Published on: February 4, 2025
In November 2024, the British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN), and the National Institute of Care Excellence (NICE) asthma guidelines1 were released superseding the previously separate guidelines from BTS/SIGN2 and NICE3. The new joint guideline, based on current clinical evidence and cost-effective modelling, clears up the previous uncertainty about the diagnosis and routine management of asthma. This resource will help understand where Fractional exhaled Nitric Oxide (FeNO) is recommended and how, by following the guidelines, there is potential income for the practice.
What does FeNO measure?
FeNO is a measurement of exhaled nitric oxide. This is normal in exhaled breath as a part of the respiratory process but is raised in the presence of eosinophilic airway inflammation, which is present in the majority of people with uncontrolled asthma symptoms. Patients at presentation are likely to have a raised FeNO level if they are not taking inhaled steroid treatment, even if they are asymptomatic on the day of testing.
What do the new guidelines say?
In adults, the guidelines recommend either blood eosinophils or FeNO as the immediate test. FeNO has the advantage of an instant result reducing the need for a second consultation to review the results. Blood eosinophils are a systemic marker so can be influenced by medication or other illnesses.
The new joint guideline states that if the FeNO result is raised above 50 ppb, and supports the clinical history and examination of the patient, no further testing is required – this is adequate to diagnose asthma. If the result is less than 50ppb but the history and examination indicate asthma as a likely diagnosis, then further testing will be required (spirometry with bronchodilator reversibility, peak flow diary charting in the absence or delay in accessing spirometry availability). If both FeNO and spirometry do not confirm the diagnosis the patient will require referral for bronchial challenge testing.
In children the first-line recommended objective test to support a diagnosis of asthma in a child with a history suggestive of asthma is FeNO – there is no alternative first-line test recommended so primary care must have access to FeNO testing for all children presenting without delay. The diagnostic level in children is 35 ppb. Again, if FeNO is raised, there is no need for further testing and a diagnosis can be made. If the FeNO result is below 35 ppb then spirometry with reversibility should be performed, or in the absence or delay in accessing spirometry a peak flow diary chart can be substituted. If spirometry also does not confirm asthma, the child will need either skin prick testing for house dust mite, or blood tests for eosinophils and total IgE. Blood tests are further along the diagnostic algorithm as it is less acceptable to children and parents.
The joint guidelines now recommend FeNO testing in certain areas of ongoing management. FeNO is recommended at routine review and before increasing medication, and specifically, once a patient is on a moderate dose Maintenance and Reliever Therapy (MART) regime, but still symptomatic to guide the need for specialist referral for consideration of biologics or increased non-steroid medication.
Using FeNO – benefits to practices
Time is a precious commodity in primary care. Access to FeNO testing to confirm a diagnosis of asthma has the potential for diagnosis to be made in a single visit as test results are instantly available. Different models of testing work well. It may be that all clinicians can perform and code a FeNO test at initial consultation, start inhaled therapy, and then review with the appropriate in-house asthma specialist where steroid naive results and response to treatment can be reviewed.
In England, practices strive to accomplish maximal Quality and Outcomes Framework (QoF)4 points to maintain practice income and fund expenses such as purchase and maintenance of equipment for example, FeNO devices. Currently, the QoF requirement for diagnosis of asthma is spirometry and one other test such as FeNO, bronchodilator reversibility or measures of variability. With the change in the BTS/SIGN/NICE guideline this will change in line with the guideline recommendations with the requirement that practices perform at least one objective test that indicates asthma. In adults initially, this could be FeNO or blood eosinophils, in children the initial test must be FeNO.
QoF points and payments
The QoF section for asthma diagnosis currently offers a maximum of 15 points. To achieve this the practice must hold an asthma register which is based on SNOMED coding- a structured clinical vocabulary for use in an electronic health record, and must have performed (and coded) the appropriate objective tests to confirm diagnosis. The practice does not need to achieve 100% to receive maximal payment.
One point in the QoF framework payment currently earns the practice £220.62 therefore if a practice successfully achieves maximal points the payment for this indicator for a year is 15 points at £220.62 totalling £3309.30 annually.
In some areas, additional payments might be achieved from locally agreed arrangements such as local enhanced service agreements.
NObreath® FeNO Device
The NObreath® FeNO device offers a significant advantage in aiding asthma diagnosis and management. The NObreath® is a non-invasive and easy-to-use tool that provides instant results, streamlining the process for patients and healthcare providers. Compared to other QoF-recommended tests, such as the bronchodilator reversibility test, which can take up to an hour, a FeNO test saves valuable time. By providing immediate results, the NObreath® supports efficient clinical decision-making, enhances patient experience, and helps practices meet QoF requirements effectively and effortlessly.
Disclaimer
All costs and figures mentioned in this article were accurate at the time of publication. Prices and other financial details are subject to change and may vary over time. We recommend checking with the relevant sources for the most up-to-date information
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