Professional Documents
Culture Documents
Summary
The British Thoracic Society and the Scottish Intercollegiate Guidelines Network have jointly
published a new British Guideline on the Management of Asthma. Significant changes have
been made to the section on diagnosis and monitoring, and sections on non-pharmacological
and pharmacological management have been updated to reflect current evidence. A new topic
of ‘difficult asthma’ is included; topics of asthma in pregnancy and occupational asthma are
unchanged. Other sections have been re-organised and updated to create a section on
organisation and delivery of care, and audit, and another on patient education and self-
management. Guidance on the content of personalised written action plans is included.
Background
The British Thoracic Society and the Scottish Intercollegiate Guidelines Network have jointly published
a new British Guideline on the Management of Asthma.1 This replaces the previous 2003 version
which was published as a supplement to Thorax,2 and the subsequent on-line versions of 2004, 2005
and 2007. Changes have been made to five sections on diagnosis and monitoring, non-
pharmacological management, pharmacological management, organisation and delivery of care, and
audit, and patient education and self-management. A new topic of difficult asthma is included within a
section on special situations, which also covers unchanged topics of asthma in pregnancy and
occupational asthma.
Significant changes have been made to this section. In adults and children, asthma should be
diagnosed by recognising a characteristic pattern of respiratory symptoms and signs in the absence of
an alternative explanation. In adults it is important to obtain objective support for the diagnosis by
demonstrating airflow obstruction varying over short periods of time using spirometry. Spirometry is
considered the preferred initial test to identify airflow obstruction, rather than peak expiratory flow
(PEF). PEF should only be used if spirometry is unavailable, to diagnose occupational asthma and to
monitor patients with established asthma. The presence or absence of airflow obstruction is also
important for determining differential diagnoses. In children, the use of spirometry or bronchial hyper-
responsiveness testing adds little to making a diagnosis.
More data are available to allow recommendations to be made about a number of non-
pharmacological interventions.
Recommended interventions
Secondary prophylaxis
- subcutaneous immunotherapy for patients with asthma who cannot avoid a clinically
significant allergen (section 3.3.3).
- Buteyko breathing technique to control symptoms (section 3.5.3).
Secondary prophylaxis
- sublingual immunotherapy (section 3.3.3).
- probiotics (section 3.4.5).
- air ionisers (section 3.5.2).
Evidence for the usefulness of other interventions in preventing or treating asthma is described. More
research is required on the use of dietary probiotics in pregnancy to reduce the incidence of childhood
asthma (section 3.1.8), on vitamin C supplementation in children with asthma (section 3.1.9), on
avoidance of indoor aeroallergens (section 3.2.2), on sublingual immunotherapy for treatment of
asthma (section 3.3.3), on complementary and alternative medicine (section 3.5), on herbal and
traditional Chinese medicine (section 3.5.4) and to establish whether immunotherapy may have a role
in primary prophylaxis (section 3.1.10).
Significant changes to this section of the guideline were published on-line in July 2007 and the new
2008 version includes only a small number of additional revisions. All major changes made in 2007
and 2008 are summarised below:
The aim of asthma management is control of the disease (newly defined as no daytime symptoms, no
2008 night time awakening due to asthma, no need for rescue medication, no exacerbations, no limitations
on activity and normal lung function) with minimal side effects.
♦ Specific written advice about steroid replacement in the event of a severe intercurrent
illness should be part of the management plan.
♦ The child should be under the care of a specialist paediatrician for the duration of the
treatment.
The guideline highlights that non-CFC beclometasone is available in more than one
2007
preparation, and their potency relative to CFC-containing beclometasone is not consistent.
NICE guidance on inhaled corticosteroids for the treatment of chronic asthma in adults and in
children aged 12 years and older,4 and for the treatment of children under the age of 12
years,5 recommends using the least costly licensed product that is suitable for the individual.
NICE recommends that if treatment with an inhaled corticosteroid and long-acting beta-2
agonist is needed, the decision over whether to use a combination device or separate inhalers
should be made on an individual basis taking into account likely treatment adherence,
therapeutic need and cost of the product(s).4,5 Use of the combination inhaler
budesonide/formoterol (Symbicort®) in a treatment regimen to provide both maintenance and
reliever therapy (Symbicort SMART®) was accepted for use within NHS Scotland in March
2007.6
2008
Omalizumab should only be initiated in specialist centres with experience of evaluation and
management of patients with severe and difficult asthma.
NICE issued guidance on the use of omalizumab for severe persistent allergic asthma in
November 2007.7 Omalizumab is recommended, within its licensed indication, as add-on
therapy to optimised standard therapy, in adults and children 12 years and older who fulfill
specific criteria for severe unstable allergic disease. Standard therapy is defined as a full trial
of, and documented compliance with, inhaled high-dose corticosteroids and long-acting beta-2
agonists in addition to leukotriene receptor antagonists, theophyllines, oral corticosteroids and
oral beta-2 agonists, as well as smoking cessation where appropriate.
Section 7.1 Difficult asthma and Section 7.2 Factors contributing to difficult asthma.
In these new sections ‘difficult asthma’ is defined as persistent symptoms and/or frequent
exacerbations despite treatment at step 4 or step 5. Assessment of patients considered to have
difficult asthma should be facilitated through a multidisciplinary difficult-asthma service provided by a
team experienced in the assessment and management of difficult disease. Patients should be
systematically evaluated, compliance with therapy assessed and the mechanism of persistent
symptoms identified. Possible factors contributing to difficult asthma are described in detail.
This section includes a significant number of changes. It contains information from two previously
separate sections – organisation and delivery of care, and also outcomes and audit. It describes the
key features of effective asthma services in primary and secondary care together with appropriate
audit measures. It is recommended that patients should receive written action plans as these have
been shown to improve outcomes. Patients who attend emergency departments or require admission
for an acute exacerbation of asthma should receive self management planning as soon as clinical
improvement is seen and before discharge. An appointment made, prior to discharge, for a review in
primary care within 30 days following discharge, improves follow-up rates. Section 8.3.2 lists all
recommended audits within the guideline.
This section provides new information on the suggested content of action plans, which need to be
written, personalised and supplemented with patient education. The key components that have been
shown to improve outcomes include using symptoms and regularly updated personal best PEF levels
as triggers, limiting the number of action points to two or three and supplying inhaled and oral steroids
for emergency use. This section also includes information on concordance and compliance, which was
presented separately in the previous version of the guideline. Minor changes have been made.
Compliance with treatment can be assessed using computer repeat-prescribing systems. Computer,
innovative web-based and nurse-led telephone-based self management programmes can increase the
use of regular medication.
References