Asthma

Introduction

The NICE/BTS/SIGN asthma guideline 2024 now recommends SABA free pathways¹ where appropriate, in those aged over 12, to reduce the risks associated with SABA overuse.

In Scope Patients with suspected asthma, newly diagnosed asthma, and those with an established diagnosis

Not in Scope Other respiratory conditions

Red Flags

Consider the need for hospital admission in any patient presenting with an acute exacerbation of asthma².

*This list is not exhaustive

Please see NHS Clinical Knowledge Summary Acute Exacerbations of Asthma for further information.

Objective tests for diagnosing asthma in those over 16 years

Seen here in flow chart format

1. Blood eosinophil count above the reference range

2. Fractional exhaled nitric oxide (FeNO) if available. FeNO level 50 ppb or more is indicative¹

If asthma is not confirmed with eosinophils or FeNO consider spirometry or peak flow as below:

3. Spirometry with bronchodilator reversibility

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

4. Peak expiratory flow (PEFR) twice daily for 2 weeks, if spirometry is not available or delayed

Diagnose asthma if PEF variability is 20% or more

If asthma is not confirmed by the above but still suspected on clinical grounds, refer for consideration of a bronchial challenge test. (Currently only available out of county)

If there is doubt about the initial diagnosis, and the patient has been using an ICS inhaler, consider a wash out period of a minimum of two weeks off ICS, before repeating objective tests. During this time the patient can monitor peak flows if able.

Objective tests for diagnosing asthma in children aged 5 - 16 years

Seen here in flow chart format

1. FeNO level in children if available¹

Diagnose asthma if the level is 35 ppb or more

2. Spirometry with bronchodilator reversibility if FeNO not available or level not raised

Diagnose asthma if the FEV1 increase is 12% or more from baseline or
If the FEV1 increase is 10% or more of the predicted normal FEV1

3. Peak Flow Readings (PEFR) twice daily for 2 weeks, if Spirometry is not available or delayed

Diagnose asthma if PEF variability is 20% or more

4. measure total IgE level and blood eosinophil count, if asthma is not confirmed by the above but still suspected on clinical grounds

Diagnose asthma if IgE levels are raised and the eosinophil count is more than 0.5 x 10 per litre. If there is still doubt refer to paediatrics

Diagnosing asthma in children under 5

Diagnosis is hard in this age group.

For children under 5 with suspected asthma, treat with inhaled corticosteroids in line with pharmacy guidelines¹. If they still have symptoms when they reach 5 years attempt objective tests.

Refer to general paediatrics any child under 5 with an admission to hospital, or 2 or more attendances to ED with wheeze in a 12 month period.

Management optimisation

Adopt a shared decision making approach with the patient and their caregivers where appropriate.

Consider possible reasons for uncontrolled asthma before starting or adjusting medicines. These may include alternative diagnoses, suboptimal adherence, suboptimal inhaler technique, smoking, occupational exposures, psychosocial factors, seasonal factors, environmental factors (air pollution indoor mould exposure etc).

Consider choice of inhaler in the context of climate change where possible. For more information please see Cornwall formulary inhaler choices document.

Management in people aged 12 and over with a new diagnosis

After starting or adjusting medicines, review the response to treatment in 8-12 weeks.

The NICE/BTS/SIGN asthma guideline 2024 now recommends SABA free pathways to reduce the risks associated with SABA overuse¹. Summarised in this new algorithm.

Anti-inflammatory reliever (AIR) and maintenance and reliever therapy (MART) regimens using a combination of ICS/formoterol are now recommended.

Only certain ICS/formoterol inhalers are licensed for reliever therapy, please see Cornwall and IOS Prescribing Guidelines for more information.

For all newly diagnosed patients with asthma provide an Asthma Management Plan.

AIR therapy

Consider if symptoms occur three or less times a week¹

MART therapy

Consider if symptoms occur more than three times a week¹, and or if experiencing more severe symptoms, eg nocturnal waking or severe exacerbation requiring oral steroids.

If adequate control is not obtained with low dose MART, then the maintenance dose of MART should be increased.
For those on moderate dose MART treatment, whose asthma remains uncontrolled check the FeNO (if available) and the blood eosinophil. If either is raised refer to secondary care.

Whilst waiting or if not raised consider the following steps
Consider 8–12 week trial of either a leukotriene receptor antagonist (LTRA) or long acting muscarinic receptor antagonist (LAMA) in addition to MART.
If control has improved but is still inadequate, continue the treatment and start a 8-12 week trial of the other medicine (LTRA or LAMA)
If control has not improved, stop the LTRA or LAMA and start a 8-12 week trial of the alternative medicine (LTRA or LAMA).

If asthma remains uncontrolled refer to Secondary Care

Management in those aged 5-11 with a new diagnosis

After starting or adjusting medicines, review the response to treatment in 8-12 weeks.

Offer a twice daily low dose inhaled corticosteroid (ICS), with a SABA plus spacer as needed¹.
If symptoms not controlled NICE suggest offering a paediatric low-dose MART. However, at time of writing in November 2024, no asthma inhalers were licensed for MART in children under 12, so use would be off label.
If using ICS plus SABA and Asthma remains uncontrolled consider adding a LTRA as needed. Review after 8-12 weeks and stop LTRA if ineffective.
If asthma remains uncontrolled consider a switch to low dose ICS/LABA combination inhaler plus SABA (with or without an LTRA depending on previous response)
Increase dose of ICS/LABA inhaler plus SABA as needed (with or without LTRA depending on previous response)

Refer to paediatrics if asthma is not controlled on moderate dose ICS/LABA maintenance treatment (with or without LTRA)

Management in under 5s with a new diagnosis

After starting or adjusting medicines, review the response to treatment in 8-12 weeks.

1. Consider 8-12 week trial of twice daily paediatric ICS as maintenance with SABA for reliever in those with suspected asthma¹ and:

Symptoms at presentation that indicate the need for maintenance therapy or
Severe acute episodes (eg requiring hospital admission, or needing more than 2 courses of oral steroids)

If symptoms do not resolve during the trial period check inhaler technique and adherence, check whether there is an environmental source and review whether an alternative diagnosis is likely. If none of these explain the failure to respond, consider referral.

2. If symptoms do improve consider stopping ICS and SABA after 8-12 weeks and review after a further 3 months. Restart if symptoms have recurred or the child has had an acute episode requiring systemic corticosteroids or hospitalisation.

3. If symptoms uncontrolled on paediatric moderate dose ICS (with SABA as needed) consider adding a LTRA. Review after 8-12 weeks and stop if ineffective and refer to Secondary Care.

Management in those already diagnosed

Identify patients who could be transferred to SABA free treatment, particularly where asthma is poorly controlled. If they are not symptomatic and are happy on their current treatment pathway it is not recommended that they are switched.

Advice and Guidance

Adult Advice and Guidance (A&G) requests can be submitted to respiratory through the e-referrals system.

Paediatric A&G can be sent to General Paediatrics for patients <16yrs.

Referral

Investigations required prior to referral

Spirometry, where available
CxR and FBC (within the last six months)

Emergency and red flags

Severe or life threatening asthma call 999 and arrange admission to RCHT ED
Acute Asthma exacerbation requiring hospital admission discuss with AcuteGP (over 16yrs) or Paediatrics as appropriate

Urgent Respiratory Referral Criteria (over 16 years)

Severe asthma attack requiring hospital admission (not just ED attendance)
Any patient who has previously required intubation due to a life threatening asthma attack, and not currently under specialist review¹

Routine Respiratory Referral Criteria (over 16 years)

Poor control despite primary care treatment optimisation as above,or patient over 12 years has had recurrent oral steroids (3 or more courses), or three or more hospital attendances. Please check patient compliance and inhaler technique prior to referring.
Suspected occupational asthma
Unclear diagnosis

Please consider including in the referral where possible:

Current treatment, and previous therapies tried. (Data on how often patients collect their inhalers would be useful)
Number of courses of oral steroids in last 12 months, and dates of these (Required if considering biologics)
Spirometry with reversibility. (Do not delay referral for severe stable asthma if awaiting spirometry)
Previous FeNo results (if available)

Consider asking the patient to provide up to date peak flow readings for their outpatient appointment

Paediatric Referral Criteria (under 16 years)

Refer to general paediatrics preschool child with admission to hospital or 2 or more attendances to ED with wheeze in a 12 month period
5-11 years refer if asthma not controlled on paediatric moderate dose ICS (with SABA as needed)
Over 12 years of age refer if asthma not controlled on moderate dose ICS/LABA maintenance (with or without LTRA)

Where appropriate please consider discussing smoking cessation with parents/guardians due to the risks of smoking exposure.

Supporting Information

For patients

For professionals

References

Page Review Information

Review date 02 January 2025

Next review date 02 January 2027

Speciality Lead GP Dr Kate Northridge

Contributors Dr Susheela Banerji, Specialist Doctor Respiratory Medicine, RCHT

Bethany Doherty, Respiratory Specialist Nurse, RCHT

Dr Stuart Nash, Paediatric Consultant, RCHT

Dr Kathryn Thomas, Paediatric Consultant, RCHT