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As we enter the winter months and it becomes cold outside, the air we breathe is dry and the protected fluid in our lungs evaporates. This environmental change triggers the muscles within our lungs to spasm as they work to maintain open airways, resulting in increased tightness and difficulty breathing. While asthma symptoms persist throughout the year, they can escalate during winter, aggravating issues such as chest pain, coughing, shortness of breath, chest tightness, and wheezing¹.

Asthma is recognised in part by the variability of symptoms. Indeed, this variability is a key consideration in making the diagnosis of asthma². Once a diagnosis is confirmed, asthma symptoms can continue to demonstrate variability. This variability may be unpredictable and unexpected due to the natural disease process, or more predictable because of exposure to individual triggers.

Asthma guidelines state that if symptoms worsen, the clinician should check adherence with prescribed medication, check inhaler technique and remove triggers². This may be overlooked when increasing doses of inhaled medication or prescribing additional medications. It is worth thinking about how this can be done in practice.

Medication adherence can be a tricky subject to bring into the consultation. It is a complex mix of patients’ health beliefs or misjudgement of their condition^3,4 and can also be influenced by cultural beliefs⁵. It is a fascinating subject and worth looking into in more depth to get an understanding of why some people will not take prescribed medication whether it is an intentional decision or a non-intentional action. The attitude and experience of the prescribing clinician can also influence a patient’s decision to adhere to a prescribed medication regimen⁶.

One of the strategies we tend to use to assess adherence is to look at the prescribing history – has the patient been prescribed adequate treatment (inhaled steroid-containing inhaler) to be taking it regularly as prescribed? Has the patient ordered excessive amounts of rescue medication (Salbutamol or Terbutaline) indicating poor symptom control? The national review of asthma deaths⁷ found these measures were potential contributors to mortality. Salbutamol overuse is the focus of the global social movement Asthma Right Care⁸, in part because of the recognised link between the overuse of rescue medication and the increase in asthma mortality and morbidity.

Another approach that can help when assessing adherence with inhaled corticosteroids is to measure fractional exhaled nitric oxide (FeNO). This measures eosinophilic airway inflammation which is a key component of most asthma types. If inhaled corticosteroids are taken regularly using the correct inhaler technique, this inflammation should be controlled unless a dose increase or addition of add-on therapy is required. If the patient is not taking regular treatment or is taking it using a poor technique, the airways will demonstrate this inflammation. If the test is undertaken following a clear explanation of what asthma is, how inhalers work and what the test will measure, the discussion on inhaler use has a good basis to work from – many people with asthma do not understand the disease process and how inhalers work so do not take them regularly. For those who are adherent with medication who can demonstrate good inhaler technique, a raised FeNO level may be an indication of the need to increase or add in medication.

Suboptimal inhaler technique is a common cause of increasing asthma symptoms and poor asthma control, yet is very common⁹. According to the systematic review published in 2016, only 31% of patients can use an inhaler correctly, and the inhaler technique has not improved over the past 40 years¹⁰.

Guidelines emphasize the importance of correct inhaler technique before escalating treatment², yet many healthcare practitioners are not confident or indeed competent in checking and coaching patients to optimise the use of inhalers. To address this, the UK Inhaler Group have produced a Standards and Competency document¹¹ to guide and encourage appropriate teaching and coaching of inhaler technique.

Checking the correct inhaler technique and assessing adherence with prescribed medication are 2 of the basics to check if a person presents with increasing asthma symptoms (not sudden acute asthma) especially if the person is found with raised FeNO levels.

The third element is to discuss and, where possible, eliminate asthma triggers. Whilst asthma has a natural variability which can often be unexpected and unpredictable, there are more obvious triggers that may be specific to the individual and will be known to increase asthma symptoms. There are a wide range of triggers from seasonal elements – increasing pollens in the spring and through summer, dampness and moulds in autumn, and respiratory infections in the winter – through exposure to perfumes and smoke, pets and animals, and house dust mites and many others besides.

Whilst some of these can also be unpredictable there are elements, especially as we go into winter for example, where a person knows from past experience that a particular season will ‘set them off’. The population with long-term health conditions are offered protection against some respiratory infections with vaccinations but viral infections have been found to cause up to 70% of asthma exacerbations¹². So, what can we do to protect our patients with asthma as we move into winter in addition to vaccine administration? During the COVID-19 pandemic where social distancing rules and mask-wearing were mandated, there was a reduction in admissions to hospitals from long-term respiratory conditions but this is not an acceptable strategy in the future.

What we can do is be sure that our patients have the appropriate medication in a device that they can and will use on a regular basis to optimise asthma control leading up to known predictable periods of likely exacerbation. The basis of this must be the patient’s understanding of what asthma is and an understanding of the expected effects of prescribed medication, supported with a personalised asthma action plan that will help patients to know their potential when asthma control is optimal, to recognise deterioration and know how to act and adjust medications safely, when to seek help and from whom.

There are various tools that will help in this patient journey such as placebo inhaler devices to practice and optimise inhaler technique, and diagrams and airway models to improve understanding of asthma. Measurement of lung function using a peak flow meter when a patient, as well as a comparator when a patient has increasing symptoms, is helpful. Measurement of FeNO is a valuable addition to the asthma toolbox to measure airway inflammation which will help the patient better understand what asthma is and how inhaled medication, in particular inhaled steroids, target inflammation. In symptomatic patients, it can open conversations around adherence and inhaler technique, guide step-up and step-down treatment decisions, and work as part of the toolkit to optimise asthma control.

Delve deeper into the impacts of winter and asthma care in our upcoming webinar with Carol Stonham; Battling Winter Wheezes: How Cold Weather Impacts Asthma and the Benefits of FeNO Monitoring, being held on Tuesday 9th January 2024 at 7pm. Learn how FeNO measurements play a pivotal role in monitoring and managing respiratory health during colder months.

References:

1. Why asthma is worse in winter [Internet]. Temple Health. 2021. [Cited Monday 13th November 2023]. Available from: https://www.templehealth.org/about/blog/why-asthma-worse-in-winter
2. British Thoracic Society, SIGN. BTS/SIGN Guideline for the management of asthma. Available from https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ [Last accessed 24.10.2023]
3. Brandstetter S, Finger T, Fischer W, et al. Differences in medication adherence are associated with beliefs about medicines in asthma and COPD. Clin Transl Allergy. 2017;7(1):1–7. doi: 10.1186/s13601-017-0175-6
4. Ahmedani BK, Peterson EL, Wells KE, et al. Asthma medication adherence: the role of God and other health locus of control factors. Ann Allergy Asthma Immunol. 2013;110(2):75-79. e2. doi: 10.1016/j.anai.2012.11.006
5. Kaplan A, Mitchell PD, Cave AJ, et al. Effective asthma management: is it time to let the AIR out of SABA? J Clin Med 9(4):921. doi: 10.3390/jcm904092
6. van Boven JF, Ryan D, Eakin MN, et al. Enhancing respiratory medication adherence: the role of health care professionals and cost-effectiveness considerations. J Allergy Clin Immunol Pract 4(5):835–846. doi: 10.1016/j.jaip.2016.03.007
7. National review of asthma deaths. Why asthma still kills (2014). Available from https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills [Last accessed 24.10.2023]
8. Asthma Right Care (PCRS) available from https://www.pcrs-uk.org/campaign/asthma-right-care [Last accessed 24.10.23]
9. van der Palen J, Thomas M, Chrystyn H, Sharma RK, van der Valk pd, Goosens M, Wilkinson T, Stonham C, Chauhan AJ, Imber V, Svedsater H, Barnes NC. A randomised open-label cross-over study of inhaler errors, preference and time to achieve correct inhaler use in patients with COPD or asthma: comparison of ELLIPTA with other inhaler devices npj Primary Care Respiratory Medicine volume 26, Article number: 16079 (2016) [last accessed 24.10.2023]
10. Sanchis J, Gich I, Pedersen S, et al Systematic review of errors in inhaler use: has patient technique improved over time?Chest 2016;150:394-406. doi:10.1016/j.chest.2016.03.041pmid:http://www.ncbi.nlm.nih.gov/pubmed/270607 26
11. UK Inhaler Group (2016, reviewed 2019) Inhaler Standards and Competency Document. Available from https://www.ukinhalergroup.co.uk/uploads/s4vjR3GZ/InhalerStandardsMASTER.docx 2019V10final.pdf [Last accessed 24.10.2023]
12. Hammond C, Kurten M, Kennedy JL. Rhinovirus and asthma: A storied history of incompatibility. Curr Allergy Asthma Rep. 2015;15:502.

As winter draws in, the NHS braces for an influx of patients infected with common respiratory viruses. For those with respiratory conditions, such as the 5.4 million asthma sufferers in the UK, the colder months pose an especially daunting threat.¹ Constricted airways, breathlessness, and tightness of the chest are typical yet distressing symptoms of asthma, an inflammatory disorder affecting around 9% of the population and capable of increasing vulnerability to respiratory infections.^1,2

Beyond the physical and mental strain caused by asthma, a DALY rate of 350 per 100,000 indicates a significant burden of asthma-related disability in the UK population.³ This is reflected in the reported 60,000 hospital admissions and 200,000 bed days for asthma sufferers each year.¹ Asthma can also be life-threatening, with asthma attacks claiming the lives of three people each day.¹

The human toll of asthma has led to a significant economic burden. This year, the direct cost of asthma in England – encompassing NHS expenses, the impact of greenhouse gas emissions, and patient travel costs – has exceeded £1.2 billion.¹ Collectively, lung conditions, including asthma, place an annual £9.6 billion burden on the NHS and exacerbate winter healthcare pressures, as individuals with these conditions are more susceptible to respiratory illnesses and cold weather.¹ Asthma has become more than a personal health concern; it is a public health and economic crisis.

Compounding a Crisis: Inadequate Diagnostic Testing Impedes Effective Decision-Making

A report published in 2023 by the British Charity Asthma + Lung UK highlights the concerning state of lung healthcare in England. Despite lung disease being the third leading cause of death, individuals suffering from breathlessness frequently wait years for a formal diagnosis, while others remain undiagnosed or are misdiagnosed.¹ One study found that an asthmatic diagnosis could not be established in over 30% of adults who had previously received positive diagnoses.⁴ The scale of this issue is brought into focus when realizing that an estimated 750,000 people are misdiagnosed as asthmatic in England, and attendant financial repercussions are estimated at £132 million each year.¹

The reasons behind these apparent oversights are complex. One contributing factor involves funding restrictions and a lack of accessibility to diagnostic tests, undermining the veracity of primary care diagnoses. As uncovered in a PwC analysis, current deficiencies in testing are estimated to cost England £2.2 billion, primarily due to preventable hospital stays and treatments.⁵

To recoup some of these costs and alleviate pressure on the NHS, Asthma + Lung UK proposed the following measures. By fully funding diagnostic testing such as FeNO, reinstating nationwide spirometry, and maximizing the potential of community diagnostic centers and primary care for diagnoses, £307 million could be saved, and 273,000 beds could be made available – with over a third of these during the critical winter period. This figure dwarfs the £250 million in emergency funds that the UK government set aside to create 5,000 extra NHS hospital beds for this winter.¹

FeNO Testing: Tackling the Burden of Lung Conditions, One Breath at a Time

As one of the three recommendations proposed by Asthma + Lung UK, improving diagnostic testing appears realistically achievable. NICE recommends a single objective test for measuring airway inflammation in the diagnosis of asthma, fractional exhaled nitric oxide (FeNO).⁶ This test works by measuring nitric oxide, a naturally occurring gas produced by cells lining the airways to help combat inflammation. In individuals with respiratory conditions, especially asthma, there is often increased production of nitric oxide due to localized inflammation. During a FeNO test, the individual breathes into a specialized device, such as the NObreath® by Bedfont Scientific Ltd, which is designed to capture and analyze its nitric oxide content. With extreme sensitivity, the device measures the concentration of nitric oxide in parts per billion. Through reading the output of the device, valuable information about the degree of inflammation in the individual’s airways can be discerned. Higher FeNO levels are indicative of greater airway inflammation, which is often associated with conditions like asthma.⁵

The NObreath®, developed by Bedfont Scientific Ltd., is a non-invasive FeNO monitor suitable for both adult and child patients. Conforming to ATS & ERS guidelines, the NObreath® works using an easy exhale-only technique and on-screen visual motivation. After a breath sample is collected and analyzed, airway inflammation can be assessed, and responses to treatment can be monitored. Furthermore, a patient interpretation guide streamlines result analysis, enabling healthcare providers to make informed decisions.⁷

While the NObreath® offers a simple and cost-effective solution to asthma diagnosis, FeNO tests and solutions essential to accurately evaluating lung health remain largely unavailable in primary care.^5,7 A comprehensive analysis conducted by the PwC suggests that if FeNO tests were to be made universally accessible to GPs across England, optimization of asthma treatment could save around £100 million.¹ Such a finding not only underscores the cost-effectiveness of FeNO testing but emphasizes its potential to enhance patient outcomes by ensuring accurate diagnoses and tailored treatments.

A Nation Blue in the Face: Heeding the Call for Improved Diagnostic Testing

The asthma crisis in England is a multifaceted challenge involving misdiagnoses and financial strain on the NHS. FeNO testing represents a solution that can aid in the accurate diagnosis of lung conditions, such as asthma, and save millions of lives when made widely available to GPs across the country and integrated into primary care. It is crucial that everyone suspected of lung conditions, such as asthma, has access to FeNO tests and that those who undergo testing receive precise diagnoses.

By embracing FeNO testing as a cornerstone of asthma management, we can significantly improve the quality of life for asthma sufferers, reduce healthcare costs, and alleviate the burden on the NHS. The time to act is now for the benefit of patients and the healthcare system nationwide. Contact Bedfont Scientific Ltd. to find out what solutions are available to aid in this journey to more accessible testing.

References and further reading

1. Saving Your Breath: How Better Lung Health Benefits Us All. (2023). Asthma + Lung UK. Available at: https://www.asthmaandlung.org.uk/saving-your-breath-report
2. Sharma S, et al. (2022). Vulnerability for Respiratory Infections in Asthma Patients: A Systematic Review. Cureus. http://doi.10.7759/cureus.28839
3. Nunes C, et al. (2017). Asthma costs and social impact. Asthma Research and Practice. http://doi.10.1186/s40733-016-0029-3
4. Aaron SD, et al. (2017). Reevaluation of Diagnosis in Adults With Physician-Diagnosed Asthma. JAMA. http://doi.10.1001/jama.2016.19627
5. ‚Abysmal‘ lack of testing for lung conditions is forcing GPs to play a ‚guessing game‘ with diagnosis. (2023). Asthma + Lung UK. Available at: https://www.asthmaandlung.org.uk/media/press-releases/abysmal-lack-testing-lung-conditions-forcing-gps-play-guessing-game-diagnosis (Accessed on 09 October 2023).
6. Asthma: diagnosis, monitoring and chronic asthma management. NICE. Available at: https://www.nice.org.uk/guidance/ng80/chapter/Recommendations#objective-tests- for-diagnosing-asthma-in-adults-young-people-and-children-aged-5-and-over (Accessed on 09 October 2023).
7. Nobreath. Available at: https://www.nobreathfeno.com/us/ (Accessed on 09 October 2023).

Harnessing the Power of FeNO Monitoring to Combat Lung Conditions – A Vital Step in Addressing the UK’s Lung Health Crisis

A new report from PwC commissioned by Asthma+Lung UK has highlighted the alarming crisis surrounding Lung Health in the UK. Sarah Woolnough, CEO of Asthma+Lung UK, said lung conditions were the third biggest killer in the UK, with the report finding that due to the lack of testing, such as FeNO monitoring, patients can also be wrongly diagnosed and an estimated 750,000 people in England are misdiagnosed with asthma, costing the NHS an estimated £132 million every year¹.

Fractional Exhaled Nitric Oxide (FeNO) is a non-invasive medical test that measures the level of nitric oxide in a person’s breath. It is a pivotal advancement in asthma care, offering precise insights into airway inflammation. By facilitating accurate diagnoses, personalising treatment plans, and enabling ongoing monitoring of asthma control, FeNO empowers healthcare providers to optimise medication use, reduce exacerbations, and enhance patient engagement. This transformative tool not only improves the quality of life for individuals with asthma but also contributes to more effective, cost-efficient healthcare management, ultimately making a profound impact on the battle against this chronic respiratory condition.

Carol Stonham MBE, RN, MSc, Queen’s Nurse, and Policy Lead PCRS, explains, “Making an accuratediagnosis of asthma relies on taking an accurate history and then performing appropriate tests to confirm the diagnosis. Spirometry (a test of lung function) was stopped during the pandemic and hasbeen very slow to restart. FeNO testing provides a valuable piece of the jigsaw to confirm whether a person has asthma (or not). It is a very quick test to perform and most people find it easy to do. The basis of asthma is airway inflammation which is what the FeNO test gives an indication of. It helps confirm a diagnosis quickly and easily and helps the patient better understand their condition and how inhalers work to treat the condition. It helps clinicians make the correct diagnosis in a timely way and get the person onto the correct treatment pathway avoiding unnecessary hospital admission and life-threatening asthma attacks.”

Jason Smith, Managing Director at Bedfont Scientific, comments, “As a leading manufacturer of breath analysis medical devices, we understand the pivotal role that innovation plays in enhancing patient care and healthcare efficiency. FeNO testing is a prime example of such innovation. We remain committed to advancing respiratory care and hope that in working towards our mission to make healthcare more accessible, our NObreath® FeNO monitor can help make a positive impact on the lives of individuals living with asthma.“

Livio Gagliardi, Acting Managing Director at Intermedical, adds, “As the official UK distributor for NObreath®, we understand the significance of accessibility and affordability. We take pride in offering a flexible three-year rental plan for the NObreath® FeNO device. Our aim is to support practices and Primary Care Networks, regardless of their size or testing volume, in ensuring equal access to FeNO testing for their patients. We are well aware of the financial constraints faced by healthcare providers and patients alike.”“What sets us apart is our democratic cost per test pricing policy. We do not penalise smaller practices; instead, we maintain a low fixed cost per test, regardless of the volume of tests conductedper year. This means that even the smallest practices can benefit from our cost-effective solution. Our rental program for the NObreath® FeNO device serves as a crucial link, as we actively strive to narrow the gap and make advanced respiratory care accessible to everyone.”

The full report can be found here: https://www.asthmaandlung.org.uk/saving-your-breath

To contact Intermedical, please call 01732 522444 or email sales@intermedical.co.uk

References

1. Asthma+Lung UK. Saving Your Breath: How Better Lung Health Benefits Us All. September 2023. Available from: https://www.asthmaandlung.org.uk/saving-your-breath-report

Access to prevention and treatment for all. Leave no one behind:

Organised by the Forum of International Respiratory Societies (FIRS) since 2016, World Lung Day is a time for everyone to take a look at what we can do individually and as a society, to work toward clean air and healthy lungs for all. Asthma is closely related to World Lung Day because it is one of the major lung health conditions that the day seeks to address.

Under-diagnosis of asthma

In 2019, asthma affected an estimated 262 million people worldwide¹ and led to 455,000 deaths globally². A study completed by Nolte et al. in 2006 involved 10,877 participants aged 14-44 years old, 11% (1,149) of whom had previously reported asthma symptoms. After further assessment provided by Global Initiative for Asthma (GINA) recommendations, 43% (493) of the 11% were diagnosed with asthma, of which a further 50% (246) had not been diagnosed before³.

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-threatening⁴.

FeNO testing and 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.

FeNO testing can be completed within seconds and provides nearly instantaneous results, compared to traditional testing like spirometry with a bronchodilator test. Thereby ensuring a larger number of individuals receive appropriate treatment for their specific conditions, leading to reduced medication wastage⁵. In England, a two-year programme from 2021-2023 showed an estimated 58,000 people with newly diagnosed asthma received faster treatment, after more than 1,200 FeNO devices entered primary care⁶, highlighting the impact FeNO testing can have on asthma care.

Visit https://www.nobreathfeno.com to find out how you can support your patients with FeNO monitoring, with the NObreath® from Bedfont® Scientific Ltd.

References:

1. Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, Abbasi-Kangevari M, Abbastabar H, Abd-Allah F, Abdelalim A, and Abdollahi M. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020;396(10258):1204-1222. DOI: 10.1016/S0140-6736(20)30925-9.
2. Asthma [Internet] World Health Organization. 2023. [Cited 24^th August 2023]. Available from: https://www.who.int/news-room/fact-sheets/detail/asthma
3. Nolte H, Nepper-Christensen S, and Backer V. Unawareness and undertreatment of asthma and allergic rhinitis in a general population. Respiratory medicine. 2006;100(2):354-362. PMID: 16005621. DOI: 10.1016/j.rmed.2005.05.012
4. The Global Asthma Report 2018 [Internet]. 2018. [Cited 25^th August 2023]. Available from: http://globalasthmareport.org/2018/index.html
5. Improving access to FeNO testing in primary care [Internet]. 2023. [Cited 25^th August 2023]. Available from: https://www.ahsnnetwork.com/programmes/respiratory-disease/bettering-access-to-feno-testing-in-primary-care/
6. New report shows impact of FeNO national programme on asthma care in England [Internet] Primary Care Respiratory Society. 2023. [Cited 24^th August 2023]. Available from: https://www.pcrs-uk.org/news/new-report-shows-impact-feno-national-programme-asthma-care-england#:~:text=During%20the%20two%2Dyear%20programme,in%20primary%20care%20in%20England.