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Guidelines in asthma
Respiratory
Medicine
(1996) 90, 375-378
Editorial
Guidelines in asthma In 1989 and 1990, four sets of guidelines for managing asthma were published (l-4). The first, produced by a group of respiratory specialists from Australia and New Zealand (1) gave advice on the management of chronic asthma. In the same year, an international group of respiratory paediatricians published advice on the management of asthma in children (2). In the following year, the first British Guidelines were published in the British Medical Journal as two papers on the management of chronic persistent asthma (3) and of acute severe asthma (4) in adults. These were supported by five fullyreferenced background papers published in Respiratory Medicine (5-9). Also in 1990, a Canadian group supported by respiratory specialists from Australia and Britain published fully-referenced guidelines on managing both acute and chronic asthma in adults and children (10). Since 1990, asthma guidelines have been published in many other countries, including an international consensus report on the diagnosis and management of asthma (11). Only two of these sets of guidelines have been revised, namely the International Paediatric Guidelines (12) and the British Guidelines (13) (twice). This editorial will briefly review the processes involved in producing the British Guidelines, and their use in the management of asthma and in auditing the management of asthma in Britain, and will look ahead to how further revisions might be developed in the future. The processes involved in producing the first British Guidelines in 1990, the first revision in 1992-93 and the second revision in 1995-96 were similar and have been described fully (14). Briefly, a number of chest physicians (including academic, teaching hospital and district general hospital consultants), general physicians, general practitioners and, in 1992 and 1995, paediatricians were invited to participate. As well as being intended to encompass the range from academic to district general hospital practice, chest physicians were chosen to reflect the geographical and age ranges of respiratory medical practitioners in Great Britain. In 1992 and 1995, participants represented nine British societies, colleges, associations and groups involved in asthma care. Colleagues, selected because of their particular 0954-611 l/96/070375+04
$12.0010
expertise, were asked to prepare draft, succinct statements on topics to be included in the Guidelines, together with more extensive, fully-referenced background papers (5-9) designed to support those inevitably didactic statements. The statement and background papers were reviewed by all participants and, where appropriate, suggested changes were made in the draft statements which were than incorporated into draft Guidelines. These were discussed in small groups and in a plenary session of all participants during a 2-day meeting at which the final draft Guidelines were agreed. In 1990, this final draft was circulated to all members of the British Thoracic Society (BTS) with a questionnaire, and then presented to a meeting of over 300 members of the BTS at the annual summer meeting. The questionnaire responses from 357 chest physicians indicated that over 80% thought the Guidelines were appropriate, acceptable and achievable. Final modifications were made and the Guidelines were submitted for publication in the British Medical Journal (3,4). There were four reasons for reviewing the British Guidelines in 1992. The first two reasons concerned P-agonists. Controversy regarding the safety of regular B-agonist therapy was raised by the publication of two papers (15,16) later in 1990 and in 1991, and there was concern over the role of long-acting inhaled P-agonists which became available after the publication of the 1990 Guidelines. The other two reasons arose from criticisms which had been levelled at the 1990 Guidelines. First, they did not include the management of asthma in children [deliberately excluded because of the recent publication of the International Guidelines (2)], and secondly, they were too long and, although published in a widely read general medical journal (3,4), were not particularly user-friendly. The revised Guidelines (13) included advice on the management of asthma in children, and also six single-page charts which summarized the advice for adults and children and which were designed for use in the general practice or hospital outpatient consultation setting, the medical admission unit or medical wards of an acute hospital, and the accident and emergency department. No background papers were published to accompany 0 1996 W. B. Saunders
Company
Ltd
376
Editorial
the 1993 Guidelines, but areas of uncertainty or controversy were highlighted. In 1995, a second revision of the British Guidelines was undertaken using identical processes, but this time it was felt that there was insufficient new data to justify a full revision, though enough to warrant a paper which would act as a commentary on the 1993 Guidelines. This paper has been submitted for publication and eight of the background papers are to be published in this issue and the next issue of Respiratory Medicine (17-24). The British Guidelines have always been based on evidence coupled, where there was no evidence, with agreed current practice. The evidence was collated by experts in each field and presented in the form of ‘state-of-the-art’ papers (5-9). These were reviewed critically by the .peers who participated in the Guidelines’ process, some of whom were equally renowned experts in the several fields included. This process is more akin to state-of-the-art review than that favoured by some guidelines’ authorities (25,26), where recommendations are graded according to the type of published evidence used, namely: Grade A, Guidelines based on well-designed randomized controlled trials or meta-analysis; Grade B, Evidence based on well-designed cohort or case controlled studies; and Grade C, Recommendations based on uncontrolled studies or consensus. Interestingly, the results of guidelines produced in these different ways are very similar. We need more information on the relative costs and effectiveness of guidelines produced by these approaches before we can judge which is preferable for a particular condition. How effective have the British Guidelines been? The answer to this in terms of outcome of asthma remains unknown, although guidelines in other conditions have been effective (27). We do know that over 75% of general practitioners (GPs) covering a population of half a million people have read the Guidelines and found them useful (28). In a national survey of 206 GPs, 78% were quite or very familiar with the 1993 Guidelines and 70% had changed how they manage asthma as a result of those Guidelines (29). One of the initial aims of the British Guidelines, which has been amply achieved, was that they should be usable as a standard for auditing the processes and outcomes of asthma care. Since 1990 there have been many papers presented at the annual meetings of the British Thoracic Society auditing asthma care in Britain, and indeed overseas, using the British Guidelines, including two national studies of
inpatient care of asthma (30,31) and an ongoing confidential enquiry into asthma deaths in six regions of Britain. Many groups have produced local guidelines for general or hospital practice or both, or local protocols based on the National Guidelines. There is a widespread view amongst GPs and hospital doctors that the Asthma Guidelines have improved the management of asthma in Britain. Whilst asthma prevalence is rising (32), asthma deaths are falling (33) and it is possible that the Guidelines have contributed to this improvement in mortality. Barnes, in his paper on inhaled glucocorticoids (17) discusses the roles of fluticasone propionate and nebulized budesonide in the management of chronic asthma. He also recommends earlier treatment with inhaled steroids, and starting treatment with higher doses of inhaled steroids followed by dose reduction when asthma control is achieved, rather than increasing the dose progressively until control is achieved. In other words, treatment should be started with a dose of inhaled steroid likely to bring the asthma under control rapidly. Neville, in his paper on patient education and guided self-management plans (18) emphasizes that education by itself, whilst increasing patients’ knowledge, does not improve morbidity due to asthma. Written self-management plans based on recommending changes of treatment as symptoms and peak flows increase or decrease, do work and are to be commended. Holgate reviews the evidence for the efficacy and positioning of inhaled sodium cromoglycate (19) and inhaled nedocromil sodium (20). The recommendations for their use in the 1996 Guidelines remain identical to those recommended in 1993. In his paper on allergen avoidance measures (21), Durham concludes that the patients likely to benefit from these can be recognized from the clinical history and simple skin prick test, and that proven methods exist for avoidance of house dust mite with bedding barrier materials, regular hot washing of bed clothes (60”(Z), removal of bedroom carpets, and regular dusting and vacuuming with an efficient cleaner. Patients with pet sensitivities should be advised regarding the removal of the pet, non-replacement of the pet when it dies, or exclusion of the pet from the bedroom and, ideally, from indoors. Occupational causes of asthma should always be sought in adults, and active and passive smoking should always be discouraged. Bucknall considers definitions of asthma severity and outcome measures in her review (22). Severity scores based on symptom control, physiological
Editorial
measurements expressed as a percentage of best function and treatment (current BTS step) are being evaluated. Outcome for ambulatory care could use the same measures, and, to date, the most widely accepted is the physiological outcome measure of percentage of best function of either peak flow or FEV,, which corrects for the degree of irreversible airflow obstruction and is independent of treatment step. For inpatient outcomes, re-admission rates show promise, but they also relate to the quality of discharge planning as well as the severity of asthma. As a result of national audits of inpatient asthma care, using the earlier BTS Guidelines as standards, Pearson et al. (31) have suggested eight process measures which deserve further study. In their paper on psychosocial factors in asthma (23), Bosley et al. address an area of considerable importance to which many pay lip service, but in which there is a dearth of high-quality research. Studies in the northern and southern hemispheres have shown that the majority of patients dying from
asthma, and the majority of those suffering near-fatal attacks of asthma, suffer from or experience major psychological
or social
adversity.
Similar
factors
occur in the lives of many patients with brittle asthma (34) and those exhibiting poor compliance with their therapy. In addition to material poverty, denial, depression, anxiety and other psychiatric illness have been highlighted as very important factors. Life crises, family conflict, increased social isolation,
shame, anger, smoking, alcohol or drug abuse are also probably important. More studies in these important
fields are required
urgently.
In the paper on recommendations for peak flow monitoring
in children
(24), Clough
highlights
the
pitfalls and precautions necessary to ensure that readings are meaningful and useful, points equally applicable to peak flow monitoring in adults. In particular, she emphasizes that manufacturers should take steps to adjust for non-linearity by adjustment of scale, and that manufacturers and regulatory
bodies should agree upon the standards for accuracy, comparability and repeatability of different meters. In summary, representatives from all groups of doctors involved in the care of patients with asthma have been involved in developing the British Guidelines. The Guidelines are extremely practical, and indeed practicable, and they have not been handed
down from ‘on high’ by a small group of ‘experts’. They are based on published evidence, where this is available, which the-art’ reviews which have led but more work
is presented in the form of ‘state-of(5%9,17-24). These are the factors to their wide acceptance and use, is needed to determine the optimal
377
methods of dissemination of asthma guidelines and to determine their effects on outcomes. B. D. W. HARRISON Department of Respiratory Medicine Norfolk and Norwich Hospital Norwich, U.K.
References 1. Woolcock A, Rubinfeld AR, Seale JP et al. Asthma management plan 1989. Med J Austral 1989; 151: 65&652. 2. Warner JO, Gotz M, Landau LL et al. Management of asthma: a consensus statement. Arch Dis Child 1989; 64: 1065-1079. 3. Statement by the British Thoracic Society, Research Unit of the Royal College of Physicians of London, King’s Fund Centre, National Asthma Campaign. Guidelines for management of asthma in adults: I-chronic persistent asthma. BMJ 1990; 301: 651-653. 4. Statement by the British Thoracic Society, Research Unit of the Royal College of Physicians of London, King’s Fund Centre, National Asthma Campaign. Guidelines for management of asthma in adults: II-acute severe asthma. BMJ 1990; 301: 767-800. 5. Barnes PJ. Preventative therapy in adults with asthma. RestGr Med 1991: 85: 355-3.57. 6. Lane DJ. Chronic persistent asthma: nebulizers and therapy additional to inhaled P-agonists and steroids. Respir Med 1991; 85: 359-363. I. Bucknall CE. Who needs referral to the hospital asthma specialist? Respir Med 1991; 85: 453455. 8. Brewis RAL. Patient education, self-management plans and peak flow measurement. Respir Med 1991; 85: 457462. 9. Neville E, Gribbin H, Harrison BDW. Acute severe asthma. Respir Med 1991; 85: 463-474. 10. Hargreaves FE, Dolovich J, Newhouse MT. The assessment and treatment of asthma: a conference report. J Allergy Clin Zmmunol 1990; 85: 1098-l 111. 11. International Consensus Report on the diagnosis and management of asthma. Clin Exp Allergy 1992; 22 (suppl): l-72. 12. International Paediatric Asthma Consensus Group. Asthma, a follow-up statement. Arch Dis Child 1992; 67: 240-248. 13. Statement by the British Thoracic Society and others. Guidelines on the management of asthma. Thorax 1993; 48: Sl-24, BMJ 1993; 306: 776-782. 14. Harrison BDW. Guidelines on the management of asthma in adults. Horizons in Medicine, No. 6. Royal College of Physicians of London: Blackwell Science, 1995. 15. Sears MR, Taylor DR, Pruit CG ef al. Regular inhaled beta-agonist treatment in bronchial asthma. Lancer 1990; 336: 1391-1396. 16. van Schayck CP, Dompeling E, Van Herwaarden CLA. Bronchodilator treatment in moderate asthma or chronic bronchitis: continuous or demand. A randomized control trial. BMJ 1991; 303: 142631. 17. Barnes PJ. Inhaled glucocorticoids: new developments relevant to updating of the Asthma Management Guidelines. Respir Med 1996; 90: 385-390.
378
Editorial
18. Neville R. Patient education and guided selfmanagement plans. Respir Med 1996; 90: 391-392. 19. Holgate ST. Inhaled sodium cromoglycate. Respir Med 1996; 90: 393-396. 20. Holgate ST. The efficacy and therapeutic position of nedocromil sodium. Respir Med 1996; 90: 397400. 2 1. Durham SR. Allergen avoidance measures. Respir Med 1996; 90: (in press). 22. Bucknall CE. Definitions of severity and outcome measures. Respir Med 1996; 90: (in press). 23. Bosley CM, Corden ZM, Cochrane GM. Psychosocial factors and asthma. Respir Med 1996; 90: (in press). 24. Clough JB. Recommendations for peak flow monitoring in children. Respir Med 1996; 90: (in press). 25. Canadian Task Force. Can Med Assoc 1979; 121: 1193-1254. 26. Scottish Intercollegiate Guidelines Network (SIGN) Clinical Guidelines Criteria for Appraisal for National Use, September 1995. 27. Grimshaw J, Freemantle N, Wallace S et al. Developing and implementing clinical practice guidelines. Qua1 Health Care 1995; 4: 55-64. 28. Harrison BDW, Nichols JM. Results of two surveys in Norfolk of the use of guidelines on asthma management, Thorax 1995; 50 (Suppl. 2): ASl.
29. 30.
31.
32.
33. 34.
McGovern V, Crockett A. Survey of GP’s attitudes towards BTS Guidelines 1996; submitted. Pearson MG, Ryland I, Harrison BDW, on behalf of the British Thoracic Society’s Standards of Care Committee. National audit of acute severe asthma in adults admitted to hospital. Qua1 Health Care 1995; 4: 24-30. Pearson MG, Ryland I, Harrison BDW, on behalf of the British Thoracic Society’s Standards of Care Committee. Comparison of the process of care of acute severe asthma in adults admitted to hospital before and 1 yr after the publication of National Guidelines. Respir Med 1996; (in press). Jarvis D, Lai E, Luczynska C, Chinn S, Burney P. Prevalence of asthma and asthma-like symptoms in young adults living in three East Anglian towns. BJ Gen Pratt 1994; 44: 493497. Lung and Asthma Information Agency. Trends Asthma Mort, Factsheet 92/l. Garden GMF, Ayres JG. Psychiatric and social aspects of brittle asthma. Thorax 1993; 48: 501-505.
Medicine
(1996) 90, 375-378
Editorial
Guidelines in asthma In 1989 and 1990, four sets of guidelines for managing asthma were published (l-4). The first, produced by a group of respiratory specialists from Australia and New Zealand (1) gave advice on the management of chronic asthma. In the same year, an international group of respiratory paediatricians published advice on the management of asthma in children (2). In the following year, the first British Guidelines were published in the British Medical Journal as two papers on the management of chronic persistent asthma (3) and of acute severe asthma (4) in adults. These were supported by five fullyreferenced background papers published in Respiratory Medicine (5-9). Also in 1990, a Canadian group supported by respiratory specialists from Australia and Britain published fully-referenced guidelines on managing both acute and chronic asthma in adults and children (10). Since 1990, asthma guidelines have been published in many other countries, including an international consensus report on the diagnosis and management of asthma (11). Only two of these sets of guidelines have been revised, namely the International Paediatric Guidelines (12) and the British Guidelines (13) (twice). This editorial will briefly review the processes involved in producing the British Guidelines, and their use in the management of asthma and in auditing the management of asthma in Britain, and will look ahead to how further revisions might be developed in the future. The processes involved in producing the first British Guidelines in 1990, the first revision in 1992-93 and the second revision in 1995-96 were similar and have been described fully (14). Briefly, a number of chest physicians (including academic, teaching hospital and district general hospital consultants), general physicians, general practitioners and, in 1992 and 1995, paediatricians were invited to participate. As well as being intended to encompass the range from academic to district general hospital practice, chest physicians were chosen to reflect the geographical and age ranges of respiratory medical practitioners in Great Britain. In 1992 and 1995, participants represented nine British societies, colleges, associations and groups involved in asthma care. Colleagues, selected because of their particular 0954-611 l/96/070375+04
$12.0010
expertise, were asked to prepare draft, succinct statements on topics to be included in the Guidelines, together with more extensive, fully-referenced background papers (5-9) designed to support those inevitably didactic statements. The statement and background papers were reviewed by all participants and, where appropriate, suggested changes were made in the draft statements which were than incorporated into draft Guidelines. These were discussed in small groups and in a plenary session of all participants during a 2-day meeting at which the final draft Guidelines were agreed. In 1990, this final draft was circulated to all members of the British Thoracic Society (BTS) with a questionnaire, and then presented to a meeting of over 300 members of the BTS at the annual summer meeting. The questionnaire responses from 357 chest physicians indicated that over 80% thought the Guidelines were appropriate, acceptable and achievable. Final modifications were made and the Guidelines were submitted for publication in the British Medical Journal (3,4). There were four reasons for reviewing the British Guidelines in 1992. The first two reasons concerned P-agonists. Controversy regarding the safety of regular B-agonist therapy was raised by the publication of two papers (15,16) later in 1990 and in 1991, and there was concern over the role of long-acting inhaled P-agonists which became available after the publication of the 1990 Guidelines. The other two reasons arose from criticisms which had been levelled at the 1990 Guidelines. First, they did not include the management of asthma in children [deliberately excluded because of the recent publication of the International Guidelines (2)], and secondly, they were too long and, although published in a widely read general medical journal (3,4), were not particularly user-friendly. The revised Guidelines (13) included advice on the management of asthma in children, and also six single-page charts which summarized the advice for adults and children and which were designed for use in the general practice or hospital outpatient consultation setting, the medical admission unit or medical wards of an acute hospital, and the accident and emergency department. No background papers were published to accompany 0 1996 W. B. Saunders
Company
Ltd
376
Editorial
the 1993 Guidelines, but areas of uncertainty or controversy were highlighted. In 1995, a second revision of the British Guidelines was undertaken using identical processes, but this time it was felt that there was insufficient new data to justify a full revision, though enough to warrant a paper which would act as a commentary on the 1993 Guidelines. This paper has been submitted for publication and eight of the background papers are to be published in this issue and the next issue of Respiratory Medicine (17-24). The British Guidelines have always been based on evidence coupled, where there was no evidence, with agreed current practice. The evidence was collated by experts in each field and presented in the form of ‘state-of-the-art’ papers (5-9). These were reviewed critically by the .peers who participated in the Guidelines’ process, some of whom were equally renowned experts in the several fields included. This process is more akin to state-of-the-art review than that favoured by some guidelines’ authorities (25,26), where recommendations are graded according to the type of published evidence used, namely: Grade A, Guidelines based on well-designed randomized controlled trials or meta-analysis; Grade B, Evidence based on well-designed cohort or case controlled studies; and Grade C, Recommendations based on uncontrolled studies or consensus. Interestingly, the results of guidelines produced in these different ways are very similar. We need more information on the relative costs and effectiveness of guidelines produced by these approaches before we can judge which is preferable for a particular condition. How effective have the British Guidelines been? The answer to this in terms of outcome of asthma remains unknown, although guidelines in other conditions have been effective (27). We do know that over 75% of general practitioners (GPs) covering a population of half a million people have read the Guidelines and found them useful (28). In a national survey of 206 GPs, 78% were quite or very familiar with the 1993 Guidelines and 70% had changed how they manage asthma as a result of those Guidelines (29). One of the initial aims of the British Guidelines, which has been amply achieved, was that they should be usable as a standard for auditing the processes and outcomes of asthma care. Since 1990 there have been many papers presented at the annual meetings of the British Thoracic Society auditing asthma care in Britain, and indeed overseas, using the British Guidelines, including two national studies of
inpatient care of asthma (30,31) and an ongoing confidential enquiry into asthma deaths in six regions of Britain. Many groups have produced local guidelines for general or hospital practice or both, or local protocols based on the National Guidelines. There is a widespread view amongst GPs and hospital doctors that the Asthma Guidelines have improved the management of asthma in Britain. Whilst asthma prevalence is rising (32), asthma deaths are falling (33) and it is possible that the Guidelines have contributed to this improvement in mortality. Barnes, in his paper on inhaled glucocorticoids (17) discusses the roles of fluticasone propionate and nebulized budesonide in the management of chronic asthma. He also recommends earlier treatment with inhaled steroids, and starting treatment with higher doses of inhaled steroids followed by dose reduction when asthma control is achieved, rather than increasing the dose progressively until control is achieved. In other words, treatment should be started with a dose of inhaled steroid likely to bring the asthma under control rapidly. Neville, in his paper on patient education and guided self-management plans (18) emphasizes that education by itself, whilst increasing patients’ knowledge, does not improve morbidity due to asthma. Written self-management plans based on recommending changes of treatment as symptoms and peak flows increase or decrease, do work and are to be commended. Holgate reviews the evidence for the efficacy and positioning of inhaled sodium cromoglycate (19) and inhaled nedocromil sodium (20). The recommendations for their use in the 1996 Guidelines remain identical to those recommended in 1993. In his paper on allergen avoidance measures (21), Durham concludes that the patients likely to benefit from these can be recognized from the clinical history and simple skin prick test, and that proven methods exist for avoidance of house dust mite with bedding barrier materials, regular hot washing of bed clothes (60”(Z), removal of bedroom carpets, and regular dusting and vacuuming with an efficient cleaner. Patients with pet sensitivities should be advised regarding the removal of the pet, non-replacement of the pet when it dies, or exclusion of the pet from the bedroom and, ideally, from indoors. Occupational causes of asthma should always be sought in adults, and active and passive smoking should always be discouraged. Bucknall considers definitions of asthma severity and outcome measures in her review (22). Severity scores based on symptom control, physiological
Editorial
measurements expressed as a percentage of best function and treatment (current BTS step) are being evaluated. Outcome for ambulatory care could use the same measures, and, to date, the most widely accepted is the physiological outcome measure of percentage of best function of either peak flow or FEV,, which corrects for the degree of irreversible airflow obstruction and is independent of treatment step. For inpatient outcomes, re-admission rates show promise, but they also relate to the quality of discharge planning as well as the severity of asthma. As a result of national audits of inpatient asthma care, using the earlier BTS Guidelines as standards, Pearson et al. (31) have suggested eight process measures which deserve further study. In their paper on psychosocial factors in asthma (23), Bosley et al. address an area of considerable importance to which many pay lip service, but in which there is a dearth of high-quality research. Studies in the northern and southern hemispheres have shown that the majority of patients dying from
asthma, and the majority of those suffering near-fatal attacks of asthma, suffer from or experience major psychological
or social
adversity.
Similar
factors
occur in the lives of many patients with brittle asthma (34) and those exhibiting poor compliance with their therapy. In addition to material poverty, denial, depression, anxiety and other psychiatric illness have been highlighted as very important factors. Life crises, family conflict, increased social isolation,
shame, anger, smoking, alcohol or drug abuse are also probably important. More studies in these important
fields are required
urgently.
In the paper on recommendations for peak flow monitoring
in children
(24), Clough
highlights
the
pitfalls and precautions necessary to ensure that readings are meaningful and useful, points equally applicable to peak flow monitoring in adults. In particular, she emphasizes that manufacturers should take steps to adjust for non-linearity by adjustment of scale, and that manufacturers and regulatory
bodies should agree upon the standards for accuracy, comparability and repeatability of different meters. In summary, representatives from all groups of doctors involved in the care of patients with asthma have been involved in developing the British Guidelines. The Guidelines are extremely practical, and indeed practicable, and they have not been handed
down from ‘on high’ by a small group of ‘experts’. They are based on published evidence, where this is available, which the-art’ reviews which have led but more work
is presented in the form of ‘state-of(5%9,17-24). These are the factors to their wide acceptance and use, is needed to determine the optimal
377
methods of dissemination of asthma guidelines and to determine their effects on outcomes. B. D. W. HARRISON Department of Respiratory Medicine Norfolk and Norwich Hospital Norwich, U.K.
References 1. Woolcock A, Rubinfeld AR, Seale JP et al. Asthma management plan 1989. Med J Austral 1989; 151: 65&652. 2. Warner JO, Gotz M, Landau LL et al. Management of asthma: a consensus statement. Arch Dis Child 1989; 64: 1065-1079. 3. Statement by the British Thoracic Society, Research Unit of the Royal College of Physicians of London, King’s Fund Centre, National Asthma Campaign. Guidelines for management of asthma in adults: I-chronic persistent asthma. BMJ 1990; 301: 651-653. 4. Statement by the British Thoracic Society, Research Unit of the Royal College of Physicians of London, King’s Fund Centre, National Asthma Campaign. Guidelines for management of asthma in adults: II-acute severe asthma. BMJ 1990; 301: 767-800. 5. Barnes PJ. Preventative therapy in adults with asthma. RestGr Med 1991: 85: 355-3.57. 6. Lane DJ. Chronic persistent asthma: nebulizers and therapy additional to inhaled P-agonists and steroids. Respir Med 1991; 85: 359-363. I. Bucknall CE. Who needs referral to the hospital asthma specialist? Respir Med 1991; 85: 453455. 8. Brewis RAL. Patient education, self-management plans and peak flow measurement. Respir Med 1991; 85: 457462. 9. Neville E, Gribbin H, Harrison BDW. Acute severe asthma. Respir Med 1991; 85: 463-474. 10. Hargreaves FE, Dolovich J, Newhouse MT. The assessment and treatment of asthma: a conference report. J Allergy Clin Zmmunol 1990; 85: 1098-l 111. 11. International Consensus Report on the diagnosis and management of asthma. Clin Exp Allergy 1992; 22 (suppl): l-72. 12. International Paediatric Asthma Consensus Group. Asthma, a follow-up statement. Arch Dis Child 1992; 67: 240-248. 13. Statement by the British Thoracic Society and others. Guidelines on the management of asthma. Thorax 1993; 48: Sl-24, BMJ 1993; 306: 776-782. 14. Harrison BDW. Guidelines on the management of asthma in adults. Horizons in Medicine, No. 6. Royal College of Physicians of London: Blackwell Science, 1995. 15. Sears MR, Taylor DR, Pruit CG ef al. Regular inhaled beta-agonist treatment in bronchial asthma. Lancer 1990; 336: 1391-1396. 16. van Schayck CP, Dompeling E, Van Herwaarden CLA. Bronchodilator treatment in moderate asthma or chronic bronchitis: continuous or demand. A randomized control trial. BMJ 1991; 303: 142631. 17. Barnes PJ. Inhaled glucocorticoids: new developments relevant to updating of the Asthma Management Guidelines. Respir Med 1996; 90: 385-390.
378
Editorial
18. Neville R. Patient education and guided selfmanagement plans. Respir Med 1996; 90: 391-392. 19. Holgate ST. Inhaled sodium cromoglycate. Respir Med 1996; 90: 393-396. 20. Holgate ST. The efficacy and therapeutic position of nedocromil sodium. Respir Med 1996; 90: 397400. 2 1. Durham SR. Allergen avoidance measures. Respir Med 1996; 90: (in press). 22. Bucknall CE. Definitions of severity and outcome measures. Respir Med 1996; 90: (in press). 23. Bosley CM, Corden ZM, Cochrane GM. Psychosocial factors and asthma. Respir Med 1996; 90: (in press). 24. Clough JB. Recommendations for peak flow monitoring in children. Respir Med 1996; 90: (in press). 25. Canadian Task Force. Can Med Assoc 1979; 121: 1193-1254. 26. Scottish Intercollegiate Guidelines Network (SIGN) Clinical Guidelines Criteria for Appraisal for National Use, September 1995. 27. Grimshaw J, Freemantle N, Wallace S et al. Developing and implementing clinical practice guidelines. Qua1 Health Care 1995; 4: 55-64. 28. Harrison BDW, Nichols JM. Results of two surveys in Norfolk of the use of guidelines on asthma management, Thorax 1995; 50 (Suppl. 2): ASl.
29. 30.
31.
32.
33. 34.
McGovern V, Crockett A. Survey of GP’s attitudes towards BTS Guidelines 1996; submitted. Pearson MG, Ryland I, Harrison BDW, on behalf of the British Thoracic Society’s Standards of Care Committee. National audit of acute severe asthma in adults admitted to hospital. Qua1 Health Care 1995; 4: 24-30. Pearson MG, Ryland I, Harrison BDW, on behalf of the British Thoracic Society’s Standards of Care Committee. Comparison of the process of care of acute severe asthma in adults admitted to hospital before and 1 yr after the publication of National Guidelines. Respir Med 1996; (in press). Jarvis D, Lai E, Luczynska C, Chinn S, Burney P. Prevalence of asthma and asthma-like symptoms in young adults living in three East Anglian towns. BJ Gen Pratt 1994; 44: 493497. Lung and Asthma Information Agency. Trends Asthma Mort, Factsheet 92/l. Garden GMF, Ayres JG. Psychiatric and social aspects of brittle asthma. Thorax 1993; 48: 501-505.