Guidance and Best Practice

A PCRS guide to the management of asthma aged 12 and over in primary care

A new report is showcasing the impact of a national AHSN Network programme to improve access to FeNO testing for asthma diagnosis. Fractional exhaled Nitric Oxide (FeNO) tests are simple, non-invasive tests to support the diagnosis of asthma. During the two-year programme an estimated 58,000 new asthmatics received a faster, more accurate diagnosis through the use of FeNO testing with an additional 1,200 devices entering use in primary care in England.

The PCRS Patient Reference Group (PRG) is a small group of people with respiratory conditions who support PCRS to ensure that we always try to embed the patient perspective in our work and consider the holistic management of patients. Our PRG members sit on our regular committees and sub-committees and contribute regularly to our work. We are grateful for their input. We have two representatives who sit on our valuable PRG who suffer from asthma. You can read their story in this article.

This pragmatic guide focuses on the ongoing management of adults and children with severe asthma receiving biologic therapy and has been developed by an expert group led by Will Carroll, University Hospital of the North Midlands, Stoke-on-Trent and including Ernie Wong, Imperial College Healthcare NHS Trust, London, Beverley Bostock, Advanced Nurse Practitioner at Mann Cottage Surgery, Moreton-in-Marsh, and Asthma Lead for the Association of Respiratory Nurse Specialists, Fiona Mosgrove a GP in Aberdeen and Clinical Lead for the Grampian Respiratory Improvement Programme and Helena Cummings

In an ideal world, asthma review appointments will be between 20 to 30 minutes in duration. But we are not living in an ideal world. Staff shortages due to ill health, burnout, and workforce issues are compounding an already pressured system, and in many practices, the maths doesn’t stack up; there are simply not enough hours in the year to see everybody in the recommended time. If practices are struggling to recruit staff to do the reviews, the time allocation for asthma reviews may be reduced to 10 minutes.

The Medicines and Healthcare Products Regulatory Agency (MHRA) has for the first time approved the use of a dual (ICS/beta-agonist) combination treatment to be prescribed as a reliever therapy for people aged 12 and over with the therapy choice situated early in the asthma treatment pathway as an alternative to its current use as a preventer therapy sitting later in traditional treatment pathways.

To consider how and when we use FeNO testing, we need to go to the definition of asthma. Both BTS/SIGN1 and GINA2 define it as a predominantly inflammatory disorder of the airways with airway hyperresponsiveness and variability in symptoms. Nitric oxide is a gas involved in the respiratory process and is present in the atmosphere in very small amounts (parts per billion). It can be easily measured in exhaled breath using a fractional exhaled nitric oxide (FeNO) test.

Asthma is a long-term condition characterised for the vast majority by trigger induced eosinophilic airway inflammation resulting in wheeze, breathlessness, cough, and chest tightness. Before embarking on any treatment for asthma, it is essential to ensure that you, as the prescriber, can describe to the person with asthma: