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H3120 Chronic asthmatic bronchitis
173A. Exercise induced asthma (v27.1)
Proactive structured review as opposed to opportunistic or unscheduled review is associated with reduced exacerbation rates and days lost from normal activity.
The diagnosis of asthma is a clinical one; there is no confirmatory diagnostic blood test, radiological investigation or histopathological investigation. In most people, the diagnosis can be corroborated by suggestive changes in lung function tests.
One of the main difficulties in asthma is the variable and intermittent nature of asthma. Some of the symptoms of asthma are shared with diseases of other systems. Features of an airway disorder in adults such as cough, wheeze and breathlessness should be corroborated where possible by measurement of airflow limitation and reversibility. Obstructive airways disease produces a decrease in peak expiratory flow (PEF) and forced expiratory volume in one second (FEV1) but which persist after bronchodilators have been administered. One or both of these should be measured, but may be normal if the measurement is made between episodes of bronchospasm. If repeatedly normal in the presence of symptoms, then a diagnosis of asthma must be in doubt.
A proportion of patients with COPD will also have asthma i.e. they have large reversibility - 400mls or more on FEV1 - but do not return to over 80 per cent predicted and have a significant smoking history. From 1 April 2006 these patients should be recorded on both the asthma and COPD registers.
A definitive diagnosis of asthma can be difficult to obtain in young children. Asthma should be suspected in any child with wheezing, ideally heard by a health professional on auscultation and distinguished from upper airway noises.
In schoolchildren, bronchodilator responsiveness, PEF variability or tests of bronchial hyperactivity may be used to confirm the diagnosis, with the same reservations as above.
Focus the initial assessment in children suspected of having asthma on:
SIGN clinical guideline 101 (2009). SIGN and BTS. British Guideline on the Management of Asthma. http://www.sign.ac.uk/pdf/sign101.pdf
It is well recognised that asthma is a variable condition and many patients will have periods when they have minimal symptoms. It is inappropriate to attempt to monitor symptom-free patients on no therapy or very occasional therapy.
This produces a significant challenge for the QOF. It is important that resources in primary care are targeted to patients with greatest need - in this instance, patients who will benefit from asthma review rather than insistence that all patients with a diagnostic label of asthma are reviewed on a regular basis.
It is for this reason that the asthma register is constructed annually by searching for patients with a history of asthma, excluding those who have had no prescription for asthma-related drugs in the preceding 12 months. This indicator has been constructed in this way as most clinical computer systems will be able to identify the defined patient list.
See indicator wording for requirement criteria.
Prepared By Jean Keenan