Category: NObreath

On Wednesday, 27th November, the National Institute for Health and Care Excellence (NICE), the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN) updated and published a joint guideline on asthma diagnosis, monitoring, and chronic asthma management. 

Streamlining asthma management

BTS/SIGN and NICE published guidelines independent of each other. To align approaches to asthma care throughout the UK, NICE has undertaken a joint review with BTS and SIGN to bring harmonisation across the board. This review brings significant changes to asthma care approaches, including applying fractional exhaled nitric oxide (FeNO) testing- an objective airway inflammation test for aiding in asthma diagnosis and management.

Previously, NICE, BTS and SIGN recommended the following:NICE:

• FeNO testing was recommended for use in adults and children during asthma diagnosis.
• FeNO levels, should be measured in conjunction with other diagnostic tests (e.g., spirometry).
• For adults: A FeNO level of 40 parts per billion (ppb) or more was regarded as a positive test.
• For children and young people (5–16 years): A FeNO level of 35 ppb or more was regarded as a positive test.

BTS and SIGN:

• FeNO testing can support asthma diagnosis, particularly when the diagnosis is uncertain or symptoms suggest eosinophilic inflammation in adults and children.
• FeNO levels, should be measured in conjunction with other diagnostic tests (e.g., spirometry).
• For adults: A FeNO level of 40 ppb or more was regarded as a positive test.
• For children and young people (5–16 years): A FeNO level of 35 ppb or more was regarded as a positive test.

What is new? NICE/BTS/SIGN guideline on asthma: diagnosis, monitoring and chronic asthma management

Asthma diagnosis (adults):

The new NICE/BTS/SIGN guidelines recommend that adults with symptoms and a history suggestive of asthma undergo blood eosinophil count or FeNO testing as initial diagnostic steps. Asthma can be diagnosed if the blood eosinophil count exceeds the laboratory reference range or if FeNO levels are 50 ppb or higher. If these initial tests are inconclusive, bronchodilator reversibility (BDR) testing with spirometry is advised. When asthma remains clinically suspected despite inconclusive results from blood eosinophil count or FeNO, BDR, or peak expiratory flow (PEF) measurements, a referral for a bronchial challenge test is recommended to confirm the diagnosis if bronchial hyper-responsiveness is detected.

Asthma diagnosis (children and young people aged 5-16):

For children with symptoms suggestive of asthma, the new NICE/BTS/SIGN guidelines recommend measuring FeNO levels as a first-line diagnostic test, provided it is available. Asthma can be diagnosed if FeNO levels are 35 ppb or higher. A NICE literature review highlighted the higher specificity of FeNO testing in children, further reinforcing its use as a first-line option for both children and adults.

Asthma management (adults):

FeNO testing provides a significant advantage to health care professionals when monitoring asthma patients, including assessment of response to newly prescribed asthma therapies and regular review of adherence to medications. FeNO monitoring applications have been acknowledged globally in other well-recognised clinical guidelines, including the American Thoracic Society (ATS) and the Global Initiative for Asthma (GINA). Not acknowledged in previous asthma clinical guidelines by NICE or BTS/SIGN, a recommendation has been made to include FeNO evaluations as part of regular yearly asthma reviews in adults, alongside reviewing before and after any changes to patients’ asthma therapy.

Economic Evaluation of asthma care

Cost of exacerbations to the NHS:

NICE calculated that on average a mild to moderate exacerbation cost the NHS on average £42 per patient. This includes a GP visit (£38) and a salbutamol metered-dose inhaler (MDI) with a spacer (£4).

For severe exacerbations, the average estimated cost was thought to increase to £102 per patient. This includes 80% of patients requiring systemic glucocorticoid steroids (adults £1.88 and children £0.60), 13% of patients visiting A&E (£113), and 7% of patients needing hospitalisation (adults £1,181 and children £1,223).

FeNO cost analysis:

NICE conducted an economic evaluation of FeNO testing, factoring in the volume of tests performed on average across the UK. On average, taking into account the resource allocation of staff time and the cost of a FeNO test, an average total cost to the NHS would be £22.21 per patient. Among the eight diagnostic tests evaluated during NICE’s review, FeNO ranked as the third most cost-effective after adult blood eosinophil count and children’s blood eosinophil count.

NICE also highlighted the potential economic advantage of performing multiple tests during the same appointment, which could save time and reduce overall costs. The most cost-effective combination was spirometry and FeNO with a total cost of £34.29, followed by BDR and FeNO (£50.52) and skin prick test and FeNO, which ranked fourth most cost-effective (£50.66). These findings suggest strategic test combinations could optimise economic and clinical outcomes.

Carol Stonham, a member of Bedfont® Scientific Limited Medical Advisory Board and policy lead for Policy Care Respiratory Society (PCRS), comments “The new NICE/BTS/SIGN asthma guidelines introduce a positive step change in the diagnosis and management of asthma for adults and children. For diagnosis the necessity to perform numerous diagnostic tests has been reduced if initial testing confirms asthma, based on the evidence and cost effectiveness. In management the step away from using short acting bronchodilators to anti-inflammatory (AIR) and Maintenance and Reliever Therapy (MART) regimes should see better asthma control, less people with symptoms, and a reduction in asthma mortality.”

FeNO testing in asthma: Key takeaways from NICE guidelines

Diagnosis:

• For adults, asthma can be diagnosed if FeNO levels are 50 ppb or higher, an increase from the previous NICE guideline’s 40 ppb or higher threshold.
• For children, asthma can be diagnosed if FeNO levels are 35 ppb or higher. This has remained the same as the previous NICE guidelines.
• FeNO testing recommended first-line testing in asthma diagnosis for adults and children.
• If the first test is diagnostic further diagnostic testing is not required.

Management:

• FeNO testing has been acknowledged as a tool in asthma management.
• Aids to inform healthcare professionals when changing or adjusting asthma therapy.
• Recommending FeNO use for asthma monitoring in adults.

Costs:

NICE’s economic evaluation revealed the average FeNO test to be on average £22.21, this includes an average consumable cost of £6.37. The NObreath® device, manufactured by Bedfont® Scientific Limited prides itself on being one of the most cost-effective products on the market. On average, NObreath® consumables (£3.70 per mouthpiece) are 42%* less than the FeNO testing consumables pricing highlighted in the NICE economic evaluation (£6.37), making the overall cost for FeNO testing 12%* less than what has originally been highlighted in the NICE economic evaluation, ensuring fair and accessible pricing for both primary and secondary care alike.  

To read the full NICE guidelines, please visit: https://www.nice.org.uk/guidance/ng244

*Based on UK pricing.

References:

• Asthma pathway (BTS, NICE, SIGN) [Internet]. National Institute for Health and Care Excellence. 2024. [Cited Wednesday 27^th November 2024]. Available from: https://www.nice.org.uk/guidance/ng244

Bedfont® outlines key updates and offers support for healthcare professionals navigating the changes.

Bedfont® Scientific Ltd., world leaders in breath analysis with over 47 years of knowledge in designing and manufacturing medical breath analysis devices, welcomes the recent update to the National Institute for Health and Care Excellence (NICE) guidelines on asthma management.

So, what’s new? NICE released the most recent asthma guidelines on Wednesday 27^th of November, which recommends a blood test to measure eosinophil levels, or a FeNO test to diagnose asthma in adults. A FeNO test is recommended as the first-line test for an asthma diagnosis in children. Confirmation of a positive asthma diagnosis is a FeNO level exceeding 50 ppb in adults and 35 ppb in children.

FeNO testing as an essential tool in improving diagnostic accuracy and tailoring treatment plans to individual patient needs. At Bedfont® we are proud to support healthcare professionals with our innovative NObreath® FeNO testing device that aligns with the latest clinical guidance, ultimately helping to deliver better outcomes for people with asthma.”

In light of the changes to asthma care and management recommendations, Bedfont® will host various educational resources, such as webinars and articles, to discuss these changes and what they mean for healthcare professionals carrying out FeNO tests.

For a more in-depth look at the guideline updates, read our latest article here: https://www.bedfont.com/new-nice-guidelines-for-asthma-feno-testing-and-the-nobreath-device-in-adult-and-paediatric-care/

References

Asthma pathway (BTS, NICE, SIGN) [Internet]. National Institute for Health and Care Excellence. 2024. [Cited Wednesday 27th November 2024]. Available from: https://www.nice.org.uk/guidance/ng244

Bedfont® Scientific Limited hosted an informative webinar Children with Asthma, with seasoned respiratory nurse Carol Stonham MBE leading the discussion along with Kirsty at Medway Asthma Self-Help (MASH). The webinar was a private screening for local Medway football coaches and gave valuable insights on managing, treating and recognising an asthma emergency.

Children spend a lot of time away from home, whether it is at school, nursery or clubs, therefore, it is important that when they are away from home, they are safe. If a child has asthma, the responsible adults around them need to know what to do in the case of an asthma emergency.

The webinar covers some important topics:

• What asthma is,
• When and how to use an inhaler,
• What to do in an asthma emergency.

How common is asthma?

Asthma is a common respiratory condition that affects around 5.4 million people in the UK¹, with 1.1 million of them being children². Asthma is the most common long-term condition among children and young people and the UK has among the highest mortality rates in Europe. It is thought that emergency admissions and deaths related to asthma are largely preventable, with these statistics being linked with deprivation².

It is encouraging to see a small reduction in deaths among children and young people as a result of asthma between 2008-2018³, however, even though the figures are low, they are still too elevated for a condition that should be manageable, making the deaths preventable.

Unfortunately, the trend seems to be rising among 15 – 24 year olds³. A report in 2019 found that out of 19 countries, young people are more likely to die from asthma in the UK, compared to those in other wealthy countries⁴. This is not good enough and we should be doing better than that.

What is asthma?

According to the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines, asthma is the presence of more than 1 of the following symptoms:

• Wheeze,
• Breathlessness,
• Chest tightness,
• Cough.

It is a combination of variable symptoms, and you may find that over weeks or months, you experience a difference in symptoms. The underlying problem is the airways, the airways can either have hyperresponsiveness, which is an increased sensitivity of the airways or inflammation.

What symptoms do asthma sufferers typically suffer from?

The most common symptoms of asthma are:

• Cough,
• Wheeze,
• Shortness of breath,
• Exercise limitation,
• Duration of symptoms,
• Triggers.

Hopefully, no one suffers from all of the above, but symptoms are variable and can come and go over a period of time. Quite often the person knows what sets their symptoms off.

How does asthma affect the lungs?

Asthma causes an inflammation of the mucous membrane, which can lead to swelling into the airspace, increase in mucous production, twitch airways and bronchospasms.

How do we measure asthma?

There are a few ways asthma can be measured/monitored. First would be a peak expiratory flow meter, this is a simple test where you have a device with a scale. First, you would make sure the slide on the scale is on 0, you would then take a deep breath in and provide a short, sharp blow into the meter.

Another way is spirometry, which is a more advanced look at how the air moves in and out of the chest. It measures how much air you can move out of your chest and how quickly you can do that, as well as the pattern the air follows as it leaves the chest. This test would be carried out in a clinic.

Finally, there is a Fractional exhaled Nitric Oxide (FeNO) test. As standard, we produce small amounts of Nitric Oxide in our breath, but when a patient has inflammation in the chest, the type typically seen in asthma, more Nitric Oxide is produced. A FeNO test, carried out by the NObreath® is suitable for both adults and children, it requires you to take a deep breath in and blow into the device at a steady pace.

Asthma is a serious, long-term condition, and poorly controlled asthma can present physical symptoms. Symptoms in children can include:

• Shortness of breath,
• Tight chest,
• Wheeze.

These symptoms can create further issues in children, as if they feel unwell, they are less likely to take part in physical activity, this then leads them to become deconditioned and at risk of obesity, which can make asthma worse. Poorly controlled asthma can also disturb sleep, which affects concentration, emotions and behaviour.

There are also psychological effects that poorly controlled asthma can have on children. Children, typically like to be like other children and having asthma can make them feel different. They might be embarrassed by their inhaler, meaning they may not use it when needed. They may have experienced an asthma attack in the past and it might make them frightened to do things that could trigger another attack, limiting them to what they can do.

Poorly controlled asthma can also affect education outcomes, as children with asthma may be absent from school for medical appointments or asthma attacks. They might also have reduced concentration due to disturbed sleep or feeling unwell.

How do we treat asthma?

There are around 119 different inhalers available, so there are lots of treatments and options. Our aim is for anyone with asthma to have:

• No daytime symptoms,
• No night symptoms,
• No activity limitations,
• No need for using a rescue inhaler,
• No side effects from treatment,
• Normal lung function.

The main part of treating asthma is treating the underlying inflammation, and if we get that treatment right, the swelling will settle down, the airways will open back up and the patient will find it easier to breathe. However, not all treatment is instant, if a brown-coloured preventer inhaler is used, it must be used for a few days. This allows the medication to settle down the inflammation slowly and once settled it is likely to be needed long-term.

Inhalers are broken down into 2 categories:

If anyone is using a blue rescue inhaler more than 3 times a week, their treatment is not quite right and this would need to be assessed. It is important to know the difference between the treatment inhaler, usually orange and brown in colour and the rescue inhaler which is always blue.

Maintenance and reliever therapy (MART) is also used, this is a combination inhaler. The inhaler contains treatment and rescue medication and is used regularly twice a day if there are symptoms. Extra doses of this inhaler should only be needed occasionally.

It is important to get the inhaler technique right, sadly, many people do not know how to use their inhaler properly and this is partly due to insufficient advice from their healthcare provider. This proves that education is key to enabling patients to take their medication correctly.

Types of inhalers:

• Pressurised metered dose inhaler,
• Spacer devices,
• Breath-actuated meter dose inhaler,
• Dry powder inhaler.

Knowing the different types and the correct way to use them is important. If you have a metered dose inhaler, the breathing technique should be slow and gentle, if you have a dry powder inhaler, you should breathe in fast and hard. If you use the fast and hard technique with a metered dose inhaler, the medication will hit your throat rather than go into your lungs, likewise with the dry powder inhalers, if you do not breathe in fast and hard, you will not move the powder into the lungs.

Spacers are available, usually for children. They are chambers for metered dose inhalers, to slow the speed of the medication and hold it for a few seconds, allowing more time for the user to breathe in. There are many different sizes of spacers available, depending on the age and capability of the users.

What if my asthma is not that good?

If you have all of the previous steps in place and your treatment is correct, asthma can still flair up. If this happens, there are steps you can take to tackle this.

• Use treatment inhalers regularly,
• Make sure you know how to best use your inhaler,
• Be aware of triggers,
• Book a review with the asthma nurse,
• If you need your blue rescue inhaler more than 3 times a week, book an appointment,
• If you are short of breath and your inhaler is not helping, make an urgent GP appointment for the same day.

What should you do in an asthma attack?

Knowing what to do during an asthma attack can be the difference between life and death, the below graphic from Asthma + Lung UK shows the steps you should take during an attack.

https://www.asthmaandlung.org.uk/conditions/asthma/asthma-attacks#:~:text=an%20AIR%20inhaler-,Sit%20up%20%2D%20try%20to%20keep%20calm.,not%20improving%2C%20repeat%20step%202

To ensure the care is right, everyone should have a personalised asthma action plan. Various formats are available, an example from Asthma + Lung UK below is:

Action plan available from https://www.asthmaandlung.org.uk/conditions/asthma/manage/your-asthma-action-plan

The green area represents when your asthma is good, this is how it feels when my asthma is good and this is the medication I take to maintain good asthma control.

Amber is when things are starting to get worse, how can I recognise when it is beginning to deteriorate? It gives you steps to follow to improve symptoms and move back into the green.

Red represents an asthma emergency and what to do in this situation.

It is important to recognise when you are in the red and what to do in case this happens, but it is also good to realise when you are in the amber so you can get yourself back on track to green.

How can we manage the effect of our triggers?

Sometimes, there is not much that can be done to avoid our triggers, but where possible, you can eliminate or avoid them. You can treat other conditions that trigger your asthma and make sure your asthma is well managed. You can predict the triggers. For example, if hay fever is a trigger, start treating your hay fever early. Lastly, always have your rescue medication to hand.

Parents and carers must understand asthma to understand how the medication works and why it is important. They need to have an asthma action plan, know how to maintain control and know what to do in an emergency. They also need to know what to do if an inhaler has been forgotten.

With asthma still an ongoing serious respiratory condition that kills children every year, this webinar has helped people understand the following:

• Asthma and the treatment,
• The goals of the treatment,
• How and when to use inhalers,
• Why asthma worsens,
• What to do in an emergency.

To watch the full webinar and gain in-depth insights, click here.

References

1. Asthma + Lung UK. [cited on 8/10/24] Available from https://www.asthmaandlung.org.uk/conditions/asthma/what-asthma
2. RCPCH State of Child Health. [cited on 8/10/24] Available from https://stateofchildhealth.rcpch.ac.uk/evidence/long-term-conditions/asthma/
3. PMC PubMed Central. Wei-Yu Chen, Ching-Wei Lin, Ju Lee, Po-Sung Chen, Hui-Ju Tsai and Jiu-Yao Wang. [cited on 8/10/24] Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102795/
4. BBC News. [cited on 8/10/24] Available from https://www.bbc.co.uk/news/health-47292157#:~:text=Young%20people%20in%20the%20UK%20are%20more%20likely%20to%20die,of%2019%20high%2Dincome%20countries.

World Lung Day was created in 2017 by the Forum of International Respiratory Societies (FIRS), the day was established to raise awareness about lung health and advocate for better lung health globally. Celebrated annually on the 25th of September, FIRS brings together several major respiratory organisations, including the American Thoracic Society (ATS) and the European Respiratory Society (ERS), to promote education and action on respiratory health issues worldwide.

This World Lung Day we are particularly focusing on asthma, a chronic respiratory condition affecting millions worldwide. In England alone, hospital admissions for asthma paint a concerning picture: 15,5328 children under the age of 19 and 34,824 adults were admitted for asthma emergencies during 2022/2023¹.

September can be a particularly challenging month for children, as the demand for GP visits and hospitals spike after the summer holidays². Figures show a 348% rise in the number of 5-14-year-olds admitted to hospital with an asthma attack in September³. This can be due to stress, coughs, colds, cold air and a lapse in asthma management routines over the summer². Another factor is air pollution, which further complicates asthma management. Between 2017 to 2019 in London alone, air pollution contributed to 7% of all paediatric asthma admissions⁴.

When asthma remains undiagnosed or receives inadequate treatment, it can lead to stress, anxiety, or depression, as well as lung infections, hindered growth and delayed puberty in children. Additionally, it can escalate to critical asthma attacks that can be life-threatening⁵.

So, what can we do to better manage asthma and reduce the need for emergency care? Establishing an early diagnosis and ensuring consistent monitoring is crucial. A key part of this is Fractional exhaled Nitric Oxide (FeNO) testing. A FeNO test measures airway inflammation, typically found in patients with asthma. The use of FeNO testing, in conjunction with a comprehensive clinical history and additional examinations, contributes to more efficient asthma diagnosis and enhances patient care. Furthermore, it enables the monitoring of patients’ responses to asthma interventions.

Carol Stonham MBE, a seasoned registered nurse who serves at Gloucestershire ICB, leading the Respiratory Clinical Programme Group, co-leads the NHSE South West Respiratory Network, and is also a member of Bedfont’s Medical Advisory Board says “The diagnosis of asthma isn’t always easy and sometimes evolves over time. We know the basis of asthma is inflamed airways, so to be able to measure that to help confirm the diagnosis as a part of the diagnostic puzzle is vital. It also demonstrates the inflammation to the patient helping them to understand the inflammatory process, and the effects of any inhaled medication they might be prescribed. It is also key at other asthma consultations to reiterate the vital aspect of patient education and to help guide follow up care and patient understanding.”.

Bedfont® Scientific Limited are world leaders in breath analysis, with over 47 years of knowledge and expertise in the design and manufacture of medical breath analysis devices; including the NObreath® FeNO device. The NObreath® plays a pivotal role in improving asthma diagnosis and management by measuring FeNO levels on a patient’s breath. This non-invasive test provides instant results, helping healthcare professionals make more informed decisions about a patient’s asthma status. The NObreath® helps ensure patients receive the right interventions at the right time, ultimately reducing the frequency of asthma attacks and hospital admissions.

As we observe World Lung Day 2024, it is clear that tackling asthma requires a multifaceted approach, by improving awareness, reducing environmental triggers like air pollution, and advancing diagnostic methods. By continuing to advocate for better respiratory care and investing in tools like FeNO testing, we can make a significant impact in reducing the burden of asthma worldwide. For more information on the NObreath® and how FeNO testing can aid in the diagnosis and management of asthma, please visit www.nobreathfeno.com.

References

1. Fingertips Public Health Profiles [Internet]. Department of Health and Social Care. 2024. [Cited
Thursday 5th September 2024]. Available from: https://fingertips.phe.org.uk/search/asthma
2. NHS warning to parents ‘asthma season’ hits [Internet]. NHS. 2019. [Cited Thursday 5th September
2024]. Available from: https://www.england.nhs.uk/2019/09/nhs-warning-to-parents-as-asthma-
season-hits/
3. Buelo A, McLean S, Julious S, Flores-Kim J, Bush A, Henderson J, Paton JY, Sheikh A, Shields M, Pinnock H. At-risk children with asthma (ARC): a systematic review. Thorax. 2018 Sep 1;73(9):813-24.
4. Health impact assessment of current and past air pollution on asthma in London [Internet]. Imperial College London. 2022. [Cited Thursday 5th September 2024]. Available from: https://www.london.gov.uk/sites/default/files/hia_asthma_air_pollution_in_london.pdf
5. Improving access to FeNO testing in primary care [Internet]. Health Innovation Network. 2023. [Cited Thursday 5th September 2024]. Available from: https://www.ahsnnetwork.com/programmes/respiratory-disease/bettering-access-to-feno-testing-in-primary-care/

Methods of measuring FeNO

Fractional exhaled nitric oxide (FeNO) measurement plays a crucial role in the diagnosis and management of airway inflammation. FeNO testing is recommended by the National Institute for Health and Care Excellence (NICE) to help diagnose asthma¹, with the NObreath® device one of three devices recommended by NICE¹.

In 2005 the American Thoracic Society (ATS) and the European Respiratory Society (ERS) published recommendations for standardised procedures of FeNO testing highlighting that whilst evidence shows ambient levels of nitric oxide (NO) do not affect the result; it is preferable to avoid doubt by removing it from the breath sample². This can be done by either ‘partitioning’ the sample; effectively ignoring the potential initial spike caused by ambient NO, or another method is inhaling through an NO scrubber before exhalation.

The NObreath® utilises the partition method. This article explores the partitioning method, how it works, and why Bedfont® Scientific Limited selected this method for the NObreath® device.

What is the partition method?

The partition method essentially ‘parts’ the breath sample, and omits the first few seconds to ensure any potential high ambient levels of NO present in the breath are not measured during sampling.

When performing a breath test with the NObreath®, the user will be prompted to take a deep breath and then instructed to blow gently into the mouthpiece with an onscreen flow meter to guide the patient on their exhalation rate. The NObreath® offers two test modes: A 12-second test mode and a 10-second test mode for those up to 10 years old who cannot complete the 12-second test mode.

As the breath sample enters the NObreath® device, the first few seconds are partitioned and vented through the device bypassing the sensor chamber. After the partition period has elapsed, the pump will draw the remaining viable sample into the sensor chamber, where the breath sample will be analysed. When the patient completes a breath test using the NObreath® a green tick will appear on the screen to indicate a successful test, and the patient’s results will be shown onscreen in parts per billion (ppb) instantly.

The NObreath® applying the partitioning method

The partition method is a user-friendly method designed to measure airway inflammation, providing instant results, and eliminating wait times for both patients and healthcare professionals. The patient does not have to inhale through a device that has been used on multiple prior patients, as even highly effective bacterial viral filters may not be 100% effective and the patient does not have to inhale through an NO scrubber*. Avoiding inhalation means these risks do not arise and this is another reason why Bedfont® chose this technique for NObreath®. The NObreath® also utilises an NO scrubber for accuracy but this does not form any part of the breath pathway.

To learn more about the NObreath® utilising partitioning method, please visit https://www.nobreathfeno.com/measuring-feno-with-the-nobreath/

FeNO testing

The use of FeNO testing, combined with a comprehensive clinical history and additional examinations, enhances the efficiency of asthma diagnosis and improves patient care. This allows for effective monitoring of patients’ responses to asthma interventions. Bedfont® are world leaders in breath analysis, with over 47 years of experience. Bedfont® has been manufacturing the NObreath® portable FeNO device for over 15 years. Used by healthcare professionals to measure airway inflammation to aid in the diagnosis and management of asthma, taking a minimal amount of valuable consultation time with the ability to monitor airway inflammation in both adult and child patients. With annual servicing and minimal consumables, the NObreath® can be used as a functional device for years**.

Visit https://www.nobreathfeno.com to learn how to support your patients with FeNO monitoring using the NObreath® from Bedfont® Scientific Limited.

*NO scrubbing filters typically utilise potassium permanganate (a potentially hazardous substance) which has been referenced in certain conditions, if inhaled, to cause irritation to the nose, throat and lungs causing coughing and/or shortness of breath^3,4,5,6.

**The NObreath® has been validated for up to 29,000 tests when used as instructed and properly maintained and serviced. The number of tests can be periodically checked within the settings of the device; when 29,000 tests are reached a service is recommended. Contact your local service centre.

References:

1. Measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO, NIOX VERO and NObreath [Internet]. National Institute for Health and Care Excellence. 2014. [Cited Monday 12^th August 2024]. Available from: https://www.nice.org.uk/guidance/dg12/chapter/1-Recommendations
2. American Thoracic Society Documents. ATS/ERS recommendations for standardised procedures for the online and offline measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide, 2005. Am J Respir Crit Care Med. 2005;171(8):912-30. DOI: 10.1164/rccm.200406-710ST.
3. Hazardous substance fact sheet [Internet]. New Jersey Department of Health and Senior Services. 2002. [Cited Monday 12^th August 2024]. Available from: https://nj.gov/health/eoh/rtkweb/documents/fs/1578.pdf
4. Safety data sheet potassium permanganate [Internet]. AquaPhoenix Scientific. 2015. [Cited Monday 12^th August 2024]. Available from: https://beta-static.fishersci.com/content/dam/fishersci/en_US/documents/programs/education/regulatory-documents/sds/chemicals/chemicals-p/S25497.pdf
5. . Potassium permanganate permanganic acid potassium salt [Internet]. Safety International Chemical Cards. 2016. [Cited Monday 12^th August 2024]. Available from: https://www.ilo.org/dyn/icsc/showcard.display?p_lang=en&p_card_id=0672&p_version=2
6. Potassium permanganate safety data sheet [Internet]. LabChem. 2014. [Cited Monday 12^th August 2024]. Available from: https://palsusa.com/wp-content/uploads/sites/6/2024/08/POTASSIUM-PERMANGANATE.pdf

FeNO Testing in Asthma Care

Although airway eosinophilic inflammation is a key characteristic of asthma, there are few methods available to measure it. This inflammation can be assessed by measuring eosinophils and eosinophilic cationic protein (ECP) in sputum or by measuring ECP in blood samples¹. However, these methods are considered time-consuming, expensive, and not readily available.

For most asthma patients, airway inflammation is driven by an allergen-induced Th2 response². Evidence from the literature suggests that fractional exhaled nitric oxide (FeNO) is a crucial biomarker for respiratory tract inflammation². Elevated FeNO levels in asthma are thought to result from inducible NOS2 expression in the inflamed airways². The NObreath® FeNO device provides a non-invasive and significantly more cost-effective alternative aid to diagnose asthma and assess airway eosinophilic inflammation.

This article delves into the challenges encountered within primary care and how the innovative technology of the NObreath® can assist. Additionally, the article discusses the transition of the use of the NObreath® from primary care environments to secondary care facilities.

Challenges in Primary Care

GPs often face restricted budgets due to resource allocation for population needs, and financial sustainability to stay within healthcare budgets and prevent overspending. Each patient appointment is typically limited to just 10 minutes.

Population needs

In the UK, approximately 5.4 million people, or about 8 in every 100 individuals, suffer from asthma³. The National Review of Asthma Deaths (NRAD) documented 195 asthma-related deaths among adults in 2013, highlighting preventable factors in 89 of the 195 deaths (46%), such as lack of specific asthma expertise (17%) and non-adherence to UK asthma guidelines (25%)⁴. FeNO testing is valuable in GP settings, as GPs often encounter a spectrum of asthma cases, from mild to severe. The NObreath® device facilitates rapid and reliable FeNO measurements, to allow GPs to make informed decisions and aid in identifying patients who do or do not require ongoing treatment⁵. This also reduces emergency visits and hospital admissions related to poorly controlled asthma.

Financial sustainability

One of the ongoing challenges in primary care is maintaining financial sustainability. The NObreath® FeNO device is cost-effective, with minimal ongoing costs. The device requires only one consumable- the NObreath® mouthpiece which has a long shelf life and an integrated infection control filter, effectively removes airborne bacteria (>99%) and viruses (>98%)⁶. The device also incurs low annual servicing costs and imposes no test limits*.

Time with patient

When a GP determines the need for a FeNO test using the NObreath®, there’s no warm-up time, and the device operates through a simple exhale-only technique with on-screen visual guidance. Patients receive instant results, eliminating wait times. Intended for adult and paediatric patients**, the NObreath® offers two test modes: a 10-second test mode for those up to 10 years old who cannot complete the 12-second test mode.  GPs can store up to 25 results in up to 50 patient profiles and view a graph of results. If a GP office possesses only one NObreath®, they benefit from the device size and portability, ensuring that healthcare providers can efficiently utilise the device wherever patient care demands.

Carol Stonham, a member of Bedfont® Scientific Limited Medical Advisory Board and policy lead for Policy Care Respiratory Society (PCRS), comments “The NObreath® is my preferred choice for primary care in managing asthma for many reasons. Primarily it suits the unpredictability of the volume of testing in primary care – none of the consumables or device needs to be used or lost in a short time frame. It is an intuitive machine which is easy to use and teaches patients of all ages.”

Primary Care to Secondary Care

Using the NObreath® device in primary care can reduce the number of inappropriate referrals to secondary care clinics. However, if a patient is referred to an asthma specialist in secondary care, the NObreath® FeNO device can aid in the diagnosis and management of asthma. The NObreath® helps differentiate between allergic (eosinophilic) and non-allergic asthma⁷. FeNO measurements show the patient’s response to the treatment, enabling accurate prescription of medication and safer, monitored adjustments. This helps patients understand their condition better by demonstrating how their FeNO levels correlate with their symptoms and treatment adherence. Measuring airway inflammation with the NObreath® can help monitor the effectiveness of medication and predict the risk of asthma attacks⁸***

Gold Standard FeNO Testing

FeNO testing is increasingly recognised as a valuable tool in the management of asthma, but what makes the NObreath® stand out from other FeNO devices on the market? Developed by Bedfont® in 2008, the NObreath® has over 15 years of clinical use and has been featured in numerous studies worldwide, contributing to the advancement of FeNO testing. Conforming to both the American Thoracic Society (ATS) and European Respiratory Society (ERS) guidelines, the NObreath® is also one of three FeNO devices recommended by the National Institute for Health Care Excellence (NICE)⁹, an independent international organisation providing national guidance and advice to improve health and social care.

To find out how you can support your patients with FeNO testing in asthma care with the NObreath®, please visit: https://www.nobreathfeno.com/

*The NObreath® has been validated for up to 29,000 tests when used as instructed and properly maintained and serviced. The number of tests can be periodically checked within the settings of the device; when 29,000 tests are reached a service is recommended. Contact your local service centre.

**NObreath® can be used on paediatric and adult patients, provided they can follow test protocol. USA only: NObreath® can be used on patients 7+ years old.

***FeNO is not a definitive indication of asthma and should be used in conjunction with (but not limited to) spirometry, patient history, and symptoms.

References:

1. Pizzichini E, Pizzichini MM, Efthimiadis A, Dolovich J, Hargreave FE. Measuring airway inflammation in asthma: eosinophils and eosinophilic cationic protein in induced sputum compared with peripheral blood. Journal of allergy and clinical immunology. 1997 Apr 1;99(4):539-44. DOI: 10.1016/S0091-6749(97)70082-4.
2. Keller AC, Rodriguez D, Russo M. Nitric oxide paradox in asthma. Memórias do Instituto Oswaldo Cruz. 2005;100:19-23. PMID: 15962094 DOI: 10.1590/s0074-02762005000900005.
3. What is Asthma? [Internet]. Asthma+ Lung UK. 2024. [Cited Monday 8^th July 2024]. Available from: https://www.asthmaandlung.org.uk/conditions/asthma/what-asthma#:~:text=Asthma%20is%20a%20common%20condition,cough%20or%20a%20tight%20chest.
4. Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Report. London, RCP; 2014.
5. Taylor DR, Pijnenburg MW, Smith AD, Jongste J. Exhaled nitric oxide measurements: clinical application and interpretation. Thorax. 2006 Sep 1;61(9):817-27. PMID: 16936238 PMCID: PMC2117092 DOI: 10.1136/thx.2005.056093.
6. Public Health England. An Evaluation of Filtration Efficiencies Against Bacterial and Viral Aerosol Challenges. Salisbury: Public Health England; 2020.
7. Ref: Coumou H, Bel EH. Improving the diagnosis of eosinophilic asthma. Expert review of respiratory medicine. 2016 Oct 2;10(10):1093-103. DOI: 10.1080/17476348.2017.1236688.
8. Saito J, Gibeon D, Macedo P, Menzies-Gow A, Bhavsar PK, Chung KF. Domiciliary diurnal variation of exhaled nitric oxide fraction for asthma control. European Respiratory Journal. 2014 Feb 1;43(2):474-84. DOI: 10.1183/09031936.00048513.
9. Measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO, NIOX VERO and NObreath [Internet]. National Institute for Health and Care Excellence. 2014. [Cited Wednesday 10^th July 2024]. Available from: https://www.nice.org.uk/guidance/dg12/chapter/5-Outcomes

Like any healthcare investment, consideration needs to be given when deciding which fractional exhaled nitric oxide (FeNO) device might best suit the clinical area in which it will be used. So, what would be sensible to consider when including FeNO devices for implementation into the respiratory pathway? And how does the NObreath® measure up?

External approval is an important factor in healthcare device purchase. It acts as an independent validation of quality and reliability. In England, approval from the National Institute of Health and Care Excellence (NICE) demonstrates that a device or medicine has been assessed by independent committees and has made evidence-based recommendations for the health and social care sector^1. Technology appraisals² assess the clinical and cost-effectiveness of health technology, including devices such as the FeNO device. As the technology market increases and additional devices are brought to market, it is important to investigate what external approval a device has received, and that it has undertaken an independent process before approval. The NObreath® has successfully undergone the required NICE technology appraisal.

Reassurance that tests performed are accurate, and repeatedly so, is vital in healthcare. The evidence for individual devices is reviewed as a part of the NICE technology appraisal. A device that is CE-marked also ensures that the manufacturer conforms to European standards for health, safety and environmental requirements.

A vital component in any healthcare system is the cost. As with many healthcare devices, this extends beyond the initial price tag. Is there an ongoing maintenance cost? What is the cost of the consumables such as mouthpieces required? Is there any potential for waste? Will the device offer longevity in a pathway if it is correctly maintained?

When considering cost, it is also worth considering the value of including the test and the potential price of not including FeNO in a respiratory pathway. Is there the potential for other costs to emerge without the test? Incorrect diagnosis resulting in lifelong unnecessary inhaled medication is seen in asthma³,with the associated costs to the patient and the healthcare system along with the additional burden a diagnosis of asthma can bring. Alternately, the cost and burden of a missed diagnosis can also occur leaving patients with untreated symptoms and the associated risk of asthma. Objective tests including FeNO are recommended^4,5,6 in making an accurate diagnosis of asthma.

Tests that are simple to perform are more likely to be used in primary care where time is short. Recent research has found many competing priorities for services currently and the pressure on workforce training and capacity⁷ has impacted primary care’s ability to reinstate spirometry services. Despite funded training for spirometry in England, it has been slow to increase because of the complexity and time taken to achieve the required standard and registration. The requirement for competence in using a FeNO device is not as onerous, does not take long to complete and is free to complete in the UK. New technology should ideally be easy for patients to use, easy for competent healthcare professionals to teach to others who might undertake testing, and suitable for testing on a broad age range. FeNO testing meets all the criteria, it is a quick simple test that is relatively easy for all ages to perform with minimal coaching, and the test procedure is easy to teach to others.  

A device that is portable and can be moved between consulting rooms will increase its use and test availability for patients. This allows a FeNO test to be quickly and easily integrated into relevant primary care consultations.

One of the most impactful things that healthcare professionals are influenced by are guidelines. These may be international, national or local guidelines. FeNO has an identified place in the current guidelines ^4,5,6. As guidelines progress to reflect the most current evidence, it is likely that FeNO testing as a part of the diagnostic process, and as a tool to monitor established asthma, will become more prominent.

Comparing the Bedfont® NObreath® FeNO device against these considerations, is it a good choice? The NObreath® has successfully been through the NICE technology appraisal so has demonstrated that it is a clinically effective device offering reliable repeatable testing and is cost-effective. The NObreath® is a non-invasive device with visual incentives to encourage patients of all ages to achieve optimal flow rate for testing. The test settings can be used for adults and children so is an all-age device. It is simple to explain and easy for patients to perform, taking a minimal amount of valuable consultation time. It is small, and easily transported. It requires annual servicing and minimal consumables and can be used as a functional device for many years.

Taking advantage of these features, some practices and primary care networks have taught all clinicians how to perform the test when the patient initially presents with a history and symptoms of asthma, so that treatment can begin without delay and the patient can be reviewed with steroid naive FeNO results as the national and international guidelines recommend.

References:

1. National Institute for Health and Care Excellence (2024). Available from https://www.nice.org.uk/guidance [Last accessed 19.6.24]
2. National Institute for Health and Care Excellence (2024). Available from https://www.nice.org.uk/About/What-we-do/Our-Programmes/NICE-guidance/NICE-technology-appraisal-guidance [Last accessed 19.6.24]
3. Aaron SD, Vandemheem KL, FitzGerald JM, Ainslie M, Gupta S et al.: Canadian Respiratory Research Network. Re-evaluation of diagnosis in adults with physician-diagnosed asthma. JAMA 2017;317:269-279
4. British Thoracic Society (2019)Guidelines for the management of asthma. Available from https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ [Last accessed 20.6.24]
5. National Institute for health and Care Excellence (2017). Asthma: diagnosis, monitoring and chronic asthma management NG80. Available from https://www.nice.org.uk/guidance/ng80 [Last accessed 20.6.24]
6. Global Initiative for Asthma (2024) Global Strategy for Asthma Management and Prevention. Available from https://ginasthma.org/2024-report/ [Last accessed 20.6.24]
7. Doe G, JC Taylor SJC, Topalovic M, Russell R, Evans RA et al (2023) Spirometry services in England post-pandemic and the potential role of AI support software: a qualitative study of challenges and opportunities. British Journal of General Practice 2023;  73 (737): e915e923. DOI: https://doi.org/10.3399/BJGP.2022.068

To mark Love Your Lungs Week, Bedfont® Scientific Ltd. raises awareness of FeNO testing in asthma care.

Love Your Lungs Week is an annual event which takes place from 21^st to 27^th June. The event aims to raise lung health awareness and promote habits that support respiratory well-being. Bedfont®, world leaders in breath analysis have over 47 years of experience in designing and manufacturing of breath analysis devices. Through innovating breath analysis devices, Bedfont® look to improve patient care with devices like the NObreath®. The NObreath® is a Fractional Exhaled Nitric Oxide (FeNO) device, recommended by NICE for FeNO measurement in asthma care.

Asthma is a chronic respiratory condition where the airways become inflamed and narrowed, making breathing difficult. Sadly 1,261 people lost their lives from asthma in 2020¹, highlighting that asthma is a serious condition. Asthma is caused by a combination of genetic and environmental factors, and as there is no cure, treating and managing the condition is essential.

FeNO is produced naturally in the lungs and can be found in exhaled breath; measuring FeNO can help assess the level of inflammation in the lungs, aiding in the diagnosis and management of asthma.

Elevated FeNO levels can suggest eosinophilic inflammation, a common underlying cause in many asthma patients. By using the NObreath® to monitor these levels, healthcare providers can tailor treatment efficiently.

Jason Smith, Managing Director of Bedfont® says “At Bedfont®, we are committed to supporting initiatives that promote lung health. Love Your Lungs Week is an excellent opportunity to raise awareness about the importance of early diagnosis and proactive management of respiratory conditions. The NObreath® FeNO device not only aids in identifying airway inflammation but also assists in monitoring treatment efficacy, ensuring that patients receive the best possible care.”

The NObreath® is fairly priced and conforms to both ATS and ERS guidelines, allowing a future where everyone has access to instant, non-invasive, simple breath testing to aid in medical diagnosis.

To find out more about FeNO testing in asthma care, please visit our website to watch an insightful webinar hosted by Carol Stonham MBE earlier in the year, ‘How FeNO testing can empower and educate healthcare professionals and patients alike:’ www.bedfont.com

1. Public health profiles. Office for Health Improvement & Disparities. [cited on 1/5/24] Available from https://fingertips.phe.org.uk/search/asthma 

Love Your Lungs Week is a national awareness event which occurs annually in June, taking place from 21st June to 27th June 2024. Initiated by the British Lung Foundation, now known as Asthma and Lung UK, the event focuses on enhancing lung health and looks to raise awareness of a variety of respiratory conditions that affect lung health. One of these conditions is asthma, which is a chronic condition where the airways become inflamed and narrowed, making breathing difficult.

What causes asthma?

It is thought that asthma is caused by a combination of genetic and environmental factors; when exposed to various irritants and substances, it can trigger asthma symptoms. There are 2 types of asthma; allergy-induced asthma and non-allergy induced asthma. Both types can have different triggers and these can vary from person to person.

Allergy-induced asthma is the most common form and can be triggered by inhaling allergens. This
can lead to an immune response in the airways which causes the symptoms of asthma. Common
allergens include:

• Pollen: From trees, grass and weeds.
• Dust Mites: Tiny creatures that thrive in household dust.
• Pet Fur: Shed by cats, dogs and other furry pets.
• Mould: Fungai that can grow indoors or outdoors in moist environments.

These can include:

• Respiratory Infections: Such as the common cold or influenza.
• Exercise: Especially in cold or dry air.
• Stress and Emotions: Intense emotions can lead to hyperventilation and tightness in the chest.
• Airborne Irritants: Such as smoke, chemical fumes, strong odours, or pollutants.

These triggers can cause the airways to swell and narrow but do not involve an allergic response. Instead, they may involve different inflammatory responses or hypersensitivity of the airways.

What impact does asthma have?

Asthma can have a significant impact on people’s lives, affecting their physical health, mental well- being and quality of life. The condition imposes lifestyle limitations, with sufferers often avoiding activities that might trigger symptoms, along with the economic burden from continuous medical care and loss of productivity due to absences from work or school.

Unfortunately, asthma-related emergency admissions remain high at over 35,000 in both adults and
children in the UK¹, and with 1,261 people sadly passing away in 2020¹, it is clear more needs to be
done to avoid these numbers increasing.

How does FeNO fit into asthma management?

• Diagnosis: FeNO testing can help in diagnosing asthma in cases where typical diagnostic tests (like spirometry) might not be conclusive. Elevated FeNO levels can suggest eosinophilic inflammation, which is a common underlying cause in many asthma patients.
• Monitoring: For ongoing asthma management, FeNO levels can provide insight into how well inflammation is being controlled through medication, particularly inhaled corticosteroids.
• Monitoring FeNO can help in adjusting medications more precisely to reduce inflammation.
• Predicting Exacerbations: High FeNO levels can indicate poorly controlled asthma and predict potential exacerbations. This can be particularly useful in managing patients who have periodic flare-ups, allowing for preventive adjustments in treatment.
• Assessing Treatment Response: Regular FeNO testing can assess the effectiveness of current asthma treatment regimens. If FeNO levels remain high despite treatment, it might suggest the need for alternative therapies or more aggressive management.

With World Asthma Day just a little over a month ago now, this years theme “Asthma Education Empowers” aimed to highlight the importance of education in asthma diagnosis and treatment. It is clear that the innovative approaches to its management, including FeNO testing, have never been more essential.

Bedfont® Scientific Limited, are world leaders in breath analysis, with over 47 years of expertise and knowledge in designing and manufacturing breath analysis devices. They are committed to improving patient safety through innovating breath analysis devices, such as the NObreath®. The device is a portable handheld FeNO device, used by healthcare professionals to aid in the diagnosis and treatment of asthma.

1. Public health profiles. Office for Health Improvement & Disparities. [cited on 7/5/24] Available from
https://fingertips.phe.org.uk/search/asthma