This Guidelines summary is part of a series of summaries of the British Thoracic Society/Scottish Intercollegiate Guidelines Network (SIGN) guideline 158: British guideline on the diagnosis and management of asthma.
This summary is taken from the British guideline on the management of asthma: quick reference guide. It focuses on recommendations for the management of difficult asthma, and includes information on contributory factors and monitoring. For the complete set of recommendations, please refer to the full guideline.
Follow the links for summaries of BTS/SIGN recommendations on the diagnosis and management of asthma in the following groups:
Grades of Recommendation
The grade of recommendation relates to the strength of the supporting evidence on which the evidence is based. It does not reflect the clinical importance of the recommendation.[A] At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results.
[B] A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1.
[C] A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++.
[D] Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+.
Definition of Difficult Asthma
Difficult asthma is defined as persistent symptoms and/or frequent asthma attacks despite treatment with:
- high-dose ICS (adults) or medium-dose ICS (children) plus a LABA (age 5 and over) or LTRA; or
- medium-dose ICS (adults) or low-dose ICS (children) plus a LABA (age 5 and over) or LTRA and an appropriate additional therapy; or
- continuous or frequent use of oral steroid.
Assessing Difficult Asthma
[D] Patients with difficult asthma should be systematically evaluated, including:- confirmation of the diagnosis of asthma, and
- identification of the mechanism of persisting symptoms and assessment of adherence to therapy
[D] This assessment should be facilitated through a dedicated multidisciplinary difficult asthma service, by a team experienced in the assessment and management of difficult asthma.
Factors Contributing to Difficult Asthma
Poor Adherence
[C] Healthcare professionals should always consider poor adherence to maintenance therapy before escalating treatment in patients with difficult asthma.
Psychosocial Factors
[C] Healthcare professionals should be aware that difficult asthma is commonly associated with coexistent psychological morbidity
[D] Assessment of coexistent psychological morbidity should be performed as part of a difficult asthma assessment. In children this may include a psychosocial assessment of the family
[D] Dysfunctional breathing should be considered as part of the assessment of patients with difficult asthma.
Monitoring Airway Response
[B] In patients with difficult asthma, consider monitoring induced sputum eosinophil counts to guide steroid treatment.