
Introduction
Asthma is a common respiratory condition that affects millions of people worldwide. As healthcare professionals, it’s crucial to stay updated on the latest guidelines for diagnosis and management. This article provides a comprehensive overview of the National Institute for Health and Care Excellence (NICE) guidelines for asthma diagnosis and management, offering valuable insights for primary care practitioners.

Asthma Diagnosis
Initial Clinical Assessment
The first step in diagnosing asthma is a thorough clinical assessment. This process begins with taking a structured clinical history, which should include inquiries about wheeze, cough, or breathlessness. It’s important to identify any daily or seasonal variations in these symptoms and determine triggers that may exacerbate them. Additionally, assessing the patient’s personal or family history of atopic disorders can provide valuable context.
During the physical examination, healthcare professionals should look for signs of expiratory polyphonic wheeze and check for any other respiratory symptoms. It’s crucial to note that while these signs can be indicative of asthma, a normal examination doesn’t rule out the condition. Furthermore, NICE guidelines emphasize that asthma cannot be diagnosed based on symptoms alone.
Age-Specific Considerations
The approach to asthma diagnosis varies depending on the patient’s age:
- For children under 5, treatment is based on clinical judgment due to the difficulties in confirming diagnosis at this age.
- Patients aged 5-16 should follow a specific pediatric flowchart for diagnosis.
- For those 17 and over, it’s important to consider the possibility of occupational asthma, especially if symptoms improve when the patient is not at work.
Objective Tests
Objective tests play a crucial role in confirming an asthma diagnosis. The order and interpretation of these tests differ slightly between children (aged 5-16) and adults (17 and over).
For children aged 5-16, the recommended order of tests is:
- Spirometry
- Bronchodilator reversibility testing (if spirometry shows obstruction)
- Fractional exhaled nitric oxide (FeNO) testing
- Peak flow variability monitoring (over 2-4 weeks)
For adults, the order is:
- Fractional exhaled nitric oxide (FeNO) levels
- Spirometry
- Bronchodilator reversibility testing (if spirometry shows obstruction)
- Peak flow variability monitoring (over 2-4 weeks)
- Histamine or methacholine direct bronchial challenge test
The interpretation of these tests is crucial for diagnosis. In general, asthma is considered unlikely if there are no positive objective tests. If one test is positive, asthma is suspected, and treatment may be initiated with a follow-up review. A diagnosis of asthma can be confirmed when two or more tests are positive.

Asthma Management
Once a diagnosis is confirmed, the focus shifts to effective management of the condition. NICE guidelines provide a comprehensive approach to asthma management, emphasizing personalized care and regular review.
General Principles
Before initiating or adjusting treatment, it’s essential to consider potential reasons for uncontrolled asthma. These may include alternative diagnoses, lack of adherence to current treatment, poor inhaler technique, smoking, or occupational exposures.
The guidelines recommend reviewing treatment 4-8 weeks after initiation or any changes. They also emphasize the importance of regular daily inhaled corticosteroids (ICS) rather than intermittent therapy, with doses adjusted to the lowest effective level.
Stepwise Approach
For adults and children aged 5-16, NICE recommends a stepwise approach to asthma management:
- Begin with a short-acting beta-2 agonist (SABA) as reliever therapy.
- If asthma remains uncontrolled, introduce a low-dose ICS.
- Add a leukotriene receptor antagonist to the ICS if symptoms persist.
- Consider adding a long-acting beta-2 agonist (LABA) to the ICS.
- Explore the option of a Maintenance and Reliever Therapy (MART) regime.
- If asthma remains uncontrolled, increase the ICS dose or refer to a specialist.
For children under 5, the approach is slightly different due to the challenges in confirming diagnosis. Treatment typically starts with a SABA as reliever therapy, followed by consideration of an 8-week trial of moderate-dose ICS if symptoms persist.
Self-Management
An essential aspect of asthma care is empowering patients to manage their condition effectively. NICE guidelines recommend providing written asthma action plans for all patients over 5 years old. These plans should include advice on managing air pollution triggers and guidance on adjusting treatment during exacerbations.
Ongoing Management
Regular review is crucial for optimal asthma control. During these reviews, healthcare professionals should:
- Assess asthma control using validated questionnaires
- Check adherence to treatment and inhaler technique
- Consider whether treatment needs to be adjusted
- Monitor symptoms using spirometry or peak flow variability testing
- Check inhaler technique at every consultation
By following these comprehensive guidelines for diagnosis and management, healthcare professionals can provide high-quality, evidence-based care for patients with asthma, improving outcomes and quality of life.