Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care. Information about decision making is also available from Realistic medicine.

Making decisions using NICE guidelines and Using SIGN guidelines explains how we use words to show the strength (or certainty) of our recommendations, information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

In this guideline, the NHS refers to NHS England and NHS Scotland unless stated otherwise. The recommendations are for all age groups unless indicated otherwise in the heading of the guideline section.

Health professionals should follow these NICE guidelines for people delivering care:

In addition, health professionals in England should follow these NICE guidelines for people delivering care:

In addition, health professionals in Scotland should follow Scottish Government guidance for people delivering care:

1.1 Initial clinical assessment

Clinical history

1.1.1

Obtain a structured clinical history in people with suspected asthma. Specifically, check for:

1.1.2

Do not confirm a diagnosis of asthma without a suggestive clinical history and a supporting objective test. Code as suspected asthma until the diagnosis is confirmed. [NICE 2017, amended BTS/NICE/SIGN 2024]

1.1.3

If the diagnosis of asthma is confirmed, record the basis for this in the person's medical records, alongside the coded diagnostic entry. [NICE 2017, amended BTS/NICE/SIGN 2024]

Physical examination

1.1.4

Examine people with suspected asthma to identify expiratory polyphonic wheeze and signs of other causes of respiratory symptoms but be aware that even if examination results are normal, the person may still have asthma. [NICE 2017]

Initial treatment and objective tests for acute symptoms at presentation

1.1.5

Treat people immediately if they are acutely unwell or highly symptomatic at presentation, and perform objective tests that may help support a diagnosis of asthma (for example, eosinophil count, fractional exhaled nitric oxide [FeNO], spirometry or peak expiratory flow [PEF] before and after bronchodilator) if the equipment is available. [NICE 2017, amended BTS/NICE/SIGN 2024]

1.1.6

If objective tests for asthma cannot be done immediately for people who are acutely unwell or highly symptomatic at presentation, carry them out when acute symptoms have been controlled, and advise people to contact their healthcare professional immediately if they become unwell while waiting to have objective tests. [NICE 2017, amended BTS/NICE/SIGN 2024]

1.1.7

Be aware that the results of spirometry and FeNO tests may be affected in people who have been treated with inhaled corticosteroids (the test results are more likely to be normal). [NICE 2017]

1.2 Objective tests for diagnosing asthma in adults, young people and children aged 5 to 16 with a history suggestive of asthma

Adults

See also algorithm A for a summary of objective tests for diagnosing asthma in adults and young people (aged over 16 years) with a history suggesting asthma.

1.2.1

Measure the blood eosinophil count or fractional exhaled nitric oxide (FeNO) level in adults with a history suggestive of asthma. Diagnose asthma if the eosinophil count is above the laboratory reference range or the FeNO level is 50 ppb or more. [BTS/NICE/SIGN 2024]

1.2.2

If asthma is not confirmed by eosinophil count or FeNO level, measure bronchodilator reversibility (BDR) with spirometry. Diagnose asthma if the FEV1 increase is 12% or more and 200 ml or more from the pre-bronchodilator measurement (or if the FEV1 increase is 10% or more of the predicted normal FEV1). [BTS/NICE/SIGN 2024]

1.2.3

If spirometry is not available or it is delayed, measure peak expiratory flow (PEF) twice daily for 2 weeks. Diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more. [BTS/NICE/SIGN 2024]

Children aged 5 to 16

See also algorithm B for a summary of objective tests for diagnosing asthma in children aged 5 to 16 with a history suggesting asthma.

1.2.5

Measure the FeNO level in children with a history suggestive of asthma. Diagnose asthma if the FeNO level is 35 ppb or more. [BTS/NICE/SIGN 2024]

1.2.6

If the FeNO level is not raised, or if FeNO testing is not available, measure BDR with spirometry. Diagnose asthma if the FEV1 increase is 12% or more from baseline (or if the FEV1 increase is 10% or more of the predicted normal FEV1). [BTS/NICE/SIGN 2024]

1.2.7

If spirometry is not available or it is delayed, measure PEF twice daily for 2 weeks. Diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more. [BTS/NICE/SIGN 2024]

1.2.8

If asthma is not confirmed by FeNO, BDR or PEF variability but still suspected on clinical grounds, either perform skin prick testing to house dust mite or measure total IgE level and blood eosinophil count.

  • Exclude asthma if there is no evidence of sensitisation to house dust mite on skin prick testing or if the total serum IgE is not raised.

  • Diagnose asthma if there is evidence of sensitisation or a raised total IgE level and the eosinophil count is more than 0.5 x 109 per litre. [BTS/NICE/SIGN 2024]

1.2.9

If there is still doubt about the diagnosis, refer to a paediatric specialist for a second opinion, including consideration of a bronchial challenge test. [BTS/NICE/SIGN 2024]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on objective tests for diagnosing asthma in adults, young people and children aged 5 to 16 with a history suggestive of asthma.

Full details of the evidence and the committee's discussion are in:

1.3 Diagnosing asthma in children under 5

Diagnosis is hard in this age group because it is difficult to do the tests and there are no good reference standards.

1.3.2

If a child is unable to perform objective tests when they are aged 5:

  • try doing the tests again every 6 to 12 months until satisfactory results are obtained

  • refer for specialist assessment if the child's asthma is not responding to treatment. [NICE 2017, BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.3.3

Refer to a specialist respiratory paediatrician any preschool child with an admission to hospital, or 2 or more admissions to an emergency department, with wheeze in a 12-month period. [BTS/NICE/SIGN 2024]

1.4 Diagnosing occupational asthma

See the BTS clinical statement on occupational asthma.

1.4.1

In people with adult-onset asthma, poorly controlled established asthma, or reappearance of childhood asthma, check for a possible occupational component by asking:

  • Are symptoms the same, better or worse on days away from work?

  • Are symptoms the same, better or worse when on holiday (time away from work, longer than usual breaks, at weekends or between shifts)?

    Make sure all answers are recorded for later review. [NICE 2017, BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.4.2

Refer people with suspected occupational asthma to an occupational asthma specialist. [NICE 2017]

1.5 Monitoring asthma control

1.5.1

Monitor asthma control at every review. In addition to asking about symptoms, check:

1.5.2

Consider using a validated symptom questionnaire (for example, the Asthma Control Questionnaire, the Asthma Control Test or the Childhood Asthma Control Test) at any asthma review. [BTS/NICE/SIGN 2024]

1.5.3

Do not use regular peak expiratory flow (PEF) monitoring to assess asthma control unless there are person-specific reasons for doing so (for example, when PEF measurement is part of the personalised asthma action plan). [BTS/NICE/SIGN 2024]

1.5.4

Consider fractional exhaled nitric oxide (FeNO) monitoring for adults with asthma:

  • at their regular review, and

  • before and after changing their asthma therapy. [BTS/NICE/SIGN 2024]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on monitoring asthma control.

Full details of the evidence and the committee's discussion are in:

1.6 Principles of pharmacological treatment

Licensed indications for asthma inhalers vary between different medicines, different doses and different devices. Not all asthma inhalers are licensed for use in line with the recommendations in this guideline. See NICE's information on prescribing medicines or SIGN's information on prescribing licensed medicines out with their marketing authorisation and refer to the summary of product characteristics for individual products.

1.6.1

Take into account and try to address the possible reasons for uncontrolled asthma before starting or adjusting medicines for asthma in adults, young people and children. These may include:

  • alternative diagnoses or comorbidities

  • suboptimal adherence (see the recommendation on adherence)

  • suboptimal inhaler technique

  • smoking (active or passive), including vaping using e-cigarettes

  • occupational exposures (see the recommendation on checking for possible occupational asthma).

  • psychosocial factors (for example, anxiety and depression, relationships and social networks)

  • seasonal factors

  • environmental factors (for example, air pollution, indoor mould exposure). [NICE 2017, BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.6.2

If possible, check the fractional exhaled nitric oxide (FeNO) level when asthma is uncontrolled. If it is raised this may indicate poor adherence to treatment or the need for an increased dose of inhaled corticosteroid (ICS). [BTS/NICE/SIGN 2024]

1.6.3

Do not prescribe short-acting beta2 agonists to people of any age with asthma without a concomitant prescription of an ICS. [BTS/NICE/SIGN 2024]

For a short explanation of why the committee made these 2024 recommendations and how they might affect practice, see the rationale and impact section on principles of pharmacological treatment.

Full details of the evidence and the committee's discussion are in evidence review P: drug classes for initial asthma management.

Inhalers

1.6.5

Base the choice of inhaler(s) for asthma on:

  • an assessment of correct technique

  • the preference of the person receiving the treatment

  • the lowest environmental impact among suitable devices

  • the presence of an integral dose counter.

    A spacer should usually be prescribed for use with a metered dose inhaler, particularly in children. See the patient decision aid on asthma inhalers and climate change. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.6.6

Give people with asthma information on their inhaler treatments. This should include the medicines they contain, how they work, when they should be taken and the correct technique to use for each device. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.6.7

Observe the person using their inhaler device (and spacer if used) to check they can use it properly:

  • at every asthma review, either routine or unscheduled

  • at every asthma-related consultation

  • when there is deterioration in asthma control

  • when the inhaler device is changed

  • when the person asks for it to be checked or changed.

    If the person is assessed as being unable to use a device properly, find an alternative. [NICE 2017, BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.6.8

If possible, prescribe the same type of device to deliver preventer and reliever treatments where more than one inhaler is needed. Consider providing an additional metered dose short-acting beta2 agonist (SABA) inhaler plus spacer for emergency use for children under 12 years who may be unable to activate a dry powder inhaler during an acute asthma attack. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.6.9

Encourage people to take their used or expired inhalers to their pharmacy for disposal. [BTS/SIGN 2019]

Digital inhalers

1.6.10

Digital inhalers are not recommended for routine use in people with asthma. [BTS/NICE/SIGN 2024]

For a short explanation of why the committee made this 2024 recommendation and how it might affect practice, see the rationale and impact section on digital inhalers.

Full details of the evidence and the committee's discussion are in evidence review R: smart inhalers.

1.7 Pharmacological management in people aged 12 and over

See also algorithm C for a summary of the pharmacological management of asthma in people aged 12 years and over.

Initial management of newly diagnosed asthma in people aged 12 and over

1.7.1

Offer a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief (as-needed AIR therapy) to people aged 12 and over with newly diagnosed asthma. [BTS/NICE/SIGN 2024]

In November 2024, only certain budesonide/formoterol inhalers were licensed for as-needed AIR therapy in mild asthma. The use of any other ICS/formoterol inhalers would therefore be off-label. The current evidence supporting the use of budesonide/formoterol is based on the use of a dry powder inhaler. See NICE's information on prescribing medicines or SIGN's information on prescribing licensed medicines out with their marketing authorisation.

1.7.2

If the person needing asthma treatment presents highly symptomatic (for example, regular nocturnal waking) or with a severe exacerbation, start treatment with low-dose MART (maintenance and reliever therapy) in addition to treating the acute symptoms as indicated (that is, a course of oral corticosteroids may be needed). Consider stepping down to as-needed AIR therapy using a low-dose ICS/formoterol inhaler at a later date if their asthma is controlled. [BTS/NICE/SIGN 2024]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on medicines for the initial management of newly diagnosed asthma in people aged 12 and over.

Full details of the evidence and the committee's discussion are in evidence review P: drug classes for initial asthma management.

Medicine combination and sequencing in people aged 12 and over

For guidance on dose ranges of inhaled corticosteroids see inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline.

1.7.3

Offer low-dose MART to people aged 12 and over with asthma that is not controlled on a low-dose ICS/formoterol combination inhaler used only as needed. [BTS/NICE/SIGN 2024]

1.7.4

Offer moderate-dose MART to people aged 12 and over with asthma that is not controlled on low-dose MART. [BTS/NICE/SIGN 2024]

1.7.5

For people aged 12 and over with asthma that is not controlled on moderate-dose MART despite good adherence:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on medicine combination and sequencing in people aged 12 and over.

Full details of the evidence and the committee's discussion are in evidence review Q: drug combinations and sequencing for asthma management.

Transferring people aged 12 and over from other treatment pathways

These recommendations are for people with uncontrolled asthma who are on the treatment pathway recommended by previous NICE and BTS/SIGN guidelines.

1.7.7

Change treatment for people with confirmed asthma who are currently using a short-acting beta2 agonist (SABA) only to a low-dose ICS/formoterol combination inhaler used as needed (as-needed AIR therapy). [BTS/NICE/SIGN 2024]

1.7.8

Consider changing treatment to low-dose MART for people with asthma that is not controlled on:

  • regular low-dose ICS plus SABA as needed

  • regular low-dose ICS/LABA (long-acting beta2 agonist) combination inhaler plus SABA as needed

  • regular low-dose ICS and supplementary therapy (LTRA) plus SABA as needed.

  • regular low-dose ICS/LABA combination inhaler and supplementary therapy (LTRA) plus SABA as needed. [BTS/NICE/SIGN 2024]

1.7.9

Consider changing treatment to moderate-dose MART for people with asthma that is not controlled on:

  • regular moderate-dose ICS plus SABA as needed

  • regular moderate-dose ICS/LABA combination inhaler plus SABA as needed

  • regular moderate-dose ICS and supplementary therapy (LTRA or LAMA, or both) plus SABA as needed

  • regular moderate-dose ICS/LABA combination inhaler and supplementary therapy (LTRA or LAMA, or both) plus SABA as needed. [BTS/NICE/SIGN 2024]

1.7.10

When changing from low- or moderate-dose ICS (or ICS/LABA combination inhaler) plus supplementary therapy to MART, consider whether to stop or continue the supplementary therapy based on the degree of benefit achieved when first introduced. [BTS/NICE/SIGN 2024]

1.7.11

Refer people with asthma that is not controlled on treatment containing a high dose of ICS to a specialist in asthma care. [BTS/NICE/SIGN 2024]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on transferring people aged 12 and over from other treatment pathways.

Full details of the evidence and the committee's discussion are in evidence review P: drug classes for initial asthma management and evidence review Q: drug combinations and sequencing for asthma management.

1.8 Pharmacological management in children aged 5 to 11

For guidance on doses on inhaled corticosteroids see inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline.

See also algorithm D for a summary of the pharmacological management of asthma in children aged 5 to 11 years.

Initial management in children aged 5 to 11

1.8.1

Offer a twice-daily paediatric low-dose inhaled corticosteroid (ICS), with a short-acting beta2 agonist (SABA) as needed, as initial treatment for children aged 5 to 11 years with newly diagnosed asthma. [BTS/NICE/SIGN 2024]

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on medicines for initial management in children aged 5 to 11.

Full details of the evidence and the committee's discussion are in evidence review P: drug classes for initial asthma management.

Medicine combination and sequencing in children aged 5 to 11

MART pathway
1.8.2

Consider paediatric low-dose MART (maintenance and reliever therapy) for children with asthma that is not controlled on paediatric low-dose ICS plus SABA as needed, as long as they are assessed to have the ability to manage a MART regimen. [BTS/NICE/SIGN 2024]

In November 2024, no asthma inhalers were licensed for MART in children under 12, so this use would be off-label. The current evidence supporting the use of MART in children aged 5 to 11 is based on the use of a dry powder inhaler. See NICE's information on prescribing medicines or SIGN's information on prescribing licensed medicines outwith their marketing authorisation.

1.8.3

Consider increasing to paediatric moderate-dose MART if asthma is not controlled on paediatric low-dose MART. [BTS/NICE/SIGN 2024]

Conventional pathway
1.8.5

Offer a twice daily paediatric low-dose ICS/LABA (long-acting beta2 agonist) combination inhaler plus SABA as needed to children assessed as unable to manage the MART regimen if their asthma is not controlled on paediatric low-dose ICS plus SABA as needed (with or without an LTRA depending on previous response). [BTS/NICE/SIGN 2024]

1.8.6

Offer a twice daily paediatric moderate-dose ICS/LABA inhaler plus SABA as needed to children with asthma that is not controlled on paediatric low-dose ICS/LABA plus SABA as needed (with or without an LTRA depending on previous response). [BTS/NICE/SIGN 2024]

All children aged 5 to 11
1.8.7

Refer children to a specialist in asthma care if their asthma is not controlled on paediatric moderate-dose MART or paediatric moderate-dose ICS/LABA maintenance treatment (with or without an LTRA, depending on previous response). [BTS/NICE/SIGN 2024]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on medicine combination and sequencing in children aged 5 to 11.

Full details of the evidence and the committee's discussion are in evidence review Q: drug combinations and sequencing for asthma management.

1.9 Pharmacological management in children under 5

These recommendations are for children under 5 with newly suspected or confirmed asthma, or with asthma symptoms that are uncontrolled on their current treatment.

See also algorithm E for a summary of the pharmacological management of asthma in children under 5.

1.9.1

Consider an 8 to12 week trial of twice-daily paediatric low-dose inhaled corticosteroid (ICS) as maintenance therapy (with a short-acting beta2 agonist [SABA] for reliever therapy) in children under 5 with suspected asthma and:

  • symptoms at presentation that indicate the need for maintenance therapy (for example, interval symptoms in children with another atopic disorder), or

  • severe acute episodes of difficulty breathing and wheeze (for example, requiring hospital admission, or needing 2 or more courses of oral corticosteroids). [BTS/NICE/SIGN 2024]

1.9.2

If symptoms do not resolve during the trial period, take the following sequential steps:

  • check inhaler technique and adherence

  • check whether there is an environmental source of their symptoms (for example mould in the home, cold housing, smokers or indoor air pollution)

  • review whether an alternative diagnosis is likely.

    If none of these explain the failure to respond to treatment, refer the child to a specialist in asthma care. [BTS/NICE/SIGN 2024]

1.9.3

Consider stopping ICS and SABA treatment after 8 to 12 weeks if symptoms are resolved. Review the symptoms after a further 3 months. [BTS/NICE/SIGN 2024]

1.9.4

If symptoms resolve during the trial period, but then:

  • symptoms recur by the 3-month review, or

  • the child has an acute episode requiring systemic corticosteroids or hospitalisation, restart regular ICS (begin at a paediatric low dose and titrate up to a paediatric moderate dose if needed) with SABA as needed and consider a further trial without treatment after reviewing the child within 12 months. [BTS/NICE/SIGN 2024]

1.9.6

If suspected asthma is uncontrolled in children under 5 on a paediatric moderate dose of ICS as maintenance therapy and a trial of an LTRA has been unsuccessful or not tolerated, stop the LTRA and refer the child to a specialist in asthma care for further investigation and management. [BTS/NICE/SIGN 2024]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on pharmacological management in children under 5.

Full details of the evidence and the committee's discussion are in evidence review P: drug classes for initial asthma management.

1.10 Decreasing maintenance therapy

1.10.1

At annual review discuss with the person with asthma (or their family or carer, if appropriate) the potential risks and benefits of decreasing their maintenance therapy when their asthma has been well controlled on their current maintenance therapy. [NICE 2017, BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.10.2

When decreasing maintenance therapy:

  • Stop or reduce dose of medicines in an order that takes into account the clinical effectiveness when introduced, side effects and the person's preference.

  • Allow at least 8 to 12 weeks before considering a further treatment reduction.

  • If considering step-down treatment for people aged 12 and over who are using low-dose maintenance inhaled corticosteroid (ICS) plus a short-acting beta2 agonist (SABA) as needed or low-dose MART (maintenance and reliever therapy), step down to low-dose ICS/formoterol combination inhaler as needed (as-needed AIR therapy). [NICE 2017, BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.10.3

Agree with the person (or their family or carer if appropriate) how the effects of decreasing maintenance therapy will be monitored and reviewed, including self-monitoring and follow-up with a healthcare professional. [NICE 2017]

1.10.4

Review and update the person's asthma action plan when decreasing maintenance therapy. [NICE 2017]

1.11 Adherence

1.12 Asthma in pregnancy and breastfeeding

For recommendations on intrapartum care, see the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies.

Pregnancy

1.12.1

People with asthma should have an asthma review during early pregnancy and in the postpartum period. Emphasise the importance and safety of maintaining good control of asthma during pregnancy and of continuing asthma medicines to avoid problems for themselves and their baby. [BTS/SIGN 2019]

1.12.2

Advise anyone who is pregnant and who smokes about the dangers for themselves and their babies and give appropriate support to stop smoking. See the NICE guideline on tobacco for more information. [BTS/SIGN 2019]

1.12.3

Advise using the following medicines as normal during pregnancy:

  • short-acting and long-acting beta2 agonists

  • inhaled corticosteroids

  • oral theophyllines. [BTS/SIGN 2019]

1.12.4

Offer oral corticosteroids during pregnancy if needed to treat exacerbations of asthma. Advise that the benefits of treatment with oral corticosteroids outweigh the risks. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.12.5

If leukotriene receptor antagonists or long-acting muscarinic receptor antagonists are needed to achieve asthma control, they should not be stopped during pregnancy. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

Breastfeeding

1.12.6

Use medicines as normal when breastfeeding in line with recommendations in the BNF. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.13 Asthma in adolescents

For guidance on transitioning to adult services, see the NICE guideline on transition from children's to adults' services for young people using health or social care services and the Scottish Parliament Information Centre briefing on transitions of young people with service and care needs between child and adult services in Scotland.

1.13.1

Discuss future career choices with adolescents with asthma and highlight occupations that might increase susceptibility to work-related asthma symptoms. [BTS/SIGN 2019]

1.13.2

Ask adolescents with asthma if they vape or smoke and encourage them to stop. If they smoke, give them advice and signpost them to local NHS stop smoking services. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.13.3

Ask about factors that may affect a person's use of their inhaler device in real life settings, such as school and social situations. [BTS/SIGN 2019]

1.14 Self-management

1.14.1

For adults, young people and children aged 5 and over with a diagnosis of asthma (and their families or carers, if appropriate):

  • Offer an asthma self-management programme, comprising a documented personalised action plan and education. In adults, they may be based on symptoms or peak expiratory flow (or both); symptom-based plans are usually preferred for children.

  • Explain that there are things that can trigger asthma symptoms and exacerbations, including indoor and outdoor pollution. Include in the personalised action plan approaches for minimising exposure to air pollution and any other personal triggers. For more guidance on how to minimise exposure and the effect of air pollution on health, see the recommendations on:

  • smoking in the NICE guideline on tobacco. [NICE 2017, amended 2021; BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.14.2

Review the content of the personalised action plan, and check that the person understands it, at the following:

  • hospital admission, including in virtual wards

  • acute consultations in primary care or emergency department

  • annual reviews. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.14.3

Consider an asthma self-management programme, comprising a written personalised action plan (including approaches to minimising exposure to indoor and outdoor air pollution) and education, for the families or carers of children under 5 with suspected or confirmed asthma. [NICE 2017, amended NICE 2021]

1.14.4

For adults (aged 17 and over) who are using an inhaled corticosteroid (ICS) in a single inhaler, offer an increased dose of ICS for 7 days, within a self-management programme, when asthma control deteriorates. Clearly outline in the person's asthma action plan how and when to do this, and what to do if symptoms do not improve.

When increasing ICS treatment:

  • consider quadrupling the regular ICS dose

  • do not exceed the maximum licensed daily dose. [NICE 2017]

1.14.5

Include advice in self-management programmes on contacting a healthcare professional for a review if asthma control deteriorates (see the recommendations on monitoring asthma control). [NICE 2020, amended BTS/NICE/SIGN 2024]

1.14.6

When implementing self-management interventions in primary care, take into account strategies to aid this, which could include:

  • the use of proactive alerts to ensure routine reviews

  • structured protocols for asthma reviews

  • support from primary care and community pharmacists

  • mailing or emailing of educational resources

  • telephone calls to provide ongoing support and advice

  • IT-based education and monitoring

  • involvement of community workers to support clinical teams in deprived and/or ethnic minority communities. [BTS/SIGN 2019]

1.14.7

Schools and health services should work together to provide in-school asthma self-management education programmes provided by appropriately trained personnel. [BTS/SIGN 2019]

For a short explanation of why the committee made the 2020 recommendation on self-management and how it might affect practice, see the rationale and impact section on self-management.

Full details of the evidence and the committee's discussion are in the evidence review from NG80: increasing ICS treatment within supported self-management for children and young people.

1.15 Risk-stratified care

1.15.1

Consider actively identifying people with asthma who are at risk of poor outcomes and tailor care to their needs. Risk factors should include:

  • non-adherence to medicines

  • over-use of short-acting beta2 agonist (SABA) inhalers (more than 2 inhalers per year)

  • needing 2 or more courses of oral corticosteroids per year

  • 2 or more visits to an emergency department or any hospital admission for asthma. [BTS/NICE/SIGN 2024]

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on risk-stratified care.

Full details of the evidence and the committee's discussion are in evidence review O: risk stratified care for people with asthma.

1.16 Organisation and delivery of care

1.16.1

In primary care, people with asthma should be reviewed at least annually and after any exacerbation by a healthcare professional with appropriate training in asthma management. The review should incorporate a written personalised action plan. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

1.16.2

Consider telehealthcare as an option for supporting self-management. [BTS/SIGN 2019]

1.16.3

Consider computerised decision support systems for patient use to support self-management. [BTS/SIGN 2019]

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster.

AIR therapy

Anti-inflammatory reliever (AIR) therapy is treatment with a reliever inhaler that contains a combination of an inhaled corticosteroid and formoterol. When this is used in response to symptoms without regular maintenance therapy it is called as-needed AIR therapy. In November 2024 the only product licensed for as-needed AIR therapy contained budesonide/formoterol.

Asthma control

Complete control of asthma is defined as no daytime symptoms, no night-time awakening due to asthma, no asthma attacks, no need for rescue medication, no limitations on activity including exercise, normal lung function (in practical terms forced expiratory volume in 1 second [FEV1] and/or peak expiratory flow [PEF] more than 80% predicted or best), and minimal side effects from treatment.

Atopic disorder

Atopic disorders are allergic conditions including allergic rhinitis (hay fever), atopic dermatitis (eczema), allergic asthma and other specific and non-specific allergic conditions such as food allergies.

Bronchial challenge test

A test to measure airway responsiveness (bronchial responsiveness). It is performed by giving small increments of a bronchoconstrictor (most commonly methacholine) and measuring the FEV1 after each dose until it falls by a predetermined amount (usually 20% from baseline).

Bronchial hyperresponsiveness

A measure of how easily bronchospasm can be induced in the airways. It is measured using a bronchial challenge test.

Bronchodilator reversibility

A measure of the ability to reverse obstruction in the airways using medicines that widen the airways (bronchodilators).

Eosinophil count

The number of eosinophils (a type of white blood cell) measured in a blood sample. Their levels are raised in asthma and other allergic diseases, and less commonly with malignant diseases, parasite infections, reactions to some medicines, and a small number of rare diseases.

FeNO test

A test that measures the amount of nitric oxide (NO) present on exhalation, usually expressed in parts per billion.

FEV1

The amount of air that can be forcibly exhaled from the lungs in one second (forced expiratory volume in one second).

Leukotriene receptor antagonist

A type of oral medicine that blocks cysteinyl leukotrienes, used in the treatment of asthma and seasonal allergies. Also known as leukotriene modifiers.

Long-acting beta2 agonist

A long-acting medicine that acts on beta-receptors in the airway to relax airway smooth muscle and relieve symptoms of asthma.

Long-acting muscarinic receptor antagonist

A long-acting medicine that acts on muscarinic receptors in the airway to relax airway smooth muscle and relieve symptoms of asthma.

Maintenance and reliever therapy (MART)

A form of combined ICS plus formoterol treatment in which a single inhaler containing ICS and formoterol is used for daily maintenance therapy and the relief of symptoms as needed. The terms low-dose MART and moderate-dose MART refer to the dosage of the maintenance component of MART. People using MART do not normally need a SABA.

Peak expiratory flow (PEF) variability

PEF is a measure of the maximum speed of expiration, generally expressed in litres per minute. PEF variability is a measure of the extent to which this varies over time and can be expressed numerically as amplitude percentage mean. This is calculated by subtracting the lowest value measured each day from the highest value on the same day, and averaging this over the number of days on which PEF is measured

Skin prick testing

A test that measures the allergic response of an individual to certain specific allergens when a very small amount of the specific allergen is introduced into the skin (usually the inner forearm).

Specialist in asthma care

A healthcare professional with higher training in respiratory medicine and proficiency in the management of asthma. In the context of this guideline, this requires both the relevant expertise and access to the resources that enable delivery of the diagnostic and management pathways described in the recommendations.

Uncontrolled asthma

A term used when asthma is having an impact on a person's lifestyle, or is restricting their normal activities, because of symptoms such as coughing, wheezing, shortness of breath and chest tightness. Uncontrolled asthma can include one or both of:

  • any asthma exacerbation needing treatment with oral corticosteroids

  • frequent regular symptoms such as:

    • needing a reliever inhaler 3 or more days per week, or

    • having 1 or more nights per week when asthma causes night-time waking.

These can be quantified by questionnaires such as the Asthma Control Questionnaire or Asthma Control test.