British Guideline on the Management of Asthma: what is new in the 2016 update

Any general practice nurse with involvement in the care of patients with asthma needs to be aware of the new BTS/SIGN guideline on asthma management as it makes important changes to how we make a diagnosis and think about and describe the therapeutic pathway

A significant update to the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) British Guideline for the Management of Asthma introduces a complete revision of the section on diagnosis, a major update to the section on pharmacological management of asthma, and updates to the sections on supported self management, non-pharmacological management of asthma, acute asthma, difficult asthma, occupational asthma, and organisation and delivery of care.

DIAGNOSING ASTHMA

The revised chapter on diagnosing asthma adopts a pragmatic, structured approach to suspecting and confirming a diagnosis of asthma.

It continues to reinforce the importance of proceeding towards a diagnosis based on the probability of asthma, and that asthma is a variable condition for which there is no definitive diagnostic test. The approach to diagnosis needs to consider a lot of factors, take place over time and include relevant tests that would confirm the diagnosis.

The guideline emphasises that diagnostic tests form only one part of an asthma diagnosis, and that all tests may give false negatives especially when the patient is asymptomatic e.g. FeNO (fractional inhaled nitrous oxide) and spirometry. A comprehensive table details the sensitivities and specificities of all diagnostic tests.

There is an extended recommendation that a ‘structured clinical assessment’ should be undertaken. (Box 1). This uses all the clinical information generally available to primary care clinicians on which initial probabilities can be based.

Spirometry is considered the investigation of choice for identification of airflow obstruction, and use of lower limit of normal is recommended, but a range of other investigations may be used to demonstrate variability and/or inflammatory/atopic status.

If, on the basis of the clinical assessment and subsequent investigations, asthma is considered likely, ‘monitored initiation of therapy’ may be considered. A positive response to treatment further confirms the diagnosis of asthma.

Importantly, the basis for diagnosis should always be recorded in the notes, so that this can always be checked back later. The READ code for ‘suspected asthma’ should be used until a diagnosis is confirmed over time.

The chapter considers adults and children together, and is centered on the same evidence base as the NICE guideline on diagnosis and monitoring, which is not due for publication until next year.

WHAT’S NEW

• A new schematic to illustrate the diagnosis pathway according to probability (Fig 1 p29 in the guideline)
• A more comprehensive table comparing different objective tests (Table 1, pp18-20)
• Introduction of concept of ‘initial structured clinical assessment’ (3.3.1, p21) – See Box 1.
• Introduction of concept of ‘monitored initiation of therapy’ (Table 3 p24)
• Diagnosis in children and adults is considered together, though there are still separate tables for alternative diagnoses

PHARMACOLOGICAL MANAGEMENT

Some major changes have been introduced to the pharmacology section of the guideline. This chapter highlights the important role of preventive treatments and gives more guidance on the sequence of treatments and when to refer for specialist opinion and support.

The main change is a move away from PRN (‘when necessary’) bronchodilators as initial treatment, straight to the introduction of low dose inhaled steroids.

A phased approach to treatment has been preserved but the numbered steps have been replaced with verbal descriptions, which emphasise and clarify the primary role of preventive treatments.

Most people with a diagnosis of asthma will start on a low dose inhaled corticosteroid (ICS), the step now known as ‘regular inhaled preventer’ therapy. They will then move through ‘initial add-on therapy’, ‘additional add-on therapies’, ‘high dose therapies’, and ‘continuous or frequent use of oral steroids’ until their asthma is controlled.

The former Step 3 has now been divided into ‘initial add-on therapy’ and ‘additional add-on therapies’.

Short acting bronchodilators (SABAs) are to be prescribed for anyone with symptomatic asthma at any step for symptom relief. But they should no longer be used on their own and are now recommended only for those with infrequent short-lived wheeze.

Using more than three doses of SABA a week should prompt a review and consideration of moving up to the next step of therapy. Anyone prescribed more than one SABA inhaler device a month should be identified and have their asthma assessed urgently. Measures should be taken to improve asthma control if this is poor.

Previously beclometasone (BDP) was used as a reference product against which other steroid strengths were compared. However, comparing other ICS with BDP has not been helpful since CFC (chlorofluorocarbon)-free inhalers were introduced, so more usefully, all ICS are banded into very low, low, medium, high dose categories to enable comparison and equivalence. The new banding of ICS by strength should be more accurate and more straightforward in practice. Two tables indicate the licensed doses of all ICS for adults and children.

The new guideline recommends that adults on high dose therapies and continuous or frequent use of oral steroids are referred for specialist care.

For the first time the guideline recommends that inhalers should be written by brand name to avoid a patient being dispensed a device which they have not used before. It also recommends that patients should receive training on using a particular device and are able to demonstrate that they can use it correctly before it is prescribed.

WHAT’S NEW

• Numbered steps have been removed in favour of verbal descriptions (Figs 2&3 pp72 and 73)
• Former Step 1 – SABAs only – has been replaced by immediate preventer treatment (7.1 p60)
• More than one SABA inhaler a month should trigger urgent review and action (7.1.1 p60)
• Former Step 3 has now been divided into two – ‘initial add-on therapy’ and ‘additional add-on therapies’( 7.3, 7.4 pp67-68) (Figs 2&3 pp72 and 73)
• ICS are no longer compared with BDP as reference product for strength. Instead all ICS are categorised into bands; very low, low, medium and high to enable comparison. (Table 9 p64 and Table 10 p66) – see Box 2.
• A recommendation that all patients on high dose therapies and continuous or frequent use of oral steroids are referred to specialist care (adults and children) (Table 9 p64 and Table 10 p66)
• Inhaler prescriptions should be written by brand name to avoid patients being given an inhaler which they have not been trained to use. (8.4 p81)

MANAGEMENT OF ACUTE ASTHMA

As reported previously in Practice Nurse the annual death rate states show a 17% increase in the number of asthma-related deaths since 2014, and the highest number of deaths due to asthma in over 10 years. As highlighted by the UK-wide National Review of Asthma Deaths (NRAD), the majority of these deaths may be considered avoidable.

The guideline has therefore updated recommendations on the management of acute asthma, pointing out that most patients who die of asthma had chronically severe asthma, but in a minority the fatal attack occurred suddenly in a patients with mild or moderately severe background disease.

Many of the deaths occurred in patients who had received inadequate treatment with ICS or oral steroids, and/or inadequate monitoring. Follow up was in adequate in some, and others should have been referred earlier for specialist advice, and there was widespread underuse of personalised, written management plans.

Heavy or increasing use of beta2 agonist therapy was associated with asthma death: prescription of more than 12 SABA inhalers a year should prompt urgent review of management.

RISK FACTORS FOR DEVELOPING NEAR-FATAL OR FATAL ASTHMA

A combination of severe asthma, recognised by:

• Previous near fatal asthma – e.g. previous ventilation or respiratory acidosis
• Previous admission for asthma, especially in the last year
• Requiring three or more classes of asthma medication
• Heavy use of beta2 agonist
• Repeated attendances at ED for asthma care, especially in the last year

AND

• Non-adherence with treatment or monitoring
• Failure to attend appointments
• Fewer general practice contacts
• Frequent home visits
• Self discharge from hospital
• Psychosis, depression, other psychiatric illness or deliberate self harm
• Current or recent major tranquilliser use
• Denial
• Alcohol or drug abus
• Obesity
• Learning difficulties
• Employment/income problems
• Social isolation
• Childhood abuse
• Severe domestic, marital or legal stress.

Most attacks of asthma severe enough to require hospital admission develop relatively slowly, so there is time for effective action. All practice staff, including practice receptionists, should be aware that asthma patients complaining of respiratory symptoms may be at risk and should have immediate access to a doctor or trained asthma nurse. A register of patients at risk may help to identify patients who are more likely to die from their asthma, and a system should be in place to contact these patients if they fail to attend for follow up.

• A table detailing levels of asthma severity (Table 12, p93]
• Initial assessment of symptoms, signs and measurements of acute asthma (Table 13, p94)
• Algorithm summarising recommended treatment for patients presenting with moderate, acute severe or life-threatening asthma in primary care (Annex 2, p 163)

OTHER CHANGES

Adherence

Non-adherence should always be considered as a cause of poor control before stepping up treatment and the update provides new guidance on the questions to ask to obtain an accurate view of adherence, using prescribing records to assess adherence. It also offers suggestions for ways of improving adherence.

Telehealthcare

The guideline says technology has the potential to contribute to the delivery of asthma care in a number of ways including:

• Supporting self-management by providing information, facilitating monitoring, enabling transfer of monitoring data, or using games to influence behaviour-change
• Remote consultations such as telephone calls, emails, texts and the Internet
• Computerised Decision Support Systems

CONCLUSION

This guideline has been updated to reflect the reality of primary care with recommendations that are practical to implement in general practice. General practice nurses should now look at the updated chapters and become familiar with the changes.