Dr Peter Saul explains how electronic updates of the BTS/SIGN guideline enable GPs to stay abreast of asthma management
Three elements make the BTS/SIGN asthma guideline one of the most critical clinical tools for GP practices.1 There is its clarity and ease of use, the support it offers to effective care under the nGMS contract and, most importantly, it is continually being updated to keep track of the latest evidence.
The quick reference guide is 20 pages long and is essentially unchanged; the full guideline,although 90 pages, is an easy read with revised recommendations from 2004 and 2005 clearly marked. You can just print out the sections you need.
Recognising that up to 15% of adult patients presenting with asthma have an occupational element, the new section on occupational asthma is a welcome refresher to an important topic many GPs may have forgotten.
As Hilary Pinnock pointed out in her article last month (‘British guideline updates recommendations on occupational asthma’, Guidelines in Practice November 2005), the guideline reminds clinicians to consider an occupational cause when patients present with adult-onset asthma or recurrence of childhood asthma.
Particularly useful is the section on diagnosis of occupational asthma and the reminder to use serial peak flow measurements to assist in this often difficult process. The guideline emphasises that early diagnosis and subsequent avoidance of the provoking factor can lead to complete recovery. This will require effective dialogue between GPs and occupational health colleagues.
One of the advantages of regular updates is that they can develop existing knowledge of the guideline. All the management algorithms remain the same but there are some additions which build on and enhance these.
This year’s revision of the guideline updates advice on inhalers and drug delivery systems.
There is welcome strengthening of recommendations on the use of pMDIs with spacers rather than nebulisers in the treatment of mild to moderate exacerbations in children and adults. Dosage depends on clinical response but consists of four to six separate puffs administered at 10-minute intervals.
This is a timely reminder for us to keep salbutamol and a spacer in the boot of the car.
There is clarification too on the role of short-acting beta2 agonists which are now recommended on an ‘as needed’ basis, and while it may be convenient for patients to take combined long-acting beta2 agonists and steroids, the guideline indicates that this combination does not offer clinical benefits.
It can be difficult for clinicians to know when to start inhaled steroids, but the guideline now contains new recommendations based on the number of exacerbations, use of bronchodilators and nighttime symptoms.
These annual updates help to keep the guideline at the cutting edge and give clinicians confidence that it offers advice based on the latest available evidence on virtually every aspect of managing patients with asthma.
- The British Thoracic Society/Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Thorax 2003; 58(S1): i1-94.