Dr Mark L Levy compares some of the recommendations from GINA and BTS/SIGN on asthma and considers how different approaches might impact on diagnosis, assessment, and patient mortality

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Read this article to learn more about:

  • death rates from asthma in the UK
  • some ways in which the BTS/SIGN guideline and the GINA strategy differ
  • the author’s reflections on whether and how these differences might impact on the UK’s high asthma mortality rates compared with other high-income countries.

Key points

The UK was one of the first countries to publish national asthma guidelines in 1990, yet the UK currently has the highest childhood asthma death rates in Europe1 and is ranked third highest for all asthma deaths in people aged 5–34 years in high income countries worldwide.2 One has to ask ‘why this is the case?’ 

The updated BTS/SIGN British guideline on the management of asthma (SIGN 153), published in 2016,3 was a welcome revision; however, the text still includes a lot of academic material that may not be of use to clinicians without a strong asthma interest; possibly explaining why the British guidelines are not followed, as evidenced in the National review of asthma deaths (NRAD)4 and recent Regulation 28 statements issued by two HM coroners on preventable childhood asthma deaths.5,6

This article is based on my personal views, and is not intended as a guide for clinicians managing asthma; readers should refer to the BTS/SIGN guideline3 and the international Global Initiative for Asthma (GINA) strategy document (2017).7 In particular, I recommend that practitioners read the text of these two documents in conjunction with the tables and figures, because the text serves to provide more detailed explanation and guidance than the tables and figures alone. 

I have highlighted some of the differences between the BTS/SIGN guideline3 and the international GINA strategy document (2017),7,8 which is updated annually and followed by many countries with a better record on asthma care than the UK. One of the key differences is that GINA moved much of the academic material into a web-based appendix for the benefit of academics9 and as a result GINA is significantly shorter than BTS/SIGN. Both reports have accompanying shorter resources: a pocket guide for GINA10 and quick reference guide for BTS/SIGN.11

Diagnosis

In a recent (2017) Canadian study asthma was misdiagnosed in 33% of adults.12 As there is no single test for diagnosing asthma, the diagnosis is based on clinical grounds. The BTS/SIGN guideline has favoured a diagnostic approach based on probability; the 2016 guideline suggests starting inhaled corticosteroids (ICS) in patients with suspected asthma,3 rather than first confirming the diagnosis as is recommended by GINA, where the diagnostic process is simplified (see GINA strategy, Box 1-1).7 In the GINA strategy, anyone with a history suggestive of asthma who has variable airflow obstruction (confirmed by spirometry or peak expiratory flow [PEF]) should be prescribed a trial of asthma therapy and reviewed after 1 to 3 months to confirm response to treatment.7

Another important point is that the diagnostic algorithm in the BTS/SIGN guideline (see Figure 1 in the guideline) might give the impression that a ‘high probability’ of asthma can only be diagnosed if the patient is atopic, which means that other asthma phenotypes (e.g. occupational asthma, late onset asthma, non-allergic asthma, and asthma with fixed airflow obstruction in older people with long-term asthma) may be underdiagnosed.

While BTS/SIGN includes FeNO testing as one option among a number for assessing the possibility of a diagnosis of asthma, GINA categorically counsels against FeNO testing, because there is as yet no long-term data on safety outcomes for people who are not treated on the basis of a negative FeNO test.7 A positive test does help to identify those who are likely to respond to inhaled corticosteroids; however, FeNO is elevated in other conditions, e.g. allergic rhinitis and rhinovirus infections.3

Asthma control

A major finding in the NRAD was that risk of future attacks was poorly identified by healthcare staff, carers, and patients, the latter mainly because for the majority of those who died, there was no evidence in their records that they had been provided with the relevant education. One in five of those who died had been treated for acute asthma attacks, 10% had been discharged from hospital within a month of dying, 39% had been prescribed more than 12 salbutamol inhalers, and 38% were issued with less than four preventer inhalers in the previous year; all of which were known risk factors for asthma attacks.4 Furthermore, the NRAD (as in past studies) found that nearly two-thirds of those who died were classified by their doctors as having mild or moderate asthma.4

Assessment of asthma control and risk is addressed differently in BTS/SIGN compared with GINA. Asthma severity should be classified for each patient, mainly to determine those patients who would likely benefit from expert assessment and opinion at one of the severe asthma clinics in the UK. Severity of asthma is defined in GINA (not defined in BTS/SIGN) as the amount of treatment required to gain control of someone’s asthma;7 therefore, the level of treatment prescribed is an unsatisfactory surrogate marker of asthma severity.

Asthma control according to GINA, comprises both ‘current symptom control’ and also ‘risk of future attacks’ (see Table 1).7,8 So, for the purpose of optimising control, both current symptom control (e.g. Royal College of Physicians [RCP] 3 questions or the Asthma control test [ACT]),3 and also other markers of poor control (e.g. past attacks, admissions, A&E attendances) and risk (e.g. pregnancy, food allergy, concomitant COPD, excess SABA, insufficient inhaled preventer medication) should be used to assess risk and the need for specialist care.7,8 In NRAD, current symptom control was assessed in only 20% of the cases, and risk was rarely detailed in the records of those who died.4

Table 1: GINA assessment of asthma control in adults, adolescents, and children 6–11 years

A. Asthma symptom controlLevel of asthma symptom control

In the past 4 weeks, has the patient had: 

Well controlled

Partly controlled

Uncontrolled 

Daytime symptoms more than twice/week?

Yes □ No □

None of these

1–2 of these    

3–4 of these

Any night waking due to asthma?

Yes □ No □

Reliever needed for symptoms* more than twice/week?

Yes □ No □

Any activity limitation due to asthma?

Yes □ No □

B. Risk factors for poor asthma outcomes

Assess risk factors at diagnosis and periodically, particularly for patients experiencing exacerbations

Measure FEV1 at start of treatment, after 3–6 months of controller treatment to record the patient’s personal best lung function, then periodically for ongoing risk assessment

Potentially modifiable independent risk factors for flare-ups (exacerbations)

  • Uncontrolled asthma symptoms 

  • High SABA use (with increased mortality if >1 x 200-dose canister/month)

  • Inadequate ICS: not prescribed ICS; poor adherence; incorrect inhaler technique

  • Low FEV1, especially if <60% predicted

  • Major psychological or socioeconomic problems

  • Exposures: smoking; allergen exposure if sensitised

  • Co-morbidities: obesity; rhinosinusitis; confirmed food allergy

  • Sputum or blood eosinophilia; elevated FeNO (in adults with allergic asthma)

  • Pregnancy

Other major independent risk factors for flare-ups (exacerbations)

  • Ever intubated or in intensive care unit for asthma

  • ≥1 severe exacerbation in last 12 months                                                                                                                                                                                                                                                                             

Having one or more of these risk factors increases the risk of exacerbations even if symptoms are well controlled.

Risk factors for developing fixed airflow limitation

  • Lack of ICS treatment

  • Exposures: tobacco smoke; noxious chemicals; occupational exposures

  • Low initial FEV1; chronic mucus hypersecretion; sputum or blood eosinophilia

Risk factors for medication side-effects

  • Systemic: frequent OCS; long-term, high dose and/or potent ICS; also taking P450 inhibitors

  • Local: high-dose or potent ICS; poor inhaler technique

* Excludes reliever taken before exercise. For children 6–11 years, also refer to the full GINA strategy for specific risk reduction strategies

GINA=Global Initiative for Asthma; FEV1=forced expiratory volume in 1 second; SABA=short-acting beta2-agonist; ICS=inhaled corticosteroid; FeNO=fractional exhaled nitric oxide; OCS=oral corticosteroid; P450 inhibitors=cytochrome P450 inhibitors such as ritonavir, ketoconazole, itraconazole

Global Initiative for Asthma. Global strategy for asthma management and prevention. GINA, 2017. Available at: www.ginasthma.org
Reproduced with permission

In the UK, GPs are reimbursed by the quality and outcomes framework (QoF).13 In my view a major failing of this system is that, as a result, many UK clinicians assess asthma control simply by asking the RCP 3 Questions (on daytime and night-time symptoms and the ability of patients to continue with their daily activities).14 While the RCP 3 Questions provide information on ‘current asthma symptoms’, they do not address the issue of risk of future asthma attacks. The GINA  approach, together with optimisation of symptom control and reduction of risk, might change UK outcomes in asthma, ideally in conjunction with the post-attack review that has been recommended in the British guideline and in NICE Quality Standard 25 on Asthma, published in 2013.3,7,15 See chapter 2 of the GINA strategy for further detailed information about assessing current symptoms, symptom control, and future risk of adverse outcomes.7

Treatment

The recommendations on chronic treatment in BTS/SIGN and GINA are similar; however GINA provides advice about how to personalise treatment to the individual patient (see Box 3-3 in GINA), depending on their preferences, phenotype, any practical issues, as well as aiming to improve control and reduce risk. Furthermore, chapter 3 in the GINA strategy targets ‘gaining control’. GINA utilises a clear diagram called the ‘control-based asthma management cycle’ to clarify the processes involved in assessing, diagnosing, managing, and reassessing patients with the aim of gaining control and minimising risk. A major change in the British guideline is that ‘treatment steps’ have apparently been scrapped and more importantly, the use of short-acting reliever inhalers (SABAs, such as salbutamol and terbutaline) are only advised for relief, with advice that treatment should be stepped up if more than three doses are needed per week,3 (see Figures 2 and 3 in the British guideline), or if it doesn’t help, or according to expert opinion if it is needed more than once every 4 hours (which is an emergency situation). Assuming patients identify and act on risk early, this guidance could improve asthma outcomes in the UK.

An important management issue, highlighted in both BTS/SIGN and GINA, is to conduct a timely post-attack review after initiating treatment to decide whether to continue or not; BTS/SIGN states 6–8 weeks, whereas GINA states 1–3 months after treatment initiation. Furthermore, anyone who does not respond or responds minimally to treatment should be referred to a specialist for confirmation of the diagnosis and advice on further treatment.3,7

Acute asthma

The sections on acute asthma management in BTS/SIGN and GINA are both useful and clear for assessing and treating acute attacks in primary and secondary care. Tables 12 and 14 on assessment of severity of attacks in adults and children3 (in the BTS/SIGN guideline; see Tables 2 and 3 in this article) and Box 4-5 (in the GINA strategy)7 on attack and post-attack assessment are particularly useful and should be available in any treatment room where people with uncontrolled asthma are treated.

Table 2: Levels of severity of acute asthma attacks in adults

Moderate acute asthma
  • Increasing symptoms
  • PEF >50–75% best or predicted
  • No features of acute severe asthma
Acute severe asthma

Any one of:

  • PEF 33–50% best or predicted
  • respiratory rate ≥25/min
  • heart rate ≥110/min
  • inability to complete sentences in one breath
Life-threatening asthma Any one of the following in a patient with severe asthma:
Clinical signs Measurements
Altered conscious level PEF <33% best or predicted
Exhaustion SpO2 <92%
Arrhythmia PaO2 <8 kPa
Hypotension ‘normal’ PaCO2 (4.6–6.0 kPa)
Cyanosis  
Silent chest  
Poor respiratory effort  
Near-fatal asthma Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures 
PEF=peak expiratory flow; SpO2 =oxygen saturation measured by a pulse oximeter; PaO2 =partial arterial pressure of oxygen; kPa=kilopascals; PaCO2 =partial arterial pressure of carbon dioxide
British Thoracic Society, Scottish Intercollegiate Guideline Network. British guideline on the management of asthma. SIGN 153. BTS/SIGN, 2016. Available at: www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/

Table 3: Levels of severity of acute asthma attacks in children

Moderate asthma

Able to talk in sentences

SpO2≥92%

PEF ≥50% best or predicted

Heart rate

  • ≤140/min in children aged 1–5 years
  • ≤125/min in children >5 years

Respiratory rate 

  • ≤40/min in children aged 1–5 years
  • ≤30/min in children >5 years
Acute severe asthma Can’t complete sentences in one breath or too breathless to talk or feed

SpO2 <92%

PEF 33–50% best or predicted

Heart rate 

  • >140/min in children aged 1–5 years
  • >125/min in children >5 years

Respiratory rate 

  • >40/min in children aged 1–5 years
  • >30/min in children >5 years
Life-threatening asthma       

Any one of the following in a child with severe asthma:

Clinical signs Measurements
Silent chest SpO2 <92%
Cyanosis PEF <33% best or predicted
Poor respiratory effort  
Hypotension   
Exhaustion   
Confusion  
SpO2 =oxygen saturation measured by a pulse oximeter; PEF=peak expiratory flow
British Thoracic Society, Scottish Intercollegiate Guideline Network. British guideline on the management of asthma. SIGN 153. BTS/SIGN, 2016. Available at: www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/

Asthma–chronic obstructive pulmonary disease overlap

A number of people whose deaths were classified as asthma deaths in NRAD were being treated as if they had chronic obstructive pulmonary disease (COPD), whereas they actually had chronic asthma with fixed airflow obstruction. GINA addresses the diagnosis and management of those people who have features of both asthma and COPD, in chapter 5; this chapter was written specifically for GPs and general physicians as a joint project between Global Initiative for Obstructive Lung Disease (GOLD) and GINA, and is helpful in diagnosing these people.7

Conclusion

In my opinion, both the BTS/SIGN guideline and the GINA strategy document have strengths and weaknesses. Both are evidence-based and written by experts in the field of asthma, and both contain significant academic detail (albeit in an appendix in GINA) to provide academics and experts with up-to-date research data and ideas for further research. Both documents contain considerable detail on practical aspects in the management of asthma; however, in my view, the GINA strategy is more user-friendly, and judging by the comparative international asthma outcome data (particularly asthma deaths) is more likely to improve UK health utilisation statistics than the BTS/SIGN guideline. Further confusion is on the horizon for UK health professionals as new guidance on asthma is due to be published by NICE in October 2017, which will in my view only serve to confuse matters further for generalist clinicians.

Key points

  • The UK ranks third for the highest total number of asthma deaths (in people aged 5–34 years of age) in high-income countries worldwide
  • The UK has the highest asthma death rate in Europe for children and young people
  • BTS/SIGN guideline (UK) and GINA strategy (international) on asthma have both recently been updated. In the author’s view:
    • the amount of academic material in the body of the BTS/SIGN guideline may make it less approachable for some practitioners than the shorter GINA strategy, which has separated the academic material into an appendix
    • the GINA strategy offers a simpler, more straightforward diagnostic process, which might make earlier treatment more likely and underdiagnosis less likely than with the BTS/SIGN protocol assessing the risk of future attacks as well as current treatment control could impact on the number of asthma deaths, especially when combined with optimal symptom control and recommended follow up
  • The GINA strategy offers clear processes for assessing and gaining control and minimising risk, and includes a chapter on asthma–COPD overlap
  • Both the BTS/SIGN guideline and GINA strategy:
    • emphasise the importance of timely review after initiating treatment
    • offer helpful advice on acute asthma management.
BTS=British Thoracic Society; SIGN=Scottish Intercollegiate Guidelines Network; GINA=Global Initiative for Asthma; COPD=chronic obstructive pulmonary disease

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References

  1. Wolfe I, Thompson M, Gill P et al. Health services for children in western Europe. Lancet 2013; 381 (9873): 1224–1234.
  2. Global Asthma Network. The global asthma report 2014. Auckland, New Zealand: Global Asthma Network, 2014. Available at: www.globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf
  3. British Thoracic Society, Scottish Intercollegiate Guideline Network. British guideline on the management of asthma. SIGN 153. BTS/SIGN, 2016. Available at: www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/
  4. Royal College of Physicians (RCP). Why asthma still kills—the national review of asthma deaths (NRAD). London; RCP, 2014. Available at: www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills 
  5. Carney T. Regulation 28—report to prevent future deaths. Courts and Tribunals Judiciary, 2016. Available at: www.judiciary.gov.uk/wp-content/uploads/2016/01/Mills-2015-0416.pdf
  6. Radcliffe S. Regulation 28: report to prevent future deaths. Courts and Tribunals Judiciary, 2017. Available at: www.judiciary.gov.uk/wp-content/uploads/2017/03/Uriely-2017-0069_Redacted.pdf 
  7. Global Initiative for Asthma. Global strategy for asthma management and prevention. GINA, 2017. Available at: www.ginasthma.org 
  8. Reddel H, Levy M. The GINA asthma strategy report: what’s new for primary care? NPJ Prim Care Respir Med 2015; 25: 15050. Available at: www.nature.com/articles/npjpcrm201550 
  9. Global Initiative for Asthma. Global strategy for asthma management and prevention. Online appendix. GINA, 2017. Available at: ginasthma.org/gina-reports/
  10. Global Initiative for Asthma. 2017 Pocket guide for asthma management and prevention. GINA, 2017. Available at: ginasthma.org/2017-pocket-guide-for-asthma-management-and-prevention/ 
  11. British Thoracic Society and Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma quick reference guide. Quick Reference Guide 153. BTS/SIGN, 2016. Available at: www.sign.ac.uk/assets/qrg153.pdf 
  12. Aaron S, Vandemheen K, FitzGerald J et al, for the Canadian Respiratory Research Network. Reevaluation of diagnosis in adults with physician-diagnosed asthma. JAMA 2017; 317 (3): 269–279.
  13. NHS Employers. Quality and outcomes framework. www.nhsemployers.org/your-workforce/primary-care-contacts/general-medical-services/quality-and-outcomes-framework (accessed 18 July 2017).
  14. Pearson M, Bucknall C, editors. Measuring clinical outcome in asthma: a patient-focused approach. London: Royal College of Physicians of London, 1999.
  15. NICE. Asthma. NICE Quality Standard 143. NICE, 2017. Available at: nice.org.uk/qs143 G