Asthma
A clinical reference for UK primary care
Last reviewed 4 May 2026 · Next review August 2026
Around 5.4 million people in the UK live with asthma. The annual asthma death toll has risen by nearly a quarter since the 2014 National Review of Asthma Deaths (NRAD), with an average of around 1,500 deaths each year in recent data and four deaths per day.1
In November 2024, NICE, BTS and SIGN published the first joint asthma guideline. NG244 is the pathway document; NG245 contains the full diagnostic and management recommendations. The most significant change for primary care is the diagnostic pathway in adults: blood eosinophil count or fractional exhaled nitric oxide (FeNO) is now first-line, with spirometry second-line.2,3
NRAD identified key risk factors for asthma death that remain central to risk-stratified care: overuse of short-acting beta-2 agonist (SABA) inhalers, underuse of inhaled corticosteroids (ICS), and inadequate follow-up after emergency presentations.1,3
Recent in asthma
Objective tests for diagnosing asthma
Per NG245, eosinophils or fractional exhaled nitric oxide (FeNO) are first-line, with spirometry second-line. Recommendations differ for adults and children aged 5 to 16.3
Adults: first-line
Eosinophils above lab reference range, or FeNO u226550 ppb
NG245 recommendation 1.2.1. Measure blood eosinophil count or FeNO level in adults with a history suggestive of asthma.3
Adults: second-line if not confirmed
BDR: FEV1 increase u226512% AND u2265200 ml
NG245 recommendation 1.2.2. Bronchodilator reversibility (BDR) with spirometry, post-bronchodilator vs pre-bronchodilator value.3
Children 5 to 16: first-line
FeNO u226535 ppb
NG245 recommendation 1.2.5. Measure FeNO level in children with a history suggestive of asthma.3
Children 5 to 16: second-line
BDR: FEV1 increase u226512%
NG245 recommendation 1.2.6. If FeNO is not raised or unavailable, measure bronchodilator reversibility with spirometry.3
If spirometry unavailable or delayed
Peak expiratory flow (PEF) twice daily for 2 weeks
NG245 recommendations 1.2.3 and 1.2.7. PEF variability supports diagnosis if spirometry is not accessible.3
Children under 5
Clinical judgement
NG245 section 1.3. Objective tests are not reliable in this age group; diagnosis is based on clinical features.3
If asthma is suspected but not confirmed
Per NG245 recommendations 1.2.4 and 1.2.8: if asthma is not confirmed by initial tests but still suspected on clinical grounds, refer for specialist tests. In children, also measure total IgE and blood eosinophil count.3
Risk factors for poor asthma outcomes
SABA over-use
More than 2 inhalers per year
NG245 lists over-use of short-acting beta-2 agonist inhalers (more than 2 per year) as a risk factor for poor outcomes. NRAD identified SABA over-use as a key indicator of poorly controlled asthma.1,3
Oral corticosteroid use
u22652 courses per year
NG245 identifies needing 2 or more courses of oral corticosteroids per year as a risk factor for poor outcomes.3
Emergency presentations
u22652 ED visits or any admission
NG245 lists 2 or more visits to an emergency department, or any hospital admission for asthma, as a risk factor for poor outcomes.3
Monitoring asthma control
Per NG245 recommendation 1.5.1, check the following at every review.3
Symptoms
Ask about current asthma symptoms
Time off work or school
Due to asthma
Reliever use
Including check of prescription record
Oral corticosteroid courses
Number in past year
Hospital or ED attendance
Any admissions or emergency visits
Validated questionnaire
Consider ACQ, ACT, or Childhood ACT
Referral pathways
Per NG245 recommendation 1.7.5: refer adults with asthma not controlled on moderate-dose MART if FeNO or eosinophils are raised. Per 1.7.6: refer if not controlled on moderate-dose MART despite trials of an LTRA and a LAMA.3
Per NG245 section 1.4 and the BTS/SIGN guidance: refer for specialist assessment if occupational exposure is suspected.3
Per NG245 recommendations 1.2.4 and 1.2.8: refer for specialist tests if asthma is not confirmed by initial objective testing but still clinically suspected.3
Same-day emergency assessment for features of acute severe or life-threatening asthma, per the BTS/SIGN management of acute asthma section retained in NG244.2
Per NG245 section 1.12: women with asthma who are pregnant or planning pregnancy should be managed in line with the specific pregnancy and breastfeeding recommendations.3
Find all NICE updates relevant to primary care
View NICE GuidelinesThis reference point is intended for UK Healthcare Professionals only. Content reports established clinical knowledge and current NICE guidance. It is not a substitute for clinical judgement or for the original guidelines. Last reviewed 4 May 2026.
References
All sources verified at last review. Where primary literature is cited, original peer-reviewed publications are linked.
- 1.Asthma + Lung UK. Asthma care is in crisis - charity sounds the siren as asthma death toll rises. Press release, 24 April 2024.
- 2.National Institute for Health and Care Excellence. Asthma pathway (BTS, NICE, SIGN). NICE guideline NG244. Published 27 November 2024.
- 3.National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN). NICE guideline NG245. Published 27 November 2024.