Författare: sian

FeNO Testing in Asthma Care

Although airway eosinophilic inflammation is a key characteristic of asthma, there are few methods available to measure it. This inflammation can be assessed by measuring eosinophils and eosinophilic cationic protein (ECP) in sputum or by measuring ECP in blood samples¹. However, these methods are considered time-consuming, expensive, and not readily available.

For most asthma patients, airway inflammation is driven by an allergen-induced Th2 response². Evidence from the literature suggests that fractional exhaled nitric oxide (FeNO) is a crucial biomarker for respiratory tract inflammation². Elevated FeNO levels in asthma are thought to result from inducible NOS2 expression in the inflamed airways². The NObreath® FeNO device provides a non-invasive and significantly more cost-effective alternative aid to diagnose asthma and assess airway eosinophilic inflammation.

This article delves into the challenges encountered within primary care and how the innovative technology of the NObreath® can assist. Additionally, the article discusses the transition of the use of the NObreath® from primary care environments to secondary care facilities.

Challenges in Primary Care

GPs often face restricted budgets due to resource allocation for population needs, and financial sustainability to stay within healthcare budgets and prevent overspending. Each patient appointment is typically limited to just 10 minutes.

Population needs

In the UK, approximately 5.4 million people, or about 8 in every 100 individuals, suffer from asthma³. The National Review of Asthma Deaths (NRAD) documented 195 asthma-related deaths among adults in 2013, highlighting preventable factors in 89 of the 195 deaths (46%), such as lack of specific asthma expertise (17%) and non-adherence to UK asthma guidelines (25%)⁴. FeNO testing is valuable in GP settings, as GPs often encounter a spectrum of asthma cases, from mild to severe. The NObreath® device facilitates rapid and reliable FeNO measurements, to allow GPs to make informed decisions and aid in identifying patients who do or do not require ongoing treatment⁵. This also reduces emergency visits and hospital admissions related to poorly controlled asthma.

Financial sustainability

One of the ongoing challenges in primary care is maintaining financial sustainability. The NObreath® FeNO device is cost-effective, with minimal ongoing costs. The device requires only one consumable- the NObreath® mouthpiece which has a long shelf life and an integrated infection control filter, effectively removes airborne bacteria (>99%) and viruses (>98%)⁶. The device also incurs low annual servicing costs and imposes no test limits*.

Time with patient

When a GP determines the need for a FeNO test using the NObreath®, there’s no warm-up time, and the device operates through a simple exhale-only technique with on-screen visual guidance. Patients receive instant results, eliminating wait times. Intended for adult and paediatric patients**, the NObreath® offers two test modes: a 10-second test mode for those up to 10 years old who cannot complete the 12-second test mode.  GPs can store up to 25 results in up to 50 patient profiles and view a graph of results. If a GP office possesses only one NObreath®, they benefit from the device size and portability, ensuring that healthcare providers can efficiently utilise the device wherever patient care demands.

Carol Stonham, a member of Bedfont® Scientific Limited Medical Advisory Board and policy lead for Policy Care Respiratory Society (PCRS), comments “The NObreath® is my preferred choice for primary care in managing asthma for many reasons. Primarily it suits the unpredictability of the volume of testing in primary care – none of the consumables or device needs to be used or lost in a short time frame. It is an intuitive machine which is easy to use and teaches patients of all ages.”

Primary Care to Secondary Care

Using the NObreath® device in primary care can reduce the number of inappropriate referrals to secondary care clinics. However, if a patient is referred to an asthma specialist in secondary care, the NObreath® FeNO device can aid in the diagnosis and management of asthma. The NObreath® helps differentiate between allergic (eosinophilic) and non-allergic asthma⁷. FeNO measurements show the patient’s response to the treatment, enabling accurate prescription of medication and safer, monitored adjustments. This helps patients understand their condition better by demonstrating how their FeNO levels correlate with their symptoms and treatment adherence. Measuring airway inflammation with the NObreath® can help monitor the effectiveness of medication and predict the risk of asthma attacks⁸***

Gold Standard FeNO Testing

FeNO testing is increasingly recognised as a valuable tool in the management of asthma, but what makes the NObreath® stand out from other FeNO devices on the market? Developed by Bedfont® in 2008, the NObreath® has over 15 years of clinical use and has been featured in numerous studies worldwide, contributing to the advancement of FeNO testing. Conforming to both the American Thoracic Society (ATS) and European Respiratory Society (ERS) guidelines, the NObreath® is also one of three FeNO devices recommended by the National Institute for Health Care Excellence (NICE)⁹, an independent international organisation providing national guidance and advice to improve health and social care.

To find out how you can support your patients with FeNO testing in asthma care with the NObreath®, please visit: https://www.nobreathfeno.com/

*The NObreath® has been validated for up to 29,000 tests when used as instructed and properly maintained and serviced. The number of tests can be periodically checked within the settings of the device; when 29,000 tests are reached a service is recommended. Contact your local service centre.

**NObreath® can be used on paediatric and adult patients, provided they can follow test protocol. USA only: NObreath® can be used on patients 7+ years old.

***FeNO is not a definitive indication of asthma and should be used in conjunction with (but not limited to) spirometry, patient history, and symptoms.

References:

1. Pizzichini E, Pizzichini MM, Efthimiadis A, Dolovich J, Hargreave FE. Measuring airway inflammation in asthma: eosinophils and eosinophilic cationic protein in induced sputum compared with peripheral blood. Journal of allergy and clinical immunology. 1997 Apr 1;99(4):539-44. DOI: 10.1016/S0091-6749(97)70082-4.
2. Keller AC, Rodriguez D, Russo M. Nitric oxide paradox in asthma. Memórias do Instituto Oswaldo Cruz. 2005;100:19-23. PMID: 15962094 DOI: 10.1590/s0074-02762005000900005.
3. What is Asthma? [Internet]. Asthma+ Lung UK. 2024. [Cited Monday 8^th July 2024]. Available from: https://www.asthmaandlung.org.uk/conditions/asthma/what-asthma#:~:text=Asthma%20is%20a%20common%20condition,cough%20or%20a%20tight%20chest.
4. Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Report. London, RCP; 2014.
5. Taylor DR, Pijnenburg MW, Smith AD, Jongste J. Exhaled nitric oxide measurements: clinical application and interpretation. Thorax. 2006 Sep 1;61(9):817-27. PMID: 16936238 PMCID: PMC2117092 DOI: 10.1136/thx.2005.056093.
6. Public Health England. An Evaluation of Filtration Efficiencies Against Bacterial and Viral Aerosol Challenges. Salisbury: Public Health England; 2020.
7. Ref: Coumou H, Bel EH. Improving the diagnosis of eosinophilic asthma. Expert review of respiratory medicine. 2016 Oct 2;10(10):1093-103. DOI: 10.1080/17476348.2017.1236688.
8. Saito J, Gibeon D, Macedo P, Menzies-Gow A, Bhavsar PK, Chung KF. Domiciliary diurnal variation of exhaled nitric oxide fraction for asthma control. European Respiratory Journal. 2014 Feb 1;43(2):474-84. DOI: 10.1183/09031936.00048513.
9. Measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO, NIOX VERO and NObreath [Internet]. National Institute for Health and Care Excellence. 2014. [Cited Wednesday 10^th July 2024]. Available from: https://www.nice.org.uk/guidance/dg12/chapter/5-Outcomes

A series of events and initiatives culminate in remarkable fundraising achievements by Med-Tech company Bedfont® and NewMed.

Bedfont® Scientific Ltd. world leaders in breath analysis, with over 47 years of expertise in the design and manufacture of medical breath analysis devices, welcomed the roaming Shaun the Sheep sculpture to its offices on Friday, 26th July, for the exciting announcement. Bedfont® teamed up with NewMed Ltd. earlier in the year to sponsor and support Heart of Kent Hospice and its various charity events throughout the year, and are extremely proud to have contributed to raising over £28,000.

Heart of Kent Hospice, based in Aylesford, is a charity with a passion for improving quality of life and provides specialist care and support to adults with terminal illnesses. Bedfont®, along with NewMed, have been actively involved in a variety of fundraising events for Heart of Kent Hospice, and have been engaging employees and the community to support this worthy cause.

In May, Bedfont® participated in the Bluebell Walk, following a picturesque walk through the North Downs and raised substantial funds through sponsorships and raffles. Bedfont® also proudly sponsored a beautiful Shaun the Sheep sculpture for the Hospice’s Shaun in the Heart of Kent art trail, the event not only highlights local artistry but also draws significant attention to the hospice’s mission. Additionally, Bedfont® took part in the Shaun the Sheep Selfie Challenge, capturing joyful moments and sharing them widely to further boost donations and awareness.

Jason Smith, Managing Director at Bedfont® Scientific Ltd., comments “At Bedfont®, we believe in the power of community and the importance of giving back. Our partnership with NewMed Ltd. and our ongoing support for the hospice, reflect our commitment to making a positive impact on the lives of those around us. We look forward to continuing our efforts and exploring new ways to support Heart of Kent Hospice in the future”

David Dadswell, Corporate Partnerships Manager at Heart of Kent Hospice, commented “Collaborating with the local business community plays a pivotal role in the Hospice’s strategy, and allows us to create increased awareness of the services we provide and supports our fundraising events to deliver the best experience for all those who participate. Both Bedfont® Scientific and NewMed fully immersed themselves into the recent Bluebell Walk as headline sponsors, exhibitors, and participants and through their efforts, we raised over £28,000. It’s the perfect partnership between organisations that have strong values around healthcare and a commitment to giving back to their local communities.

To find out more about Bedfont® and the continued efforts in supporting Heart of Kent Hospice, follow us on social media @BedfontLtd

Like any healthcare investment, consideration needs to be given when deciding which fractional exhaled nitric oxide (FeNO) device might best suit the clinical area in which it will be used. So, what would be sensible to consider when including FeNO devices for implementation into the respiratory pathway? And how does the NObreath® measure up?

External approval is an important factor in healthcare device purchase. It acts as an independent validation of quality and reliability. In England, approval from the National Institute of Health and Care Excellence (NICE) demonstrates that a device or medicine has been assessed by independent committees and has made evidence-based recommendations for the health and social care sector^1. Technology appraisals² assess the clinical and cost-effectiveness of health technology, including devices such as the FeNO device. As the technology market increases and additional devices are brought to market, it is important to investigate what external approval a device has received, and that it has undertaken an independent process before approval. The NObreath® has successfully undergone the required NICE technology appraisal.

Reassurance that tests performed are accurate, and repeatedly so, is vital in healthcare. The evidence for individual devices is reviewed as a part of the NICE technology appraisal. A device that is CE-marked also ensures that the manufacturer conforms to European standards for health, safety and environmental requirements.

A vital component in any healthcare system is the cost. As with many healthcare devices, this extends beyond the initial price tag. Is there an ongoing maintenance cost? What is the cost of the consumables such as mouthpieces required? Is there any potential for waste? Will the device offer longevity in a pathway if it is correctly maintained?

When considering cost, it is also worth considering the value of including the test and the potential price of not including FeNO in a respiratory pathway. Is there the potential for other costs to emerge without the test? Incorrect diagnosis resulting in lifelong unnecessary inhaled medication is seen in asthma³,with the associated costs to the patient and the healthcare system along with the additional burden a diagnosis of asthma can bring. Alternately, the cost and burden of a missed diagnosis can also occur leaving patients with untreated symptoms and the associated risk of asthma. Objective tests including FeNO are recommended^4,5,6 in making an accurate diagnosis of asthma.

Tests that are simple to perform are more likely to be used in primary care where time is short. Recent research has found many competing priorities for services currently and the pressure on workforce training and capacity⁷ has impacted primary care’s ability to reinstate spirometry services. Despite funded training for spirometry in England, it has been slow to increase because of the complexity and time taken to achieve the required standard and registration. The requirement for competence in using a FeNO device is not as onerous, does not take long to complete and is free to complete in the UK. New technology should ideally be easy for patients to use, easy for competent healthcare professionals to teach to others who might undertake testing, and suitable for testing on a broad age range. FeNO testing meets all the criteria, it is a quick simple test that is relatively easy for all ages to perform with minimal coaching, and the test procedure is easy to teach to others.  

A device that is portable and can be moved between consulting rooms will increase its use and test availability for patients. This allows a FeNO test to be quickly and easily integrated into relevant primary care consultations.

One of the most impactful things that healthcare professionals are influenced by are guidelines. These may be international, national or local guidelines. FeNO has an identified place in the current guidelines ^4,5,6. As guidelines progress to reflect the most current evidence, it is likely that FeNO testing as a part of the diagnostic process, and as a tool to monitor established asthma, will become more prominent.

Comparing the Bedfont® NObreath® FeNO device against these considerations, is it a good choice? The NObreath® has successfully been through the NICE technology appraisal so has demonstrated that it is a clinically effective device offering reliable repeatable testing and is cost-effective. The NObreath® is a non-invasive device with visual incentives to encourage patients of all ages to achieve optimal flow rate for testing. The test settings can be used for adults and children so is an all-age device. It is simple to explain and easy for patients to perform, taking a minimal amount of valuable consultation time. It is small, and easily transported. It requires annual servicing and minimal consumables and can be used as a functional device for many years.

Taking advantage of these features, some practices and primary care networks have taught all clinicians how to perform the test when the patient initially presents with a history and symptoms of asthma, so that treatment can begin without delay and the patient can be reviewed with steroid naive FeNO results as the national and international guidelines recommend.

References:

1. National Institute for Health and Care Excellence (2024). Available from https://www.nice.org.uk/guidance [Last accessed 19.6.24]
2. National Institute for Health and Care Excellence (2024). Available from https://www.nice.org.uk/About/What-we-do/Our-Programmes/NICE-guidance/NICE-technology-appraisal-guidance [Last accessed 19.6.24]
3. Aaron SD, Vandemheem KL, FitzGerald JM, Ainslie M, Gupta S et al.: Canadian Respiratory Research Network. Re-evaluation of diagnosis in adults with physician-diagnosed asthma. JAMA 2017;317:269-279
4. British Thoracic Society (2019)Guidelines for the management of asthma. Available from https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ [Last accessed 20.6.24]
5. National Institute for health and Care Excellence (2017). Asthma: diagnosis, monitoring and chronic asthma management NG80. Available from https://www.nice.org.uk/guidance/ng80 [Last accessed 20.6.24]
6. Global Initiative for Asthma (2024) Global Strategy for Asthma Management and Prevention. Available from https://ginasthma.org/2024-report/ [Last accessed 20.6.24]
7. Doe G, JC Taylor SJC, Topalovic M, Russell R, Evans RA et al (2023) Spirometry services in England post-pandemic and the potential role of AI support software: a qualitative study of challenges and opportunities. British Journal of General Practice 2023;  73 (737): e915e923. DOI: https://doi.org/10.3399/BJGP.2022.068

Plastic Free July, a pivotal initiative of the Plastic Free Foundation, was launched in 2011 by Rebecca Prince-Ruiz. This global movement is dedicated to realising a world free of plastic waste. The staggering figure of 20 million metric tons of plastic litter that infiltrates our environment annually¹ underscores the urgent need for collective action against this pervasive global issue.

Bedfont®, world leaders in breath analysis, is fully committed to reducing its impact on the environment. By working with employees, customers and suppliers, materials are sustainably sourced and, where possible, recyclable or biodegradable materials are used.

Plastic packaging can take hundreds to thousands of years to decompose, accumulating plastic waste in landfills and natural habitats and creating long-term environmental pollution.

Bedfont® are always taking steps to reduce plastic waste; a couple of examples are:

These steps are part of the broader Bedfont® Eco Resolution. By making these changes, Bedfont® is not only reducing plastic waste but also reinforcing its commitment to sustainability.

As we celebrate Plastic Free July, Bedfont® is dedicated to continuing efforts to reduce plastic usage, lower its carbon footprint, and innovate in ways that benefit both its distributors and the environment.

To keep up to date with the Bedfont® Eco Resolution make sure you follow our social channels.

1. ICUN, Issues Brief, Plastic Pollution. [cited on 19/6/24] Available from https://www.iucn.org/resources/issues-brief/plastic-pollution

To mark Love Your Lungs Week, Bedfont® Scientific Ltd. raises awareness of FeNO testing in asthma care.

Love Your Lungs Week is an annual event which takes place from 21^st to 27^th June. The event aims to raise lung health awareness and promote habits that support respiratory well-being. Bedfont®, world leaders in breath analysis have over 47 years of experience in designing and manufacturing of breath analysis devices. Through innovating breath analysis devices, Bedfont® look to improve patient care with devices like the NObreath®. The NObreath® is a Fractional Exhaled Nitric Oxide (FeNO) device, recommended by NICE for FeNO measurement in asthma care.

Asthma is a chronic respiratory condition where the airways become inflamed and narrowed, making breathing difficult. Sadly 1,261 people lost their lives from asthma in 2020¹, highlighting that asthma is a serious condition. Asthma is caused by a combination of genetic and environmental factors, and as there is no cure, treating and managing the condition is essential.

FeNO is produced naturally in the lungs and can be found in exhaled breath; measuring FeNO can help assess the level of inflammation in the lungs, aiding in the diagnosis and management of asthma.

Elevated FeNO levels can suggest eosinophilic inflammation, a common underlying cause in many asthma patients. By using the NObreath® to monitor these levels, healthcare providers can tailor treatment efficiently.

Jason Smith, Managing Director of Bedfont® says “At Bedfont®, we are committed to supporting initiatives that promote lung health. Love Your Lungs Week is an excellent opportunity to raise awareness about the importance of early diagnosis and proactive management of respiratory conditions. The NObreath® FeNO device not only aids in identifying airway inflammation but also assists in monitoring treatment efficacy, ensuring that patients receive the best possible care.”

The NObreath® is fairly priced and conforms to both ATS and ERS guidelines, allowing a future where everyone has access to instant, non-invasive, simple breath testing to aid in medical diagnosis.

To find out more about FeNO testing in asthma care, please visit our website to watch an insightful webinar hosted by Carol Stonham MBE earlier in the year, ‘How FeNO testing can empower and educate healthcare professionals and patients alike:’ www.bedfont.com

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