The SIGN/BTS guideline will encourage best practice in primary care management of asthma, says Dr Peter Saul
The SIGN/BTS asthma guideline published last month comes as manna from heaven to GPs confused by the increasing numbers of treatment options developed in recent years for their asthma patients.
The guideline goes further than merely updating the 1995 BTS and more recent SIGN guidelines, and provides comprehensive signposts to the management of all aspects of asthma.
It offers practical advice on aspects ranging from disease prevention to the treatment of acute severe episodes as well as documenting which treatments have a good evidence base.
Asthma can be difficult to diagnose. The guideline draws attention to the clinical signs, the need to exclude other diseases and to repeat measurements of airflow. The importance of the presence of wheeze in adults and children is emphasised. It is likely that these recommendations will increase our use of peak flow meters in practice to aid diagnosis.
One of the issues in managing patients and families with a history of asthma is dealing with the questions. Will he grow out of it? What can we do to prevent other children developing it? Will my asthma improve if I stop smoking? The guideline offers evidence-based answers to many of these questions, addressing topical issues such as the preventative benefits of early microbial exposure, the effect of environmental exposure to chemicals or allergens, the role of exercise and sex differences.
The guideline contains a comprehensive review of all the pharmacological treatments. In most patients with stable asthma, metered dose inhalers (with spacers when appropriate) are rated as good as other inhaler devices. The guideline points out that there is no clinical advantage in using combined products.
The guideline advocates a stepwise approach to management. Practical goals are set for therapy and recommendations are separated into those for adults, children from 5-12 years and children under 5 years. They detail a range of short and long acting bronchodilators, inhaled steroids, leukotriene receptor antagonists, theophyllines and other drugs available. It is good to see each fitted into its place in the treatment jigsaw for each age group.
Acute management is dealt with in detail, with an emphasis placed on clinical assessment. Clinical markers such as pulse rate, ability to complete sentences in one breath and respiratory rate are recommended for assessment. A bronchodilator delivered by nebuliser remains the mainstay of treatment, but the importance of high flow oxygen to drive it is emphasised. Perhaps GPs should be making more frequent use of those oxygen cylinders lying idle in practices and in the boots of GP co-op cars. The guideline recommends prescribing larger doses of oral steroids and frequent re-assessment of the patient.
Looking after patients with chronic illness is a continuing process and this guideline recognises this, offering advice on developing management plans and stressing the importance of patient education. The vital role of the practice nurse is highlighted, as is the need for effective review procedures.
This guideline is down to earth but has a rigorous scientific approach. It offers a wealth of information across the whole landscape of asthma and its management. Both the •summaryê which runs to 18 pages and the full document of 94 pages are relatively easy to read and are well and clearly presented, with recommendations colour coded according to age group.
Perhaps the most important thing for any reader is that as well as guiding clinical practice, this guideline will make you think.
- See 'New joint guideline should raise standards of asthma care'
- British Guideline on the Management of Asthma: a national clinical guideline has been published as a supplement to Thorax, Vol 58 (Suppl 1), and can also be downloaded from the SIGN website: www.sign.ac.uk