Updated Guidelines 2026: first biologics for COPD

NICE now recommends dupilumab (TA1142, March 2026) and mepolizumab (TA1166, June 2026) as specialist add-on treatments for adults with uncontrolled COPD (1 or more severe, or 2 or more moderate, exacerbations in the previous 12 months) and raised blood eosinophils (0.3 × 10⁹/L or more) despite triple inhaled therapy (dupilumab also on LAMA + LABA if an ICS is not appropriate). NICE NG115 has been updated to signpost them. What this means for you: check the eosinophil count and exacerbation history in your frequent exacerbators on optimised inhalers, and refer to respiratory if they meet the criteria — these are not GP-initiated drugs.

Respiratory Medicine for GPs: Your Essential Guide

Crackles, wheezes and whistles — no, it's not a jazz band, it's your 10 o'clock clinic

☕ Tea-Friendly Learning ⏰ For GP Trainees Short on Time 🚩 Red Flag Focused

Last Updated: 19 September 2026

Executive Summary: What You'll Master Today

Because you have 47 other things to do before lunch, and that's just the morning list

Quick Facts at a Glance:

1,400+

UK asthma deaths in 2018

23%

of primary-care chest X-rays negative in the year before a lung cancer diagnosis

SABA inhalers a year flags high-risk asthma

130,000

emergency COPD admissions a year in England

Sources: ONS figure quoted in BTS/NICE/SIGN NG245 (2024); Macmillan rapid referral guide for lung cancer; NG245 rec 1.15.1; NICE TA1142 committee figures (reported by Medscape, Jan 2026).

📥 Downloads

path: RESPIRATORY

🌐 Web Resources

NICE CKS – Asthma
Practical primary-care summary of diagnosis, management and prescribing.
NICE CKS – COPD
Stable COPD, exacerbations and when to refer.
NICE NG245 – Asthma (BTS/NICE/SIGN, 2024)
The joint guideline behind FeNO-first diagnosis and AIR/MART.
NICE NG115 – COPD in over 16s
Diagnosis, inhaled therapy pathway, exacerbations and biologics signposting.
NICE NG114 – COPD exacerbation antibiotics
Antibiotic choice, dose and course length.
NICE NG250 – Pneumonia (2025)
CRB65, place of care, antibiotic tables for adults and children.
NICE NG12 – Suspected cancer
Lung cancer and mesothelioma referral and chest X-ray criteria.
NICE NG158 – Venous thromboembolism
Wells score, PERC and interim anticoagulation for suspected PE.
NICE TA1142 – Dupilumab for COPD
Eligibility criteria for the first COPD biologic.
British Thoracic Society – Asthma pathway
Joint BTS/NICE/SIGN pathway including acute asthma.
Asthma + Lung UK – Professionals
Primary-care guides and patient leaflets you can hand out.
RCGP
Curriculum and learning resources for GP trainees.

📚 Quick Navigation

💡

No ICS, no SABA — at any age — NG245 says never prescribe a salbutamol-type reliever to someone with asthma without an inhaled steroid alongside it. Try: "The blue inhaler opens the airways, but it doesn't touch the swelling underneath — it's like bailing water out of a boat without fixing the leak."

🎯

One inhaler, two jobs — AIR and MART use a single steroid + formoterol inhaler as the reliever. Say it simply: "This is now your only inhaler. Whenever you'd have reached for the blue one, use this one instead." Then check they've actually stopped the old blue one.

⚠️

A normal chest X-ray is not a free pass — X-rays miss some lung cancers. Safety-net clearly and re-review anyone whose cough, weight loss or breathlessness keeps going: "Your X-ray looks reassuring today, but if the cough is still there in a few weeks, I want to see you again."

💊

"30 for the smokers' lungs, 40–50 for the wheezy ones" — COPD exacerbation: prednisolone 30 mg daily for 5 days (NG115). Acute asthma in adults: prednisolone 40–50 mg daily for at least 5 days (BTS/SIGN, in the BTS/NICE/SIGN asthma pathway).

🩺

Oximeters can flatter — NICE NG250 warns that pulse oximeters may be inaccurate in people with pigmented (darker) skin. If the SpO₂ looks fine but the patient doesn't, trust the patient.

🔑

Ask the holiday question — In adult-onset or worsening asthma, NG245 asks you to check for work triggers: "Is your breathing better, worse or the same on days off and on holiday?" If the answer is "better", think occupational asthma and refer to an occupational asthma specialist.

🏥

Set pneumonia expectations early — NG250's recovery timeline stops the day-5 "it's not working" call: fever settles by about 1 week, cough and breathlessness substantially better by 6 weeks, fatigue may linger to 3 months, back to normal by about 6 months.

🚩 Red Flags — Do Not Miss

🚩

Silent chest, cyanosis, exhaustion, confusion or SpO₂ below 92% in asthma — life-threatening attack: call 999, give oxygen and bronchodilators while you wait.

🚩

Sudden breathlessness or pleuritic pain with tachycardia or a swollen leg — suspected PE: same-day assessment using the Wells score.

🚩

Aged 40 or over with unexplained haemoptysis — suspected cancer pathway referral for lung cancer (NG12).

🚩

Breathless, hypotensive, trachea shifted after sudden chest pain — possible tension pneumothorax: 999.

🚩

Pneumonia with CRB65 of 2 or more, or signs of sepsis — consider hospital referral (NG250); follow NICE sepsis guidance.

Typical features

Sudden breathlessness, pleuritic chest pain, haemoptysis
Tachycardia, low SpO₂, signs of DVT (swollen, tender calf)
Risk factors: recent surgery or immobility, previous VTE, active cancer, pregnancy

The NICE NG158 pathway

Low suspicion and another diagnosis likely? Consider the PERC rule (PE rule-out criteria) to decide whether any further tests are needed
Otherwise use the 2-level Wells score
More than 4 (PE likely): CTPA immediately if possible, or interim therapeutic anticoagulation if it can't be done straight away
4 or less (PE unlikely): D-dimer with the result within 4 hours if possible; if not, interim anticoagulation

In real life: most GPs refer suspected PE the same day to the local ambulatory or acute medical team, who run the Wells–D-dimer–CTPA pathway. Know your local route before you need it.

💊 Prescribing Pearl: NG158 names apixaban or rivaroxaban as first-line anticoagulants for confirmed PE (at least 3 months). Standard licensed starting regimens are apixaban 10 mg twice daily for 7 days then 5 mg twice daily, or rivaroxaban 15 mg twice daily for 21 days then 20 mg once daily. Verification note: these doses were confirmed from trial and product literature, not directly from CKS/BNF during this build — check the BNF and your local anticoagulation policy (renal function, weight, interactions) before prescribing. Second line if neither DOAC is suitable: LMWH followed by dabigatran or edoxaban, or LMWH with warfarin (NG158).

Features

Sudden one-sided pleuritic pain ± breathlessness
Reduced breath sounds and hyper-resonance on the affected side
Primary spontaneous: typically young, tall, thin men and smokers
Secondary: underlying lung disease (e.g. COPD) — often sicker with a small leak

Tension pneumothorax — 999

Rapidly worsening breathlessness, low BP, tachycardia
Tracheal deviation away from the affected side
Needs immediate decompression by the emergency team

⚠️ Out of date rule: the old "size over 2 cm = chest drain" teaching has gone. The BTS pleural disease guideline (2023) says conservative management can be considered for minimally symptomatic primary spontaneous pneumothorax regardless of size, with ambulatory care or aspiration/drain for others. The decision belongs in hospital — your job is same-day referral for a chest X-ray and assessment.

✅ Patient question — "Can I fly?" BTS advice is that flying is considered safe 7 days after the pneumothorax has resolved on X-ray.

🛑 Suspected cancer pathway referral (NG12) if:

chest X-ray findings suggest lung cancer, or
aged 40 or over with unexplained haemoptysis
For mesothelioma: chest X-ray findings suggest mesothelioma

Terminology: "2-week wait" is now the suspected cancer pathway referral. Since October 2023 the target is a diagnosis or ruling-out of cancer within 28 days of referral (Faster Diagnosis Standard).

NG12: offer an urgent, direct-access chest X-ray to people aged 40 and over with 2 or more of these unexplained symptoms — or 1 or more if they have ever smoked:

Cough
Fatigue
Shortness of breath

Chest pain
Weight loss
Appetite loss

⚠️ Mesothelioma twist: for mesothelioma, 1 symptom is enough if the person has ever smoked or has been exposed to asbestos. Always ask about work history — asbestos exposure may be decades old.

NG12: consider an urgent, direct-access chest X-ray in people aged 40 and over with any of:

Persistent or recurrent chest infection
Finger clubbing
Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
Chest signs consistent with lung cancer or pleural disease

✅ Safety-net script: "The X-ray is to be thorough, not because I think something is definitely wrong. If the cough or tiredness is still there after the result, please come back — don't wait for us to chase you."

Severity levels from BTS/SIGN, held within the BTS/NICE/SIGN asthma pathway. Use % of best PEF (or % predicted if best unknown).

Level	Features (any one)	Action in general practice
Moderate	PEF over 50–75%; no severe features	Treat in surgery or at home; assess response
Acute severe	PEF 33–50%; RR 25/min or more; pulse 110/min or more; can't complete sentences in one breath	Treat now; admit if severe features persist after initial treatment
Life-threatening	PEF below 33%; SpO₂ below 92%; silent chest; cyanosis; poor respiratory effort; arrhythmia; hypotension; exhaustion; altered consciousness	999 and admit; oxygen and nebulised bronchodilators while waiting

💊 Prescribing Pearl (adults): Salbutamol via a spacer, one puff at a time with tidal breathing, repeating every 60 seconds up to 10 puffs (or nebulised salbutamol if available) — BTS/SIGN pathway. Oxygen to keep SpO₂ 94–98%. Prednisolone 40–50 mg once daily for at least 5 days (BTS/SIGN via the Scottish Right Decisions asthma pathway). Second-line bronchodilator: nebulised ipratropium is added in acute severe/life-threatening asthma by the emergency or hospital team.

⚠️ Watch-out: people with severe attacks may not look distressed, and may not have every feature. Lower your admission threshold for afternoon or evening attacks, recent night symptoms or admissions, previous near-fatal asthma, or social concerns.

CRB65 of 2 or more: consider hospital referral (NG250, 2025)
Any sign of a more serious illness (e.g. cardiorespiratory failure or sepsis): refer to hospital regardless of score
Can't take oral antibiotics: consider referral or seek specialist advice about IV options at home
Not improving as expected on antibiotics: refer to hospital

Remember: CRB65 is a mortality score — it doesn't catch hypoxia, pleural effusion or frailty. NG250 asks you to combine it with clinical judgement.

🃏 Flip-card quick recall — tap to reveal

Wells score cut-off for "PE likely"?tap to flip

More than 4. CTPA immediately if possible — otherwise start interim anticoagulation (NG158).

Haemoptysis — which age triggers a cancer referral?tap to flip

40 and over, unexplained → suspected cancer pathway referral (NG12).

Asthma patient with a quiet chest and SpO₂ 90%?tap to flip

Life-threatening asthma. 999, oxygen 94–98%, bronchodilators, steroids.

Normal eosinophil count — asthma excluded?tap to flip

No. Sensitivity only ~22–42%. Good rule-in (specificity 81–91%), poor rule-out — move to spirometry with BDR.

When can someone fly after a pneumothorax?tap to flip

7 days after X-ray resolution (BTS advice).

Focused respiratory data gathering

Ten good minutes of history beats any single test — especially for asthma, where NG245 insists on a suggestive history before you test.

🧠 Mnemonic: BREATHS — the respiratory history in seven questions

Breathlessness — sudden or gradual? At rest or on exertion? Grade it with the MRC dyspnoea scale.

Red flags — haemoptysis, weight loss, appetite loss, hoarseness, night sweats, chest pain.

Exposures — smoking (pack-years), vaping, occupation (dusts, fumes, asbestos), pets and birds.

Atopy — personal or family history of asthma, eczema or allergic rhinitis (hay fever).

Timing and triggers — worse at night or early morning? Seasonal? Exercise, cold air, allergens, work?

Home — damp and mould, cold housing, indoor smoking or air pollution (all named in NG245).

Sputum and systemic — colour, volume, blood; fever, fatigue, sweats.

Timing questions

Cough under 3 weeks = acute; 3–8 weeks = subacute; over 8 weeks = chronic
Constant or variable? Variability hints at asthma
Better on days off work or on holiday?

Medication questions

ACE inhibitor (dry cough), beta-blockers (can worsen asthma)
Reliever use — check the prescription record, not just memory
Oral steroid courses in the past year

Pack-years: (cigarettes per day ÷ 20) × years smoked. Twenty a day for 20 years = 20 pack-years. "Roughly how many a day, and for how many years?" is kinder than "How much do you smoke?"

General inspection

Respiratory rate — count it, don't estimate
Accessory muscle use, pursed-lip breathing
Ability to speak in full sentences
Central cyanosis; finger clubbing
Supraclavicular and cervical lymph nodes

Chest examination

Tracheal position and chest expansion
Percussion: dull (fluid, consolidation) vs hyper-resonant (air)
Wheeze: expiratory polyphonic suggests asthma or COPD; monophonic or inspiratory noise suggests a fixed obstruction
Crackles: coarse (infection, bronchiectasis) vs fine (fibrosis, fluid)
Calves — for DVT if PE is on the list

⚠️ Normal chest ≠ no asthma: NG245 reminds you that a person may still have asthma even if the examination is completely normal. Test, don't guess.

SpO₂ (room air)
BTS target for most acutely unwell adults: 94–98%. In people at risk of hypercapnic (CO₂-retaining) respiratory failure, such as severe COPD: 88–92%.

✅ Peak flow
Best of three blows. Compare with the patient's own best (use % predicted only if the best is unknown). Ideally before and after a bronchodilator.

Rate, pulse, temperature, BP
You need RR and BP for CRB65, pulse and PEF for asthma severity. Write the numbers, not "obs normal".

⚠️ Pigmented skin: pulse oximeters may be inaccurate in people with pigmented (darker) skin (NG250). Interpret a "normal" SpO₂ alongside how the person looks and their other observations.

Diagnostic approach in primary care

NG245 turned asthma diagnosis into a sequence of "rule-in" tests. Stop as soon as one is positive.

🔀 Asthma diagnosis in adults (over 16) — NG245 sequence

START: history suggestive of asthma (code as "suspected asthma" until confirmed)

↓

❓ Blood eosinophils above the lab reference range, OR FeNO 50 ppb or more?

YES ↓NO ↓

Asthma confirmed — record the basis in the notes

Spirometry with bronchodilator reversibility: FEV1 up 12% or more AND 200 ml or more (or up 10% or more of predicted)?

↓ if spirometry unavailable or delayed

PEF twice daily for 2 weeks: variability 20% or more?

↓ still not confirmed but suspected

Refer for a bronchial challenge test

FeNO (fractional exhaled nitric oxide — a breath test for airway inflammation). Diagnostic cut-offs: 50 ppb in adults, 35 ppb in children 5–16. Less sensitive in smokers and in obesity.

✅ Children 5–16: FeNO first → spirometry with BDR (12% or more from baseline, or 10% of predicted) → PEF variability → skin prick test to house dust mite or total IgE + eosinophils. No sensitisation or normal IgE excludes asthma.

🩸 How reliable is a raised eosinophil count for asthma?

Short answer: a good rule-IN test, a poor rule-OUT test. Figures from the BTS/NICE/SIGN NG245 evidence review G (2024), which looked at people with suspected asthma not on inhaled steroids.

Population	Cut-off used	Sensitivity	Specificity
Non-smoking adults	360 cells/µL	42%	81%
Non-smoking adults	3.4%	56%	66%
Adults, mixed smoking status	>300/µL	22%	85%
Adults, mixed smoking status	4.15%	36%	83%
Adults, mixed smoking status	4.4%	23%	91%
Adults, mixed smoking status	150/µL	79%	66%
Children and young people	500/µL	37%	91%*

*Children's study measured bronchial hyper-responsiveness on methacholine challenge rather than a clinical asthma diagnosis. All evidence was rated low to very low quality (small studies, unclear blinding, varied cut-offs).

✅ What a raised count tells you: when the cut-off sits at or above the upper limit of normal, specificity is mostly 81–91% — so in someone with a suggestive history, a count above the lab's reference range makes asthma likely. That's why NG245 lets you diagnose on it.

🛑 What a normal count doesn't tell you: at those same cut-offs sensitivity is only about 22–42% — well over half of people with asthma have a "normal" count. A normal result means move to the next test (spirometry with reversibility), never "not asthma".

How it compares (NG245 rationale): eosinophils, FeNO (at 40–50 ppb), PEF variability, bronchodilator reversibility and bronchial challenge all showed specificity over 80%, but only FeNO and bronchial challenge reached sensitivity over 70%. No single test is good enough alone — hence the sequence.

⚠️ Interpreting the FBC:

Use your lab's upper reference limit — NG245 deliberately sets no fixed number for adults
Don't borrow the 0.5 × 10⁹/L figure: that is the children's rule (with raised IgE or house-dust-mite sensitisation), not the adult cut-off
Don't confuse it with 0.3 × 10⁹/L, the COPD biologic threshold
The count varies with timing (symptomatic or not), other allergic disease, infection or other illness, smoking and some medicines — interpret it against the history. Ideally test before starting inhaled steroids.

💡 Practical pearl: eosinophils come free with an FBC — the committee costed the test at about £7.66 including phlebotomy — which makes it the easiest first test when FeNO isn't available in your practice.

⚠️ Test before treating if you can: inhaled steroids make FeNO and spirometry more likely to look normal (NG245). If someone is acutely unwell, treat first and test when settled — and do the tests at presentation if the equipment is there, because they're more likely to be positive when symptomatic.

Test	Use it for	Key point
Post-bronchodilator spirometry	Confirming COPD	FEV1/FVC below 0.7 confirms airflow obstruction (NG115)
Chest X-ray	Suspected lung cancer, persistent symptoms, alternative diagnoses	Not routinely needed to diagnose typical pneumonia in primary care (NG250 allows a clinical diagnosis)
FBC and eosinophils	Asthma diagnosis (adults); COPD steroid responsiveness; biologic eligibility	Eosinophils 0.3 × 10⁹/L or more matter for COPD biologics
Sputum culture	Pneumonia or COPD exacerbation not improving; suspected TB	Send if symptoms haven't improved after antibiotics (NG250)
Bronchial challenge	Asthma still suspected after the above	Secondary care only

🛑 Suspected cancer pathway: CXR suggests lung cancer or mesothelioma; aged 40 or over with unexplained haemoptysis (NG12).

Same day / emergency: life-threatening or persisting acute severe asthma; suspected PE; suspected pneumothorax; pneumonia with CRB65 2 or more (consider) or any sign of sepsis or respiratory failure.

Routine specialist referral:

Asthma uncontrolled on moderate-dose MART with raised FeNO or eosinophils, or after trials of an LTRA and a LAMA (NG245)
Asthma uncontrolled on a high-dose ICS regimen
Suspected occupational asthma — refer to an occupational asthma specialist
Pre-school child with a hospital admission, or 2 or more emergency department visits, for wheeze in 12 months (paediatric respiratory)
Diagnostic doubt in children after testing
COPD meeting biologic criteria (TA1142 / TA1166)

CRB65 — pneumonia in primary care (NG250)

Letter	1 point each
C	Confusion (AMT 8 or less, or new disorientation)
R	Respiratory rate 30/min or more
B	BP: systolic below 90 or diastolic 60 or less
65	Age 65 or over

Score	30-day mortality	Consider
0	Low (under 1%)	Primary care with safety-netting
1	Intermediate (1–10%)	Primary care, or virtual ward / SDEC / hospital at home / hospital
2	Intermediate (1–10%)	Hospital referral
3–4	High (over 10%)	Hospital referral

⚠️ Correction: CURB65 (with urea) is the hospital score. In general practice use CRB65 — you won't have a urea result in a home visit.

2-level PE Wells score (NG158)

Feature	Points
Clinical signs of DVT	3
Alternative diagnosis less likely than PE	3
Heart rate over 100	1.5
Immobilisation 3+ days or surgery in previous 4 weeks	1.5
Previous DVT or PE	1.5
Haemoptysis	1
Malignancy (on treatment, treated in last 6 months, or palliative)	1

Interpretation: more than 4 = PE likely (CTPA immediately); 4 or less = PE unlikely (D-dimer within 4 hours).

MRC dyspnoea scale (used in NG115)

Grade	Description
1	Breathless only with strenuous exercise
2	Short of breath when hurrying on the level or walking up a slight hill
3	Walks slower than people of the same age on the level, or stops for breath when walking at own pace
4	Stops for breath after about 100 metres or a few minutes on the level
5	Too breathless to leave the house, or breathless when dressing

🗣️ Cough

Duration is the first sorting question (NICE CKS Cough; BTS).

Viral upper respiratory tract infection (most common)
Acute bronchitis; pneumonia
Exacerbation of asthma or COPD
COVID-19, influenza, whooping cough (pertussis)
Don't forget: PE, heart failure, inhaled foreign body

Post-infectious cough (the most common reason)
Whooping cough
Asthma or COPD unmasked by an infection
Start thinking about the chronic list if it isn't settling

Asthma (including cough-variant) and COPD
Upper airway cough (rhinitis, sinusitis, post-nasal drip)
Gastro-oesophageal reflux (often worse lying down)
ACE inhibitor
Bronchiectasis, interstitial lung disease, TB
Lung cancer ⚠️ — check the NG12 criteria

😮‍💨 Breathlessness

Think beyond the lungs — the heart and blood count too.

Respiratory: asthma, COPD, pneumonia, PE, pneumothorax, effusion, interstitial lung disease, lung cancer

Cardiac: heart failure, arrhythmia (e.g. AF), angina, valve disease

✅ Other: anaemia, deconditioning, obesity, anxiety or breathing pattern disorder (dysfunctional breathing)

⚠️ Systemic: thyrotoxicosis, metabolic acidosis (e.g. diabetic ketoacidosis)

🔥 Chest Pain

Character narrows the list quickly.

🛑 Pleuritic (sharp, worse on breathing in): PE, pneumothorax, pneumonia, pleurisy

Central, heavy: angina, acute coronary syndrome, aortic dissection (tearing, to the back)

Burning: reflux, oesophageal spasm

✅ Localised and reproducible: costochondritis, muscle strain, rib injury

🎵 Wheeze and Noisy Breathing

Not all that wheezes is asthma.

Asthma: variable, reversible, often with atopy

COPD: persistent and progressive, smoking history, age over 35

🛑 Anaphylaxis: sudden, with rash, swelling or low blood pressure — adrenaline first

✅ Heart failure: wheeze with oedema and orthopnoea ("cardiac asthma")

⚠️ Inducible laryngeal obstruction (formerly vocal cord dysfunction): inspiratory noise, throat tightness, poor inhaler response. Monophonic or unexplained stridor suggests a fixed obstruction — investigate.

History that suggests asthma

Wheeze, cough, breathlessness or chest tightness that varies
Worse at night, early morning or seasonally
Clear triggers (exercise, cold air, allergens, work)
Personal or family history of asthma or allergic rhinitis

Rules of the road

Never confirm asthma without a suggestive history and a supporting objective test
Code as "suspected asthma" until confirmed
Record the basis for the diagnosis in the notes
Look for alternative diagnoses

The test sequence: eosinophils or FeNO first, then spirometry with reversibility, then peak-flow variability, then a bronchial challenge. See the flowchart in Investigations.

✅ The one-line version: a raised eosinophil count (above the lab range) or FeNO of 50 ppb or more rules asthma in; a normal result rules nothing out — eosinophils miss more than half of people with asthma (sensitivity roughly 22–42% at upper-normal cut-offs; specificity 81–91%). Full figures are in Investigations. "Your blood test supports asthma" is fine; "Your blood test shows you don't have asthma" is not.

⚠️ Under 5s: no objective tests. Treat suspected asthma with an 8–12 week ICS trial, stop it, and see whether symptoms return. Try the tests once the child reaches 5 (retry every 6–12 months if they can't do them).

🛑 The big change: no one with asthma should be on a SABA (short-acting beta-agonist, e.g. salbutamol) without an inhaled corticosteroid (NG245 rec 1.6.3).

Newly diagnosed: as-needed AIR (anti-inflammatory reliever) — a low-dose ICS/formoterol inhaler taken only when needed.
Highly symptomatic or presenting with a severe exacerbation? Start at low-dose MART instead (plus oral steroids if needed), and consider stepping down to AIR later.

Not controlled on AIR → low-dose MART (maintenance and reliever therapy: the same ICS/formoterol inhaler taken regularly and as the reliever).

Not controlled → moderate-dose MART.

Not controlled on moderate-dose MART with good adherence → check FeNO and blood eosinophils. Either raised → refer to a specialist in asthma care.

Neither raised → 8–12 week trial of an LTRA (leukotriene receptor antagonist, e.g. montelukast) or a LAMA (long-acting muscarinic antagonist) on top of moderate-dose MART. Controlled → continue. Better but not controlled → keep it and trial the other. No better → stop it and trial the other.

Still uncontrolled after both → refer to a specialist in asthma care (biologics territory).

⚠️ Before every step up: check adherence (prescription record), inhaler technique, smoking or vaping, alternative diagnoses, occupational and environmental triggers, and psychosocial factors (NG245 1.6.1). Review response 8–12 weeks after any change.

Moving patients from the old pathway (uncontrolled asthma)

Currently on	Switch to (NG245)
SABA only	As-needed AIR
Low-dose ICS or ICS/LABA (± LTRA) + SABA	Consider low-dose MART
Moderate-dose ICS or ICS/LABA (± LTRA/LAMA) + SABA	Consider moderate-dose MART
Any high-dose ICS regimen, still uncontrolled	Refer to a specialist in asthma care

✅ If it isn't broken: people who are well controlled on an older regimen don't have to switch — the transfer recommendations apply to uncontrolled asthma.

Children aged 5–11

Twice-daily paediatric low-dose ICS + SABA as needed.

Not controlled and able to manage MART → consider paediatric low-dose MART, then moderate-dose MART.

Can't manage MART → consider adding an LTRA for 8–12 weeks (stop if ineffective) → then paediatric low-dose ICS/LABA + SABA → then moderate-dose ICS/LABA + SABA.

Uncontrolled on paediatric moderate-dose MART or ICS/LABA → refer.

⚠️ Licensing: in November 2024 no inhaler was licensed for MART in children under 12, so use is off-label (NG245) — follow GMC guidance on off-label prescribing and document the discussion. For children under 12 using a dry powder inhaler, consider an extra SABA metered-dose inhaler + spacer for emergencies, as they may not be able to use a DPI during an attack.

Children under 5

8–12 week trial of twice-daily paediatric low-dose ICS (+ SABA) if interval symptoms with another atopic condition, or severe episodes (admission, or 2 or more oral steroid courses)
Symptoms resolve → consider stopping; review after 3 months. Recur → restart ICS
Uncontrolled on paediatric moderate-dose ICS → consider an LTRA trial → then refer
Any hospital admission, or 2 or more ED attendances with wheeze in 12 months → refer to a paediatric respiratory specialist

At every review (NG245 1.5.1)

Symptoms and a validated questionnaire (ACQ, ACT or Childhood ACT)
Time off work or school
Reliever use — check the prescription record
Oral steroid courses; ED visits or admissions
Watch the inhaler technique being done, every time
Consider FeNO at review in adults, and before and after changing therapy

"Uncontrolled" means (NG245)

Any exacerbation needing oral steroids, or
Reliever needed on 3 or more days a week, or
Night waking from asthma 1 or more nights a week

🛑 High-risk register (NG245 1.15.1): poor adherence; more than 2 SABA inhalers a year; 2 or more oral steroid courses a year; 2 or more ED visits or any admission for asthma. Flag them and review proactively.

✅ Self-management: everyone aged 5+ gets a written personalised asthma action plan, reviewed at annual review, after any exacerbation and at every acute consultation. Adults on a single ICS inhaler (not MART) can be told to quadruple the ICS dose for 7 days when control slips, within their action plan and not exceeding the maximum licensed dose (NG245 1.14.4).

Pregnancy: review asthma early in pregnancy and postpartum. Continue SABA, LABA, ICS and theophyllines as normal; don't stop an LTRA or LAMA that's needed; give oral steroids for exacerbations — the benefits outweigh the risks (NG245 1.12).

⚠️ Don't: routinely use regular peak-flow monitoring to assess control, unless there's a person-specific reason (NG245 1.5.3). Digital "smart" inhalers are not recommended for routine use.

🛑 Treat each emergency asthma consultation as acute severe until shown otherwise (BTS/SIGN). Severity table and red flags are in Red Flags.

Moderate attack (PEF over 50–75%)

Salbutamol via spacer, one puff at a time, up to 10 puffs
Prednisolone 40–50 mg daily for at least 5 days
Good response → continue or step up usual treatment; review

Acute severe / life-threatening

Oxygen to SpO₂ 94–98%
Nebulised (oxygen-driven) salbutamol if available
Prednisolone 40–50 mg
Admit if no response or any life-threatening feature — 999

After the attack: BTS/SIGN advise GP follow-up within 2 working days of discharge. Use the visit to find out why it happened: adherence, technique, triggers, and whether the action plan was used.

✅ MART users: in an emergency they're treated like anyone else — salbutamol, steroids, oxygen. The MART conversation happens once they're stable.

💊 First-line (AIR and MART, age 12+): budesonide/formoterol dry powder inhaler. In November 2024 only certain budesonide/formoterol inhalers were licensed for as-needed AIR; other ICS/formoterol products would be off-label (NG245). Dose, frequency and maximum daily inhalations: these vary by product and strength and I could not verify them directly against CKS or the BNF during this build — prescribe from the BNF and the product's SmPC, and use your local formulary product.

⚠️ Second-line add-ons (on moderate-dose MART): montelukast (LTRA) or a LAMA, each as an 8–12 week trial. Warn about neuropsychiatric reactions with montelukast (sleep disturbance, nightmares, mood change, agitation) and ask families to report them — MHRA advice referenced in NG245. Doses not verified from CKS/BNF in this build — check the BNF.

Acute attack prescribing (verified): prednisolone 40–50 mg once daily for at least 5 days in adults (BTS/SIGN, BTS/NICE/SIGN pathway). Salbutamol up to 10 puffs via spacer, one at a time.

✅ Script for AIR: "This inhaler has a small dose of steroid mixed with a fast reliever. Use it whenever you're wheezy or tight. Every puff treats the inflammation as well as the symptoms — which is why it cuts serious attacks."

Suspect COPD (NG115) in people over 35 with a risk factor (usually smoking) and 1 or more of: exertional breathlessness, chronic cough, regular sputum, frequent winter "bronchitis", wheeze.

✅ Confirm with: post-bronchodilator spirometry — FEV1/FVC below 0.7. Symptoms alone are not enough.

Features favouring COPD

Smoking or occupational exposure history
Progressive, persistent breathlessness
Onset in mid-life or later
Little variation day to day

Features of asthma / steroid responsiveness

Previous secure asthma diagnosis or atopy
Higher blood eosinophil count
FEV1 varying by 400 ml or more over time
Peak-flow diurnal variation of 20% or more

⚠️ Why it matters: these "asthmatic features" decide the fork in the inhaler pathway (LAMA + LABA versus LABA + ICS). Look them up before your first prescription, not after the third exacerbation.

Airflow obstruction (post-bronchodilator FEV1/FVC below 0.7)

Stage	FEV1 % predicted
1 – Mild	80% or more (diagnose only if symptoms present)
2 – Moderate	50–79%
3 – Severe	30–49%
4 – Very severe	Below 30%

Beyond FEV1: severity also depends on breathlessness (MRC scale — see Scoring Systems), exacerbation frequency, BMI, oxygen levels and comorbidities. NICE does not use the GOLD A/B/E groups — so the old "Group A–D" treatment grid on this page has been replaced with the NG115 pathway.

✅ The fundamentals come first (NG115):

Treatment for tobacco dependence — the single most effective intervention
Pneumococcal and annual flu vaccination
Pulmonary rehabilitation for people functionally limited by breathlessness (usually MRC grade 3 and above)
Personalised self-management plan; optimise comorbidities
Check inhaler technique before any step up

🔀 Inhaled therapy pathway (NG115)

START: SABA or SAMA (short-acting muscarinic antagonist) as needed

↓ still breathless or exacerbating despite fundamentals

❓ Asthmatic features / features suggesting steroid responsiveness?

NO ↓YES ↓

LAMA + LABA

LABA + ICS

↓

1 severe (hospital) or 2 moderate exacerbations in a year → LAMA + LABA + ICS. Symptoms only → 3-month trial of triple; revert if no better

Symptoms still affecting quality of life, or exacerbations → LAMA + LABA + ICS

⚠️ Before starting triple therapy: NG115 asks for a clinical review confirming that non-drug care is optimised, tobacco-dependence treatment has been offered, and the symptoms and "exacerbations" really are COPD — not heart failure, anxiety or another condition.

💊 Prescribing Pearl: First-line maintenance for most (no asthmatic features): a LAMA + LABA combination inhaler. Second-line / asthmatic features: LABA + ICS, escalating to LAMA + LABA + ICS (triple). Choose the product from your local formulary based on the device the person can use. Specific product doses were not verified against CKS/BNF in this build — prescribe from the BNF/SmPC. ICS in COPD raises pneumonia risk — explain this before starting.

Patient script: "These inhalers won't undo the damage, but they help your lungs work with what they've got — and rehab and stopping smoking will do even more than the inhalers."

Definition (NICE): a sustained worsening of symptoms from the person's usual stable state, beyond normal day-to-day variation, and acute in onset. Many exacerbations are viral or non-infective and won't respond to antibiotics (NG114).

💊 Steroids (NG115): prednisolone 30 mg once daily for 5 days if there's a significant increase in breathlessness interfering with daily activities (and no contraindication).

Antibiotics (NG114): consider one after weighing symptom severity (especially change in sputum colour and increased volume or thickness), previous exacerbations, hospital admissions and risk of complications, previous sputum cultures, and resistance risk.

Choice	Antibiotic and adult dose (NG114)	Course
First-line	Amoxicillin 500 mg three times a day (see BNF for severe infection)	5 days
First-line alternative	Doxycycline 200 mg on day 1, then 100 mg once daily	5 days in total
First-line alternative	Clarithromycin 500 mg twice a day	5 days
Second-line	No improvement after 2–3 days: switch to an alternative first-choice antibiotic from a different class, guided by sputum results	5 days
Higher risk of treatment failure	Co-amoxiclav 500/125 mg three times a day, co-trimoxazole 960 mg twice a day, or levofloxacin 500 mg once daily (levofloxacin only if others unsuitable — MHRA fluoroquinolone restrictions)	5 days

Higher-risk alternatives as tabulated in NG114's visual summary, reproduced in the BLMK ICB primary-care antimicrobial guideline. Check the BNF for renal and hepatic dosing.

⚠️ On prophylactic azithromycin? Don't stop it. NG114 says the acute antibiotic should be from a different class — so choose amoxicillin or doxycycline, not clarithromycin.

✅ Expectation-setting: Asthma + Lung UK notes an exacerbation lasts 11–13 days on average — "You won't feel fully back to normal the day the tablets run out, and that's expected." Rescue packs suit people who can recognise an exacerbation and know when to use them.

Hospital: severe breathlessness, acute confusion, cyanosis, rapidly worsening symptoms, SpO₂ below their usual level, can't cope at home
Respiratory specialist: diagnostic uncertainty, young onset or strong family history, rapid decline, frequent exacerbations despite optimised therapy, assessment for oxygen or lung volume reduction
Biologics: uncontrolled on triple therapy (or LAMA + LABA if ICS unsuitable) with eosinophils 0.3 × 10⁹/L or more — see the alert banner

💊 Biologics (specialist-initiated): Dupilumab (TA1142, March 2026) and mepolizumab (TA1166, June 2026). Response is assessed at 12 months against exacerbation numbers. You don't prescribe these — but you do spot the eligible patient.

Hospital and specialist referral indications above summarise NG115 and CKS COPD; confirm local thresholds with your respiratory team.

Diagnosis in primary care: NG250 accepts a clinical diagnosis without a chest X-ray — lower respiratory tract infection symptoms plus focal chest signs, raised respiratory rate, low saturations or illness severity.

Severity: CRB65 plus clinical judgement → low, moderate or high severity. Score 0: primary care. Score 1: primary care or virtual ward / SDEC / hospital at home / hospital. Score 2+: consider hospital. Full table in Scoring Systems.

⚠️ Children: NG250 advises considering hospital referral or specialist paediatric advice for children and young people with community-acquired pneumonia. CRB65 is not used in under 18s.

Severity	First-line (adults)	Alternative (penicillin allergy / amoxicillin unsuitable)
Low	Amoxicillin 500 mg three times a day for 5 days (higher doses possible — see BNF)	Doxycycline 200 mg day 1 then 100 mg once daily (5 days total), or clarithromycin 500 mg twice a day for 5 days; erythromycin 500 mg four times a day for 5 days in pregnancy
Moderate	Amoxicillin 500 mg three times a day for 5 days, plus clarithromycin 500 mg twice a day for 5 days if atypical pathogens suspected (erythromycin in pregnancy)	Doxycycline or clarithromycin as above
High	Hospital: co-amoxiclav + clarithromycin (oral or IV)	Hospital: levofloxacin (MHRA restrictions apply)

💊 Prescribing Pearl: stop adult antibiotics after 5 days unless microbiology suggests otherwise or the person isn't clinically stable (fever in the past 48 hours, or more than 1 of: systolic BP below 90, HR over 100, RR over 24, SpO₂ below 90% on air) — NG250 rec 1.6.3.

✅ New in 2025 for children: NG250 cut amoxicillin courses to 3 days for non-severe pneumonia in children aged 3 months to 11 years (5 days for 1–2 months and 12–17 years). Paediatric doses are in NG250 table 2.

By about…	Most adults can expect (NG250)
1 week	Fever resolved
4 weeks	Chest pain and sputum substantially reduced
6 weeks	Cough and breathlessness substantially reduced
3 months	Most symptoms resolved; fatigue may linger
6 months	Back to normal

🛑 Safety-net (NG250): seek help if symptoms worsen rapidly or significantly, don't start to improve within 3 days, or they become systemically unwell. Reassess and consider non-bacterial causes (e.g. influenza); refer if not improving on antibiotics; send sputum if not already done.

Follow-up X-ray (after hospital discharge): not routine. Consider one at 6 weeks for people with lung cancer risk factors (e.g. smokers, over 50), persisting or worsening symptoms, or unexplained weight loss (NG250 1.12).

⚠️ Golden rule: NG245 asks you to watch the person use their inhaler (and spacer) at every asthma review, every asthma-related consultation, whenever control worsens, when the device changes, and when they ask. If they can't use it properly, find an alternative.

Choosing a device (NG245 1.6.5)

Base the choice on four things — then prescribe by brand so the device doesn't change at the pharmacy.

Can they demonstrate correct technique?
What do they prefer?

Lowest environmental impact among suitable devices
An integral dose counter

Also: use the same device type for preventer and reliever where possible; usually prescribe a spacer with a metered-dose inhaler (particularly for children); encourage returning used inhalers to the pharmacy for disposal.

Feature	pMDI (pressurised metered-dose inhaler)	DPI (dry powder inhaler)
How to breathe in	Slow and steady	Quick and deep
Hand–breath coordination	Needed (unless using a spacer)	Not needed — breath-activated
Works with a spacer?	Yes	No
Good for	Young children and acute attacks (with spacer)	People with a good inspiratory flow
Carbon footprint	Higher (propellant gas)	Lower

pMDI technique

Most common device — and the easiest to get wrong.

Remove the cap and shake

Breathe out gently, away from the inhaler

Seal lips; start breathing in slowly and press the canister once

Keep breathing in slowly and deeply; hold for up to 10 seconds

Wait about 30 seconds before a second puff

🛑 Common errors: breathing in too fast, firing before breathing in, several puffs at once, not shaking.

DPI technique

Easier coordination, but it needs a strong breath in.

Load the dose (twist, click, slide or pierce — device-specific)

Breathe out gently, away from the device

Seal lips and breathe in quickly and deeply

Hold the breath for up to 10 seconds

Rinse mouth after a steroid-containing inhaler

✅ Tip: show them with a placebo device, then watch them do it back — "teach-back" catches errors that "Any questions?" never will.

Spacers

Cheap, low-tech and under-used.

✅ Benefits:

Remove the need for coordination
More drug reaches the lungs, less in the mouth
Less oral thrush with steroid inhalers
Can replace a nebuliser in many acute attacks

Technique:

Attach the shaken inhaler to the spacer
One puff into the spacer at a time
Either several normal (tidal) breaths, or one slow deep breath and hold
Repeat for each puff

🃏 Flip-card quick recall — tap to reveal

Breath for a pMDI vs a DPI?tap to flip

pMDI: slow and steady.
DPI: quick and deep.

4 factors for choosing a device (NG245)?tap to flip

Technique, preference, lowest environmental impact, dose counter.

Child under 12 on a DPI — what extra device?tap to flip

Consider a SABA pMDI + spacer for emergencies (NG245 1.6.8).

Where should old inhalers go?tap to flip

Back to the pharmacy for disposal — not the household bin.

Reframe the conversation

The GTN analogy — a favourite with trainers.

Think about it: a GTN spray holds up to about 200 doses, much like a salbutamol inhaler. Would you be relaxed about someone using a whole GTN spray a month for "just a bit of chest pain"? So why do we accept it for "just a bit of wheeze"?

🛑 The numbers that matter: NG245 flags more than 2 SABA inhalers a year as a marker of risk, and says SABA should never be prescribed in asthma without an ICS. Run a search of your practice list — it's a quick, powerful quality-improvement project.

✅ Script: "Needing your blue inhaler a lot isn't a sign it's working — it's a sign the asthma isn't controlled. Let's treat the cause so you need it less."

Inhalers and the climate

Good control first — greener devices second.

Control comes first: inhalers are essential, and never switch or stop them without a proper discussion and technique check
Metered-dose inhalers contain propellant gases with a much higher carbon footprint than dry powder inhalers
Poorly controlled asthma has a bigger footprint — more reliever use, more attacks, more healthcare visits
NG245 makes "lowest environmental impact among suitable devices" part of device choice

Share the decision: use the BTS/NICE/SIGN patient decision aid on asthma inhalers and climate change.

⚠️ Remember: a greener inhaler that the patient can't use is worse for them and the planet.

You've Got This! 💪

Remember: you don't need to be a respiratory physician to provide excellent respiratory care. You just need to know when to worry, when to treat, and when to refer.

You can confidently diagnose asthma with a FeNO or eosinophil count, start AIR, run the COPD inhaler fork, and treat most chest infections and exacerbations with a 5-day course. Refer the uncontrolled asthmatic on moderate-dose MART, the frequent COPD exacerbator with high eosinophils, and anyone meeting NG12.

And the one thing never to miss? The quiet, tired asthmatic who "isn't wheezing any more" — a silent chest is the loudest warning in medicine.

☕ Now go reward yourself with that well-deserved coffee