diagnosis, monitoring and chronic asthma management

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NICE guideline

Published: 29 November 2017

Last updated: 22 March 2021

www.nice.org.uk/guidance/ng80

conditions#notice-of-rights).

"(%A%&#"!&',A

The recommendations in this guideline represent the view of NICE, arrived at after careful

consideration of the evidence available. When exercising their judgement, professionals

and practitioners are expected to take this guideline fully into account, alongside the

individual needs, preferences and values of their patients or the people using their service.

It is not mandatory to apply the recommendations, and the guideline does not override the

responsibility to make decisions appropriate to the circumstances of the individual, in

consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment

or in a procedure should be reported to the Medicines and Healthcare products Regulatory

Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the

guideline to be applied when individual professionals and people using services wish to

use it. They should do so in the context of local and national priorities for funding and

developing services, and in light of their duties to have due regard to the need to eliminate

unlawful discrimination, to advance equality of opportunity and to reduce health

inequalities. Nothing in this guideline should be interpreted in a way that would be

inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally

sustainable health and care system and should assess and reduce the environmental

impact of implementing NICE recommendations wherever possible.

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

conditions#notice-of-rights).

Page 2 of

"!'!'&A

Overview ...................................................................................................................................... 5

Who is it for? .......................................................................................................................................... 5

Recommendations ....................................................................................................................... 6

1.1 Initial clinical assessment ................................................................................................................ 6

1.2 Diagnosing asthma in young children ........................................................................................... 8

1.3 Objective tests for diagnosing asthma in adults, young people and children aged 5 and

over ......................................................................................................................................................... 9

1.4 Diagnostic summary ....................................................................................................................... 15

1.5 Principles of pharmacological treatment ...................................................................................... 18

1.6 Pharmacological treatment pathway for adults (aged 17 and over) .......................................... 19

1.7 Pharmacological treatment pathway for children and young people aged 5 to 16 .................. 21

1.8 Pharmacological treatment pathway for children under 5 .......................................................... 22

1.9 Adherence ........................................................................................................................................ 24

1.10 Self-management ........................................................................................................................... 24

1.11 Decreasing maintenance therapy ................................................................................................. 25

1.12 Risk stratification ............................................................................................................................ 26

1.13 Monitoring asthma control ............................................................................................................ 26

Terms used in this guideline ................................................................................................................. 27

Putting this guideline into practice ............................................................................................ 31

Recommendations for research .................................................................................................32

Diagnosing and monitoring asthma ..................................................................................................... 32

Managing chronic asthma .................................................................................................................... 33

Rationale and impact ................................................................................................................... 35

Self-management .................................................................................................................................. 35

Context ......................................................................................................................................... 37

Diagnosis and monitoring ..................................................................................................................... 37

Managing chronic asthma .................................................................................................................... 38

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

conditions#notice-of-rights).

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The aims of this guideline .................................................................................................................... 39

Finding more information and committee details .....................................................................40

Update information ..................................................................................................................... 41

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

conditions#notice-of-rights).

Page 4 of

This guideline replaces ESNM3, ESNM22, ESNM34, ESNM53 and ESNM55.

This guideline is the basis of QS25 and QS181.

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This guideline covers diagnosing, monitoring and managing asthma in adults, young

people and children. It aims to improve the accuracy of diagnosis, help people to control

their asthma and reduce the risk of asthma attacks. It does not cover managing severe

asthma or acute asthma attacks.

In March 2021, we highlighted the importance of including advice in the personalised

action plan on minimising indoor air pollution and reducing exposure to outdoor air

pollution.

"A&A'A"%=A

• GPs and practice nurses

• Healthcare professionals in secondary care and tertiary asthma services

• Commissioners and providers

• People with suspected or diagnosed asthma, their families and carers

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

conditions#notice-of-rights).

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" !'"!&A

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.

Making decisions using NICE guidelines explains how we use words to show the

strength (or certainty) of our recommendations, and has information about

prescribing medicines (including off-label use), professional guidelines, standards

and laws (including on consent and mental capacity), and safeguarding.

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See also algorithm A for initial clinical assessment in adults, young people and children

with suspected asthma.

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1.1.1

Take a structured clinical history in people with suspected asthma. Specifically,

check for:

• wheeze, cough or breathlessness, and any daily or seasonal variation in

these symptoms

• any triggers that make symptoms worse

• a personal or family history of atopic disorders. [2017]

1.1.2

Do not use symptoms alone without an objective test to diagnose asthma. [2017]

1.1.3

Do not use a history of atopic disorders alone to diagnose asthma. [2017]

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

conditions#notice-of-rights).

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,&A+ !'"!A

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. [2017]

!'A'%' !'A!A"')A'&'&A"%A('A&, #'" &A'A

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1.1.5

Treat people immediately if they are acutely unwell at presentation, and perform

objective tests for asthma (for example, fractional exhaled nitric oxide [FeNO],

spirometry and peak flow variability) if the equipment is available and testing will

not compromise treatment of the acute episode. [2017]

1.1.6

If objective tests for asthma cannot be done immediately for people who are

acutely unwell 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. [2017]

1.1.7

Be aware that the results of spirometry and FeNO tests may be affected in people

who have been treated empirically with inhaled corticosteroids. [2017]

&'!A"%A&' A

1.1.8

Do not offer the following as diagnostic tests for asthma:

• skin prick tests to aeroallergens

• serum total and specific IgE

• peripheral blood eosinophil count

• exercise challenge (to adults aged 17 and over). [2017]

1.1.9

Use skin prick tests to aeroallergens or specific IgE tests to identify triggers after

a formal diagnosis of asthma has been made. [2017]

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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(#'"!A&' A

1.1.10

Check for possible occupational asthma by asking employed people with

suspected new-onset asthma, or established asthma that is poorly controlled:

• Are symptoms better on days away from work?

• Are symptoms better 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. [2017]

1.1.11

Refer people with suspected occupational asthma to an occupational asthma

specialist. [2017]

1:2A!"&!A&' A!A,"(!A%!A

1.2.1

For children under 5 with suspected asthma, treat symptoms based on

observation and clinical judgement, and review the child on a regular basis (see

the section on pharmacological treatment pathway for children under 5). If they

still have symptoms when they reach 5 years, carry out objective tests (see the

section on objective tests for diagnosing asthma in adults, young people and

children aged 5 and over and algorithm B). [2017]

1.2.2

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

• continue to treat based on observation and clinical judgement

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

obtained

• consider referral for specialist assessment if the child repeatedly cannot

perform objective tests and is not responding to treatment. [2017]

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

conditions#notice-of-rights).

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1:3A')A'&'&A"%A!"&!A&' A!A('&;A

,"(!A#"#A!A%!AA5A!A")%A

See also table 1 for a summary of objective test threshold levels.

!"&'A(&A

1.3.1

Those responsible for planning diagnostic service support to primary care (for

example, clinical commissioning groups) should consider establishing asthma

diagnostic hubs to achieve economies of scale and improve the practicality of

implementing the recommendations in this guideline. [2017]

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Fractional exhaled nitric oxide

1.3.2

Offer a FeNO test to adults (aged 17 and over) if a diagnosis of asthma is being

considered. Regard a FeNO level of 40 parts per billion (ppb) or more as a

positive test. [2017]

1.3.3

Consider a FeNO test in children and young people (aged 5 to 16) if there is

diagnostic uncertainty after initial assessment and they have either:

• normal spirometry or

• obstructive spirometry with a negative bronchodilator reversibility (BDR) test.

Regard a FeNO level of 35 ppb or more as a positive test.

Note: apply the principles in recommendation 1.2.2 for young children unable

to do the FeNO test adequately. [2017]

1.3.4

Be aware that a person's current smoking status can lower FeNO levels both

acutely and cumulatively. However, a high level remains useful in supporting a

diagnosis of asthma. [2017]

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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Spirometry

1.3.5

Offer spirometry to adults, young people and children aged 5 and over if a

diagnosis of asthma is being considered. Regard a forced expiratory volume in

1 second/forced vital capacity (FEV1/FVC) ratio of less than 70% (or below the

lower limit of normal if this value is available) as a positive test for obstructive

airway disease (obstructive spirometry). [2017]

Bronchodilator reversibility

1.3.6

Offer a BDR test to adults (aged 17 and over) with obstructive spirometry (FEV1/

FVC ratio less than 70%). Regard an improvement in FEV1 of 12% or more,

together with an increase in volume of 200 ml or more, as a positive test. [2017]

1.3.7

Consider a BDR test in children and young people (aged 5 to 16) with obstructive

spirometry (FEV1/FVC ratio less than 70%). Regard an improvement in FEV1 of

12% or more as a positive test. [2017]

Peak expiratory flow variability

1.3.8

Monitor peak flow variability for 2 to 4 weeks in adults (aged 17 and over) if there

is diagnostic uncertainty after initial assessment and a FeNO test and they have

either:

• normal spirometry or

• obstructive spirometry, reversible airways obstruction (positive BDR) but a

FeNO level of 39 ppb or less.

Regard a value of more than 20% variability as a positive test. [2017]

1.3.9

Consider monitoring peak flow variability for 2 to 4 weeks in adults (aged 17 and

over) if there is diagnostic uncertainty after initial assessment and they have:

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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• obstructive spirometry and

• irreversible airways obstruction (negative BDR) and

• a FeNO level between 25 ppb and 39 ppb.

Regard a value of more than 20% variability as a positive test. [2017]

1.3.10

Monitor peak flow variability for 2 to 4 weeks in children and young people (aged

5 to 16) if there is diagnostic uncertainty after initial assessment and a FeNO test

and they have either:

• normal spirometry or

• obstructive spirometry, irreversible airways obstruction (negative BDR) and a

FeNO level of 35 ppb or more.

Regard a value of more than 20% variability as a positive test. [2017]

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Direct bronchial challenge test with histamine or methacholine

In November 2017, the use of histamine and methacholine described in

recommendations 1.3.11 and 1.3.12 was off label. See NICE's information on

prescribing medicines.

1.3.11

Offer a direct bronchial challenge test with histamine or methacholine to adults

(aged 17 and over) if there is diagnostic uncertainty after a normal spirometry and

either a:

• FeNO level of 40 ppb or more and no variability in peak flow readings or

• FeNO level of 39 ppb or less with variability in peak flow readings.

Regard a PC20 value of 8 mg/ml or less as a positive test. [2017]

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

conditions#notice-of-rights).

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1.3.12

Consider a direct bronchial challenge test with histamine or methacholine in

adults (aged 17 and over) with:

• obstructive spirometry without bronchodilator reversibility and

• a FeNO level between 25 ppb and 39 ppb and

• no variability in peak flow readings (less than 20% variability over 2 to

4 weeks).

Regard a PC20 value of 8 mg/ml or less as a positive test. [2017]

1.3.13

If a direct bronchial challenge test with histamine or methacholine is unavailable,

suspect asthma and review the diagnosis after treatment, or refer to a centre

with access to a histamine or methacholine challenge test. [2017]

!"&&A!A%!A!A,"(!A#"#AA5A'"A16A

See also algorithm B for objective tests in young people and children aged 5 to 16.

1.3.14

Diagnose asthma in children and young people (aged 5 to 16) if they have

symptoms suggestive of asthma and:

• a FeNO level of 35 ppb or more and positive peak flow variability or

• obstructive spirometry and positive bronchodilator reversibility. [2017]

1.3.15

Suspect asthma in children and young people (aged 5 to 16) if they have

symptoms suggestive of asthma and:

• a FeNO level of 35 ppb or more with normal spirometry and negative peak

flow variability or

• a FeNO level of 35 ppb or more with obstructive spirometry but negative

bronchodilator reversibility and no variability in peak flow readings or

• normal spirometry, a FeNO level of 34 ppb or less and positive peak flow

variability.

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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Do not rule out other diagnoses if symptom control continues to remain poor

after treatment. Review the diagnosis after 6 weeks by repeating any

abnormal tests and reviewing symptoms. [2017]

1.3.16

Refer children and young people (aged 5 to 16) for specialist assessment if they

have obstructive spirometry, negative bronchodilator reversibility and a FeNO

level of 34 ppb or less. [2017]

1.3.17

Consider alternative diagnoses and referral for specialist assessment in children

and young people (aged 5 to 16) if they have symptoms suggestive of asthma but

normal spirometry, a FeNO level of 34 ppb or less and negative peak flow

variability. [2017]

!"&&A!A('&AA17A!A")%A

See also algorithm C for objective tests in adults aged 17 and over.

1.3.18

Diagnose asthma in adults (aged 17 and over) if they have symptoms suggestive

of asthma and:

• a FeNO level of 40 ppb or more with either positive bronchodilator

reversibility or positive peak flow variability or bronchial hyperreactivity or

• a FeNO level between 25 ppb and 39 ppb and a positive bronchial challenge

test or

• positive bronchodilator reversibility and positive peak flow variability

irrespective of FeNO level. [2017]

1.3.19

Suspect asthma in adults (aged 17 and over) with symptoms suggestive of

asthma, obstructive spirometry and:

• negative bronchodilator reversibility, and either a FeNO level of 40 ppb or

more, or a FeNO level between 25 ppb and 39 ppb and positive peak flow

variability or

• positive bronchodilator reversibility, a FeNO level between 25 ppb and

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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39 ppb and negative peak flow variability.

Do not rule out other diagnoses if symptom control continues to remain poor

after treatment. Review the diagnosis after 6 to 10 weeks by repeating

spirometry and objective measures of asthma control and reviewing

symptoms. [2017]

1.3.20

Consider alternative diagnoses, or referral for a second opinion, in adults (aged

17 and over) with symptoms suggestive of asthma and:

• a FeNO level below 40 ppb, normal spirometry and positive peak flow

variability or

• a FeNO level of 40 ppb or more but normal spirometry, negative peak flow

variability, and negative bronchial challenge test or

• obstructive spirometry with bronchodilator reversibility, but a FeNO level

below 25 ppb, and negative peak flow variability or

• positive peak flow variability but normal spirometry, a FeNO level below

40 ppb, and a negative bronchial challenge test or

• obstructive spirometry with negative bronchodilator reversibility, a FeNO level

below 25 ppb, and negative peak flow variability (if measured). [2017]

!"&&A!A#"#A*"A%A(!A'"A#%"% A!A"')A'&'A

For young children who cannot perform objective tests, see the section on diagnosing

asthma in young children.

1.3.21

If an adult, young person or child with symptoms suggestive of asthma cannot

perform a particular test, try to perform at least 2 other objective tests. Diagnose

suspected asthma based on symptoms and any positive objective test results.

[2017]

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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1.3.22

Record the basis for a diagnosis of asthma in a single entry in the person's

medical records, alongside the coded diagnostic entry. [2017]

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The following algorithms have been produced that summarise clinical assessment and

objective testing for asthma. Table 1 summarises the objective test threshold levels.

Table 1 Positive test thresholds for objective tests for adults, young people and children

(aged 5 and over)

Test Population Positive result

Fractional exhaled

nitric oxide (FeNO)

Adults 40 ppb or more

FeNO

Children

and young

people

35 ppb or more

Obstructive spirometry

Adults,

young

people and

children

Forced expiratory volume in 1 second/forced vital

capacity (FEV1/FVC) ratio less than 70% (or below the

lower limit of normal if this value is available)

Bronchodilator

reversibility (BDR) test

Adults

Improvement in FEV1 of 12% or more and increase in

volume of 200 ml or more

BDR test

Children

and young

people

Improvement in FEV1 of 12% or more

Peak flow variability

Adults,

young

people and

children

Variability over 20%

Direct bronchial

challenge test with

histamine or

methacholine

Adults

Provocative concentration of methacholine causing a

20% fall in FEV1 (PC20) of 8 mg/ml or less

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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Test Population Positive result

Direct bronchial

challenge test with

histamine or

methacholine

Children

and young

people

n/a

"%' &A

Algorithm A Initial clinical assessment for adults, young people and children with suspected asthma

A full-size downloadable PDF version of algorithm A is available in tools and resources.

Algorithm B Objective tests for asthma in children and young people aged 5 to 16

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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A full-size downloadable PDF version of algorithm B is available in tools and resources.

Algorithm C Objective tests for asthma in adults aged 17 and over

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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A full-size downloadable PDF version of algorithm C is available in tools and resources.

1:5A%!#&A"A#% ""A'%' !'A

1.5.1

Take into account the possible reasons for uncontrolled asthma, before starting

or adjusting medicines for asthma in adults, young people and children. These

may include:

• alternative diagnoses

• lack of adherence

• suboptimal inhaler technique

• smoking (active or passive)

• occupational exposures

• psychosocial factors

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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• seasonal or environmental factors. [2017]

1.5.2

After starting or adjusting medicines for asthma, review the response to

treatment in 4 to 8 weeks (see the section on monitoring asthma control). [2017]

1.5.3

If inhaled corticosteroid (ICS) maintenance therapy is needed, offer regular daily

ICS rather than intermittent or 'when required' ICS therapy. [2017]

1.5.4

Adjust maintenance therapy ICS doses over time, aiming for the lowest dose

required for effective asthma control. [2017]

1.5.5

Ensure that a person with asthma can use their inhaler device:

• at any asthma review, either routine or unscheduled

• whenever a new type of device is supplied. [2017]

1:6A% ""A'%' !'A#'*,A"%A('&A

>A17A!A")%?A

This section is for people with newly diagnosed asthma or asthma that is uncontrolled on

their current treatment. Where the recommendations represent a change from traditional

clinical practice, people whose asthma is well controlled on their current treatment should

not have their treatment changed purely to follow this guidance.

1.6.1

Offer a short-acting beta

agonist (SABA) as reliever therapy to adults (aged

17 and over) with newly diagnosed asthma. [2017]

1.6.2

For adults (aged 17 and over) with asthma who have infrequent, short-lived

wheeze and normal lung function, consider treatment with SABA reliever therapy

alone. [2017]

1.6.3

Offer a low dose of an ICS as the first-line maintenance therapy to adults (aged

17 and over) with:

• symptoms at presentation that clearly indicate the need for maintenance

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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therapy (for example, asthma-related symptoms 3 times a week or more, or

causing waking at night) or

• asthma that is uncontrolled with a SABA alone. [2017]

1.6.4

If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as

maintenance therapy, offer a leukotriene receptor antagonist (LTRA) in addition to

the ICS and review the response to treatment in 4 to 8 weeks. [2017]

1.6.5

If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and an

LTRA as maintenance therapy, offer a long-acting beta

agonist (LABA) in

combination with the ICS, and review LTRA treatment as follows:

• discuss with the person whether or not to continue LTRA treatment

• take into account the degree of response to LTRA treatment. [2017]

1.6.6

If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and a

LABA, with or without an LTRA, as maintenance therapy, offer to change the

person's ICS and LABA maintenance therapy to a MART regimen with a low

maintenance ICS dose. [2017]

1.6.7

If asthma is uncontrolled in adults (aged 17 and over) on a MART regimen with a

low maintenance ICS dose, with or without an LTRA, consider increasing the ICS

to a moderate maintenance dose (either continuing on a MART regimen or

changing to a fixed dose of an ICS and a LABA, with a SABA as a reliever

therapy). [2017]

1.6.8

If asthma is uncontrolled in adults (aged 17 and over) on a moderate maintenance

ICS dose with a LABA (either as MART or a fixed-dose regimen), with or without

an LTRA, consider:

• increasing the ICS to a high maintenance dose (this should only be offered as

part of a fixed-dose regimen, with a SABA used as a reliever therapy) or

• a trial of an additional drug (for example, a long-acting muscarinic receptor

antagonist or theophylline) or

• seeking advice from a healthcare professional with expertise in asthma.

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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[2017]

1:7A% ""A'%' !'A#'*,A"%A%!A

!A,"(!A#"#AA5A'"A16A

This section is for children and young people with newly diagnosed asthma or asthma that

is uncontrolled on their current treatment. Where the recommendations represent a

change from traditional clinical practice, children and young people whose asthma is well

controlled on their current treatment should not have their treatment changed purely to

follow guidance.

In November 2017, the use of some medicines was off label:

• Not all LTRAs and LABAs had a UK marketing authorisation for children and

young people aged under 18 for the use described in recommendations 1.7.4 and

1.7.5.

• The use of MART described in recommendations 1.7.6, 1.7.7 and 1.7.8 was off label

in children and young people (aged under 12).

See NICE's information on prescribing medicines.

1.7.1

Offer a SABA as reliever therapy to children and young people (aged 5 to 16) with

newly diagnosed asthma. [2017]

1.7.2

For children and young people (aged 5 to 16) with asthma who have infrequent,

short-lived wheeze and normal lung function, consider treatment with SABA

reliever therapy alone. [2017]

1.7.3

Offer a paediatric low dose of an ICS as the first-line maintenance therapy to

children and young people (aged 5 to 16) with:

• symptoms at presentation that clearly indicate the need for maintenance

therapy (for example, asthma-related symptoms 3 times a week or more, or

causing waking at night) or

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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• asthma that is uncontrolled with a SABA alone. [2017]

1.7.4

If asthma is uncontrolled in children and young people (aged 5 to 16) on a

paediatric low dose of ICS as maintenance therapy, consider an LTRA in addition

to the ICS and review the response to treatment in 4 to 8 weeks. [2017]

1.7.5

If asthma is uncontrolled in children and young people (aged 5 to 16) on a

paediatric low dose of ICS and an LTRA as maintenance therapy, consider

stopping the LTRA and starting a LABA in combination with the ICS. [2017]

1.7.6

If asthma is uncontrolled in children and young people (aged 5 to 16) on a

paediatric low dose of ICS and a LABA as maintenance therapy, consider

changing their ICS and LABA maintenance therapy to a MART regimen with a

paediatric low maintenance ICS dose. Ensure that the child or young person is

able to understand and comply with the MART regimen. [2017]

1.7.7

If asthma is uncontrolled in children and young people (aged 5 to 16) on a MART

regimen with a paediatric low maintenance ICS dose, consider increasing the ICS

to a paediatric moderate maintenance dose (either continuing on a MART

regimen or changing to a fixed dose of an ICS and a LABA, with a SABA as a

reliever therapy). [2017]

1.7.8

If asthma is uncontrolled in children and young people (aged 5 to 16) on a

paediatric moderate maintenance ICS dose with LABA (either as MART or a fixed-

dose regimen), consider seeking advice from a healthcare professional with

expertise in asthma and consider either:

• increasing the ICS dose to paediatric high maintenance dose (only as part of

a fixed-dose regimen, with a SABA used as a reliever therapy) or

• a trial of an additional drug (for example, theophylline). [2017]

1:8A% ""A'%' !'A#'*,A"%A%!A

(!%A5A

It can be difficult to confirm asthma diagnosis in young children, therefore these

recommendations apply to children with suspected or confirmed asthma. Asthma

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

conditions#notice-of-rights).

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diagnosis should be confirmed when the child is able to undergo objective tests (see the

section on diagnosing asthma in young children).

This section is for children under 5 with newly suspected or confirmed asthma, or with

asthma symptoms that are uncontrolled on their current treatment. Where the

recommendations represent a change from traditional clinical practice, children whose

asthma is well controlled on their current treatment should not have their treatment

changed purely to follow this guidance.

1.8.1

Offer a SABA as reliever therapy to children under 5 with suspected asthma. This

should be used for symptom relief alongside all maintenance therapy. [2017]

1.8.2

Consider an 8-week trial of a paediatric moderate dose of an ICS in children

under 5 with:

• symptoms at presentation that clearly indicate the need for maintenance

therapy (for example, asthma-related symptoms 3 times a week or more, or

causing waking at night) or

• suspected asthma that is uncontrolled with a SABA alone. [2017]

1.8.3

After 8 weeks, stop ICS treatment and continue to monitor the child's symptoms:

• if symptoms did not resolve during the trial period, review whether an

alternative diagnosis is likely

• if symptoms resolved then reoccurred within 4 weeks of stopping ICS

treatment, restart the ICS at a paediatric low dose as first-line maintenance

therapy

• if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS

treatment, repeat the 8-week trial of a paediatric moderate dose of ICS.

[2017]

1.8.4

If suspected asthma is uncontrolled in children under 5 on a paediatric low dose

of ICS as maintenance therapy, consider an LTRA in addition to the ICS. [2017]

In November 2017, not all LTRAs had a UK marketing authorisation for this use in

children aged under 5. See NICE's information on prescribing medicines.

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

conditions#notice-of-rights).

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1.8.5

If suspected asthma is uncontrolled in children under 5 on a paediatric low dose

of ICS and an LTRA as maintenance therapy, stop the LTRA and refer the child to

a healthcare professional with expertise in asthma for further investigation and

management. [2017]

1:9A%!A

1.9.1

For guidance on managing non-adherence to medicines in people with asthma,

see the NICE guideline on medicines adherence. [2017]

1:10A@ ! !'A

1.10.1

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 written

personalised action plan and education.

• Explain that pollution can trigger or exacerbate asthma, and include in the

personalised action plan approaches for minimising exposure to indoor and

outdoor air pollution.

For more guidance on how to minimise exposure and the effect of air

pollution on health, see:

• the recommendations on vulnerable groups in the NICE guideline on air

pollution: outdoor air quality and health and

• the recommendations on people with asthma, other respiratory conditions or

cardiovascular conditions in the NICE guideline on indoor air quality at home.

[2017, amended 2021]

1.10.2

Within a self-management programme, offer an increased dose of ICS for 7 days

to adults (aged 17 and over) who are using an ICS in a single inhaler, 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

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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increasing ICS treatment:

• consider quadrupling the regular ICS dose

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

1.10.3

For children and young people aged 5 to 16 with a diagnosis of asthma, include

advice in their self-management programme on contacting a healthcare

professional for a review if their asthma control deteriorates (see the section on

monitoring asthma control). [2020]

1.10.4

For children and young people aged 5 to 16 with deteriorating asthma who have

not been taking their ICS consistently, explain that restarting regular use may

help them to regain control of their asthma. The evidence for increasing ICS

doses to self-manage deteriorating asthma control is limited. [2020]

1.10.5

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. [2017, amended 2021]

For a short explanation of why the committee made the 2020 recommendations on

self-management and removed the 2017 recommendation on increasing ICS treatment

within a self-management programme in children and young people and how this

might affect practice, see the rationale and impact section on self-management.

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

increasing ICS treatment within supported self-management for children and young

people.

1:11A%&!A !'!!A'%#,A

1.11.1

Consider decreasing maintenance therapy when a person's asthma has been

controlled with their current maintenance therapy for at least 3 months. [2017]

1.11.2

Discuss with the person (or their family or carer if appropriate) the potential risks

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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and benefits of decreasing maintenance therapy. [2017]

1.11.3

When reducing 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.

• Only consider stopping ICS treatment completely for people who are using

low dose ICS alone as maintenance therapy and are symptom free. [2017]

1.11.4

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 a follow-up with a healthcare professional. [2017]

1.11.5

Review and update the person's asthma action plan when decreasing

maintenance therapy. [2017]

1:12A&A&'%'.'"!A

1.12.1

Consider using risk stratification to identify people with asthma who are at

increased risk of poor outcomes, and use this information to optimise their care.

Base risk stratification on factors such as non-adherence to asthma medicines,

psychosocial problems and repeated episodes of unscheduled care for asthma.

[2017]

1:13A"!'"%!A&' A"!'%"A

1.13.1

Monitor asthma control at every review. If control is suboptimal:

• confirm the person's adherence to prescribed treatment in line with the

recommendations on assessing adherence in the NICE guideline on

medicines adherence

• review the person's inhaler technique

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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• review if treatment needs to be changed

• ask about occupational asthma (see recommendation on checking for

possible occupational asthma) and/or other triggers, if relevant. [2017]

1.13.2

Consider using a validated questionnaire (for example, the Asthma Control

Questionnaire or Asthma Control Test) to monitor asthma control in adults (aged

17 and over). [2017]

1.13.3

Monitor asthma control at each review in adults, young people and children aged

5 and over using either spirometry or peak flow variability testing. [2017]

1.13.4

Do not routinely use FeNO to monitor asthma control. [2017]

1.13.5

Consider FeNO measurement as an option to support asthma management in

people who are symptomatic despite using inhaled corticosteroids. (This

recommendation is from NICE's diagnostics guidance on measuring fractional

exhaled nitric oxide concentration in asthma.) [2017]

1.13.6

Do not use challenge testing to monitor asthma control. [2017]

1.13.7

Observe and give advice on the person's inhaler technique:

• at every consultation relating to an asthma attack, in all care settings

• when there is deterioration in asthma control

• when the inhaler device is changed

• at every annual review

• if the person asks for it to be checked. [2017]

% &A(&A!A'&A(!A

This section defines terms that have been used in a particular way for this guideline. For

other definitions, see the NICE glossary.

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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+#%'"%,A#",#"!A*-A

A wheeze is a continuous, whistling sound produced in the airways during breathing. It is

caused by narrowing or obstruction in the airways. An expiratory polyphonic wheeze has

multiple pitches and tones heard over different areas of the lung when the person

breathes out.

A"&&A

ICS doses and their pharmacological strengths vary across different formulations. In

general, people with asthma should use the smallest doses of ICS that provide optimal

control for their asthma, in order to reduce the risk of side effects.

For adults aged 17 and over:

• less than or equal to 400 micrograms budesonide or equivalent would be considered a

low dose

• more than 400 micrograms to 800 micrograms budesonide or equivalent would be

considered a moderate dose

• more than 800 micrograms budesonide or equivalent would be considered a high

dose.

For children and young people aged 16 and under:

• less than or equal to 200 micrograms budesonide or equivalent would be considered a

paediatric low dose

• more than 200 micrograms to 400 micrograms budesonide or equivalent would be

considered a paediatric moderate dose

• more than 400 micrograms budesonide or equivalent would be considered a

paediatric high dose.

A

Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment

in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily

maintenance therapy and the relief of symptoms as required. MART is only available for

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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ICS and LABA combinations in which the LABA has a fast-acting component (for example,

formoterol).

')A'&'A'"A!"&A&' A

Tests carried out to help determine whether a person has asthma, the results of which are

not based on the person's symptoms, for example, tests to measure lung function or

evidence of inflammation. There is no single objective test to diagnose asthma.

&A&'%'.'"!A

Risk stratification is a process of categorising a population by their relative likelihood of

experiencing certain outcomes. In the context of this guideline, risk stratification involves

categorising people with asthma by their relative likelihood of experiencing negative

clinical outcomes (for example, severe exacerbations or hospitalisations). Factors including

non-adherence to asthma medicines, psychosocial problems and repeated episodes of

unscheduled care can be used to guide risk stratification. Once the population is stratified,

the delivery of care for the population can be targeted with the aim of improving the care

of the strata with the highest risk.

(&#'A&' A

Suspected asthma describes a potential diagnosis of asthma based on symptoms and

response to treatment that has not yet been confirmed with objective tests.

!"!'%"A&' A

Uncontrolled asthma describes asthma that has an impact on a person's lifestyle or

restricts their normal activities. Symptoms such as coughing, wheezing, shortness of

breath and chest tightness associated with uncontrolled asthma can significantly decrease

a person's quality of life and may lead to a medical emergency. Questionnaires are

available that can be quantify this.

This guideline uses the following pragmatic thresholds to define uncontrolled asthma:

• 3 or more days a week with symptoms or

• 3 or more days a week with required use of a SABA for symptomatic relief or

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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• 1 or more nights a week with awakening due to asthma.

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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(''!A'&A(!A!'"A#%'A

NICE is recommending objective testing with spirometry and FeNO for most people with

suspected asthma. This is a significant enhancement to current practice, which will take

the NHS some time to implement, with additional infrastructure and training needed in

primary care. New models of care, being developed locally, could offer the opportunity to

implement these recommendations. This may involve establishing diagnostic hubs to make

testing efficient and affordable. They will be able to draw on the positive experience of

NICE's primary care pilot sites, which trialled the use of FeNO.

The investment and training required to implement the new guidance will take time. In the

meantime, primary care services should implement what they can of the new guidelines,

using currently available approaches to diagnosis until the infrastructure for objective

testing is in place.

NICE has produced tools and resources to help you put this guideline into practice.

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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" !'"!&A"%A%&%A

The 2017 guideline committees made the following recommendations for research on

diagnosing and monitoring asthma and for managing chronic asthma (marked [2017]). The

committee's full set of recommendations for research are detailed in the 2017 full guideline

on asthma: diagnosis and monitoring and the 2017 full guideline on chronic asthma

management.

As part of the 2020 update, the guideline committee made 1 new recommendation for

research on managing asthma within a self-management programme for children and

young people (marked [2020]).

!"&!A!A "!'"%!A&' A

1A!"&!A&' A!A%!A!A,"(!A#"#AA5A'"A16A

What is the acceptability and diagnostic accuracy of objective tests that could be used to

comprise a diagnostic pathway for asthma in children and young people aged 5 to 16 (for

example, exercise challenge, direct bronchial challenge with histamine or methacholine,

indirect bronchial challenge with mannitol and peripheral blood eosinophil count)? [2017]

2A!"&!A&' A!A('&A>A17A!A")%?A

What is the clinical and cost effectiveness of using an indirect bronchial challenge test

with mannitol to diagnose asthma in adults (aged 17 and over)? [2017]

3A"!'"%!A%!A'"A'%' !'A

What is the clinical and cost effectiveness of using electronic alert systems designed to

monitor and improve adherence with regular inhaled maintenance therapy in people with

asthma? [2017]

4A"!'"%!A!%A'!$(A

What is the current frequency and the current method being used to check the inhaler

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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technique of people with asthma? What is the optimal frequency and the best method of

checking inhaler technique to improve clinical outcomes for people with asthma? [2017]

5A"!'"%!A&' A"!'%"A(&!A'@'%A

What is the long-term (more than 12 months) clinical and cost effectiveness of using tele-

healthcare as a means to monitor asthma control in adults, young people and children?

Methods of tele-healthcare can include telephone interview (with healthcare professional

involvement) and internet or smartphone-based monitoring support (no healthcare

professional involvement). [2017]

!!A%"!A&' A

6A!%&!A'A"&A"AA*'!AA#%&"!&A&@

! !'A#%"% A"%A%!A!A,"(!A#"#A

For children and young people with asthma that is managed in primary care, is there an

advantage to increasing the inhaled corticosteroid (ICS) dose when asthma control has

deteriorated compared with using the usual dose in a self-management programme?

[2020]

For a short explanation of why the committee made the recommendation for research,

see the rationale on increasing the dose of ICS within a personalised self-

management programme for children and young people.

Full details of the recommendation for research are in evidence review A: increasing

ICS treatment within supported self-management for children and young people.

7A'%'!A&' A'%' !'A

In adults, young people and children with asthma who have not been treated previously, is

it more clinically and cost effective to start treatment with a reliever alone (a short-acting

beta

agonist [SABA]) or with a reliever (a SABA) and maintenance therapy (such as ICS)?

Are there specific prognostic features that indicate that one of these treatment options

may be more appropriate for some groups? [2017]

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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8A"!@!A !'!!A'%#,A!A%!A!A,"(!A#"#A

>(!%A16?A

Is maintenance therapy more effective with a paediatric low dose of ICS plus a leukotriene

receptor antagonist (LTRA) or with a paediatric low dose of ICS plus a long-acting beta

agonist (LABA) in the treatment of asthma in children and young people (under 16) who

have uncontrolled asthma on a paediatric low dose of ICS alone? [2017]

9A'"!A !'!!A'%#,A"%A&' A(!"!'%"A"!AA

"%'A"&A"AA#(&AA*'A"%A*'"('AA

What is the clinical and cost effectiveness of offering additional maintenance therapy to

adults, young people and children with asthma that is uncontrolled on a moderate dose of

ICS plus LABA with or without LTRA? [2017]

10A%&!A#% ""A'%' !'A

In adults, young people and children with well-controlled asthma, what are the objective

measurements and prognostic factors that indicate that a decrease in regular maintenance

treatment is appropriate? [2017]

11A #%")!A%!A'"A&' A '"!A

What are the most clinically and cost-effective strategies to improve medicines adherence

in adults, young people and children with asthma who are non-adherent to prescribed

medicines? [2017]

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

conditions#notice-of-rights).

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'"!A!A #'A

This section briefly explain why the committee made the recommendations and how they

might affect practice. They link to details of the evidence and a full description of the

committee's discussion.

@ ! !'A

Recommendations 1.10.3 and 1.10.4

,A'A" ''A!A'A%" !'"!&A

The evidence for children and young people found that increasing the dose of inhaled

corticosteroid (ICS) when asthma control deteriorates did not result in any benefits or

harms compared to the usual dose in terms of reducing subsequent asthma

exacerbations. It was limited to only 1 study with a small number of participants who had a

personalised action plan. The committee also looked at studies in adults, but agreed that

the evidence was not applicable because of the high average age of participants.

The 2017 guideline recommended that quadrupling the dose of ICS could be considered

within a self-management programme for children and young people whose asthma is

deteriorating. The 2020 update committee agreed that this 2017 recommendation was

based on limited evidence, mostly in adults, and that the new evidence identified in this

update did not support this. However, it also agreed that there wasn't any significant

evidence to suggest that increasing the dose of ICS is harmful compared to the usual

dose. Based on their experience, the committee agreed that increasing the dose of ICS

within the licensed limit would not adversely affect child growth. This was supported by

the evidence, which showed that increasing the ICS dose in the short term did not result in

a statistically significant decrease in child growth, even though the doses used in the

study exceeded the licensed limit. Therefore, the committee decided to remove the 2017

recommendation rather than replacing it with a recommendation that prohibits increasing

the dose of ICS.

The committee discussed the importance of a personalised action plan to guide children

and young people if their asthma worsens and to reassure them that they are in control of

their treatment. Children and young people who find that increasing their dose of ICS is

Asthma: diagnosis, monitoring and chronic asthma management (NG80)

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helpful when their asthma control worsens should be able to continue to do this as an

agreed strategy in their action plan. However, based on their experience the committee

members agreed that it is important to review the child or young person's self-

management plan if their asthma control is deteriorating. Reviews involve checking current

medicines and inhaler technique, discussing any factors that may be triggering symptoms,

discussing adherence and education needs, and reviewing their action plan. They should

be carried out as needed, in addition to annual review. The committee also stressed the

importance of continuing regular ICS maintenance therapy, or restarting it if the child or

young person has stopped taking it, to prevent deterioration.

The committee discussed the importance of an individualised approach for children and

young people, because they have varied and changing support needs at different ages.

Studies have shown that most child asthma deaths involve children who have frequent but

mild symptoms that are not responding to management in their personalised action plan.

This recommendation should help to ensure that these children and young people receive

the support that they need if they start to have problems with their asthma control.

The committee agreed that further research is needed to give clearer guidance on

increasing the dose of ICS in children and young people within a self-management

programme and made a recommendation for research on increasing the dose of ICS within

a personalised self-management programme for children and young people to promote

further research and inform future practice.

"*A'A%" !'"!&A 'A'A#%'A

The recommendations will lead to an increase in the review of self-management

programmes for children and young people and reduce the variation in current practice for

this. The increase in resources needed for this is likely to be offset by a reduction in the

cost of treating asthma exacerbations.

Return to recommendations

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"!'+'A

Asthma is a chronic inflammatory respiratory disease. It can affect people of any age, but

often starts in childhood. Asthma is a variable disease which can change throughout a

person's life, throughout the year and from day to day. It is characterised by attacks (also

known as exacerbations) of breathlessness and wheezing, with the severity and frequency

of attacks varying from person to person. The attacks are associated with variable airflow

obstruction and inflammation within the lungs, which if left untreated can be life-

threatening, however with the appropriate treatment can be reversible.

In 2018, the Global Asthma report estimated that asthma affects 339 million people

worldwide. It is the most common chronic condition to affect children, and in the UK

approximately 5.4 million people (1.1 million children and 4.3 million adults) currently get

treatment for asthma (Asthma UK).

The causes of asthma are not well understood. A number of risk factors are associated

with the condition, often in combination. These influences can be genetic (the condition

clusters in families) and/or environmental (such as inhalation of allergens or chemical

irritants). Occupational causes of asthma in adults are often under-recognised.

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There is currently no gold standard test available to diagnose asthma; diagnosis is

principally based on a thorough history taken by an experienced clinician. Studies of adults

diagnosed with asthma suggest that up to 30% do not have clear evidence of asthma.

Some may have had asthma in the past, but it is likely that many have been given an

incorrect diagnosis. Conversely, other studies suggest that asthma may be

underdiagnosed in some cases.

The diagnosis recommendations will improve patient outcomes and will be cost effective

to the NHS in the long-term; NICE's cost impact assessment projects a saving of

approximately £12 million per year in England, before implementation costs.

Initial clinical assessment should include questions about symptoms (wheezing, cough,

breathing and chest problems) and any personal or family history of allergies, atopic

disorders or asthma. Various tests can be used to support a diagnosis, but there is no

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single test that can definitively diagnose asthma.

A number of methods and assessments are available to determine the likelihood of

asthma. These include measuring airflow obstruction (spirometry and peak flow) and

assessment of reversibility with bronchodilators, with both methods being widely used in

current clinical practice. However, normal results do not exclude asthma and abnormal

results do not always mean it is asthma, because they could be indicators of other

respiratory diseases or spurious readings.

Testing for airway inflammation is increasingly used as a diagnostic strategy in clinical

practice. This includes measuring fractional exhaled nitric oxide (FeNO).

Other diagnostic strategies include blood or skin prick tests to detect allergic reactions to

environmental influences, exercise tests to detect evidence of bronchoconstriction, and

measures of airway hyperreactivity such as histamine/methacholine or mannitol challenge

tests. However, it is debatable which test or measure, or combination of them, is the most

effective to accurately diagnose asthma.

It is recognised that asthma control is suboptimal in many people with asthma. This has an

impact on their quality of life, their use of healthcare services and the associated costs.

Asthma control can be monitored by measuring airway obstruction or inflammation and by

using validated questionnaires, but the most effective monitoring strategy is unclear.

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The severity of asthma varies; some people have severe asthma that limits normal

activities, whereas others are able to lead a relatively normal life. The illness fluctuates

during the year and over time, so the level of treatment needs to be tailored to the

person's current level of asthma severity. Many people with asthma, particularly children,

seem to have fewer symptoms over time, and an important part of management is

decreasing treatment if asthma is well controlled.

There is no cure for asthma, so management focuses on reducing exposure to known

triggers if possible, relief of symptoms if there is airway narrowing, and reduction in airway

inflammation by regular preventive treatment. Adherence to regular treatment reduces the

risk of significant asthma attacks in most people with asthma. The focus of asthma

management in recent years has been on supporting people with asthma and their

healthcare professional to devise a personalised treatment plan that is effective and

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relatively easy to implement.

A &A"A'&A(!A

The guideline covers children under 5, children and young people aged 5 to 16, and adults

aged 17 and over with suspected or diagnosed asthma. The guideline applies to all

primary, secondary and community care settings in which NHS-funded care is provided for

people with asthma.

The sections on diagnosing and monitoring asthma (sections 1.1 to 1.4 and 1.13) aim to

provide clear advice on effectively diagnosing people presenting with new symptoms of

suspected asthma and monitoring to ensure optimum asthma control. It is not intended to

be used to re-diagnose people who already have an asthma diagnosis.

The sections on managing chronic asthma (sections 1.5 to 1.12) aim to provide clear advice

for healthcare professionals and people with asthma to develop a personalised action plan.

The plan should support self-management of asthma, and ensure that the person is

receiving the best possible treatment for their current level of illness. It focuses on the

pharmacological management of chronic asthma, in particular the treatment pathway for

people with uncontrolled asthma. It also covers adherence to treatment, risk stratification

and self-management.

The guideline does not cover severe, difficult-to-control asthma or the management of

acute asthma attacks.

In 2018, new evidence was identified by the NICE surveillance team on increasing the dose

of inhaled corticosteroids within a self-management programme in children and young

people with asthma. Topic experts, including those who helped to develop the 2017

guideline, agreed that the new evidence could have an impact on the recommendations.

This evidence was reviewed and the recommendations in this area updated.

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!!A "%A!"% '"!A!A" ''A

'&A

To find NICE guidance on related topics, including guidance in development, see the NICE

topic page on asthma.

For full details of the evidence and the guideline committees' discussions, see the 2020

evidence review and 2017 full guidelines. You can also find information about how the

guideline was developed, including details of the committees.

NICE has produced tools and resources to help you put this guideline into practice. For

general help and advice on putting NICE guidelines into practice, see resources to help

you put guidance into practice.

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#'A!"% '"!A

March 2021: In recommendations 1.10.1 and 1.10.5, we clarified that approaches to

minimising indoor air pollution and reducing exposure to outdoor air pollution should be

included in a personalised action plan because pollution can trigger and exacerbate

asthma. We added links to the NICE guidelines on air pollution: outdoor air quality and

health and indoor air quality at home in recommendation 1.10.1.

February 2020: We reviewed the evidence on increasing the dose of inhaled

corticosteroids within a self-management programme in children and young people with

asthma and removed a recommendation. We made new recommendations on self-

management in children and young people. These recommendations are marked [2020].

Recommendations marked [2017] last had an evidence review in 2017. In some cases

minor changes have been made to the wording to bring the language and style up to date,

without changing the meaning.

ISBN: 978-1-4731-2461-5

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