New Asthma Guidelines Flashcards
What are the 4 classifications of asthma?
- Intermittent Asthma
- Mild Persistent Asthma
- Moderate Persistent Asthma
- Severe Persistent Asthma
What is the definition of intermittent Asthma?
- Symptoms less than once a week.
- Brief episodes of symptoms.
- Nocturnal symptoms not more than twice a month.
- Normal pulmonary function between episodes (FEV1 and Peak Expiratory Flow Rate (PEFR) >80% predicted).
What is the definition of mild persistent Asthma?
Symptoms more than once a week but less than once a day.
Episodes may affect activity.
Nocturnal symptoms more than twice a month.
Pulmonary function tests show FEV1 and PEFR >80% predicted.
What is the definition of moderate persistent asthma?
Daily symptoms occur with daily use of short-acting beta2 agonists.
Nocturnal symptoms more than once a week.
Pulmonary function tests show FEV1 and PEFR between 60% to 80% predicted.
What is the definition of severe persistent asthma?
Continuous daily symptoms with frequent exacerbations limiting physical activities.
Frequent nocturnal asthma symptoms.
Pulmonary function tests show FEV1 and PEFR <60% predicted or best possible with treatment
What are the 4 clinical symptoms of asthma?
- Wheezing
- Cough
- Dyspnoea
- Chest Tightness
What 2 objective tests are used to diagnose asthma in patients 17 and over?
- FeNO testing
- Spirometry with a bronchodilator reversibility (BDR) test
What test is first line objective test for diagnosing asthma in adults and young people with a history suggesting asthma?
Blood eosinophils or FeNO testing.
What is second line for diagnosing asthma in adults and young people with a history suggesting asthma?
Bronchodilator
reversibility (BDR)
with spirometry
What is third- line for diagnosing asthma in adults and young people with a history suggesting asthma?
Peak expiratory flow variability.
If bronchodilator reversibility spirometry is delayed or not available.
If asthma is not confirmed by eosinophil count, FeNO, BDR, or PEF variability but is still suspected clinically what should be the next steps?
consider an alternative diagnosis and arrange specialist referral for consideration of a bronchial challenge test (asthma is diagnosed if bronchial hyper-responsiveness is present).
If eosinophil count
is above the laboratory
reference range or
FeNO level is 50 ppb or
more what should be done?
With a history of asthma, confirm diagnosis
If eosinophil count or FeNO is not at reference level what should be considered?
Bronchodilator reversibility with spirometry
We should consider whether there is a reversible airflow obstruction 12% or more from baseline and 200ml or more (Or 10% or more of predicted normal) we can confirm diagnosis
If bronchodilator reversibility with spirometry is not diagnostic of asthma what testing should we look to?
Bronchial challenge test
If there is bronchial hyperresponsive present then we can confirm diagnosis of asthma.
If not we should consider an alternative diagnosis.
If a patient is acutely unwell or highly symptomatic at presentation what should be done?
Treat them.
if the person is able and the equipment is available, otherwise carry out objective tests when acute symptoms are controlled.
.
Be aware that the results of spirometry and fractional exhaled nitric oxide (FeNO) tests may be affected in people who have been treated with inhaled corticosteroids (the test results are more likely to be normal).
What results in FeNO testing are considered positive?
in adults level of >= 40 parts per billion (ppb) is considered positive
in children a level of >= 35 parts per billion (ppb) is considered positive
What spirometry reading is considered an obstructive picture?
FEV1/FVC ratio less than 70% (or below the lower limit of normal if this value is available) is considered obstructive
What is considered a positive result in reversibility testing?
in adults, a positive test is indicated by an improvement in FEV1 of 12% or more and increase in volume of 200 ml or more
in children, a positive test is indicated by an improvement in FEV1 of 12% or more
How do we monitor asthma control at an asthma review?
1.5.2
Consider using a validated symptom questionnaire (for example, the Asthma Control Questionnaire, the Asthma Control Test or the Childhood Asthma Control Test) at any asthma review. [BTS/NICE/SIGN 2024]
1.5.3
Do not use regular peak expiratory flow (PEF) monitoring to assess asthma control unless there are person-specific reasons for doing so (for example, when PEF measurement is part of the personalised asthma action plan). [BTS/NICE/SIGN 2024]
1.5.4
Consider fractional exhaled nitric oxide (FeNO) monitoring for adults with asthma:
at their regular review, and
before and after changing their asthma therapy. [BTS/NICE/SIGN 2024]
What questions must be asked at every asthma review?
In people with adult-onset asthma, poorly controlled established asthma, or reappearance of childhood asthma, check for a possible occupational component by asking:
Are symptoms the same, better or worse on days away from work?
Are symptoms the same, better or worse when on holiday (time away from work, longer than usual breaks, at weekends or between shifts)?
Make sure all answers are recorded for later review. [NICE 2017, BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]
1.4.2
Refer people with suspected occupational asthma to an occupational asthma specialist. [NICE 2017]
If someone is newly diagnosed with asthma and are aged 12 and over what pharmalogical intervention do we offer them?
Offer low-dose ICS/formoterol combination inhaler
to be taken as needed (AIR therapy)
If a patient presents highly-symptomatic (eg. regular noctural waking) or with a severe exacerbation and is newly diagnosed with asthma what medication should they be placed on?
- start treatment with low-dose MART (maintenance and reliever therapy)
- treat the acute symptoms as appropriate (e.g. a course of oral corticosteroids may be indicated)
If a patient that is started on a low-dose MART and their asthma is now well controlled what should we consider?
Consider stepping down to low-dose ICS/formoterol combined inhaler
If a patient’s asthma is not well-controlled on a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler what should be done?
Switch to a low-dose MART (daily maintenance therapy and the relief of symptoms as needed)
