic area. The pathways are interactive and designed to be used
online. This pdf version gives you a single pathway diagram and
uses numbering to link the boxes in the diagram to the associated
recommendations.
To view the online version of this pathway visit:
http://pathways.nice.org.uk/pathways/asthma
Pathway last updated: 13 January 2015
Copyright NICE 2015. All rights reserved

NICEPathways
Pathways

Asthma management

Asthma pathway
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NICE Pathways

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Person with chronic asthma

No additional information

Inhaled corticosteroids

Chronic asthma in children aged under 12 years


This guidance should be read in conjunction with the recommendations on inhaler devices
below.
For children under the age of 12 years with chronic asthma in whom treatment with an inhaled
corticosteroid (ICS) is considered appropriate, the least costly product that is suitable for an
individual child (taking into consideration technology appraisal guidance 38 and 10), within its
marketing authorisation, is recommended.
For children under the age of 12 years with chronic asthma in whom treatment with an ICS and
long-acting beta-2 agonist (LABA) is considered appropriate, the following apply.
The use of a combination device within its marketing authorisation is recommended as an
option.
The decision to use a combination device or the two agents in separate devices should be
made on an individual basis, taking into consideration therapeutic need and the likelihood of
treatment adherence.
If a combination device is chosen then the least costly device that is suitable for the individual
child is recommended.
These recommendations are from inhaled corticosteroids for chronic asthma (NICE technology
appraisal guidance 131).
NICE has written information for patients and the public explaining the guidance on inhaled
corticosteroids.

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Adults and children aged 12 and older


For adults and children aged 12 years and older with chronic asthma in whom treatment with an
inhaled corticosteroid (ICS) is considered appropriate, the least costly product that is suitable for
an individual, within its marketing authorisation, is recommended.
For adults and children aged 12 years and older with chronic asthma in whom treatment with an
ICS and long-acting beta-2 agonist (LABA) is considered appropriate, the following apply.
The use of a combination device within its marketing authorisation is recommended as an
option.
The decision to use a combination device or the two agents in separate devices should be
made on an individual basis, taking into consideration therapeutic need and the likelihood of
treatment adherence.
If a combination device is chosen then the least costly device that is suitable for the individual is
recommended.
These recommendations are from inhaled corticosteroids for adults and children aged 12 and
older (NICE technology appraisal guidance 138).
NICE has written information for patients and the public explaining the guidance on inhaled
corticosteroids.
Inhaler devices for children aged under 5 years
For children under the age of 5 years with chronic stable asthma both corticosteroids and
bronchodilator therapy should be routinely delivered by pressurised metered dose inhaler
(pMDI) and spacer system, with a facemask where necessary.
Where this combination is not clinically effective for the child and depending on the child's
condition, nebulised therapy may be considered and in the case of children aged 3 to 5 years, a
dry powder inhaler (DPI) may also be considered.
Choice of device to be made within the pMDI and spacer range should be primarily governed by
specific individual need and the likelihood of good compliance. Once these factors have been
taken into account, choice should be made on the basis of cost minimisation.

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These recommendations are from inhaler devices for children aged under 5 years (NICE
technology appraisal guidance 10).
NICE has written information for patients and the public explaining the guidance on inhaler
devices.
Inhaler devices for children aged 515 years
It is recommended that in addition to therapeutic need (including chosen drug and dose), the
following factors be taken into account when choosing inhaler devices for individual children
with chronic asthma:
the ability of the child to develop and maintain an effective technique with the specific
device
the suitability of a device for the child's and carer's lifestyles, considering factors such as
portability and convenience
the child's preference for and willingness to use a particular device.
The general recommendations above should be taken into account when considering the
following specific guidance:
A press-and-breathe pressurised metered dose inhaler (pMDI) and suitable spacer device
is recommended as the first-line choice for the delivery of inhaled corticosteroids as part of
regular planned daily therapy, with the aim of maximising benefits of preventive therapy in
attaining good asthma control, and minimising potential systemic absorption. Where
clinicians believe that an individual child's adherence to the press-and-breathe pMDI and
spacer combination is likely to be so poor as to undermine effective asthma control, other
alternative devices (taking account of the factors outlined in 1.1 and evidence of
equivalence of clinical effectiveness) should be considered, bearing in mind the need to
minimise the risks of systemic absorption of corticosteroids.
In the case of other inhaled drugs, primarily bronchodilators, it is recommended that a wider
range of devices be considered to take account of their more frequent spontaneous use,
the greater need for portability, and the clear feedback that symptom response provides to
the device user. In such circumstances the factors outlined above are likely to be of greater
importance in choosing a device.
Where more than one device satisfies the considerations outlined above in a particular
child, it is recommended that the device with the lowest overall cost (taking into account
daily required dose and product price per dose) should be chosen.
On selection of an inhaler device, it is important that consideration is given to other aspects of
asthma care that influence the effective delivery of inhaled therapy, including:
individual practical training in the use of the specific device

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monitoring of effective inhaler technique and adherence to therapy


regular (i.e. no less than annual) review of inhaler needs, which may change over time with
increasing age.
These recommendations are from inhaler devices for children aged 515 years (NICE
technology appraisal guidance 38).
NICE has written information for patients and the public explaining the guidance on inhaler
devices.

Quality standards
The following quality statements are relevant to this part of the pathway.
3.

Written and personalised action plans

4.

Inhaler technique

Resources
The following implementation tools are relevant to this part of the pathway.
Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12
years and over: audit support
Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12
years: audit support
Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12
years and over: costing report
Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12
years: costing template

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Difficult or severe asthma

Fractional exhaled nitric oxide measurement


Fractional exhaled nitric oxide measurement is recommended as an option to support asthma
management (in conjunction with the British guideline on the management of asthma 2012) in
people who are symptomatic despite using inhaled corticosteroids.
This recommendation is from Measuring fractional exhaled nitric oxide concentration in asthma:
NIOX MINO, NIOX VERO and Nobreath (NICE diagnostics guidance 12).
Omalizumab
Omalizumab is recommended as an option for treating severe persistent confirmed allergic IgEmediated asthma as an add-on to optimised standard therapy in people aged 6 years and older:
who need continuous or frequent treatment with oral corticosteroids (defined as 4 or more
courses in the previous year), and
only if the manufacturer makes omalizumab available with the discount agreed in the
patient access scheme.
Optimised standard therapy is defined as a full trial of and, if tolerated, documented compliance
with inhaled high-dose corticosteroids, long-acting beta2 agonists, leukotriene receptor
antagonists, theophyllines, oral corticosteroids, and smoking cessation if clinically appropriate.
People currently receiving omalizumab whose disease does not meet the criteria above should
be able to continue treatment until they and their clinician consider it appropriate to stop.
These recommendations are from omalizumab for treating severe persistent allergic asthma
(review of technology appraisal guidance 133 and 201) (NICE technology appraisal guidance
278).
NICE has written information for patients and the public explaining the guidance on
omalizumab.
Interventional procedures guidance
NICE has published guidance with special arrangements for consent, audit and clinical
governance on bronchial thermoplasty for severe asthma (NICE interventional procedure
guidance 419).

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Quality standards
The following quality statements are relevant to this part of the pathway.
3.
11.

Written and personalised action plans


Difficult asthma

Resources
The following implementation tool is relevant to this part of the pathway.
Omalizumab for treating severe persistent allergic asthma (review of technology appraisal
guidance 133 and 201): costing statement

Acute exacerbations

NICE has published quality statements relevant to people presenting with respiratory symptoms
or exacerbations (see below).

Quality standards
The following quality statements are relevant to this part of the pathway.
6.

Assessing asthma control

7.

Assessing severity

8.

Treatment for acute asthma

9.

Specialist review

Follow-up

NICE has published a quality statement relevant to people who have received treatment for an
acute exacerbation (see below).

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Quality standards
The following quality statement is relevant to this part of the pathway.
10.

Follow-up in primary care

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Sources
Omalizumab for treating severe persistent allergic asthma (review of technology appraisal
guidance 133 and 201). NICE technology appraisal guidance 278 (2013)
Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12
years and over. NICE technology appraisal guidance 138 (2008)
Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12
years. NICE technology appraisal guidance 131 (2008)
Inhaler devices for routine treatment of chronic asthma in older children (aged 515 years).
NICE technology appraisal guidance 38 (2002)
Guidance on the use of inhaler systems (devices) in children under the age of 5 years with
chronic asthma. NICE technology appraisal guidance 10 (2000)
Bronchial thermoplasty for severe asthma. NICE interventional procedure guidance 419 (2012)
Measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO, NIOX VERO
and Nobreath. NICE diagnostics guidance 12 (2014)

Your responsibility
The guidance in this pathway represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Those working in the NHS, local authorities, the wider
public, voluntary and community sectors and the private sector should take it into account when
carrying out their professional, managerial or voluntary duties. Implementation of this guidance
is the responsibility of local commissioners and/or providers. Commissioners and providers are
reminded that it is their responsibility to implement the guidance, in their local context, in light of
their duties to avoid unlawful discrimination and to have regard to promoting equality of
opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.

Copyright
Copyright National Institute for Health and Care Excellence 2015. All rights reserved. NICE
copyright material can be downloaded for private research and study, and may be reproduced
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for educational and not-for-profit purposes. No reproduction by or for commercial organisations,


or for commercial purposes, is allowed without the written permission of NICE.

Contact NICE
National Institute for Health and Care Excellence
Level 1A, City Tower
Piccadilly Plaza
Manchester
M1 4BT
www.nice.org.uk
nice@nice.org.uk
0845 003 7781

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