The way to diagnose and manage asthma has changed with FeNO testing.
Joint guidance between NICE, BTS and SIGN has recently been published for diagnosis and monitoring asthma.
The most significant change to the guidance is diagnosing asthma with clinical history and FeNO.
NICE guidelines and FeNO:
Key points
The NICE Guideline NG245 Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN), published on 27 November 2024, outlines a robust and evidence-based framework for diagnosing, monitoring, and managing asthma. A central aspect of this guidance is the use of FeNO (Fractional exhaled Nitric Oxide) testing, a non-invasive and highly accurate method to assess airway inflammation caused by eosinophils.
FeNO testing measures nitric oxide levels in exhaled breath, offering critical insights into inflammation that is often characteristic of asthma, particularly eosinophilic asthma. This testing complements other diagnostic tools like spirometry and bronchodilator reversibility (BDR), making it an integral part of the NICE asthma care pathway.
Key NICE Recommendations for FeNO Testing:
For Adults (16 Years and Older):
A FeNO level of 50 parts per billion (ppb) or more suggests significant eosinophilic airway inflammation and supports an asthma diagnosis.
For Children (Aged 5 to 16):
A FeNO level of 35 ppb or more indicates eosinophilic airway inflammation, supporting asthma diagnosis.
Integration with Other Diagnostic Tools:
FeNO testing should be used alongside spirometry and bronchodilator reversibility (BDR) testing to confirm or rule out asthma.
Monitoring and Management:
FeNO variability can help guide treatment adjustments, particularly in determining the effectiveness of inhaled corticosteroids (ICS).
Explore the NICE Guideline NG244 NG245 DocumentFeNO variability can help guide treatment adjustments, particularly in determining the effectiveness of inhaled corticosteroids (ICS).
QOF
The Quality and Outcomes Framework (QOF) now incorporates FeNO testing as an essential part of asthma care. This reflects NICE NG245’s emphasis on objective testing to improve diagnostic accuracy and treatment efficacy.
Key QOF Indicators Include:
Using FeNO tests to confirm asthma in children and adults with suspected airway inflammation.
Combining FeNO results with spirometry and clinical assessments for a holistic approach to asthma diagnosis.
Monitoring FeNO variability to assess response to treatment and guide changes in therapy.
These indicators aim to reduce misdiagnoses, enhance personalised care, and promote evidence-based practices across healthcare systems.
Why the change?
Asthma is a complex condition with symptoms that overlap with other respiratory diseases, such as chronic obstructive pulmonary disease (COPD) and chronic cough. Traditional diagnostic methods often rely on subjective assessments or spirometry alone, leading to potential misdiagnoses or delayed treatment. The updated NICE NG245 guidance addresses these challenges by prioritising FeNO testing.
Key Reasons for the Change:
Improved Diagnostic Precision:
FeNO testing directly measures eosinophilic inflammation, a hallmark of asthma.
By providing clear FeNO levels, it aids in distinguishing asthma from non-asthmatic conditions.
Enhanced Treatment Decisions:
FeNO and inhaled corticosteroids: FeNO results help determine whether patients need ICS treatment and monitor their effectiveness over time.
High FeNO levels indicate uncontrolled inflammation, necessitating a review of therapy.
Optimised Outcomes:
FeNO testing ensures patients receive appropriate treatment, reducing the risks of exacerbations and improving quality of life.
By including FeNO for asthma diagnosis, the NICE guideline offers a pathway for timely, accurate care.
Asthma is a disease that is often challenging to assess as there is no single objective test available to confirm a diagnosis, and as a whole lacks a gold standard.2 Historically, a diagnosis of asthma has been principally based on thorough history taken by an experienced clinician. Multiple studies suggest that up to 30% of adults diagnosed2 with the condition do not have clear evidence of asthma. Some studies have even found that asthma may have been underdiagnosed.
Published evidence in patients with severe asthma suggests that at least 30% of patients are partially or non-adherent with their prescribed medications. Poor adherence was associated with 38% of asthma deaths.3
The introduction of FeNO testing will aid clinicians to make better clinical decisions for patients with suspected asthma.
Across the UK
5.4
million people
are currently receiving treatment for asthma. That’s 1 in every 11 people!4
It costs the NHS
£1b
per year
to treat and care for people with asthma4
Studies suggest
30%
of adults
diagnosed with the condition do not have clear evidence of asthma2
Diagnostic algorithms
The NICE NG245 guidance provides a detailed diagnostic algorithm to ensure accurate and consistent asthma diagnosis. This algorithm integrates FeNO testing with other clinical and objective measures to confirm or rule out asthma.
NICE Diagnostic Algorithm for Asthma:
Initial Clinical Assessment:
Document symptoms, including wheezing, breathlessness, chest tightness, and cough.
Identify potential triggers, such as allergens, exercise, or occupational exposures.
Objective Testing:
FeNO Testing:
Adults: A FeNO level of 50 ppb or more indicates eosinophilic inflammation.
Children (5–16 years): A FeNO level of 35 ppb or more suggests eosinophilic asthma.
FeNO levels below these thresholds do not exclude asthma but warrant further testing.
Spirometry:
Measures airflow obstruction. A reduced FEV1/FVC ratio supports an asthma diagnosis.
Bronchodilator Reversibility (BDR):
Assesses reversibility of airway obstruction after bronchodilator use.
Integrated Diagnosis:
Combine FeNO results with spirometry, BDR findings, and clinical history to confirm or rule out asthma.
Reassess with FeNO and spirometry if results are inconclusive.
Reassess and Monitor:
Use FeNO variability to guide treatment adjustments and evaluate long-term control.
FeNO in Asthma Management
FeNO testing is a cornerstone of modern asthma management, offering actionable insights into airway inflammation and guiding personalised treatment strategies.
Applications in Asthma Management:
Guiding ICS Therapy:
High FeNO levels suggest a need for increased corticosteroid doses, while low levels may indicate successful inflammation control.
Monitoring Disease Progression:
Regular FeNO testing ensures inflammation levels are managed effectively, reducing exacerbations.
Monitoring Disease Progression:
Regular FeNO testing ensures inflammation levels are managed effectively, reducing exacerbations.
FeNO in Occupational Asthma:
Identifies inflammation caused by workplace exposures and guides mitigation strategies.
FeNO Variability:
Tracks changes in airway inflammation over time, enabling proactive adjustments to treatment plans.
By integrating FeNO for asthma monitoring, healthcare providers can ensure optimal patient outcomes.
Download NICE guidelines
Access the full NICE NG245 guideline Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) to stay informed about best practices in asthma diagnosis and management. This comprehensive document provides detailed recommendations for integrating FeNO testing into clinical workflows..
NICE guidelinesNObreath® FeNO testing monitor
The NObreath® FeNO testing device, developed by Bedfont, is a state-of-the-art device fully compliant with NICE NG245 recommendations.
This innovative, yet widely used in primary care tool, provides accurate, non-invasive FeNO measurements, making it a valuable resource for clinicians diagnosing and managing asthma.
This innovative, yet widely used in primary care tool, provides accurate, non-invasive FeNO measurements, making it a valuable resource for clinicians diagnosing and managing asthma.
Why Choose NObreath®?
High Precision:
Delivers accurate FeNO measurements to identify eosinophilic inflammation, supporting asthma diagnosis and treatment decisions. Evaluated against Chemiluminescence Method, the gold standard for FeNO measurement. (reference chemiluminescence evaluation Doc)
User-Friendly Design:
Compact, portable, and easy to use, suitable for GP surgeries, CDC’s, diagnostic hubs, asthma clinics and busy acute settings.
Cost-Effective:
Reduces unnecessary treatments and improves long-term outcomes, aligning with QOF requirements.
Flexible capital cost with low entry yearly rental option available for £695 including servicing costs.
Flexible capital cost with low entry yearly rental option available for £695 including servicing costs.
Dedicated Primary care equipment offers to allow easier financial access to the testing device.
Lower cost of consumables when compared to other FeNO testing system.
5 Years Warranty on monitor and sensor.
Real-Time Results:
Provides immediate FeNO levels, enabling quick clinical decision-making.
Learn More about NObreath® FeNO testing deviceEnhanced Monitoring:
Tracks FeNO variability to assess the effectiveness of treatments like ICS.
Unique Features of the NObreath® FeNO monitor:
Fully compliant with FeNO guidelines for asthma care.
Supports personalised treatment plans by measuring FeNO levels in asthma, FeNO in allergic asthma, and FeNO in occupational asthma.
References
We have used facts and figures from NICE and other reputable sources to compile the content on this web page about the NICE guidelines. These are referenced in the bibliography below.
NICE BTS SIGN Guideline NG245: Asthma: diagnosis, monitoring, and chronic asthma management https://www.nice.org.uk/guidance/ng245/resources/asthma-diagnosis-monitoring-and-chronic-asthma-management-bts-nice-sign-pdf-66143958279109
NICE QOF Indicators: Objective testing in asthma https://www.nice.org.uk/indicators/ind272-asthma-objective-tests/chapter/indicator
NICE Asthma guidance resources https://www.nice.org.uk/guidance/ng245/resources
Bedfont® NObreath® FeNO FeNo testing device: NObreath product details, user manual and technical specifications https://resources.bedfont.com/nobreath-resources/
Chemiluminescence validation study 2011 – Kapande et al. – Comparative Repeatability of Two Handheld Fractional Exhaled Nitric Oxide Monitors