New guidelines on the management of asthmaBMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7385.346 (Published 15 February 2003) Cite this as: BMJ 2003;326:346
Need to be widely disseminated to improve care of people with asthma
- P John Rees (), consultant physician
Previous guidelines for the management of asthma produced by the British Thoracic Society and others have been disseminated widely and have been influential on the approach to asthma management in the United Kingdom and internationally. The latest full version was produced in 1993,1 with a review and position statement in 1995.2 The coordinating committee at that time predicted that the next revision would be a rewrite in 1997-8, so a new version is overdue. When we reviewed the 1993 guidelines we pointed out a lack of clarity on the evidence base and the need for expert opinion where evidence is lacking.3 Both of these areas are addressed in the new guidelines4 through the methods and format familiar from the Scottish Intercollegiate Guidelines Network (http://www.sign.ac.uk/). The new British guidelines have been produced jointly by the British Thoracic Society and Scottish Intercollegiate Guidelines Network, in collaboration with various other bodies.
The levels of evidence and grades of recommendations are given a clear hierarchy, but the method of the Scottish Intercollegiate Guidelines Network also identifies “recommended best practice based on the clinical experience of the guideline development group.” Although this might seem a reversion to earlier consensus or opinion based guidelines, it is very useful where necessary evidence is found to be lacking despite an extensive literature search. This if often the case in areas where clinicians need most help. Where there is evidence it is clearly set out, although the writers sometimes add their own view—for example, in the suggestion that senior medical staff should be consulted before the use of intravenous magnesium, although it carries an A recommendation and 1++ evidence.
In the initial chapters on diagnosis, natural history, and non-pharmacological management only one of the recommendations achieves the top A grade, reflecting the need for further research in these areas. Graded A is the recommendation that breast feeding should be encouraged and its benefits include a protective effect in relation to wheezing in early life. Interestingly, in the chapter of pregnancy later in the document, encouraging women with asthma to breast feed gets only a C weighting. This reflects the care needed in the interpretation of evidence and wording of recommendations, and the influence of entry criteria and end points in the studies evaluated. Even if breast feeding reduces virus induced wheeze in the early years, a study5 subsequent to the work on the guidelines has confirmed that breastfeeding does not protect against asthma in later childhood6 or adulthood, and may increase the risk. Evidence and recommendations that seem robust now will be challenged, and the large reference base in these guidelines is an excellent resource for readers who want to evaluate the strength of the evidence for themselves.
In the sections on pharmacological treatment and management the evidence and recommendations are divided into age groups—younger than 5, 5-12, and older than 12 years—and grade A recommendations appear much more widely. The steps in the management of chronic asthma in adults and children, familiar from previous guidelines, have a welcome simplification in much clearer charts. The major change is in the approach to step 3, where the guidelines have caught up with current practice of using a long acting bronchodilator as the first approach when low dose inhaled steroids are inadequate. The previous alternative of an increase in the inhaled steroid dose to the 800-2000 μg range has been moved up to step 4.
In the management of acute asthma continued emphasis lies on appropriate initial assessment and adequate immediate treatment. The dose of oral steroid in adults is standardised to 40-50 mg prednisolone daily and the dose of intravenous hydrocortisone reduced from 200 mg to 100 mg six hourly. The profile of nebulised ipratropium in acute exacerbations in adults has been elevated slightly compared with previous guidelines.
The acute management chart in adults for emergency departments has gone down from four to three categories bringing together moderate (peak flow 50-75%) and severe (peak flow 33-50%) into one main group for treatment recommendations, and the chart has acquired a very useful time expectation for the steps in the assessment and treatment.
The guidelines are written clearly, the summary charts are improved, the references are extensive, and useful additional chapters are included on topics such as pregnancy, occupational asthma, concordance or compliance, and audit datasets. However, the impact of the guideline will depend on the enthusiasm with which it is disseminated and taken up. This has been relatively successful in the past, but more will need to be done to reach all relevant doctors, nurses, and patients and to encourage active audit and evaluation. The document sets out a plan for this activity, which will need to be implemented vigorously to make the most of the extensive work that has gone in to the new guidelines.
Discontinuity between primary care, emergency deprtments, and even within secondary units hinders the integrated care of asthma in many areas. One way to address this is through greater involvement of patients in their own management. Asthma action plans have been shown to work when these plans are personalised and imaginatively linked to the individual patient's goals and problems. The guidelines provide an excellent resource and should act as a stimulus for patients and staff to work together to provide appropriate care in asthma.
Competing interests JR has accepted support for travel and accommodation related to international scientific conferences and fees for speaking at scientific meetings from a number of pharmaceutical companies that produce products used in the treatment of asthma.