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Since its publication in 2003, the British guideline on the management of asthma from the British Thoracic Society and the Scottish Intercollegiate Guidelines Network (BTS/SIGN) has been part of an innovative rolling programme that has made regular updates available on the BTS and SIGN websites (www.brit-thoracic.org.uk and www.sign.ac.uk).

This process has involved annual revisions for some chapters, for example the section on pharmacological management, in order to incorporate emerging evidence. Other sections, such as that on diagnosis, have been substantially rewritten for the first time in the recent 2008 guideline.1 Some chapters have been merged and suggestions for audits (see later) are now explicitly integrated with the recommendations throughout the guideline.

There is an awareness in the guidance that a ‘one size fits all’ approach to guidelines does not adequately reflect the diversity of clinical practice. This is addressed in a new chapter on ‘special situations’, which includes a section on difficult asthma as well as advice on asthma in pregnancy, and on occupational asthma.

What is new?

The revised British guideline on the management of asthma contains recommendations based on the usual SIGN rating system (Figure 1). Some important revisions to the guideline include:1

• complete rewriting of the section on diagnosis with recommendation of an appropriate ‘trial of treatment’ based on clinical assessment of high, intermediate, or low probability of asthma
• strengthening of the recommendation that regular reviews for people with asthma should include self-management education, including the provision of a written personal asthma action plan
• a new section advocating a systematic approach to the diagnosis and management of patients with ‘difficult’ asthma.

The guideline also reminds clinicians that in patients whose control is poor, it is important to review the diagnosis, check inhaler technique, discuss concordance, and identify triggers before stepping up treatment. The key recommendations from the guideline are summarised in Table 1.

Figure 1: Key to evidence statements and grades of recommendations
Levels of Evidence
1++	High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias.
1+	Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias.
1-	Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias.
2++	High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal.
2+	Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal.
2-	Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal.
3	Non-analytic studies, e.g. case reports, case series.
4	Expert opinion.
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A	At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++ and directly applicable to the target population; or
	A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results.
B	A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
	Extrapolated evidence from studies rated as 1++ or 1+
C	A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
	Extrapolated evidence from studies rated as 2++.
D	Evidence level 3 or 4; or
	Extrapolated evidence from studies rated as 2+.
Good practice points
√	Recommended best practice based on the clinical experience of the guideline development group.
	Audit point.
RCT=randomised controlled trials
British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. A national clinical guideline. SIGN: Edinburgh, 2008. This material was reproduced with kind permission of the British Thoracic Society

Table 1: Key recommendations1
Grade		Recommendation
Diagnosis of asthma in adults and children
D	The diagnosis of asthma is based on the recognition of a characteristic pattern of symptoms and signs and the absence of an alternative explanation for them. The key is to take a careful clinical history
B	Focus the initial assessment in children suspected of having asthma on: presence of key features in the history and examination careful consideration of alternative diagnoses
Achieving asthma control
	The aim of asthma management is control of the disease. Control is defined as: no daytime symptoms no night time awakening due to asthma no need for rescue medication no exacerbations no limitations on activity including exercise normal lung function with minimal side-effects
√	Before initiating a new drug therapy practitioners should check compliance with existing therapies, inhaler technique, and eliminate trigger factors
B in adults √ for children up to 12 years	Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique
Regular review and self-management
A	In primary care, people with asthma should be reviewed regularly by a nurse or doctor with appropriate training in asthma management. The review should incorporate a written action plan
B	Consider carrying out routine reviews by telephone for people with asthma
B	Initiatives that encourage regular, structured review explicitly incorporating self-management education should be used to increase ownership of personalised action plans
Difficult asthma
D	Patients with difficult asthma should be systematically evaluated, including: confirmation of the diagnosis of asthma identification of the mechanism of persisting symptoms and assessment of adherence with therapy
D	This assessment should be facilitated through a dedicated multidisciplinary difficult asthma service, by a team experienced in the assessment and management of difficult asthma

Diagnosis

Primary care clinicians will understand the ‘probability’ approach to diagnosis, which is advocated in the new guideline. The process of reaching a probable diagnosis starts as soon as the patient enters the surgery and tells their story. Examination findings, combined with the personal or family history, will increase or decrease the probability of a diagnosis of asthma. A trial of treatment as appropriate is the preferred approach, with investigations reserved to resolve diagnostic doubt. Figure 2 shows an algorithm to aid asthma diagnosis in adults.

Figure 2: Algorithm for the diagnosis of asthma in adults

British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. A national clinical guideline. SIGN: Edinburgh, 2008. This material was reproduced with kind permission of the British Thoracic Society

High probability of asthma

The likelihood of a diagnosis of asthma is classed as high if:

• the patient has a history of variable symptoms of coughing and wheezing and has been treated for some years for atopic conditions such as rhinitis or eczema, or whose family members are known to have a tendency to atopy
• careful questioning reveals symptoms to be worse at night, or triggered by viral infections, exercise, or allergy
• widespread wheeze is heard on examination or a peak flow reading is significantly different (>20%) from one recorded previously
• serial peak flow readings (in older children and adults) may provide corroborative evidence for a diagnosis of asthma, although it is important to appreciate that peak flows are effort-dependent and can be misleading if they are not interpreted in the context of the clinical situation;1 for example, a series of normal readings in an asymptomatic patient does not exclude asthma; wide variations in readings in the absence of symptoms may result from poor technique. Peak flow charting is of particular value in establishing a link with occupational exposure2
• an obstructive spirogram that reverses to normal with treatment supports the diagnosis of asthma—however, because asthma is a variable condition, a normal spirogram in an asymptomatic patient does not exclude asthma. The new guideline emphasises that spirometry provides additional information, allowing obstructive and restrictive causes for a low peak flow to be distinguished.

If the probability of asthma is high, a trial of treatment with a moderate dose of inhaled steroids is recommended. The healthcare professional should monitor the response to treatment, both symptomatically and with repeated measures of lung function in older children and adults, with a good response to treatment confirming the diagnosis of asthma. Provided inhaler technique and compliance are good, a poor response should lead to reconsideration of the diagnostic possibilities.1

Alternative diagnosis probable

After assessment of the patient, the clinical situation may suggest a diagnosis other than asthma; for example: symptoms of light-headedness and tingling may suggest hyperventilation/panic attack; a significant smoking history increases the possibility of chronic obstructive pulmonary disease (COPD); and nocturnal breathlessness in a patient with angina may point to heart failure. In these situations, it is appropriate to investigate for and treat the more probable diagnosis, reconsidering the possibility of asthma in those patients who do not respond to therapy.

Intermediate probability of asthma

If the diagnosis is not clear, or the response to asthma treatment is poor, further investigations will be needed. Spirometry is the pivotal test as the differential diagnosis and approach to management depend on whether the patient has airflow obstruction (i.e. forced expiratory volume in one second [FEV1]/forced vital capacity [FVC] ratio <70%). Spirometry results can reveal:1

• airflow obstruction, which usually indicates asthma and/or COPD, although the differential diagnosis includes causes such as inhaled foreign body, bronchiectasis, and lung cancer. A ‘trial of treatment’ for asthma is recommended, with repeated spirometry to assess response. This may be tested with a formal reversibility test to bronchodilators, or a trial of inhaled steroids over 6 to 8 weeks, or oral steroids over 2 weeks
• absence of airflow obstruction—the differential diagnosis includes hyperventilation, heart failure, gastro-oesophageal reflux, or pulmonary fibrosis, which will require further investigation
• normal spirometry—if recorded in a patient who is asymptomatic at the time of the test, does not exclude a diagnosis of asthma.

If the diagnosis remains unclear and asthma is still a clinical possibility, referral for further investigations should be considered. Assessment of airway responsiveness and eosinophilic airway inflammation may help to clarify the diagnosis, although these tests are not yet widely available in clinical practice.

Children with asthma

The diagnosis of asthma in children follows a similar process to that in adults of establishing probabilities and observing the response to a trial of treatment. There are, however, some specific points to note, which are:

• it is important to clarify what parents mean when they use the word ‘wheeze’3
• the common clinical pattern in infants of viral-associated wheeze will normally stop by school age1,4—differentiation from asthma may only be clear in retrospect
• clinicians should not forget other important diagnoses (such as cystic fibrosis, inhaled foreign bodies) especially in children with focal chest signs, symptoms from birth, or those who are failing to thrive.1

If there is an intermediate probability of asthma, and no features to support an alternative diagnosis, strategies can include: adopting a policy of watchful waiting if symptoms are mild and scheduling a review after a set period; a trial of treatment followed by carefully observed withdrawal to rule out spontaneous improvement; or further investigations. School age children can usually perform spirometry; other investigations may require referral.

Achieving control

The aim of asthma management is to control asthma such that the patient has no (or very occasional) symptoms (Table 1), and there is evidence from clinical trials that this is achievable in the majority of patients.5 In reality, patients will wish to balance the perceived disadvantages of taking regular treatment with the potential benefit of maintaining perfect control. Studies suggest that most people underestimate the degree of control that is possible.6

Stepping up treatment

Before stepping up treatment in patients whose control is poor clinicians should:

• review the diagnosis—this is important even if a diagnosis of asthma has previously been confirmed, as another problem may have developed to cause the increasing symptoms
• check inhaler technique—only a minority of patients using a metered dose inhaler have adequate inhaler technique, with slightly better performance for other devices7
• assess compliance—less than half of patients from UK general practice take their preventer treatment as prescribed8 but if the GP and patient can agree on the treatment goals, that is likely to improve compliance
• check for triggers—if possible, aim to reduce the patient’s exposure to triggers, although effectiveness of avoidance strategies is often limited by the difficulty of achieving an adequate reduction in aero-allergens, such as the house dust mite.9 Rhinitis is a common association with allergic asthma and should normally be treated with nasal steroids.10 Occupational triggers should be considered in adults, who should be referred for investigation if an occupational cause is likely.

Updates to the stepped approach

The updated therapeutic steps in the BTS/SIGN guideline are very similar to previous versions and continue to emphasise the need to start at the appropriate step, stepping up or down according to control (see Figure 3 for an example of stepped care in adults). New points include:1

• advice to clinicians that smoking reduces the effect of inhaled steroids, so that higher doses may be needed
• combination inhalers have the advantage of reducing the risk of monotherapy with long-acting beta2-agonists by ensuring that they are taken with inhaled steroids
• the use of budesonide/formoterol in a single inhaler as both rescue and regular treatment is an option in adult patients at step 3 who are on both drugs yet remain poorly controlled11
• it is important not to exceed safe doses of inhaled steroids. Children who are maintained on doses above 800 µg daily of beclometasone or equivalent should be under the care of a specialist respiratory paediatrician.

Suggested audit criteria are:

• the percentage of adults using >800 µg/day of inhaled beclametasone without documented consideration of add-on therapy
• the percentage of children prescribed or using >800 µg/day of inhaled beclametasone who are not under the care of a specialist respiratory physician.

Figure 3: Stepped care in adults

*Beclometasone dipropionate or equivalent; SR=sustained release

British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. A national clinical guideline. SIGN: Edinburgh, 2008. This material was reproduced with kind permission of the British Thoracic Society

Regular review and self-management

A key function of regular reviews is to provide education supported by personal asthma action plans. This is a Grade A recommendation in the new BTS/SIGN guideline, based on a substantial weight of evidence summarised in a Cochrane review.1,12 In order to meet individual need, there can be flexibility in who undertakes the review (the practice nurse or the GP, provided that they have appropriate asthma training), and how the review is delivered; for example, telephone may be a convenient alternative to face-to-face consultations, provided that arrangements are tailored to asthma severity and the need to deal with inhaler-related problems.

Table 2 gives a summary of the components of an action plan,13 the supporting evidence, and practical advice on how this may be implemented.

Suggested audit criteria are:

• the percentage of clinicians who have taken part in suitable asthma educational update within last two years
• the percentage of patients receiving written action plans.

Table 2: Summary of the key components of a personalised action plan1
Component of an action plan	Result	Practical considerations
Format of action points Symptom vs peak flow triggered Standard written instructions Traffic light configuration	Similar effect Consistently beneficial Not clearly better than standard instructions	Asthma UK action plans include both symptom triggers and peak flow levels at which action should be taken
Number of action points 2–3 action points 4 action points	Consistently beneficial Not clearly better than 2–3 points	Usual action points are: PEF <80% best: increase inhaled steroids PEF <60% best: commence oral steroids PEF <40% best: seek urgent medical advice
Peak expiratory flow levels Based on percentage personal best PEF Based on percentage predicted PEF	Consistently beneficial Not consistently better than usual care	Personal best should be assessed once treatment has been optimised and peak flows are stable Best peak flow should be updated every few years in adults, and more frequently in growing children
Treatment instructions Individualised using inhaled and oral steroids Individualised using oral steroids only Individualised using inhaled steroids	Consistently beneficial Insufficient data to evaluate Insufficient data to evaluate	Patients may safely hold an emergency supply of prednisolone tablets for use if their symptoms continue to deteriorate and/or if their peak flow falls to 60% of their best Increasing inhaled steroids is ineffective if patients are already taking moderate or high doses (≥400 μg daily) and these patients should be advised to move straight to the oral steroid step Those on low doses (e.g. 200 μg) of inhaled steroids may be advised to increase the dose substantially (e.g. to 1200 μg daily) at the onset of a deterioration Any patients who have stopped medication should be reminded to recommence their inhaled steroids
PEF=peak expiratory flow British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. A national clinical guideline. SIGN: Edinburgh, 2008. This material was reproduced with kind permission of the British Thoracic Society

Difficult asthma

The key message for primary care is that patients with ‘difficult’ asthma-like symptoms or persistent exacerbations despite prescription of high-dose asthma therapy require a systematic approach to diagnosis and treatment. This is usually best addressed by a dedicated multidisciplinary ‘difficult asthma service’. Management of these situations is often complex and includes revisiting the diagnosis as these patients often prove not to have asthma at all. The medical and psychosocial factors that contribute to the ‘difficult’ situation should be addressed.

Summary

This update of the long-established BTS/SIGN British guideline on the management of asthma is likely to be remembered for its approach to the diagnosis of asthma. Professionals will appreciate the ‘probability’ approach, which reflects clinical practice. It continues to emphasise the well-recognised challenges of achieving asthma control and implementing self-management. Practical advice on the management of patients with poor asthma control and the core components of an asthma action plan should provide welcome advice for clinicians.

Key points

The approach to diagnosis is based on the clinical probability of asthma, informed by spirometric evidence of obstruction and objective evidence of variability. A trial of treatment is the preferred approach to confirming or refuting the clinical diagnosis, with investigations reserved to resolve diagnostic doubt In children the diagnosis is made on the basis of a typical clinical picture after consideration of alternative diagnoses. Further investigations should be considered for children who do not respond to a trial of treatment, or where the diagnosis is not clear The aim of asthma management is no (or very few) symptoms. In patients who are not controlled, reconsider the diagnosis, discuss compliance, check inhaler technique and explore triggers before increasing treatment in line with the therapeutic steps Review by an asthma-trained professional and encouragement of self-management skills are complementary aspects of regular structured consultations, which may be provided flexibly (face-to-face or by telephone) to meet individual clinical needs ‘Difficult’ asthma-like symptoms are best managed by a dedicated multidisciplinary team following a systematic approach

Practice-based commissioning take home messages

written by Dr David Jenner, NHS Alliance PBC Lead People with asthma should be offered a self-management plan at review Telephone reviews for patients with asthma are effective but currently do not qualify for QOF points Patients with difficult to control asthma should be reviewed by a multidisciplinary team This team could be commissioned and provided in community setting to avoid costly and repeated hospital attendance Respiratory outpatient appointment: costs £217 (new), £104 (follow up)a Paediatric outpatient costs: £241 (new), £121 (follow up)a

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References

1. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. A national clinical guideline (SIGN 101). SIGN: Edinburgh, 2008.
2. British Occupational Health Research Foundation. Guidelines for the prevention, identification & management of occupational asthma: Evidence review & recommendations. BOHRF: London, 2004.
3. Cane R, Ranganathan S, McKenzie S. What do parents of wheezy children understand by “wheeze”? Arch Dis Child 2000; 82 (4): 327–332.
4. Martinez F, Wright A, Taussig L et al. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med 1995; 332 (3) :133–138.
5. Bateman E, Boushey H, Bousquet J et al. Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study. Am J Respir Crit Care Med 2004; 170 (8): 836–844.
6. Haughney J, Barnes G, Partridge M, Cleland J. The Living & Breathing Study: a study of patients’ views of asthma and its treatment. Prim Care Respir J 2004; 13 (1): 28–35.
7. Brocklebank D, Ram F, Wright J et al. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess 2001; 5 (26): 1–149.
8. van Staa T, Cooper C, Leufkens H et al. The use of inhaled corticosteroids in the United Kingdom and the Netherlands. Respir Med 2003; 97 (5): 578–585.
9. Gøtzsche P, Johansen H. House dust mite control measures for asthma. Cochrane Database of Systematic Reviews 2008; (2): CD001187.
10. Scadding G, Durham, S, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2008; 38 (1): 19–42.
11. O’Byrne P, Bisgaard H, Godard P et al. Budesonide/formoterol combination therapy as both maintenance and reliever medication in asthma. Am J Respir Crit Care Med 2005; 171 (2): 129–136.
12. Gibson P, Powell H, Coughlan J et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Systematic Rev 2003; (1): CD001117.
13. Gibson P, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2004; 59 (2): 94–99.G

Dr Hilary Pinnock
Senior Clinical Research Fellow, University of Edinburgh

Principal in General Practice,
Whitstable Medical Practice, Kent