How asthma management is changing – what nurses need to know 

Respiratory nurse lead Carol Stonham outlines what nurses in primary care need to know about changes in the diagnosis and treatment of asthma, following recently updated UK joint guidelines

In November 2024 a joint UK asthma guideline was published by NICE, the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN). This offers greater clarity in how to diagnose asthma, and an updated, evidence-based approach to treatment.

Prior to this, clinicians had been navigating some conflicting national and international guidelines and strategies, as well as local recommendations. This has often led to difficulty in diagnosing asthma accurately.  In addition, despite increasing availability of different asthma medications and clear recommendations 10 years ago from the National Review of Asthma Deaths, the number of people dying from asthma has barely changed.¹

The new guideline offers a chance to offer a standardised, evidence-based approach that respiratory experts believe should improve outcomes for people living with asthma. Anyone diagnosing or managing asthma should be familiar with the new guidelines – this article introduces the main changes, but it is important for nurses to read through the guidelines for more detail.

Stepwise approach to diagnosis

The diagnosis of asthma has always relied heavily on a history in keeping with a likely diagnosis of asthma, and this has not changed. However, the new guidelines recommend only one positive objective test is required to confirm the diagnosis – rather than two, as recommended in previous NICE guidelines and consequently in QOF. (This is one of the areas where NICE and BTS/SIGN asthma guidelines previously diverged.)^3,4

The choice of testing follows a sequential approach. The initial test should be measurement of fractional exhaled nitric oxide (FeNO) levels, or alternatively in adults there is now the option to measure blood eosinophil levels.

The stepwise approach to diagnosis in adults can be summarised as:

1. Measure blood eosinophil count or FeNO level in adults with a history suggestive of asthma. An eosinophil count above the laboratory reference range, or a FeNO above 50ppb, is enough to confirm diagnosis.
2. If the blood eosinophil or FeNO is negative, the next diagnostic test should be spirometry with bronchodilator reversibility (BDR). An increase in FEV1 of 12% or more and 200ml or more post-bronchodilator supports a diagnosis of asthma. The guidelines recognise that there may be a delay in accessing spirometry or BDR, however.
3. If spirometry is not available, or delayed, peak expiratory flow (PEF) variability can be used as an alternative. PEF should be measured twice daily for 2 weeks. Mean variability of 20% or more can be interpreted as a positive test confirming diagnosis.
4. If asthma not confirmed by any of the above tests, then refer for bronchial challenge testing.

The guidance reminds us to consider occupational asthma, although this aspect is not covered in detail. Further information and guidance should be sought from the BTS Occupational Asthma Clinical Statement.⁵

In children aged 5-16, the stepwise approach is:

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1. The initial test to support a diagnosis in children with a history suggestive of asthma is a FeNO test. A result above 35ppb is positive. Again, this test alone is appropriate to confirm a diagnosis.
2. If the result is negative (below 35ppb), further testing is required using spirometry with BDR. An improvement of 12% post-bronchodilator confirms diagnosis.
3. If spirometry is not available, or delayed, PEF variability is also appropriate for children, with 20% or more variability indicating a positive diagnosis.

If these tests fail to confirm diagnosis the child will need either skin prick testing to house dust mite or a blood test for IgE. Sensitisation to house dust mite or raised IgE along with raised blood eosinophils (above 0.5 x10⁹ per litre) confirm the diagnosis. If testing remains negative, a referral for specialist opinion and consideration of challenge testing is required.

In any age group, alternative diagnoses should be kept in mind, especially if all tests fail to confirm asthma.

New stepwise treatment approach

The guidelines have made a big change to the management of asthma and now align more closely with international Global Initiative for Asthma (GINA) recommendations.⁶

The striking difference most nurses will notice is move away from prescribing short acting beta-agonists (SABAs) in the treatment algorithms.

NICE emphasises that SABAs should not be prescribed at all without a concomitant prescription of an inhaled corticosteroid (ICS), and they are no longer recommended even in combination with an ICS in newly diagnosed patients.

Treatment in people aged 12 and over

In this group treatment recommendations can be summarised as follows:

• For patients with minimal symptoms, a 2-in-1 combination inhaler, including the long-acting beta agonist (LABA) formoterol and an inhaled corticosteroid (ICS), is recommended for as-needed symptom relief. This is referred to as an AIR (anti-inflammatory reliever) regimen. The formoterol acts as rapidly and effectively as a SABA in treating acute symptoms. So when used as a reliever inhaler, the ICS-formoterol both relieves acute symptoms and reduces underlying inflammation. This approach also effectively titrates the preventer ICS medication in line with asthma symptoms, helping to reduce future symptoms and risk (unlike SABA use, which allows untreated inflammation to escalate). Note that currently only a few inhalers are licensed to be used in this way.
• If the person is more symptomatic, or has experienced an exacerbation, low-dose MART (maintenance and reliever therapy) should be prescribed, using a formoterol-containing ICS combination. Many of the formoterol containing combination inhalers are licensed to be used as a MART regimen. This regimen involves using the combination inhaler twice-daily as treatment, and as-needed for symptom relief.
• If poor asthma control is experienced despite the low-dose MART regimen, after checking the basics of asthma care (eg, inhaler technique, adherence, smoking, co-morbidities, triggers), a move to a moderate-dose MART regimenis recommended. This means using a formoterol-ICS combination inhaler with an increased dose of ICS.
• If, despite moderate dose MART treatment, the person continues to experience regular asthma symptoms or exacerbation, another new recommendation is to check their FeNO level and eosinophil count, which can then help guide treatment decisions.
  • A normal FeNO (below 50ppb for adults) and within-range eosinophil count suggests the inflammation is under control, so a third medication can be added. This could be a long-acting muscarinic antagonist (LAMA). Note that triple therapy inhalers combining a LAMA with formoterol and ICS are not licensed for use as MART; patients can instead be prescribed a separate LAMA inhaler alongside moderate-dose MART. The other option is to add in an oral leukotriene receptor antagonist (LTRA) such as montelukast. Whichever therapy is added in, it is important to review the patient to further titrate treatment, or swap to the alternative, or if this fails refer to a specialist.
  • If either the FeNO or eosinophil result is raised, the patient should be referred to a specialist for consideration of a biologic asthma medication.

Treatment in children aged 5-11 years

In children aged between 5 and 11 years the pathway can be summarised as:

• Start by prescribing a paediatric low-dose ICS with a separate SABA for symptom relief – what has until now been the traditional treatment.
• If, despite this, the child’s symptoms are not controlled, then prescribe a paediatric low-dose MART regimen, provided the child is able to manage this. The dilemma here is that there are currently no inhalers licensed for MART regimens in this age group, so it would be prescribed off-label, but following guideline recommendation. Consultation notes will need to reflect this. NICE notes that evidence supporting low-dose MART in children aged 5-11 is based on use of a dry powder inhaler.  In this age group it is worth considering whether a SABA and spacer should also be prescribed, as they may not be able to actuate a dry powder device in an emergency situation.
• Escalate treatment in those who continue to have symptoms (having first checked inhaler technique, adherence, and trigger exposure) to a paediatric moderate-dose MART regimen. If this still does not control symptoms, the child should be referred for specialist advice.
• If the child is unable to manage a MART regimen, consider adding a leukotriene receptor antagonist (LTRA) to the low-dose ICS with separate SABA and review 8-12 weeks later. If ineffective the LTRA should be stopped.
• If still uncontrolled, offer a twice-daily ICS and long-acting bronchodilator agonist (LABA) combination inhaler, with a separate SABA for symptoms (with or without LTRA depending on response). It can be escalated to a paediatric moderate-dose ICS and LABA combination inhaler, again with a separate SABA for symptoms. Further changes beyond this should be on the recommendation of a specialist.

For more detailed summaries of the treatment pathways see the NICE treatment summary flow-charts for people aged 12 and over and for children aged 5-11.

Switching existing asthma patients to new treatments

Patients on SABA only

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The cohort of people that will require review and likely a change in treatment is those using SABA therapy alone. In previous iterations of the BTS/SIGN and NICE guidelines a SABA-only regimen was recommended for mild asthma, so it is likely there is a considerable number of these patients in every practice. The guidelines now state that we should not prescribe SABA in people of any age with asthma, without a concomitant prescription of ICS.

Searches on clinical record systems will quickly identify this cohort.  If truly asymptomatic most of the time, these patients should be offered AIR therapy (combination inhaler including formoterol and ICS, used for as-needed symptom relief). Patient education, as always, is vital for patients to engage in their care and accept change. To help the patient understand why they need to switch to the combination inhaler, explain what asthma is, with inflammation at its core, how inhalers work, and why not treating inflammation is a risky strategy.  Many patients will have received advice from clinicians about the importance of always carrying their blue inhaler so will need to understand the rationale and importance of switching. An explanation that the bronchodilator is not being changed but is being ‘upgraded’ usually reassures patients.

Patients on any regimen that includes ICS

If patients on any ICS containing regimen for previously diagnosed asthma are stable and symptom-free they do not necessarily need to be moved onto one of the new treatment pathways. However, it is important to remember many people with asthma normalise their symptoms and adjust activity and lifestyle to accommodate it. At review, make sure to ask probing questions to ascertain if a person is truly asymptomatic and well.

For those with symptoms that are not on a MART regime, the guidelines recommend moving to a MART regime without reducing the dose of ICS.

If the person is on a high-dose ICS and symptomatic, a specialist opinion should be sought.

Remember always that people have the right to be involved in discussions and make informed decisions about their care. NICE reiterates this and refers to the NICE Making Decisions About Your Care document.⁷

Carol Stonham is a Primary Care Respiratory Society UK Trustee, vice chair of the Taskforce for Lung Health, and co-clinical lead for the NHS England South West respiratory network

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References

1. Royal College of Physicians. Why asthma still kills; the national review of asthma deaths (NRAD). 2014
2. NICE. Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN). [NG245] 27 November 2024
3. British Thoracic Society/Scottish Intercollegiate Guideline Network (2019) Guideline for the management of asthma.
4. (2017) Asthma NG 80. Archived and replaced by NG 245
5. British Thoracic Society. BTS Clinical Statement on Occupational Asthma. 2022
6. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2024
7. Making decisions about your care.

Further reading and resources

RightBreathe. Inhalers

PCRS UK. Asthma Guidance and Best Practice