Guideline calls for greater recognition of 'difficult asthma'

GUIDELINE CALLS FOR GREATER RECOGNITION OF
‘DIFFICULT ASTHMA’

CLEAR EVIDENCE THAT NEBULISERS ARE AS GOOD AS SPACERS

A substantially updated guideline just published is calling for greater recognition of ‘difficult asthma’. The term ‘difficult asthma’ generally refers to a clinical situation where a prior diagnosis of asthma exists, but asthma-like symptoms and exacerbations persist, despite prescription of high-dose asthma therapy.

The guideline, entitled ‘British Guideline on the Management of Asthma’, has been produced by the Scottish Intercollegiate Guidelines Network (SIGN) - part of NHS Quality Improvement Scotland - in conjunction with the British Thoracic Society (BTS), and builds upon the work undertaken both separately and jointly by both organisations since 1990.

As the general management of asthma has improved, the burden suffered by those at the severe and difficult end of the spectrum has become greater. The guideline’s new section on ‘difficult asthma’ emphasises the importance of accurate diagnosis in this group of patients where it is often necessary to separate out several co-morbidities. The guideline also emphasises the need to take a systematic approach to the management of these patients.

Moreover, the guideline stresses that the current practice of using nebulisers to deliver high doses of airway-opening medicines in emergency departments to those with out of control asthma, is very often not necessary - the guideline emphasises that there is clear evidence that using a spacer to administer much lower doses is at least equally effective as a nebuliser in treating most such exacerbations.

In addition, the guideline calls for greater use of written personalised action plans, when giving control to the person with asthma as part of self-management education. Written personalised action plans are an important part of self-management education and yet often not offered to those with asthma. The latest guideline emphasises how such action plans can improve health outcomes. The evidence is particularly good for those in secondary care with moderate to severe asthma.

The guideline also contains:

a completely rewritten section on diagnosis for both adults and children;
updated sections on pharmacological and non-pharmacological management;
a section on diagnosing and treating occupational asthma - it is estimated that 1 in 8 asthma patients has contracted the condition through their occupation.

Dr Graham Douglas, Consultant Respiratory Physician at Aberdeen Royal Infirmary, and co-chair of the standards steering group, said: “This substantially updated guideline builds upon the work that SIGN and the British Thoracic Society have been undertaking together since 2003. We hope that the guideline continues to serve as a basis for high quality management of both acute and chronic asthma. Sections of the guideline will continue to be updated on the BTS and SIGN websites on an annual basis, in order to ensure that the most up-to-date findings are made available as quickly as possible to benefit patients.”

Editors Note:

Asthma is a condition that affects the airways. When a person with asthma comes into contact with something that irritates their airways, the muscles around the walls of the airways tighten so that they become narrower and the lining becomes inflamed and starts to swell. Sometimes sticky mucus or phlegm builds up which can further narrow the airways. Asthma UK estimates that 5.2m people in the UK are currently receiving treatment for asthma.
The first British Guidelines on how to manage asthma for health professionals in the UK were published in 1990. Subsequently, in a joint initiative, the British Thoracic Society and the Scottish Intercollegiate Guidelines Network have regularly updated these to take account of the latest evidence.
A spacer is a large plastic or metal container, with a mouthpiece at one end and a hole for the pressurised metered dose aerosol inhaler at the other. Spacers only work with a press-and-puff type inhalers.
A nebuliser is a machine that creates a mist of medicine, which is then breathed in through a mask or mouthpiece. They are commonly used to give high doses of reliever medicine in an emergency situation, for example in hospital or a doctor's surgery.
SIGN develops national clinical guidelines aimed at reducing variations in clinical practice and in outcomes for patients. Founded in 1993, SIGN became part of the national clinical effectiveness body, NHS Quality Improvement Scotland on 1 January 2005.
The British Thoracic Society (BTS) was formed in 1982. BTS’s objective is to improve the standards of care of people who have respiratory diseases.
NHS Quality Improvement Scotland has been established to lead in improving the quality of care and treatment delivered by NHSScotland. To do this it sets standards and monitors performance, and provides NHSScotland with advice, guidance and support on effective clinical practice and service improvements.
The SIGN/BTS guideline, ‘British Guideline on the Management of Asthma’, is available from www.sign.ac.uk.

Media Contact: Stephen Ferguson on 07779 329 689