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BTS/SIGN guideline for the management of asthma

Hilary Pinnock
MB ChB MRCGP
GPIAG Clinical Research Fellow
Department of General Practice and Primary Care
University of Aberdeen

Principal in General Practice
Whitstable Health Centre, Kent
E:hpinnock@gpiag-asthma.org

British Thoracic Society
W:www.brit-thoracic.org.uk

Scottish Intercollegiate Guideline Network
W:www.sign.ac.uk

Copies of the Guideline and the "Quick Reference Guide" can be downloaded from both websites. Case studies, slides and posters to ­facilitate the implementation of the guideline are available

Guidelines do not change practice. Even evidence-based guidelines, such as the Guideline on the management of asthma recently published jointly by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guideline Network (SIGN),(1) are no more than expensive publications unless they stimulate clinicians to read and take action on the issues covered. Mindful of this, the BTS and SIGN have attached considerable importance to the implementation of their recommendations and have published a range of audit and educational resources on their websites. This article will focus on three of the key messages from the guideline, and will suggest how clinicians can assess their current practice and plan for change. It is hoped that GPs and nurses updating their portfolios and considering development plans with practice colleagues will find these suggestions useful.

Diagnosis of asthma

What does the guideline recommend?

  • Objective tests should be used to try to confirm a diagnosis of asthma before long-term therapy is started.
  • The criteria on which the diagnosis has been made should be recorded.

The guideline highlights three steps in making a diagnosis of asthma that should be clearly recorded in the patient's records:

  1. A typical history of variable symptoms of cough, wheeze and chest tightness, supported by variable chest signs and possibly a family or personal ­history of atopy.
  2. Objective demonstration of variability with peak flows. In practice this is often conveniently achieved with home charting. The guideline ­advises that ­variability of more than 20% confirms asthma.
  3. A good response to treatment.

Diagnosis is particularly difficult in infants.(2) Some will have persistent asthma, many will be transient early wheezers, a few will have other more serious pathology. The BTS/SIGN guideline helpfully provides a list of symptoms not usually associated with asthma that should prompt a search for alternative diagnoses. Wheeze, heard by a healthcare professional, should be noted in the patient's records as objective confirmation of the patient's description. A good symptomatic response supports a diagnosis of asthma, but to exclude coincidental improvement it is important to check that symptoms relapse when therapy is withdrawn.

How well are we doing in our practice?
Audit criterion - The percentage of patients with an asthma diagnosis made within the last year who have objective evidence of variability recorded in their notes.

A simple proforma that can be used to assess how your practice diagnoses asthma is available on the website of the General Practice Airways Group (GPIAG). Results already submitted suggest that less than half have 20% variability clearly recorded.

Where can we find out more about diagnosing asthma?
Chapter 2 of the BTS/SIGN guideline discusses the diagnosis and natural history of asthma. Several of the case studies on the BTS website are designed to focus a practice discussion on diagnosis: Jessica is a teenager whose colds tend to go to her chest; Bob is a smoker who may have chronic obstructive pulmonary disorder; Laura describes symptoms of exercise-induced asthma; and Charlie was only 11 months old when he started to wheeze.

What practical suggestions will help us to change practice?

  • The first step is a conscious decision on the part of all clinicians to respond to a suggestive history by asking the patient to undertake peak flow ­charting. There are practical problems with this: GP consultations are often short, leaving little time to explain how to home chart, so a simple ­instruction sheet for patients may help to ­reinforce information. Some patients may need time with an asthma-trained nurse to ensure they understand what is required.
  • Peak flow meters are available on prescription, although it may be useful to have a supply to lend those patients who pay prescription charges.
  • A structured means of recording the diagnostic steps is important. Suitable templates can be designed for computer systems. "Diagnostic ­stickers" for the patient's notes are available to download from the GPIAG website (see Figure 1).(3)

[[NIP10_fig1_18]]

Treatment at steps 2 and 3

What does the guideline recommend?

  • Inhaled steroids are the recommended preventer drug for adults and children for achieving overall treatment goals.
  • Carry out a trial of other treatments before ­increasing the inhaled corticosteroid dose above 800mg a day for adults or 400mg a day for ­children.(*)

*Doses given are for beclomethasone via a metered-dose inhaler: adjust for fluticasone and/or other devices

The guideline emphasises the importance of using adequate doses of inhaled steroids to achieve control of asthma, which should then be titrated down to the lowest dose that maintains effective control. Often, relatively low and reassuringly safe doses will be sufficient for maintenance therapy.(4,5) If symptoms persist the clinical situation needs to be reassessed: Is the diagnosis correct? Is the patient using the inhaled steroid? Can they use the inhaler device? Is there an environmental trigger?

The new guideline has clarified the actions to take at "step 3". If control is not achieved with moderate doses of inhaled steroids, most patients will benefit from "add-on therapy".(6) Long-acting b-agonists are firstline in adults and older children, and leukotriene receptor antagonists are recommended in children under five. Response to treatment should be monitored so that ineffective therapy can be discontinued.

How well are we doing in our practice?
Audit criterion - The percentage of adults using more than 800µg of inhaled steroids daily who have been offered an add-on therapy.

The "step 3" audit proforma from the GPIAG website gives clear instructions on identifying adults with asthma who are using more than the recommended maintenance dose of inhaled steroids. Results already submitted suggest that the majority will already be using long-acting b-agonists.

Where can we find out more about the ­therapeutic management of asthma?
Chapter 4 of the BTS/SIGN guideline discusses the pharmacological management of asthma. Using the case studies on the BTS website within a team meeting could help to promote discussion and hopefully reach a consensus about appropriate management. The cases cover a range of ages and scenarios: Charlie's asthma deteriorates when he starts school; Bob has just had an acute attack; Mary is having problems walking the dog. Histories for participants and notes for facilitators, as well as overheads, are included.

What practical suggestions will help us change practice?

  • Regular review using standardised recording tools, such as the RCP 3 questions,(7) can facilitate ­identification of patients who are not well ­controlled and enable treatment to be modified.
  • Most inhalers are issued as "repeat prescriptions", and use of the computer to identify high use of bronchodilators can be an effective way of ­identifying those people whose asthma warrants reassessment.

Self-management plans

What does the guideline recommend?

  • Offer self-management education, including ­written asthma action plans focusing on individual needs, to all patients with asthma, particularly those admitted to hospital.
  • Every asthma consultation is an opportunity to review, reinforce and extend knowledge and skills.

Despite the evidence that the use of self-management plans improves morbidity and reduces acute attacks,(8) only a minority of patients have an "Asthma Action Plan".(9) This may be because self-management is seen as complex and time-consuming to implement.

In reality, education is a process, not an event: an initial discussion and the provision of a written action plan by an asthma nurse can lay the foundation for on-going education, which can be reinforced and refined by all healthcare professionals at every asthma consultation. An acute presentation can be used to reinforce or refine the actions the patient took in response to their symptoms. The development of hayfever can lead to a brief discussion about how to recognise the early ­symptoms of loss of asthma control.

Action plans should be written and should focus on individual needs, covering avoidance of triggers, as well as information about inhalers, encouragement to step up treatment if control deteriorates and to step down once control is regained. Some people will need emergency supplies of oral steroids.

How well are we doing in our practice?
Although the guideline is clear that all patients with asthma should have self-management education, it might be appropriate to focus initially on high-risk groups.

Audit criterion - The percentage of patients who have had an acute attack who have been given a written action plan.

Where can we find out more about the self-management of asthma?
Chapter 10 of the BTS/SIGN guideline discusses patient education and self-management. Several of the case studies feature self-management plans, particularly Mary, whose asthma is triggered when she goes to stay with her daughter who keeps cats, and Nigel, who has a history of asthma attacks.

What practical suggestions will help us to change practice?

  • Although the initial education and discussion about ­self-management may well be seen as the role of an asthma nurse, it is important that all members of the team support the concept and reinforce the messages whenever appropriate.
  • Practices will need to consider a range of resources. Suitable materials are available from the National Asthma Campaign website. Their "Be in Control" resources include diary cards and "credit card" action plans for completion by a healthcare professional. Their professional pack includes advice on using their materials.

References

  1. BRS/SIGN. British guideline on the management of asthma. Thorax 2003;58(S1):i1-i94.
  2. Stephenson P. Management of wheeze and cough in infants and pre-school children in primary care. Prim Care Respir J 2002;11(2):42-4.
  3. Ryan D, Pinnock H. Diagnosis of asthma. Opinion sheet 10. Birmingham: GPIAG; 2001.
  4. Haahtela T, et al. Comparison of a beta agonist, terbutaline, with an inhaled corticosteroid, budesonide, in newly detected asthma. N Engl J Med 1991;325:388-92.
  5. Anonymous: for the CAMP study. Long term effects of ­budesonide or nedocromil in ­children with asthma. The Childhood Asthma Management Program Research Group. N Engl J Med 2000;343:1054-63.
  6. Pauwels RA, et al. Effect of inhaled formoterol and ­budesonide on exacerbations of asthma. N Engl J Med 1997;337:1405-11.
  7. Pearson M, Bucknall C. Measuring clinical outcome in asthma: a patient focussed approach. London: RCP; 1999.
  8. Gibson PG, et al. Self-­management education and ­regular practitioner review for adults with asthma (Cochrane Review). In: Cochrane Library. Issue 1. Oxford: Update Software; 2000.
  9. Price D, Wolfe S. Delivery of asthma care: patient's use of and views on healthcare services, as determined from a nationwide interview survey. Asthma J 2000;5:141-4.

Resources
General Practice Airways Group
W:www.gpiag.org
This website includes readymade audit tools to support ­guideline ­implementation. Other resources include opinion sheets on key aspects of asthma care and ­diagnosis ­"stickers"

National Asthma Campaign (NAC)
W:www.asthma.org.uk
To order a sample pack of "Be in Control" materials, which can be used to provide written action plans, you can call
T:020 7704 5888
Alternatively, you can download the materials from the NAC website
If you wish to speak to someone about how to use the materials, the NAC helpline is staffed by asthma-trained nurses from 9am to 5pm
T:0845 7010203

Royal College of Physicians
W:www.rcplondon.ac.uk
The RCP 3 ­questions (see ref 7) are available to download onto Avery labels from the BTS website