Asthma
DIAGNOSIS:1
The respiratory team recommend diagnosis is made based on the BTS guidelines which suggest the diagnosis of asthma is made predominantly clinically by the presence of symptoms (wheeze, breathlessness, chest tightness, cough):
ASTHMA TESTS:
Asthma control test: https://www.asthmacontroltest.com/en-gb/welcome/
Spirometry(>5 years)– An obstructive picture (FEV1/FVC <70%)
Peak Flow (possible over 8yrs)– either 2 week history of diurnal variation or historical record of low PEFRs during symptomatic episodes compared to asymptomatic periods. (PEFR variability of 20% strongly suggestive of asthma)
FeN)– (If available) - adults over 17yrs or consider children 5-17yrs if diagnostic uncertainty e.g normal spirometry/peak flow
Consider referral for child/young person – If symptoms suggestive of asthma but all investigations negative. Or obstructive spirometry but no bronchodilator reversibility and normal FeNO.
QOF diagnosis – requires spirometry and one other objective test (e.g. FeNo or diurnal variability)
SIGNS OF UNCONTROLLED ASTHMA:
(again assess asthma control using asthma control test >20 is good control)
- 3 or more days a week with symptoms
- 2 or more days a week requiring SABA for symptomatic relief
- 1 or more nights with awakenings due to asthma
- High number of repeat SABAs: 6 SABAs/year = 3.3 reliever doses/day. 12 SABAs/year = 6.6 reliever doses/day2
PRIMARY CARE MANAGEMENT (before referral):
- Cornwall & IoS Adult Asthma Prescribing Guidelines: Simple asthma should be managed via the Cornwall and IoS guideline here. (Please also see BTS chart and guidance below).
- Please use DPIs in preference to MDIs in over 7s where possible (due to huge climate impact of MDIs). See https://youtu.be/vCqW9DmXTxc
- Referral is appropriate after ‘additional controller therapies’ step of BTS step pathway.
- STEP UP: if using SABA more than 3 times per week
- Montelukast should be trialled and benefit evaluated, stop if no benefit to patient.
- Always check inhaler technique & adherence/ script pick up prior to increasing treatment
- All patients should have a written Personal Asthma Action Plan (https://www.asthma.org.uk/advice/manage-your-asthma/action-plan/)
British Thoracic Society Guideline on the Management of Asthma available here
Categorisation of inhaled steroids by dose (adults):https://www.sign.ac.uk/media/1387/sign158-categorisation-of-inhaled-corticosteroids-adults.pdf
Categorisation of inhaled steroids by dose (children):https://www.sign.ac.uk/media/1388/sign158-categorisation-of-inhaled-corticosteroids-children.pdf
WHEN TO REFER TO SECONDARY CARE:
- Poor control despite asthma treatment optimization: 2 or more courses of oral steroids/year, step 5 of asthma pathway, multiple admissions, persistently symptomatic – for consideration of biologics (A&G also available for advice re poor control)
- Suspected occupational asthma
- Unclear diagnosis
- Severe asthma attack (hospital admission, not just ED attendance) – these patients will usually have been picked up by secondary care and offered follow up
- Near fatal asthma attack (needing intubation) – may possibly need specialist review indefinitely.
- SEVERE ASTHMA CLINIC– occurs once a month and acts as a ”one-stop clinic”. Refer through usual e-referral system for patients on maximal inhaled therapy OR recurrent oral steroids OR multiple hospital admissions
REFERRAL REQUIREMENTS:
- Include in the referral letter the number of ICS containing & salbutamol prescriptions issued and the number of courses of oral steroids over the last 12 months and therapies previously tried – must include this as and when oral steroids were as patients cannot often recall this and this information is needed prior to starting on biologics etc
- Spirometry with reversibility –if possible (if not possible include previous spirometry results). (but don’t delay referral for severe asthma)
- Chest Xray and FBC (within the past 6 months)
Provide a peak flow meter and diary, initiate peak flow monitoring where patient is capable
- Check inhaler technique – please ensure this is checked before referral as a high number of treatment failures are due to poor technique.
USEFUL RESOURCES:
- Cornwall and IoS prescribing guideline here.
- British Thoracic Society Guideline on the Management of Asthma available here
- Asthma leaflet for parents: https://www.beatasthma.co.uk/wp-content/uploads/2017/10/4-Asthma-Info-leafleft-for-parents-2.pdf
- Useful site for inhaler/spacer technique:-https://www.asthma.org.uk/advice/inhaler-videos/
- Asthma UK: https://www.asthma.org.uk/advice/
- Asthma slide rule – calculates dose per day - https://www.pcrs-uk.org/arc-slide-rule
REFERENCES:
- BTS Asthma quick reference guide 2019: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/
- primary care respiratory update - https://www.pcrs-uk.org/sites/pcrs-uk.org/files/pcru/articles/2019-Autumn-Issue-18-SevereAsthmaReferral.pdf
Review date: April 2022
Next review due: April 2023
Reviewing GP: Dr Madeleine Attridge
Contributors: Dr Susheela Banerji
Jill Leyshon (specialist respiratory nurse)