Self-management

Asthma pathway (BTS, NICE, SIGN) [SIGN 244]

This content is from the BTS, NICE and SIGN guideline - Asthma: diagnosis, monitoring and chronic asthma management (SIGN 245), 2024.

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.

 

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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:

[NICE 2017, amended 2021; BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

 

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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]

 

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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]

 

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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]

 

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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]

 

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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]

 

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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]

 

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1.14.8 Provide self-management education in line with the recommendations on education programmes in the section on enabling patients to actively participate in their care in the NICE guideline on patient experience in adult NHS services.

[BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

 

             

Rationale and impact

Why the committee made the recommendations

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 with 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 they agreed that the evidence was not applicable because of the high average age of participants.

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 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 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. They made a research recommendation 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.

How the recommendation might affect practice

The recommendation 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.

 

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