The video version of this podcast can be found here: ·      https://youtu.be/-64tUk-zkWk This channel may make reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on diagnosing, monitoring, and managing chronic asthma, NG245, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on initial assessment and diagnosis. In the next three episodes, I will cover:·      Treating asthma in patients aged 12 and over·      Treating asthma in children aged 5 to 11, and those under 5·      And finally, Asthma monitoring, general treatment principles, and management in special groups The new guideline is a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.   Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through  There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast: ·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrkThe link to the new collaborative NICE guideline on chronic asthma can be found here:·      https://www.nice.org.uk/guidance/ng245The table on alternative diagnoses in wheezy children in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here: ·      https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/diagnosis/alternative-diagnoses-in-wheezy-children/The table on alternative diagnoses in adults in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here: ·      https://rightdecisions.scot.nhs.uk/asthma-pathway-bts-nice-sign-sign-244/diagnosis/alternative-diagnoses-in-adults/The algorithm A for a summary of objective tests for diagnosing asthma in adults and young people (aged over 16 years) with a history suggesting asthma can be found here: ·      https://www.nice.org.uk/guidance/ng245/resources/bts-nice-and-sign-algorithm-a-summary-of-objective-tests-for-diagnosing-asthma-pdf-13556516365The algorithm B for a summary of objective tests for diagnosing asthma in children aged 5 to 16 with a history suggesting asthma can be found here: ·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-b-objective-tests-for-diagnosing-asthma-in-children-aged-5-to-16-with-a-history-pdf-13556516366The algorithm C for a summary of the pharmacological management of asthma in people aged 12 years and over can be found here:·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-c-pharmacological-management-of-asthma-in-people-aged-12-years-and-over-bts-nice-pdf-13556516367The algorithm D for a summary of the pharmacological management of asthma in children aged 5 to 11 years can be found here:·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-d-pharmacological-management-of-asthma-in-children-aged-5-to-11-years-bts-nice-sign-pdf-13556516368The algorithm E for a summary of the pharmacological management of asthma in children under 5 can be found here:·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-e-pharmacological-management-of-asthma-in-children-under-5-bts-nice-sign-pdf-13556516369The MHRA safety advice on the risk of neuropsychiatric reactions in people taking montelukast can be found here:·      https://www.gov.uk/drug-safety-update/montelukast-reminder-of-the-risk-of-neuropsychiatric-reactionsThe table of inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline can be found here:·      https://www.nice.org.uk/guidance/ng245/resources/inhaled-corticosteroid-doses-for-the-bts-nice-and-sign-asthma-guideline-pdf-13558148029The NICE guideline on air pollution: outdoor air quality and health can be found here:·      https://www.nice.org.uk/guidance/ng70The NICE guideline on indoor air quality at home can be found here:·      https://www.nice.org.uk/guidance/ng149 Disclaimer:The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.Hello and welcome, I am Fernando, a GP in the UK. Today, we will go throughthe new NICE guideline on diagnosing, monitoring, and managing chronic asthma, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode we’ll just focus on initial assessment and diagnosis.In the next three episodes, we will cover:·      Treating asthma in patients aged 12 and over·      Treating asthma in children aged 5 to 11, and those under 5·      And finally, Asthma monitoring, general treatment principles, and management in special groupsSo, stay tuned for those!Right, let’s jump into it.The new guideline is a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you’ll find a link to it in the episode description.As the initial clinical assessment we will get the history, checking for symptoms such as wheezing, a cough, shortness of breath, chest tightness and any triggers that make symptoms worse as well as a personal or family history of asthma or allergic rhinitis. And we will consider alternative diagnoses depending on the symptoms and presentation. There are tables produced in the previous BTS/SIGN guideline on alternative diagnoses in wheezy children and adults that you can have a look at, and I have put a link to them in the episode description.We will then do a physical examination to check for expiratory polyphonic wheeze and signs of other possible causes, being aware that asthma can present with a normal examination.However, we will not confirm the diagnosis of asthma without a suggestive clinical history and a supporting objective test. What should be our approach if there are acute symptoms at presentation?Well, we will start treatment immediately if they are acutely unwell or highly symptomatic, and perform objective tests to confirm a diagnosis of asthma if the equipment is available. However, if objective tests for asthma cannot be done immediately, we will carry them out when acute symptoms have been controlled, even though we need to be aware that the results of spirometry and FeNO tests may be affected with inhaled corticosteroids, as the test results are more likely to be normal. So, let’s look at the objective diagnostic tests that we will need to organise.But before, we need to know that, from a diagnosis perspective, there are three groups of patients:·      Those aged over 16·      Those aged 5 to 16 and·      Those aged under 5NICE has produced summaries of objective tests in the various age groups and a link to them can be found in the episode description.Let’s start with those over the age of 16. For them, as the initial tests we will measure the blood eosinophil count or fractional exhaled nitric oxide (FeNO) level.We will then diagnose asthma if the eosinophil count is above the reference range or the FeNO level is 50 ppb or more. If asthma is not confirmed by eosinophil count or FeNO level, we will then measure bronchodilator reversibility with spirometry and we will diagnose asthma if the FEV1 increase is 12% or more AND 200 ml or more from the pre-bronchodilator measurement or, also, and this is new, if the FEV1 increase is 10% or more of the predicted normal FEV1. Let’s look at this in a bit more detail. NICE has argued that the change in FEV1 is best given as the percentage change compared with, not the person’s baseline, but the person's predicted FEV1. Using this calculation, a change of 10% or more is abnormal and therefore diagnostic. If we use the more traditional way as a percentage from the baseline FEV1, then a positive reversibility should be slightly higher, 12% for both adults and children. In adults, the change should also be 200 ml or more. So NICE decided to include both ways of measuring reversibility in their recommendations, that is 10% or more of predicted or 12% or more from baseline FEV1. If spirometry is not available or it is delayed, we will measure peak expiratory flow (PEF) twice daily for 2 weeks and we will diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more. This is calculated by subtracting the lowest value measured each day from the highest value on the same day, and averaging this over the number of days on which PEF is measuredIf asthma is not confirmed by eosinophil count, FeNO, BDR or PEF variability, but it’s still suspected on clinical grounds, we will refer for consideration of a bronchial challenge test. Then, asthma we will be diagnosed if bronchial hyper-responsiveness is present. And let’s remember that bronchial hyper-responsiveness is a measure of how easily bronchospasm can be induced in the airways. Let’s now look at the second group of patients, those aged 5 to 16.In this age group, as the initial test we will measure the FeNO level and diagnose asthma if the FeNO level is 35 ppb or more. This is a change in practice because before in the old guideline, FeNO testing was not recommended as an initial test in this age group. Also, please note that we will not use eosinophil count as an initial test here, although it can play a part at a later stage. But we will come to that a little later.So, if the FeNO level is not raised, or if FeNO testing is not available, we will measure BDR with spirometry and diagnose asthma if the FEV1 increase is 10% or more of the predicted normal FEV1or 12% or more from baseline FEV1. Please note that it does not need to be more than 200ml in this age group. If spirometry is not available or it is delayed, we will measure PEF twice daily for 2 weeks and diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more, that is, exactly the same as for adults. If asthma is not confirmed by FeNO, BDR or PEF variability but still suspected on clinical grounds, we will either perform skin prick testing to house dust mite or measure total IgE level and blood eosinophil count.We will then:Diagnose asthma if there is evidence of sensitisation or if there is a raised total IgE level and the eosinophil count is more than 0.5 x 109 per litre. If there is still doubt about the diagnosis, we will refer to a paediatrician for a second opinion, which will include consideration of a bronchial challenge test. What about diagnosing asthma in children under 5Diagnosis in children under 5 is hard because it is difficult to do the tests and there are no good reference standards.So, for children under 5 with suspected asthma, we should treat with inhaled corticosteroids in line with NICE recommendations and review them on a regular basis. If they still have symptoms when they reach 5 years, we will attempt objective tests.If a child is unable to perform objective tests when they are aged 5:We will try doing the tests again every 6 to 12 months until satisfactory results are obtained orWe will refer for specialist assessment if the symptoms are not responding to treatment. On a separate basis, we will refer to a specialist respiratory paediatrician any preschool child with an admission to hospital, or 2 or more admissions to an emergency department, with wheeze in a 12-month period. Before ending this episode, let’s touch on the subject of diagnosing occupational asthma.And for this, in adult-onset asthma, poorly controlled established asthma, or reappearance of childhood asthma, we should check for a possible occupational component by asking the following questions:Are symptoms the same, better or worse on days away from work? andAre symptoms the same, better or worse when on holiday (or time away from work, longer than usual breaks, at weekends or between shifts)?If the answer is yes to any of those questions, we will suspect occupational asthma and we will refer them to a specialist. So that is it, a review of the initial assessment and diagnosis of asthma.We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.Thank you for listening and goodbye.

Ver todos los episodios