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NICE to recommend GPs use breath tests to help diagnose and manage asthma

GPs are to be encouraged to use nitric oxide breath tests to help diagnose and manage asthma, under plans unveiled in new draft guidance from NICE.

The proposed diagnostic guidance recommends testing exhaled nitric oxide concentrations – or fractional exhaled nitric oxide (FeNO) – along with other clinical tests, to help confirm a diagnosis of eosinophilic asthma in both children and adults.

The guidance also recommends FeNO testing to help guide asthma management in patients who remain symptomatic despite taking inhaled corticosteroids (ICS), on the basis it could help doctors to check whether patients are adhering to treatment and reduce their risk of exacerbations.

NICE said achieving an accurate diagnosis of asthma is often complicated and can take many years, and that FeNO testing ‘improved the accuracy of diagnosis when used in addition to other tests’, although it cautions the test is only suitable for ‘ruling in’ rather than excluding asthma.

The guidance specifically advises FeNO testing ‘as an option to help with diagnosing asthma in adults and children who, after initial clinical examination, are considered to have an intermediate probability of having asthma (as defined in the British guideline on the management of asthma, 2012) and when bronchodilator reversibility testing is intended’.

The diagnostics advisory committee said measurement of FeNO, along with bronchodilator reversibility testing, can be done in primary care and therefore offers a cost-effective alternative to approaches that require tests to be done in secondary care. 

The committee also agreed FeNO testing is ‘a useful marker to measure whether people use their medicines as agreed with their clinician’ and ‘could be a useful tool for doctors to improve concordance, by which the patient and clinicians make decisions together about their treatment’. Currently, around 30% of patients do not take ICS for asthma control as prescribed. 

However, the committee warned FeNO levels should not be used as a basis for stepping down treatment in patients with well-controlled asthma, because the potential risks of under-treatment outweigh the benefits.

The draft states: ‘The committee concluded that FeNO measurement should not be recommended to help with stepping down ICS use in adults or children whose asthma is well managed.

‘However, it considered FeNO measurement to be cost and clinically effective when used as an option to support symptomatic asthma management in people using inhaled corticosteroids.’

The new advice marks a significant shift on FeNO testing since the most recent British guideline on the management of asthma developed by SIGN experts, which concluded protocols for FeNO testing in diagnosis and monitoring ‘have not been well defined and more work is needed’.  

NICE Draft diagnostic guidance on measuring fractional exhaled nitric oxide concentration in asthma

 

NICE draft diagnostic guidance on breath tests for asthma – key points

 

Recommendations:

1. Fractional exhaled nitric oxide (FeNO) testing is recommended as an option to help with diagnosing asthma in adults and children:

- who, after initial clinical examination, are considered to have an intermediate probability of having asthma (as defined in the British guideline on the management of asthma, 2012) and

- when bronchodilator reversibility testing is intended.

Further investigation is recommended for people whose FeNO test result is negative, because a negative result does not exclude asthma.

2. FeNO measurement is recommended as an option to support asthma management (in conjunction with the British guideline on the management of asthma, 2012) in people who are symptomatic despite using inhaled corticosteroids.

 

FeNO measurement:

- Three commercial devices covered: NIOX MINO, NIOX VERO and NObreath  

- Cut-offs of between 47 and 76 parts per billion (ppb) should be used in adults and 30 to 55 ppb in children

- FeNO levels above these cut-offs diagnose asthma with 88–100% specificity in adults and 92–100% specificity in children

Readers' comments (8)

  • There must be many things which are "cost effective" to do in GP - but who is it cost effective for. Why are the workings out of this affirmation not stated?

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  • Vinci Ho

    Very high specificity to rule in but what is the sensitivity of the test ?

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  • I've never heard of these tests. Are they done in GP surgeries ? How are they done ?

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  • need to know how much does meter to measure cost?

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  • more money to come from gp's budget that is not reimbursed, so thats 24 hour bp monitors, NO tests for asthmatics, all work in that secondry care wants to dump.....

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  • FENO testing is a very useful tool in asthma management, and can be useful in distinguishing eosinophilic and neutrophilic inflammatory phenotypes. In the USA FENO testing is often carried out in adjacent communities by sending exhalate samples to a central testing point, thereby spreading the cost. The same could be done within a cluster of adjacent practices.

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  • Very useful test to diagnose asthma in adults and children (age>5 yr), to adjust the dosage of inhaled corticosteroids accordingly to needs and also as a part of investigations of unclear reason of chronic cough. It costs £ 8.66/test + expenses related to buying NIOX MINO machine + technician time. We have been using this test in our Kent Primary Care Respiratory Clinic for more than 6 years.

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  • I'm a respiratory nurse who works across different sites. In Yorkshire. I'm lucky enough to use this test. And couldn't be without it. The niox machine was given to us for free off the aerocrine rep and all it costs is for the tests that are used. In my own opinion this saves lots of money. Less trials of preventers, hospital appointments and putting patients on combinations when all they need to do is take their clenil. I couldn't be without my machine now, especially with the asthmatics who see me who blame all their symptoms on their asthma when they can be attributed to other things. This is welcome news and I think once more people in primary care use it, it will become standard practice quite quickly.

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