Balancing the needs of the many and the few: where next for adult asthma guidelines?

Asthma differs from many other chronic conditions in that most key management decisions are made in non-specialist settings, such as general practitioner surgeries and accident and emergency departments. Diagnosis in primary care relies on recognition of a characteristic pattern of symptoms and the occurrence of asthma attacks, sometimes supplemented by basic lung function tests. Ongoing management is guided by the assessment of symptoms and simple lung function measures of airflow obstruction, with little attempt made to personalise management. This approach is flawed because the inadequate specificity of symptoms, as well as the low sensitivity of variable airflow obstruction, means that a diagnosis of asthma is often difficult to exclude with confidence. Moreover, even if diagnosed correctly, dissociation between inflammation, airflow obstruction, and symptoms means that a generalised stepwise approach to managing asthma on the basis of symptoms is unlikely to be successful in a substantial proportion of patients. As a result, effective treatments are used inefficiently, and outcomes are often worse than they could be. Rather than use of either a population-based or personalised approach for the diagnosis and management of asthma, we recommend a new combined approach, in which treatment decisions are driven by objective assessment of key treatable mechanistic traits. Asthma affects 300 million people worldwide and is principally diagnosed and managed in primary care. Globally, asthma is a factor in 250 000 deaths annually, and costs billions of pounds in health-care expenditure.1 The UK has among the highest asthma mortality rates of high-income countries in younger age groups (aged 5-34 years), the highest asthma admission rates in Europe, and the highest rates of asthma symptoms globally in children.2,3 Despite major advancements in asthma management and therapies, and the introduction of care pathways, hospital admission rates continue to be higher than expected, and tragically preventable deaths from asthma still occur in young people.4 A 2018 Lancet Commission4 on asthma argues that this stalling of progress reflects our continued reliance on outdated concepts of disease and a population-based, generalised approach to managing a highly heterogeneous condition on the basis of symptoms. The Commission suggests that advances in our understanding

Automated summary

Asthma management is predominantly done in non-specialist settings, with traditional approaches based on population-based generalizations often proving ineffective. A new combined approach, focusing on treatable mechanistic traits, is recommended to improve outcomes.