Part 1: Understanding the changes – Asthma diagnosis & first steps in the new guidelines
In light of the recent update to the National Institute of Care Excellence (NICE) guidelines for asthma care and management, Bedfont® Scientific Limited sponsored an informative webinar by Intermedical (UK) Limited. Seasoned respiratory nurse Carol Stonham MBE led the session, where she discussed the changes to the guidelines in detail and why Fractional exhaled Nitric Oxide (FeNO) testing is vital to the asthma pathway.
In this first part of our three-part series covering this insightful webinar, we focus on the foundations: patient-centred care, changes in diagnostic criteria, and the importance of the structured clinical assessment.
Carol Stonham MBE, has been a registered nurse since 1986, transitioning from acute hospital settings to primary care by 1990. She serves at the Gloucestershire ICB and leads the Respiratory Clinical Programme Group, as well as co-leading the NHSE South West Respiratory Network. Carol is also a member of the Bedfont® Medical Advisory Board.
Intermedical (UK) Limited are a leading specialist provider of medical diagnostic and therapy equipment in the UK’s cardio-respiratory healthcare sector. Trusted in respiratory health since 1997, they are the exclusive distributor of the Bedfont® NObreath® FeNO device in the UK.
Usually, guideline updates involve adjustments to recommendations here and there, but this update represents a seismic shift in how asthma is diagnosed and managed. This blog will examine what the guidelines tell us and where FeNO fits in.
The first recommendation, which healthcare professionals (HCPs) must be aware of and follow, is that healthcare should be patient-centred. Patients should be given enough time and information to make informed decisions about their care. Unfortunately, this can be tricky if the areas in which the HCPs work have a restrictive formulary.
How is asthma diagnosed?
Firstly, as a HCP, you should take a good and clear history to ensure asthma is suspected before you test for it. It is easy to see a cough or a wheeze, but this is not how a diagnosis should be made.
The recommendation has gone from HCP-reported wheeze to just “reported wheeze”. This is something to be cautious about, as the patient’s interpretation of a wheeze could be very different from what a HCP interprets as a wheeze.
- Noisy breathing, cough, and chest tightness are the symptoms you could expect someone with asthma to have, but it is important to remember that they should vary. This means the symptoms are not the same every day; the variation could be the time of day or time of year, for example.
- The patient should be able to identify triggers, such as “my symptoms are worse when I go from warm to cold”, etc.
- You should ask about a family history of atopic disorders and be sure that the symptoms are not due to anything else. All other possibilities should be ruled out before you arrive at asthma.
Previously, the Quality and Outcomes Framework (QOF) said that more than one objective test is sufficient for an asthma diagnosis, and the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) said you could diagnose asthma with no supportive tests.
The new joint guideline from NICE/BTS/SIGN brings clarity and consistency to asthma diagnosis, stating that a diagnosis can be made with a suggestive clinical history and just one supportive objective test, making the process easier for HCPS to follow.
As mentioned in the previous guideline, when an asthma diagnosis is made, it must be recorded how you came to that diagnosis. This is an important step, as if further down the line the patient is not responding to treatment, the HCP can go back to the diagnosis and see how the diagnosis was made to be sure it was correct.
What to do with patients who are presenting?
Typically, two groups of people present in primary care: those who come in looking and feeling perfectly well but say they have been wheezy and tight-chested at times, but feel perfectly fine today. Then, some come in and are experiencing symptoms at the time, and when you delve into the history, you find that it has been going on for a little while and that something has tipped them into an exacerbation.
The guidelines say that patients must be treated if they are acutely unwell at presentation. It may be unsafe to send them away without treatment while you wait for tests. If possible, carry out a test there and then, and if the patient is not well enough to take a test or the tests aren’t available, then it is recommended that you start treatment immediately and carry out the tests when possible. However, it is recognised that by doing this, the test results could return to normal due to the treatment.
The guideline recommends the following tests for asthma diagnosis:
- Blood eosinophils,
- FeNO test,
- Spirometry,
- Peak flow with bronchodilator reversibility (BDR).
Ideally, you want to do the test there and then and choose the quickest and easiest option for the patient. Usually, tests such as spirometry and peak flow aren’t easy to do when the patient is unwell; therefore, a FeNO test would be the ideal option.
Patient examination
When examining a patient, you should look for the classic expiratory polyphonic wheeze. This is specifically seen in patients with asthma when they breathe out. However, patients presenting well that have reported being unwell may not have this wheeze, which should not rule out an asthma diagnosis, so testing should be conducted.
Test sequence
Once a clear history and a physical examination has taken place and asthma is suspected, you can move on to carrying out tests.
The first-line test for adults and young people over 16 is blood eosinophils or FeNO. While blood eosinophils may be considered appropriate for adults, a follow-up appointment to discuss the results would be required. It is possible to look up previous blood test results, but people, especially young people, do not often have regular blood tests, so this information may not be available. Unfortunately, primary care is usually short on time, so the quickest test option would be a FeNO test, if available. The test is quick and easy, non-invasive, and can be carried out within the same appointment.
- If the blood eosinophils or FeNO result suggests asthma, you do not need to proceed any further with testing, as an asthma diagnosis can be made.
- If these results do not suggest asthma, you should move on to BDR with spirometry. The guidelines recognise that spirometry isn’t as widely available as it should be, so if there is a delay in access to this test, you can move on to a peak flow diary.
- If these further tests do not suggest asthma, you can move on to the bronchial challenge. However, this is a last resort test, not a test that should be carried out in primary care. A bronchial challenge test is high risk, and you should ensure easy access to resuscitation facilities.
We will look at the test sequence for children aged 5-16 in part 2.
What’s next?
Now that the groundwork for asthma diagnosis under the new guidelines has been laid out, it is time to look at the tools transforming how we confirm the diagnosis. In Part 2, we will explore why FeNO testing is taking centre stage and how it fits into asthma care across all age groups.
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