Asthma: diagnosis, monitoring and chronic asthma management

This guideline covers diagnosing, monitoring and managing asthma in adults, young people and children. It aims to improve the accuracy of diagnosis, help people to control their asthma and reduce the risk of asthma attacks. It does not cover managing severe asthma or acute asthma attacks.

# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including offlabel use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

# Initial clinical assessment
See also algorithm A for initial clinical assessment in adults, young people and children with suspected asthma.

## Clinical history
Take a structured clinical history in people with suspected asthma. Specifically, check for:
wheeze, cough or breathlessness, and any daily or seasonal variation in these symptoms
any triggers that make symptoms worse
a personal or family history of atopic disorders. 
Do not use symptoms alone without an objective test to diagnose asthma. 
Do not use a history of atopic disorders alone to diagnose asthma. 

## Physical examination
Examine people with suspected asthma to identify expiratory polyphonic wheeze and signs of other causes of respiratory symptoms, but be aware that even if examination results are normal the person may still have asthma. 

## Initial treatment and objective tests for acute symptoms at presentation
Treat people immediately if they are acutely unwell at presentation, and perform objective tests for asthma (for example, fractional exhaled nitric oxide , spirometry and peak flow variability) if the equipment is available and testing will not compromise treatment of the acute episode. 
If objective tests for asthma cannot be done immediately for people who are acutely unwell at presentation, carry them out when acute symptoms have been controlled, and advise people to contact their healthcare professional immediately if they become unwell while waiting to have objective tests. 
Be aware that the results of spirometry and FeNO tests may be affected in people who have been treated empirically with inhaled corticosteroids. 

## Testing for asthma
Do not offer the following as diagnostic tests for asthma:
skin prick tests to aeroallergens
serum total and specific IgE
peripheral blood eosinophil count
exercise challenge (to adults aged 17 and over). 
Use skin prick tests to aeroallergens or specific IgE tests to identify triggers after a formal diagnosis of asthma has been made. 

## Occupational asthma
Check for possible occupational asthma by asking employed people with suspected new-onset asthma, or established asthma that is poorly controlled:
Are symptoms better on days away from work?
Are symptoms better when on holiday (time away from work longer than usual breaks at weekends or between shifts)? Make sure all answers are recorded for later review. 
Refer people with suspected occupational asthma to an occupational asthma specialist. 

# Diagnosing asthma in young children
For children under 5 with suspected asthma, treat symptoms based on observation and clinical judgement, and review the child on a regular basis (see the section on pharmacological treatment pathway for children under 5). If they still have symptoms when they reach 5 years, carry out objective tests (see the section on objective tests for diagnosing asthma in adults, young people and children aged 5 and over and algorithm B). 
If a child is unable to perform objective tests when they are aged 5:
continue to treat based on observation and clinical judgement
try doing the tests again every 6 to 12 months until satisfactory results are obtained
consider referral for specialist assessment if the child repeatedly cannot perform objective tests and is not responding to treatment. 

# Objective tests for diagnosing asthma in adults, young people and children aged 5 and over
See also table 1 for a summary of objective test threshold levels.

## Diagnostic hubs
Those responsible for planning diagnostic service support to primary care (for example, clinical commissioning groups) should consider establishing asthma diagnostic hubs to achieve economies of scale and improve the practicality of implementing the recommendations in this guideline. 

## Airway inflammation measures
Offer a FeNO test to adults (aged 17 and over) if a diagnosis of asthma is being considered. Regard a FeNO level of 40 parts per billion (ppb) or more as a positive test. 
Consider a FeNO test in children and young people (aged 5 to 16) if there is diagnostic uncertainty after initial assessment and they have either:
normal spirometry or
-bstructive spirometry with a negative bronchodilator reversibility (BDR) test.Regard a FeNO level of 35 ppb or more as a positive test. Note: apply the principles in recommendation 1.2.2 for young children unable to do the FeNO test adequately. 
Be aware that a person's current smoking status can lower FeNO levels both acutely and cumulatively. However, a high level remains useful in supporting a diagnosis of asthma. 

## Lung function tests
Offer spirometry to adults, young people and children aged 5 and over if a diagnosis of asthma is being considered. Regard a forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio of less than 70% (or below the lower limit of normal if this value is available) as a positive test for obstructive airway disease (obstructive spirometry). 
Offer a BDR test to adults (aged 17 and over) with obstructive spirometry (FEV1/FVC ratio less than 70%). Regard an improvement in FEV1 of 12% or more, together with an increase in volume of 200 ml or more, as a positive test. 
Consider a BDR test in children and young people (aged 5 to 16) with obstructive spirometry (FEV1/FVC ratio less than 70%). Regard an improvement in FEV1 of 12% or more as a positive test. 
Monitor peak flow variability for 2 to 4 weeks in adults (aged 17 and over) if there is diagnostic uncertainty after initial assessment and a FeNO test and they have either:
normal spirometry or
-bstructive spirometry, reversible airways obstruction (positive BDR) but a FeNO level of 39 ppb or less. Regard a value of more than 20% variability as a positive test. 
Consider monitoring peak flow variability for 2 to 4 weeks in adults (aged 17 and over) if there is diagnostic uncertainty after initial assessment and they have:
-bstructive spirometry and
irreversible airways obstruction (negative BDR) and
a FeNO level between 25 ppb and 39 ppb.Regard a value of more than 20% variability as a positive test. 
Monitor peak flow variability for 2 to 4 weeks in children and young people (aged 5 to 16) if there is diagnostic uncertainty after initial assessment and a FeNO test and they have either:
normal spirometry or
-bstructive spirometry, irreversible airways obstruction (negative BDR) and a FeNO level of 35 ppb or more.Regard a value of more than 20% variability as a positive test. 

## Airway hyperreactivity measures
In November 2017, the use of histamine and methacholine described in recommendations 1.3.11 and 1.3.12 was off label. See NICE's information on prescribing medicines.
Offer a direct bronchial challenge test with histamine or methacholine to adults (aged 17 and over) if there is diagnostic uncertainty after a normal spirometry and either a:
FeNO level of 40 ppb or more and no variability in peak flow readings or
FeNO level of 39 ppb or less with variability in peak flow readings.Regard a PC20 value of 8 mg/ml or less as a positive test. 
Consider a direct bronchial challenge test with histamine or methacholine in adults (aged 17 and over) with:
-bstructive spirometry without bronchodilator reversibility and
a FeNO level between 25 ppb and 39 ppb and
no variability in peak flow readings (less than 20% variability over 2 to 4 weeks). Regard a PC20 value of 8 mg/ml or less as a positive test. 
If a direct bronchial challenge test with histamine or methacholine is unavailable, suspect asthma and review the diagnosis after treatment, or refer to a centre with access to a histamine or methacholine challenge test. 

## Diagnosis in children and young people aged 5 to 16
See also algorithm B for objective tests in young people and children aged 5 to 16.
Diagnose asthma in children and young people (aged 5 to 16) if they have symptoms suggestive of asthma and:
a FeNO level of 35 ppb or more and positive peak flow variability or
-bstructive spirometry and positive bronchodilator reversibility. 
Suspect asthma in children and young people (aged 5 to 16) if they have symptoms suggestive of asthma and:
a FeNO level of 35 ppb or more with normal spirometry and negative peak flow variability or
a FeNO level of 35 ppb or more with obstructive spirometry but negative bronchodilator reversibility and no variability in peak flow readings or
normal spirometry, a FeNO level of 34 ppb or less and positive peak flow variability.Do not rule out other diagnoses if symptom control continues to remain poor after treatment. Review the diagnosis after 6 weeks by repeating any abnormal tests and reviewing symptoms. 
Refer children and young people (aged 5 to 16) for specialist assessment if they have obstructive spirometry, negative bronchodilator reversibility and a FeNO level of 34 ppb or less. 
Consider alternative diagnoses and referral for specialist assessment in children and young people (aged 5 to 16) if they have symptoms suggestive of asthma but normal spirometry, a FeNO level of 34 ppb or less and negative peak flow variability. 

## Diagnosis in adults aged 17 and over
See also algorithm C for objective tests in adults aged 17 and over.
Diagnose asthma in adults (aged 17 and over) if they have symptoms suggestive of asthma and:
a FeNO level of 40 ppb or more with either positive bronchodilator reversibility or positive peak flow variability or bronchial hyperreactivity or
a FeNO level between 25 ppb and 39 ppb and a positive bronchial challenge test or
positive bronchodilator reversibility and positive peak flow variability irrespective of FeNO level. 
Suspect asthma in adults (aged 17 and over) with symptoms suggestive of asthma, obstructive spirometry and:
negative bronchodilator reversibility, and either a FeNO level of 40 ppb or more, or a FeNO level between 25 ppb and 39 ppb and positive peak flow variability or
positive bronchodilator reversibility, a FeNO level between 25 ppb and 39 ppb and negative peak flow variability.Do not rule out other diagnoses if symptom control continues to remain poor after treatment. Review the diagnosis after 6 to 10 weeks by repeating spirometry and objective measures of asthma control and reviewing symptoms. 
Consider alternative diagnoses, or referral for a second opinion, in adults (aged 17 and over) with symptoms suggestive of asthma and:
a FeNO level below 40 ppb, normal spirometry and positive peak flow variability or
a FeNO level of 40 ppb or more but normal spirometry, negative peak flow variability, and negative bronchial challenge test or
-bstructive spirometry with bronchodilator reversibility, but a FeNO level below 25 ppb, and negative peak flow variability or
positive peak flow variability but normal spirometry, a FeNO level below 40 ppb, and a negative bronchial challenge test or
-bstructive spirometry with negative bronchodilator reversibility, a FeNO level below 25 ppb, and negative peak flow variability (if measured). 

## Diagnosis in people who are unable to perform an objective test
For young children who cannot perform objective tests, see the section on diagnosing asthma in young children.
If an adult, young person or child with symptoms suggestive of asthma cannot perform a particular test, try to perform at least 2 other objective tests. Diagnose suspected asthma based on symptoms and any positive objective test results. 

## Good clinical practice in asthma diagnosis
Record the basis for a diagnosis of asthma in a single entry in the person's medical records, alongside the coded diagnostic entry. 

# Diagnostic summary
The following algorithms have been produced that summarise clinical assessment and objective testing for asthma. Table 1 summarises the objective test threshold levels.
Test
Population
Positive result
Fractional exhaled nitric oxide (FeNO)
Adults
ppb or more
FeNO
Children and young people
ppb or more
Obstructive spirometry
Adults, young people and children
Forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio less than 70% (or below the lower limit of normal if this value is available)
Bronchodilator reversibility (BDR) test
Adults
Improvement in FEV1 of 12% or more and increase in volume of 200 ml or more
BDR test
Children and young people
Improvement in FEV1 of 12% or more
Peak flow variability
Adults, young people and children
Variability over 20%
Direct bronchial challenge test with histamine or methacholine
Adults
Provocative concentration of methacholine causing a 20% fall in FEV1 (PC20) of 8 mg/ml or less
Direct bronchial challenge test with histamine or methacholine
Children and young people
n/a

## Algorithms
A full-size downloadable PDF version of algorithm A is available in tools and resources.
A full-size downloadable PDF version of algorithm B is available in tools and resources.
A full-size downloadable PDF version of algorithm C is available in tools and resources.

# Principles of pharmacological treatment
Take into account the possible reasons for uncontrolled asthma, before starting or adjusting medicines for asthma in adults, young people and children. These may include:
alternative diagnoses
lack of adherence
suboptimal inhaler technique
smoking (active or passive)
-ccupational exposures
psychosocial factors
seasonal or environmental factors. 
After starting or adjusting medicines for asthma, review the response to treatment in 4 to 8 weeks (see the section on monitoring asthma control). 
If inhaled corticosteroid (ICS) maintenance therapy is needed, offer regular daily ICS rather than intermittent or 'when required' ICS therapy. 
Adjust maintenance therapy ICS doses over time, aiming for the lowest dose required for effective asthma control. 
Ensure that a person with asthma can use their inhaler device:
at any asthma review, either routine or unscheduled
whenever a new type of device is supplied. 

# Pharmacological treatment pathway for adults (aged 17 and over)
This section is for people with newly diagnosed asthma or asthma that is uncontrolled on their current treatment. Where the recommendations represent a change from traditional clinical practice, people whose asthma is well controlled on their current treatment should not have their treatment changed purely to follow this guidance.
Offer a short-acting beta2 agonist (SABA) as reliever therapy to adults (aged 17 and over) with newly diagnosed asthma. 
For adults (aged 17 and over) with asthma who have infrequent, short-lived wheeze and normal lung function, consider treatment with SABA reliever therapy alone. 
Offer a low dose of an ICS as the first-line maintenance therapy to adults (aged 17 and over) with:
symptoms at presentation that clearly indicate the need for maintenance therapy (for example, asthma-related symptoms 3 times a week or more, or causing waking at night) or
asthma that is uncontrolled with a SABA alone. 
If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as maintenance therapy, offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks. 
If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and an LTRA as maintenance therapy, offer a long-acting beta2 agonist (LABA) in combination with the ICS, and review LTRA treatment as follows:
discuss with the person whether or not to continue LTRA treatment
take into account the degree of response to LTRA treatment. 
If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and a LABA, with or without an LTRA, as maintenance therapy, offer to change the person's ICS and LABA maintenance therapy to a MART regimen with a low maintenance ICS dose. 
If asthma is uncontrolled in adults (aged 17 and over) on a MART regimen with a low maintenance ICS dose, with or without an LTRA, consider increasing the ICS to a moderate maintenance dose (either continuing on a MART regimen or changing to a fixed dose of an ICS and a LABA, with a SABA as a reliever therapy). 
If asthma is uncontrolled in adults (aged 17 and over) on a moderate maintenance ICS dose with a LABA (either as MART or a fixed-dose regimen), with or without an LTRA, consider:
increasing the ICS to a high maintenance dose (this should only be offered as part of a fixed-dose regimen, with a SABA used as a reliever therapy) or
a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline) or
seeking advice from a healthcare professional with expertise in asthma. 

# Pharmacological treatment pathway for children and young people aged 5 to 16
This section is for children and young people with newly diagnosed asthma or asthma that is uncontrolled on their current treatment. Where the recommendations represent a change from traditional clinical practice, children and young people whose asthma is well controlled on their current treatment should not have their treatment changed purely to follow guidance.
In November 2017, the use of some medicines was off label:
Not all LTRAs and LABAs had a UK marketing authorisation for children and young people aged under 18 for the use described in recommendations 1.7.4 and 1.7.5.
The use of MART described in recommendations 1.7.6, 1.7.7 and 1.7.8 was off label in children and young people (aged under 12).
See NICE's information on prescribing medicines.
Offer a SABA as reliever therapy to children and young people (aged 5 to 16) with newly diagnosed asthma. 
For children and young people (aged 5 to 16) with asthma who have infrequent, short-lived wheeze and normal lung function, consider treatment with SABA reliever therapy alone. 
Offer a paediatric low dose of an ICS as the first-line maintenance therapy to children and young people (aged 5 to 16) with:
symptoms at presentation that clearly indicate the need for maintenance therapy (for example, asthma-related symptoms 3 times a week or more, or causing waking at night) or
asthma that is uncontrolled with a SABA alone. 
If asthma is uncontrolled in children and young people (aged 5 to 16) on a paediatric low dose of ICS as maintenance therapy, consider an LTRA in addition to the ICS and review the response to treatment in 4 to 8 weeks. 
If asthma is uncontrolled in children and young people (aged 5 to 16) on a paediatric low dose of ICS and an LTRA as maintenance therapy, consider stopping the LTRA and starting a LABA in combination with the ICS. 
If asthma is uncontrolled in children and young people (aged 5 to 16) on a paediatric low dose of ICS and a LABA as maintenance therapy, consider changing their ICS and LABA maintenance therapy to a MART regimen with a paediatric low maintenance ICS dose. Ensure that the child or young person is able to understand and comply with the MART regimen. 
If asthma is uncontrolled in children and young people (aged 5 to 16) on a MART regimen with a paediatric low maintenance ICS dose, consider increasing the ICS to a paediatric moderate maintenance dose (either continuing on a MART regimen or changing to a fixed dose of an ICS and a LABA, with a SABA as a reliever therapy). 
If asthma is uncontrolled in children and young people (aged 5 to 16) on a paediatric moderate maintenance ICS dose with LABA (either as MART or a fixed-dose regimen), consider seeking advice from a healthcare professional with expertise in asthma and consider either:
increasing the ICS dose to paediatric high maintenance dose (only as part of a fixed-dose regimen, with a SABA used as a reliever therapy) or
a trial of an additional drug (for example, theophylline). 

# Pharmacological treatment pathway for children under 5
It can be difficult to confirm asthma diagnosis in young children, therefore these recommendations apply to children with suspected or confirmed asthma. Asthma diagnosis should be confirmed when the child is able to undergo objective tests (see the section on diagnosing asthma in young children).
This section is for children under 5 with newly suspected or confirmed asthma, or with asthma symptoms that are uncontrolled on their current treatment. Where the recommendations represent a change from traditional clinical practice, children whose asthma is well controlled on their current treatment should not have their treatment changed purely to follow this guidance.
Offer a SABA as reliever therapy to children under 5 with suspected asthma. This should be used for symptom relief alongside all maintenance therapy. 
Consider an 8week trial of a paediatric moderate dose of an ICS in children under 5 with:
symptoms at presentation that clearly indicate the need for maintenance therapy (for example, asthma-related symptoms 3 times a week or more, or causing waking at night) or
suspected asthma that is uncontrolled with a SABA alone. 
After 8 weeks, stop ICS treatment and continue to monitor the child's symptoms:
if symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely
if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy
if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8week trial of a paediatric moderate dose of ICS. 
If suspected asthma is uncontrolled in children under 5 on a paediatric low dose of ICS as maintenance therapy, consider an LTRA in addition to the ICS. In November 2017, not all LTRAs had a UK marketing authorisation for this use in children aged under 5. See NICE's information on prescribing medicines.
If suspected asthma is uncontrolled in children under 5 on a paediatric low dose of ICS and an LTRA as maintenance therapy, stop the LTRA and refer the child to a healthcare professional with expertise in asthma for further investigation and management. 

# Adherence
For guidance on managing non-adherence to medicines in people with asthma, see the NICE guideline on medicines adherence. 

# Self-management
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 written personalised action plan and education.
Explain that pollution can trigger or exacerbate asthma, and include in the personalised action plan approaches for minimising exposure to indoor and outdoor air pollution.For more guidance on how to minimise exposure and the effect of air pollution on health, see:
the recommendations on vulnerable groups in the NICE guideline on air pollution: outdoor air quality and health and
the recommendations on people with asthma, other respiratory conditions or cardiovascular conditions in the NICE guideline on indoor air quality at home. 
Within a self-management programme, offer an increased dose of ICS for 7 days to adults (aged 17 and over) who are using an ICS in a single inhaler, 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. 
For children and young people aged 5 to 16 with a diagnosis of asthma, include advice in their self-management programme on contacting a healthcare professional for a review if their asthma control deteriorates (see the section on monitoring asthma control). 
For children and young people aged 5 to 16 with deteriorating asthma who have not been taking their ICS consistently, explain that restarting regular use may help them to regain control of their asthma. The evidence for increasing ICS doses to self-manage deteriorating asthma control is limited. 
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. 
For a short explanation of why the committee made the 2020 recommendations on self-management and removed the 2017 recommendation on increasing ICS treatment within a self-management programme in children and young people and how this might affect practice, see the rationale and impact section on self-management .
Full details of the evidence and the committee's discussion are in evidence review A: increasing ICS treatment within supported self-management for children and young people.
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# Decreasing maintenance therapy
Consider decreasing maintenance therapy when a person's asthma has been controlled with their current maintenance therapy for at least 3 months. 
Discuss with the person (or their family or carer if appropriate) the potential risks and benefits of decreasing maintenance therapy. 
When reducing maintenance therapy:
Stop or reduce dose of medicines in an order that takes into account the clinical effectiveness when introduced, side effects and the person's preference.
Only consider stopping ICS treatment completely for people who are using low dose ICS alone as maintenance therapy and are symptom free. 
Agree with the person (or their family or carer if appropriate) how the effects of decreasing maintenance therapy will be monitored and reviewed, including self-monitoring and a followup with a healthcare professional. 
Review and update the person's asthma action plan when decreasing maintenance therapy. 

# Risk stratification
Consider using risk stratification to identify people with asthma who are at increased risk of poor outcomes, and use this information to optimise their care. Base risk stratification on factors such as non-adherence to asthma medicines, psychosocial problems and repeated episodes of unscheduled care for asthma. 

# Monitoring asthma control
Monitor asthma control at every review. If control is suboptimal:
confirm the person's adherence to prescribed treatment in line with the recommendations on assessing adherence in the NICE guideline on medicines adherence
review the person's inhaler technique
review if treatment needs to be changed
ask about occupational asthma (see recommendation on checking for possible occupational asthma) and/or other triggers, if relevant. 
Consider using a validated questionnaire (for example, the Asthma Control Questionnaire or Asthma Control Test) to monitor asthma control in adults (aged 17 and over). 
Monitor asthma control at each review in adults, young people and children aged 5 and over using either spirometry or peak flow variability testing. 
Do not routinely use FeNO to monitor asthma control. 
Consider FeNO measurement as an option to support asthma management in people who are symptomatic despite using inhaled corticosteroids. (This recommendation is from NICE's diagnostics guidance on measuring fractional exhaled nitric oxide concentration in asthma.) 
Do not use challenge testing to monitor asthma control. 
Observe and give advice on the person's inhaler technique:
at every consultation relating to an asthma attack, in all care settings
when there is deterioration in asthma control
when the inhaler device is changed
at every annual review
if the person asks for it to be checked. 

# Terms used in this guideline
This section defines terms that have been used in a particular way for this guideline. For other definitions, see the NICE glossary.

## Expiratory polyphonic wheeze
A wheeze is a continuous, whistling sound produced in the airways during breathing. It is caused by narrowing or obstruction in the airways. An expiratory polyphonic wheeze has multiple pitches and tones heard over different areas of the lung when the person breathes out.

## ICS doses
ICS doses and their pharmacological strengths vary across different formulations. In general, people with asthma should use the smallest doses of ICS that provide optimal control for their asthma, in order to reduce the risk of side effects.
For adults aged 17 and over:
less than or equal to 400 micrograms budesonide or equivalent would be considered a low dose
more than 400 micrograms to 800 micrograms budesonide or equivalent would be considered a moderate dose
more than 800 micrograms budesonide or equivalent would be considered a high dose.
For children and young people aged 16 and under:
less than or equal to 200 micrograms budesonide or equivalent would be considered a paediatric low dose
more than 200 micrograms to 400 micrograms budesonide or equivalent would be considered a paediatric moderate dose
more than 400 micrograms budesonide or equivalent would be considered a paediatric high dose.

## MART
Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required. MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol).

## Objective test to diagnose asthma
Tests carried out to help determine whether a person has asthma, the results of which are not based on the person's symptoms, for example, tests to measure lung function or evidence of inflammation. There is no single objective test to diagnose asthma.

## Risk stratification
Risk stratification is a process of categorising a population by their relative likelihood of experiencing certain outcomes. In the context of this guideline, risk stratification involves categorising people with asthma by their relative likelihood of experiencing negative clinical outcomes (for example, severe exacerbations or hospitalisations). Factors including non-adherence to asthma medicines, psychosocial problems and repeated episodes of unscheduled care can be used to guide risk stratification. Once the population is stratified, the delivery of care for the population can be targeted with the aim of improving the care of the strata with the highest risk.

## Suspected asthma
Suspected asthma describes a potential diagnosis of asthma based on symptoms and response to treatment that has not yet been confirmed with objective tests.

## Uncontrolled asthma
Uncontrolled asthma describes asthma that has an impact on a person's lifestyle or restricts their normal activities. Symptoms such as coughing, wheezing, shortness of breath and chest tightness associated with uncontrolled asthma can significantly decrease a person's quality of life and may lead to a medical emergency. Questionnaires are available that can be quantify this.
This guideline uses the following pragmatic thresholds to define uncontrolled asthma:
-r more days a week with symptoms or
-r more days a week with required use of a SABA for symptomatic relief or
-r more nights a week with awakening due to asthma.# Putting this guideline into practice
NICE is recommending objective testing with spirometry and FeNO for most people with suspected asthma. This is a significant enhancement to current practice, which will take the NHS some time to implement, with additional infrastructure and training needed in primary care. New models of care, being developed locally, could offer the opportunity to implement these recommendations. This may involve establishing diagnostic hubs to make testing efficient and affordable. They will be able to draw on the positive experience of NICE's primary care pilot sites, which trialled the use of FeNO.
The investment and training required to implement the new guidance will take time. In the meantime, primary care services should implement what they can of the new guidelines, using currently available approaches to diagnosis until the infrastructure for objective testing is in place.
NICE has produced tools and resources to help you put this guideline into practice.
Adoption support resource
Resource impact report
Resource impact templates# Recommendations for research
The 2017 guideline committees made the following recommendations for research on diagnosing and monitoring asthma and for managing chronic asthma (marked ). The committee's full set of research recommendations is detailed in the 2017 full guideline on asthma: diagnosis and monitoring and the 2017 full guideline on chronic asthma management.
As part of the 2020 update, the guideline committee made 1 new research recommendation on managing asthma within a self-management programme for children and young people (marked ).

# Diagnosing and monitoring asthma

## Diagnosing asthma in children and young people aged 5 to 16
What is the acceptability and diagnostic accuracy of objective tests that could be used to comprise a diagnostic pathway for asthma in children and young people aged 5 to 16 (for example, exercise challenge, direct bronchial challenge with histamine or methacholine, indirect bronchial challenge with mannitol and peripheral blood eosinophil count)? 

## Diagnosing asthma in adults (aged 17 and over)
What is the clinical and cost effectiveness of using an indirect bronchial challenge test with mannitol to diagnose asthma in adults (aged 17 and over)? 

## Monitoring adherence to treatment
What is the clinical and cost effectiveness of using electronic alert systems designed to monitor and improve adherence with regular inhaled maintenance therapy in people with asthma? 

## Monitoring inhaler technique
What is the current frequency and the current method being used to check the inhaler technique of people with asthma? What is the optimal frequency and the best method of checking inhaler technique to improve clinical outcomes for people with asthma? 

## Monitoring asthma control using tele-healthcare
What is the long-term (more than 12 months) clinical and cost effectiveness of using tele-healthcare as a means to monitor asthma control in adults, young people and children? Methods of tele-healthcare can include telephone interview (with healthcare professional involvement) and internet or smartphone-based monitoring support (no healthcare professional involvement). 

# Managing chronic asthma

## Increasing the dose of ICS within a personalised self-management programme for children and young people
For children and young people with asthma that is managed in primary care, is there an advantage to increasing the inhaled corticosteroid (ICS) dose when asthma control has deteriorated compared with using the usual dose in a self-management programme? 
For a short explanation of why the committee made the recommendation for research, see the rationale on increasing the dose of ICS within a personalised self-management programme for children and young people .
Full details of the research recommendation are in evidence review A: increasing ICS treatment within supported self-management for children and young people.
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## Starting asthma treatment
In adults, young people and children with asthma who have not been treated previously, is it more clinically and cost effective to start treatment with a reliever alone (a short-acting beta2 agonist ) or with a reliever (a SABA) and maintenance therapy (such as ICS)? Are there specific prognostic features that indicate that one of these treatment options may be more appropriate for some groups? 

## Second-line maintenance therapy in children and young people (under 16)
Is maintenance therapy more effective with a paediatric low dose of ICS plus a leukotriene receptor antagonist (LTRA) or with a paediatric low dose of ICS plus a long-acting beta2 agonist (LABA) in the treatment of asthma in children and young people (under 16) who have uncontrolled asthma on a paediatric low dose of ICS alone? 

## Additional maintenance therapy for asthma uncontrolled on a moderate dose of ICS plus LABA with or without LTRA
What is the clinical and cost effectiveness of offering additional maintenance therapy to adults, young people and children with asthma that is uncontrolled on a moderate dose of ICS plus LABA with or without LTRA? 

## Decreasing pharmacological treatment
In adults, young people and children with well-controlled asthma, what are the objective measurements and prognostic factors that indicate that a decrease in regular maintenance treatment is appropriate? 

## Improving adherence to asthma medication
What are the most clinically and cost-effective strategies to improve medicines adherence in adults, young people and children with asthma who are non-adherent to prescribed medicines? # Rationale and impact
This section briefly explain why the committee made the recommendations and how they might affect practice. They link to details of the evidence and a full description of the committee's discussion.

# Self-management
Recommendations 1.10.3 and 1.10.4

## Why the committee changed 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 to 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 agreed that the evidence was not applicable because of the high average age of participants.
The 2017 guideline recommended that quadrupling the dose of ICS could be considered within a self-management programme for children and young people whose asthma is deteriorating. The 2020 update committee agreed that this 2017 recommendation was based on limited evidence, mostly in adults, and that the new evidence identified in this update did not support this. However, it also agreed that there wasn't any significant evidence to suggest that increasing the dose of ICS is harmful compared to the usual dose. Based on their experience, the committee agreed that increasing the dose of ICS within the licensed limit would not adversely affect child growth. This was supported by the evidence, which showed that increasing the ICS dose in the short term did not result in a statistically significant decrease in child growth, even though the doses used in the study exceeded the licensed limit. Therefore, the committee decided to remove the 2017 recommendation rather than replacing it with a recommendation that prohibits increasing the dose of ICS.
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 also stressed the importance of continuing regular ICS maintenance therapy, or restarting it if the child or young person has stopped taking it, to prevent deterioration.
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 and 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 recommendations might affect practice
The recommendations 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.
Return to recommendations# Context
Asthma is a chronic inflammatory respiratory disease. It can affect people of any age, but often starts in childhood. Asthma is a variable disease which can change throughout a person's life, throughout the year and from day to day. It is characterised by attacks (also known as exacerbations) of breathlessness and wheezing, with the severity and frequency of attacks varying from person to person. The attacks are associated with variable airflow obstruction and inflammation within the lungs, which if left untreated can be life-threatening, however with the appropriate treatment can be reversible.
In 2018, the Global Asthma report estimated that asthma affects 339 million people worldwide. It is the most common chronic condition to affect children, and in the UK approximately 5.4 million people (1.1 million children and 4.3 million adults) currently get treatment for asthma (Asthma UK).
The causes of asthma are not well understood. A number of risk factors are associated with the condition, often in combination. These influences can be genetic (the condition clusters in families) and/or environmental (such as inhalation of allergens or chemical irritants). Occupational causes of asthma in adults are often under-recognised.
There is currently no gold standard test available to diagnose asthma; diagnosis is principally based on a thorough history taken by an experienced clinician. Studies of adults diagnosed with asthma suggest that up to 30% do not have clear evidence of asthma. Some may have had asthma in the past, but it is likely that many have been given an incorrect diagnosis. Conversely, other studies suggest that asthma may be underdiagnosed in some cases.
The diagnosis recommendations will improve patient outcomes and will be cost effective to the NHS in the long-term; NICE's cost impact assessment projects a saving of approximately 12 million per year in England, before implementation costs.
Initial clinical assessment should include questions about symptoms (wheezing, cough, breathing and chest problems) and any personal or family history of allergies, atopic disorders or asthma. Various tests can be used to support a diagnosis, but there is no single test that can definitively diagnose asthma.
A number of methods and assessments are available to determine the likelihood of asthma. These include measuring airflow obstruction (spirometry and peak flow) and assessment of reversibility with bronchodilators, with both methods being widely used in current clinical practice. However, normal results do not exclude asthma and abnormal results do not always mean it is asthma, because they could be indicators of other respiratory diseases or spurious readings.
Testing for airway inflammation is increasingly used as a diagnostic strategy in clinical practice. This includes measuring fractional exhaled nitric oxide (FeNO).
Other diagnostic strategies include blood or skin prick tests to detect allergic reactions to environmental influences, exercise tests to detect evidence of bronchoconstriction, and measures of airway hyperreactivity such as histamine/methacholine or mannitol challenge tests. However, it is debatable which test or measure, or combination of them, is the most effective to accurately diagnose asthma.
It is recognised that asthma control is suboptimal in many people with asthma. This has an impact on their quality of life, their use of healthcare services and the associated costs. Asthma control can be monitored by measuring airway obstruction or inflammation and by using validated questionnaires, but the most effective monitoring strategy is unclear.
The severity of asthma varies; some people have severe asthma that limits normal activities, whereas others are able to lead a relatively normal life. The illness fluctuates during the year and over time, so the level of treatment needs to be tailored to the person's current level of asthma severity. Many people with asthma, particularly children, seem to have fewer symptoms over time, and an important part of management is decreasing treatment if asthma is well controlled.
There is no cure for asthma, so management focuses on reducing exposure to known triggers if possible, relief of symptoms if there is airway narrowing, and reduction in airway inflammation by regular preventive treatment. Adherence to regular treatment reduces the risk of significant asthma attacks in most people with asthma. The focus of asthma management in recent years has been on supporting people with asthma and their healthcare professional to devise a personalised treatment plan that is effective and relatively easy to implement.
The guideline covers children under 5, children and young people aged 5 to 16, and adults aged 17 and over with suspected or diagnosed asthma. The guideline applies to all primary, secondary and community care settings in which NHS-funded care is provided for people with asthma.
The sections on diagnosing and monitoring asthma (sections 1.1 to 1.4 and 1.13) aim to provide clear advice on effectively diagnosing people presenting with new symptoms of suspected asthma and monitoring to ensure optimum asthma control. It is not intended to be used to rediagnose people who already have an asthma diagnosis.
The sections on managing chronic asthma (sections 1.5 to 1.12) aim to provide clear advice for healthcare professionals and people with asthma to develop a personalised action plan. The plan should support self-management of asthma, and ensure that the person is receiving the best possible treatment for their current level of illness. It focuses on the pharmacological management of chronic asthma, in particular the treatment pathway for people with uncontrolled asthma. It also covers adherence to treatment, risk stratification and self-management.
The guideline does not cover severe, difficult-to-control asthma or the management of acute asthma attacks.
In 2018, new evidence was identified by the NICE surveillance team on increasing the dose of inhaled corticosteroids within a self-management programme in children and young people with asthma. Topic experts, including those who helped to develop the 2017 guideline, agreed that the new evidence could have an impact on the recommendations. This evidence was reviewed and the recommendations in this area updated.