Category: NObreath

On Wednesday, 27th November, the National Institute for Health and Care Excellence (NICE), the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN) updated and published a joint guideline on asthma diagnosis, monitoring, and chronic asthma management. 

Streamlining asthma management

BTS/SIGN and NICE published guidelines independent of each other. To align approaches to asthma care throughout the UK, NICE has undertaken a joint review with BTS and SIGN to bring harmonisation across the board. This review brings significant changes to asthma care approaches, including applying fractional exhaled nitric oxide (FeNO) testing- an objective airway inflammation test for aiding in asthma diagnosis and management.

Previously, NICE, BTS and SIGN recommended the following:NICE:

• FeNO testing was recommended for use in adults and children during asthma diagnosis.
• FeNO levels, should be measured in conjunction with other diagnostic tests (e.g., spirometry).
• For adults: A FeNO level of 40 parts per billion (ppb) or more was regarded as a positive test.
• For children and young people (5–16 years): A FeNO level of 35 ppb or more was regarded as a positive test.

BTS and SIGN:

• FeNO testing can support asthma diagnosis, particularly when the diagnosis is uncertain or symptoms suggest eosinophilic inflammation in adults and children.
• FeNO levels, should be measured in conjunction with other diagnostic tests (e.g., spirometry).
• For adults: A FeNO level of 40 ppb or more was regarded as a positive test.
• For children and young people (5–16 years): A FeNO level of 35 ppb or more was regarded as a positive test.

What is new? NICE/BTS/SIGN guideline on asthma: diagnosis, monitoring and chronic asthma management

Asthma diagnosis (adults):

The new NICE/BTS/SIGN guidelines recommend that adults with symptoms and a history suggestive of asthma undergo blood eosinophil count or FeNO testing as initial diagnostic steps. Asthma can be diagnosed if the blood eosinophil count exceeds the laboratory reference range or if FeNO levels are 50 ppb or higher. If these initial tests are inconclusive, bronchodilator reversibility (BDR) testing with spirometry is advised. When asthma remains clinically suspected despite inconclusive results from blood eosinophil count or FeNO, BDR, or peak expiratory flow (PEF) measurements, a referral for a bronchial challenge test is recommended to confirm the diagnosis if bronchial hyper-responsiveness is detected.

Asthma diagnosis (children and young people aged 5-16):

For children with symptoms suggestive of asthma, the new NICE/BTS/SIGN guidelines recommend measuring FeNO levels as a first-line diagnostic test, provided it is available. Asthma can be diagnosed if FeNO levels are 35 ppb or higher. A NICE literature review highlighted the higher specificity of FeNO testing in children, further reinforcing its use as a first-line option for both children and adults.

Asthma management (adults):

FeNO testing provides a significant advantage to health care professionals when monitoring asthma patients, including assessment of response to newly prescribed asthma therapies and regular review of adherence to medications. FeNO monitoring applications have been acknowledged globally in other well-recognised clinical guidelines, including the American Thoracic Society (ATS) and the Global Initiative for Asthma (GINA). Not acknowledged in previous asthma clinical guidelines by NICE or BTS/SIGN, a recommendation has been made to include FeNO evaluations as part of regular yearly asthma reviews in adults, alongside reviewing before and after any changes to patients’ asthma therapy.

Economic Evaluation of asthma care

Cost of exacerbations to the NHS:

NICE calculated that on average a mild to moderate exacerbation cost the NHS on average £42 per patient. This includes a GP visit (£38) and a salbutamol metered-dose inhaler (MDI) with a spacer (£4).

For severe exacerbations, the average estimated cost was thought to increase to £102 per patient. This includes 80% of patients requiring systemic glucocorticoid steroids (adults £1.88 and children £0.60), 13% of patients visiting A&E (£113), and 7% of patients needing hospitalisation (adults £1,181 and children £1,223).

FeNO cost analysis:

NICE conducted an economic evaluation of FeNO testing, factoring in the volume of tests performed on average across the UK. On average, taking into account the resource allocation of staff time and the cost of a FeNO test, an average total cost to the NHS would be £22.21 per patient. Among the eight diagnostic tests evaluated during NICE’s review, FeNO ranked as the third most cost-effective after adult blood eosinophil count and children’s blood eosinophil count.

NICE also highlighted the potential economic advantage of performing multiple tests during the same appointment, which could save time and reduce overall costs. The most cost-effective combination was spirometry and FeNO with a total cost of £34.29, followed by BDR and FeNO (£50.52) and skin prick test and FeNO, which ranked fourth most cost-effective (£50.66). These findings suggest strategic test combinations could optimise economic and clinical outcomes.

Carol Stonham, a member of Bedfont® Scientific Limited Medical Advisory Board and policy lead for Policy Care Respiratory Society (PCRS), comments “The new NICE/BTS/SIGN asthma guidelines introduce a positive step change in the diagnosis and management of asthma for adults and children. For diagnosis the necessity to perform numerous diagnostic tests has been reduced if initial testing confirms asthma, based on the evidence and cost effectiveness. In management the step away from using short acting bronchodilators to anti-inflammatory (AIR) and Maintenance and Reliever Therapy (MART) regimes should see better asthma control, less people with symptoms, and a reduction in asthma mortality.”

FeNO testing in asthma: Key takeaways from NICE guidelines

Diagnosis:

• For adults, asthma can be diagnosed if FeNO levels are 50 ppb or higher, an increase from the previous NICE guideline’s 40 ppb or higher threshold.
• For children, asthma can be diagnosed if FeNO levels are 35 ppb or higher. This has remained the same as the previous NICE guidelines.
• FeNO testing recommended first-line testing in asthma diagnosis for adults and children.
• If the first test is diagnostic further diagnostic testing is not required.

Management:

• FeNO testing has been acknowledged as a tool in asthma management.
• Aids to inform healthcare professionals when changing or adjusting asthma therapy.
• Recommending FeNO use for asthma monitoring in adults.

Costs:

NICE’s economic evaluation revealed the average FeNO test to be on average £22.21, this includes an average consumable cost of £6.37. The NObreath® device, manufactured by Bedfont® Scientific Limited prides itself on being one of the most cost-effective products on the market. On average, NObreath® consumables (£3.70 per mouthpiece) are 42%* less than the FeNO testing consumables pricing highlighted in the NICE economic evaluation (£6.37), making the overall cost for FeNO testing 12%* less than what has originally been highlighted in the NICE economic evaluation, ensuring fair and accessible pricing for both primary and secondary care alike.  

To read the full NICE guidelines, please visit: https://www.nice.org.uk/guidance/ng244

*Based on UK pricing.

References:

• Asthma pathway (BTS, NICE, SIGN) [Internet]. National Institute for Health and Care Excellence. 2024. [Cited Wednesday 27^th November 2024]. Available from: https://www.nice.org.uk/guidance/ng244

Bedfont® outlines key updates and offers support for healthcare professionals navigating the changes.

Bedfont® Scientific Ltd., world leaders in breath analysis with over 47 years of knowledge in designing and manufacturing medical breath analysis devices, welcomes the recent update to the National Institute for Health and Care Excellence (NICE) guidelines on asthma management.

Bedfont® manufactures the NObreath® Fractional exhaled Nitric Oxide (FeNO) device, which aids in diagnosing and managing asthma. Nitric oxide is a gas found in exhaled breath that indicates airway inflammation commonly found in eosinophilic asthma.

The previous guidelines for asthma management from NICE recommended FeNO testing alongside other objective tests, such as spirometry and peak flow. A FeNO reading of over 40 parts per billion (ppb) in adults and 35 ppb in children suggested a diagnosis of asthma if carried out with a positive spirometry or peak flow result.

So, what’s new? NICE released the most recent asthma guidelines on Wednesday 27^th of November, which recommends a blood test to measure eosinophil levels, or a FeNO test to diagnose asthma in adults. A FeNO test is recommended as the first-line test for an asthma diagnosis in children. Confirmation of a positive asthma diagnosis is a FeNO level exceeding 50 ppb in adults and 35 ppb in children.

It is also proposed that FeNO tests should be offered at regular adult asthma reviews for monitoring, including before and after changing asthma medication. A FeNO test should also be undertaken if a patient presents with poorly controlled asthma.

Jason Smith, CEO at Bedfont® comments “We welcome the updated NICE guidelines, which provide even greater clarity and emphasis on the role of FeNO testing in asthma care. These updates underscore the importance of

FeNO testing as an essential tool in improving diagnostic accuracy and tailoring treatment plans to individual patient needs. At Bedfont® we are proud to support healthcare professionals with our innovative NObreath® FeNO testing device that aligns with the latest clinical guidance, ultimately helping to deliver better outcomes for people with asthma.”

In light of the changes to asthma care and management recommendations, Bedfont® will host various educational resources, such as webinars and articles, to discuss these changes and what they mean for healthcare professionals carrying out FeNO tests.

For a more in-depth look at the guideline updates, read our latest article here: https://www.bedfont.com/new-nice-guidelines-for-asthma-feno-testing-and-the-nobreath-device-in-adult-and-paediatric-care/

References

Asthma pathway (BTS, NICE, SIGN) [Internet]. National Institute for Health and Care Excellence. 2024. [Cited Wednesday 27th November 2024]. Available from: https://www.nice.org.uk/guidance/ng244

Love Your Lungs Week is a national awareness event which occurs annually in June, taking place from 21st June to 27th June 2024. Initiated by the British Lung Foundation, now known as Asthma and Lung UK, the event focuses on enhancing lung health and looks to raise awareness of a variety of respiratory conditions that affect lung health. One of these conditions is asthma, which is a chronic condition where the airways become inflamed and narrowed, making breathing difficult.

Symptoms of asthma include:

• Coughing
• Wheezing
• Chest tightness
• Shortness of breath

What causes asthma?

It is thought that asthma is caused by a combination of genetic and environmental factors; when exposed to various irritants and substances, it can trigger asthma symptoms. There are 2 types of asthma; allergy-induced asthma and non-allergy induced asthma. Both types can have different triggers and these can vary from person to person.

Allergy-induced asthma is the most common form and can be triggered by inhaling allergens. This
can lead to an immune response in the airways which causes the symptoms of asthma. Common
allergens include:

• Pollen: From trees, grass and weeds.
• Dust Mites: Tiny creatures that thrive in household dust.
• Pet Fur: Shed by cats, dogs and other furry pets.
• Mould: Fungai that can grow indoors or outdoors in moist environments.

If these allergens are inhaled by someone with allergy-induced asthma, an allergic reaction can take place that causes the airways to swell, narrow and produce excess mucus.

Non-allergy induced asthma does not depend on an allergic reaction and is often triggered by factors not relating to allergies.

These can include:

• Respiratory Infections: Such as the common cold or influenza.
• Exercise: Especially in cold or dry air.
• Stress and Emotions: Intense emotions can lead to hyperventilation and tightness in the chest.
• Airborne Irritants: Such as smoke, chemical fumes, strong odours, or pollutants.

These triggers can cause the airways to swell and narrow but do not involve an allergic response. Instead, they may involve different inflammatory responses or hypersensitivity of the airways.

What impact does asthma have?

Asthma can have a significant impact on people’s lives, affecting their physical health, mental well- being and quality of life. The condition imposes lifestyle limitations, with sufferers often avoiding activities that might trigger symptoms, along with the economic burden from continuous medical care and loss of productivity due to absences from work or school.

Unfortunately, asthma-related emergency admissions remain high at over 35,000 in both adults and
children in the UK¹, and with 1,261 people sadly passing away in 2020¹, it is clear more needs to be
done to avoid these numbers increasing.

What about FeNO testing?

Fractional Exhaled Nitric Oxide (FeNO) is found in exhaled breath and can aid in the diagnosis and treatment of asthma. FeNO is naturally produced in the lungs through a complex biological process. The measurement of FeNO helps assess the level of inflammation in the lungs, aiding in the diagnosis and treatment of asthma. Using a FeNO device like the NObreath® is a quick and easy, non-invasive way to read a person’s FeNO level. FeNO testing is especially useful for managing asthma in patients who are known to have allergic triggers, as it specifically measures the type of inflammation most commonly associated with allergic asthma.

How does FeNO fit into asthma management?

• Diagnosis: FeNO testing can help in diagnosing asthma in cases where typical diagnostic tests (like spirometry) might not be conclusive. Elevated FeNO levels can suggest eosinophilic inflammation, which is a common underlying cause in many asthma patients.
• Monitoring: For ongoing asthma management, FeNO levels can provide insight into how well inflammation is being controlled through medication, particularly inhaled corticosteroids.
• Monitoring FeNO can help in adjusting medications more precisely to reduce inflammation.
• Predicting Exacerbations: High FeNO levels can indicate poorly controlled asthma and predict potential exacerbations. This can be particularly useful in managing patients who have periodic flare-ups, allowing for preventive adjustments in treatment.
• Assessing Treatment Response: Regular FeNO testing can assess the effectiveness of current asthma treatment regimens. If FeNO levels remain high despite treatment, it might suggest the need for alternative therapies or more aggressive management.

With World Asthma Day just a little over a month ago now, this years theme “Asthma Education Empowers” aimed to highlight the importance of education in asthma diagnosis and treatment. It is clear that the innovative approaches to its management, including FeNO testing, have never been more essential.

Bedfont® Scientific Limited, are world leaders in breath analysis, with over 47 years of expertise and knowledge in designing and manufacturing breath analysis devices. They are committed to improving patient safety through innovating breath analysis devices, such as the NObreath®. The device is a portable handheld FeNO device, used by healthcare professionals to aid in the diagnosis and treatment of asthma.

Bedfont® hosted an insightful webinar which looked in depth at how FeNO testing can empower and educate healthcare professionals alike. To read the Bedfont® blog article on this subject, and to watch the webinar, please click here.

1. Public health profiles. Office for Health Improvement & Disparities. [cited on 7/5/24] Available from
https://fingertips.phe.org.uk/search/asthma

A history of Fractional exhaled Nitric Oxide (FeNO) testing: where it all began

The story of FeNO began in the 1990s after it gained a lot of interest from researchers in the potential it posed as a non-invasive biomarker for airway inflammation. When airways are inflamed, Nitric Oxide (NO) is naturally produced by your body to help combat inflammation. This production of NO was observed by researchers to be significantly higher in patients with asthma. Researchers initially used a technology called ‘chemiluminescence’, to undertake research into FeNO and asthma. Over time, as FeNO testing evolved, so did available technologies on the market, and FeNO testing with electrochemical sensors was introduced as a more robust and cost-effective solution.

Chemiluminescence vs electrochemical FeNO technology: why electrochemical sensor technology is now considered ‘gold standard’

Both chemiluminescence and electrochemical sensor technology is adopted as a means of measuring and quantifying levels of nitric oxide in exhaled breath. Although both technologies are incredibly accurate and reliable when measuring exhaled nitric oxide, they both have note-worthy differences⁹. Whilst considered a highly sensitive and specific method for testing exhaled nitric oxide, chemiluminescence technology has some significant drawbacks, including the costly nature of the technology, and the additional complexity of using chemiluminescence devices⁹.

Chemiluminescence technology often requires additional specialist training as well as extra requirements for regular maintenance and calibration, which can lead to significant hikes in operational costs. Additionally, the size and portability of chemiluminescence devices are often at a disadvantage, as devices tend to be very bulky and less portable in comparison to other FeNO technologies such as electrochemical FeNO technology⁹.

Because of the difficulties chemiluminescence technology presented for widespread adoption in clinical practice, electrochemical technology was considered an alternative technology for carrying out FeNO testing in secondary and primary care. A number of studies were carried out comparing chemiluminescence technology to electrochemical technology, which found that there was a good correlation between the two technologies. A revolutionary finding, due to the cost-effective, accurate and portable nature of electrochemical technology for FeNO testing.

Electrochemical Technology and NObreath^®: Dawn of A New Era

The need for more cost-effective, portable, and accurate solutions for FeNO testing was found in electrochemical technology, and a flurry of innovation from med-tech industries ensued, the NObreath^® was born.

The NObreath^® was developed by Bedfont^® Scientific Ltd. in 2008, reflecting on over 10 years of FeNO development. Taking into consideration any obstacles current FeNO technology highlighted on market, the aim for Bedfont^® was to develop the ultimate FeNO test solution, creating an electrochemical FeNO device developed with health care providers and patients in mind.

NObreath^® vs alternative electrochemical FeNO technologies on the market: are they just as accurate?

NObreath^® has been developed with accuracy and repeatability in mind and has been subject to the stringent processes of CE, FDA, CFDA and PMDA clearance (to name but a few) as part of their respective product registration and have also been shown in clinical research to result in excellent repeatability, reproducibility and comparability.

Additionally, the NObreath^® device’s electrochemical sensor has been validated against chemiluminescence technology and has shown a good correlation between both technologies⁷. The NObreath^® has been subject to many clinical studies and case study write-ups proving its accuracy and repeatability.

Further to clinical studies, case studies, and scrutiny by a number of different regulatory bodies, NObreath^® has been subject to a number of lab condition tests to ensure accuracy, repeatability and stability of the electrochemical sensor, for up to 29,000 tests*, giving patients and healthcare professionals continued and accurate use with the NObreath®.

Finally, in addition to FeNO testing being a widely adopted test for airway inflammation in asthma patients such as ATS and ERS FeNO guidelines1, the NObreath^® is one of three FeNO devices recommended by NICE⁵, an independent international organisation responsible for driving improvement and excellence in the health and social care system.

NObreath^®: Breaking barriers in innovation and accessibility for all

NObreath^® breaks barriers with its innovative features, making NObreath^® the device of choice for healthcare providers.

Instant results

Why wait? Save precious clinic time with the NObreath^® by receiving an instant and accurate FeNO test result.

‘No nonsense’ pricing for a cost-effective solution

NObreath^® prides itself on being the most cost-effective FeNO solution on the market, by providing competitive pricing for mouthpieces and NObreath^® devices. This is in addition to a long shelf life for mouthpieces, making test per patient the most cost-effective solution for operational overheads, increasing accessibility to all.

Incentive flow rate

The NObreath^® has a selection of incentive flow rates suitable for all ages, to ensure patients exhale to a flow rate of 50ml/s for optimal and accurate FeNO testing.

FeNO testing without limits

The NObreath^® has been designed to ensure continued use, meaning your device can be used over and over again**, reducing cost to your clinic, and limiting wastage for better environmental sustainability. Furthermore, to ensure continued use of your NObreath^®, our easy ‘plug and play’ components mean healthcare professionals can easily maintain the NObreath^® on-site without having to delay or suspend clinics due to off-site servicing or delay in having to purchase a new FeNO device.

Integrated infection control

The NObreath^® device has integrated antimicrobial technology, in addition to integrated bacterial and viral filters in the NObreath^® mouthpieces for improved infection control. Simple exhalation-only technique.

Simple exhalation-only technique

The exhalation-only technique on the NObreath^® makes FeNO testing easy for all. There is no need to inhale through the device, as our partitioning method ensures any ambient NO is removed from the breath sample. As the breath sample enters the NObreath^®, the first few seconds are partitioned and vented through the monitor bypassing the sensor chamber. After the partition period has elapsed, the pump will begin to draw the remaining viable sample into the sensor chamber, where the breath sample will be analysed in real-time. As the sensor measures the sample in real-time, by the end of the test, the result is instantly shown onscreen. Removal of potential environmental NO is advised by ‘ATS/ERS recommendations 2005 for standardized procedures for the measurement of exhaled nitric oxide (FeNO) testing’¹, so you can have peace of mind that your FeNO result is accurate and dependable. Learn more about our partitioning method here: https://www.nobreathfeno.com/measuring-feno-with-the-nobreath/

Electrochemical technology: The new ‘gold standard’ for FeNO testing

The evidence showing the comparison to the NObreath^® electrochemical FeNO device is directly comparable to chemiluminescence technology and other available electrochemical FeNO technology on the market; you can be sure that you own the ultimate FeNO test solution, an easy-to-use exhalation-only device, providing health care professionals with accurate and reliable results, utilising ‘gold standard’ and cost-effective electrochemical technology, with added portability for clinic use, and much more.

Visit https://www.nobreathfeno.com to find out how you can support your patients with FeNO monitoring, with the NObreath^® from Bedfont^® Scientific Ltd.

*Subject to correct use, maintenance and servicing
** Subject to 29,000 tests

References:
1. American Thoracic Society and European Respiratory Society. ATS/ERS recommendations for standardized procedures for the online and offline measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide. American Journal of Respiratory and Critical Care Medicine. 2005;171(8):912-930.

2. Inoue Y, Sato S, Manabe T, Makita E, Chiyotanda M, Takahashi K, Yamamoto H, Yanagida N, and Ebisawa M. Measurement of exhaled nitric oxide in children: A comparison between NObreath® and NIOX VERO® analyzers. Allergy, asthma and immunology research. 2018;10(5):478-489.

3. Harnan SE, Tappenden P, Essat M, Gomersall T, Minton J, Wong R, Pavord I, Everard M, and Lawson R. Measurement of exhaled nitric oxide concentration in asthma: A Systematic review and economic evaluation of NIOX MINO®, NIOX VERO®, and NObreath®. Health Technology Assessment. 2015;19(82):1-330.

4. Kang SY, Lee SM, and Lee SP. Measurement of fractional exhaled nitric oxide in adults: comparison of two different analysers (NIOX VERO® and NObreath®). Tuberculosis and Respiratory Diseases. 2021;84(3):182-187.

5. National Institute for Health and Care Excellence. Measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO®, NIOX VERO®, and NObreath®[DG12]. 2014. Available from: https://www.nice.org.uk/guidance/dg12/chapter/5-Outcomes

6. Pisi R, Aiello M, Tzani P, Marangio E, Olivieri D, and Chetta A. Measurement of fractional exhaled nitric oxide by a new portable device: comparison with the standard technique. Journal of Asthma. 2010;47(7):805-809.

7. Antus B, Horvath I, and Barta I. Assessment of exhaled nitric oxide by a new hand-held device. Respiratory Medicine. 2010;104(9):1377-1380.

8. Yune S, Lee JY, Choi DC, and Lee BY. Fractional exhaled nitric oxide: Comparison between portable devices and correlation with sputum eosinophils. Allergy, Asthma and Immunology Research. 2015;7(4);404-408.

9. Maniscalco M;Vitale C;Vatrella A;Molino A;Bianco A;Mazzarella G; M. Fractional exhaled nitric oxide-measuring devices: Technology updateMauro [Internet]. U.S. National Library of Medicine; 2016 [cited 2023 Nov 22]. Available from: https://pubmed.ncbi.nlm.nih.gov/27382340/

As we enter the winter months and it becomes cold outside, the air we breathe is dry and the protected fluid in our lungs evaporates. This environmental change triggers the muscles within our lungs to spasm as they work to maintain open airways, resulting in increased tightness and difficulty breathing. While asthma symptoms persist throughout the year, they can escalate during winter, aggravating issues such as chest pain, coughing, shortness of breath, chest tightness, and wheezing¹.

Asthma is recognised in part by the variability of symptoms. Indeed, this variability is a key consideration in making the diagnosis of asthma². Once a diagnosis is confirmed, asthma symptoms can continue to demonstrate variability. This variability may be unpredictable and unexpected due to the natural disease process, or more predictable because of exposure to individual triggers.

Asthma guidelines state that if symptoms worsen, the clinician should check adherence with prescribed medication, check inhaler technique and remove triggers². This may be overlooked when increasing doses of inhaled medication or prescribing additional medications. It is worth thinking about how this can be done in practice.

Medication adherence can be a tricky subject to bring into the consultation. It is a complex mix of patients’ health beliefs or misjudgement of their condition^3,4 and can also be influenced by cultural beliefs⁵. It is a fascinating subject and worth looking into in more depth to get an understanding of why some people will not take prescribed medication whether it is an intentional decision or a non-intentional action. The attitude and experience of the prescribing clinician can also influence a patient’s decision to adhere to a prescribed medication regimen⁶.

One of the strategies we tend to use to assess adherence is to look at the prescribing history – has the patient been prescribed adequate treatment (inhaled steroid-containing inhaler) to be taking it regularly as prescribed? Has the patient ordered excessive amounts of rescue medication (Salbutamol or Terbutaline) indicating poor symptom control? The national review of asthma deaths⁷ found these measures were potential contributors to mortality. Salbutamol overuse is the focus of the global social movement Asthma Right Care⁸, in part because of the recognised link between the overuse of rescue medication and the increase in asthma mortality and morbidity.

Another approach that can help when assessing adherence with inhaled corticosteroids is to measure fractional exhaled nitric oxide (FeNO). This measures eosinophilic airway inflammation which is a key component of most asthma types. If inhaled corticosteroids are taken regularly using the correct inhaler technique, this inflammation should be controlled unless a dose increase or addition of add-on therapy is required. If the patient is not taking regular treatment or is taking it using a poor technique, the airways will demonstrate this inflammation. If the test is undertaken following a clear explanation of what asthma is, how inhalers work and what the test will measure, the discussion on inhaler use has a good basis to work from – many people with asthma do not understand the disease process and how inhalers work so do not take them regularly. For those who are adherent with medication who can demonstrate good inhaler technique, a raised FeNO level may be an indication of the need to increase or add in medication.

Suboptimal inhaler technique is a common cause of increasing asthma symptoms and poor asthma control, yet is very common⁹. According to the systematic review published in 2016, only 31% of patients can use an inhaler correctly, and the inhaler technique has not improved over the past 40 years¹⁰.

Guidelines emphasize the importance of correct inhaler technique before escalating treatment², yet many healthcare practitioners are not confident or indeed competent in checking and coaching patients to optimise the use of inhalers. To address this, the UK Inhaler Group have produced a Standards and Competency document¹¹ to guide and encourage appropriate teaching and coaching of inhaler technique.

Checking the correct inhaler technique and assessing adherence with prescribed medication are 2 of the basics to check if a person presents with increasing asthma symptoms (not sudden acute asthma) especially if the person is found with raised FeNO levels.

The third element is to discuss and, where possible, eliminate asthma triggers. Whilst asthma has a natural variability which can often be unexpected and unpredictable, there are more obvious triggers that may be specific to the individual and will be known to increase asthma symptoms. There are a wide range of triggers from seasonal elements – increasing pollens in the spring and through summer, dampness and moulds in autumn, and respiratory infections in the winter – through exposure to perfumes and smoke, pets and animals, and house dust mites and many others besides.

Whilst some of these can also be unpredictable there are elements, especially as we go into winter for example, where a person knows from past experience that a particular season will ‘set them off’. The population with long-term health conditions are offered protection against some respiratory infections with vaccinations but viral infections have been found to cause up to 70% of asthma exacerbations¹². So, what can we do to protect our patients with asthma as we move into winter in addition to vaccine administration? During the COVID-19 pandemic where social distancing rules and mask-wearing were mandated, there was a reduction in admissions to hospitals from long-term respiratory conditions but this is not an acceptable strategy in the future.

What we can do is be sure that our patients have the appropriate medication in a device that they can and will use on a regular basis to optimise asthma control leading up to known predictable periods of likely exacerbation. The basis of this must be the patient’s understanding of what asthma is and an understanding of the expected effects of prescribed medication, supported with a personalised asthma action plan that will help patients to know their potential when asthma control is optimal, to recognise deterioration and know how to act and adjust medications safely, when to seek help and from whom.

There are various tools that will help in this patient journey such as placebo inhaler devices to practice and optimise inhaler technique, and diagrams and airway models to improve understanding of asthma. Measurement of lung function using a peak flow meter when a patient, as well as a comparator when a patient has increasing symptoms, is helpful. Measurement of FeNO is a valuable addition to the asthma toolbox to measure airway inflammation which will help the patient better understand what asthma is and how inhaled medication, in particular inhaled steroids, target inflammation. In symptomatic patients, it can open conversations around adherence and inhaler technique, guide step-up and step-down treatment decisions, and work as part of the toolkit to optimise asthma control.

Delve deeper into the impacts of winter and asthma care in our upcoming webinar with Carol Stonham; Battling Winter Wheezes: How Cold Weather Impacts Asthma and the Benefits of FeNO Monitoring, being held on Tuesday 9th January 2024 at 7pm. Learn how FeNO measurements play a pivotal role in monitoring and managing respiratory health during colder months.

References:

1. Why asthma is worse in winter [Internet]. Temple Health. 2021. [Cited Monday 13th November 2023]. Available from: https://www.templehealth.org/about/blog/why-asthma-worse-in-winter
2. British Thoracic Society, SIGN. BTS/SIGN Guideline for the management of asthma. Available from https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ [Last accessed 24.10.2023]
3. Brandstetter S, Finger T, Fischer W, et al. Differences in medication adherence are associated with beliefs about medicines in asthma and COPD. Clin Transl Allergy. 2017;7(1):1–7. doi: 10.1186/s13601-017-0175-6
4. Ahmedani BK, Peterson EL, Wells KE, et al. Asthma medication adherence: the role of God and other health locus of control factors. Ann Allergy Asthma Immunol. 2013;110(2):75-79. e2. doi: 10.1016/j.anai.2012.11.006
5. Kaplan A, Mitchell PD, Cave AJ, et al. Effective asthma management: is it time to let the AIR out of SABA? J Clin Med 9(4):921. doi: 10.3390/jcm904092
6. van Boven JF, Ryan D, Eakin MN, et al. Enhancing respiratory medication adherence: the role of health care professionals and cost-effectiveness considerations. J Allergy Clin Immunol Pract 4(5):835–846. doi: 10.1016/j.jaip.2016.03.007
7. National review of asthma deaths. Why asthma still kills (2014). Available from https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills [Last accessed 24.10.2023]
8. Asthma Right Care (PCRS) available from https://www.pcrs-uk.org/campaign/asthma-right-care [Last accessed 24.10.23]
9. van der Palen J, Thomas M, Chrystyn H, Sharma RK, van der Valk pd, Goosens M, Wilkinson T, Stonham C, Chauhan AJ, Imber V, Svedsater H, Barnes NC. A randomised open-label cross-over study of inhaler errors, preference and time to achieve correct inhaler use in patients with COPD or asthma: comparison of ELLIPTA with other inhaler devices npj Primary Care Respiratory Medicine volume 26, Article number: 16079 (2016) [last accessed 24.10.2023]
10. Sanchis J, Gich I, Pedersen S, et al Systematic review of errors in inhaler use: has patient technique improved over time?Chest 2016;150:394-406. doi:10.1016/j.chest.2016.03.041pmid:http://www.ncbi.nlm.nih.gov/pubmed/270607 26
11. UK Inhaler Group (2016, reviewed 2019) Inhaler Standards and Competency Document. Available from https://www.ukinhalergroup.co.uk/uploads/s4vjR3GZ/InhalerStandardsMASTER.docx 2019V10final.pdf [Last accessed 24.10.2023]
12. Hammond C, Kurten M, Kennedy JL. Rhinovirus and asthma: A storied history of incompatibility. Curr Allergy Asthma Rep. 2015;15:502.