Asthma nice guidlines.pdf

7/30/2019 Asthma nice guidlines.pdf

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The British Thoracic Societ

Scottish Intercollegiate Gidelines Network

British Gideline on the

Management of Asthma

Quick Reference Guide

May 2008revised May 2011


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The College ofEmergency Medicine

British Thoracic Society

Scottish Intercollegiate Guidelines Network

British Gideline on the Management of Asthma

Quick Reference Guide

Ma 2008Revised May 2011


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ISBN 978 1 905813 29 2

First pblished 2003

Revised edition pblished 2008Revised edition pblished 2009

Revised edition pblished 2011

SIGN and the BTS consent to the photocopying of this QRG for the purpose ofimplementation in the NHS in England, Wales, Northern Ireland and Scotland.

British Thoracic Societ,17 Doght Street, London WC1N 2PL

www.brit-thoracic.org.k

Scottish Intercollegiate Gidelines NetworkElliott Hose, 8 -10 Hillside Crescent, Edinbrgh EH7 5EA

www.sign.ac.k


5/281Applies to all children Applies to children 5-12 Applies to children under 5 GeneralApplies only to adults

DIAGNOSIS IN CHILDREN

INITIAL CLINICAL ASSESSMENT

CLINICAL FEATuRES THAT INCREASE THE PROBABILITy OF ASTHMA

CLINICAL FEATuRES THAT LOWER THE PROBABILITy OF ASTHMA

With a thorogh histor and examination, a child can sall be classed into one of three grops:

high probabilit diagnosis of asthma likely low probabilit diagnosis other than asthma likely intermediate probabilit diagnosis uncertain.

More than one of the following symptoms - wheeze, cough,difficulty breathing, chest tightness - particularly if these are

frequent and recurrent; are worse at night and in the early morning;occur in response to, or are worse after, exercise or other triggers,

such as exposure to pets; cold or damp air, or with emotions or

laughter; or occur apart from colds

Personal history of atopic disorder Family history of atopic disorder and/or asthma

Widespread wheeze heard on auscultation History of improvement in symptoms or lung function in response

to adequate therapy.

Symptoms with colds only, with no interval symptoms Isolated cough in the absence of wheeze or difficulty breathing History of moist cough Prominent dizziness, light-headedness, peripheral tingling Repeatedly normal physical examination of chest when

symptomatic

Normal peak expiratory flow (PEF) or spirometry whensymptomatic

No response to a trial of asthma therapy Clinical features pointing to alternative diagnosis

B Focs the initial assessment in children sspected of having asthma on: presence of ke featres in histor and examination carefl consideration of alternative diagnoses.

Record the basis on which a diagnosis of asthma is suspected.


6/282 Applies to all children Applies to children 5-12 Applies to children under 5 GeneralApplies only to adults

In some children, particlarl the nder 5s, there is insfficient evidence for a firm diagnosis ofasthma bt no featres to sggest an alternative diagnosis.

Possible approaches (dependent on freqenc and severit of smptoms) inclde:

watchfl waiting with review trial of treatment with review spirometr and reversibilit testing.

DIAGNOSIS IN CHILDREN

HIGH PROBABILITy OF ASTHMA

LOW PROBABILITy OF ASTHMA

INTERMEDIATE PROBABILITy OF ASTHMA

C In children with an intermediate probabilit of asthma who can perform spirometr and haveno evidence of airwas obstrction:

consider testing for atopic stats, bronchodilator reversibilit and if possible, bronchialhper-responsiveness sing methacholine, exercise or mannitol

consider specialist referral.

Remember - The diagnosis of asthma in children is a clinical one. It is based on

recognising a characteristic pattern of episodic symptoms in the absence of analternative explanation.

In children with a high probabilit of asthma:

start a trial of treatment review and assess response

reserve further testing for those with a poor response.

In children with a low probabilit of asthma consider more detailed investigation and specialist

referral.

In children with an intermediate probabilit of asthma who can perform spirometry and have

evidence of airwas obstrction, assess the change in FEV1 or PEF in response to an inhaledbronchodilator (reversibility) and/or the response to a trial of treatment for a specified period:

if there is significant reversibility, or if a treatment trial is beneficial, a diagnosis of asthmais probable. Continue to treat as asthma, but aim to find the minimum effective dose of

therapy. At a later point, consider a trial of reduction, or withdrawal, of treatment.

if there is no significant reversibility, and treatment trial is not beneficial, consider tests foralternative conditions.

In children with an intermediate probabilit of asthma who cannot perform spirometry, offer a

trial of treatment for a specified period:

if treatment is beneficial, treat as asthma and arrange a review if treatment is not beneficial, stop asthma treatment, and consider tests for alternative conditions

and specialist referral.


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Clinical assessment

Considerreferral

Continue

treatment and

find minimum

effective dose

Assess compliance and

inhaler technique.

Consider further

investigation and/or referral

Continue

treatment

Further investigation.

Consider referral

+VE -VE

HIGH PROBABILITYdiagnosis of asthma

likely

INTERMEDIATE

PROBABILITY

diagnosis uncertain

or poor response to

asthma treatment

LOW PROBABILITYother diagnosis likely

Consider tests of

lung function*

and atopy

Response? Response?

Investigate/

treat other

condition

Trial of asthma

treatment

Yes No No Yes

* Lung function tests include spirometry before and after bronchodilator (test of airway reversibility) andpossible exercise or methacholine challenge (tests of airway responsiveness).

Most children over the age of 5 years can perform lung function tests.

Presentation with suspected asthma in children

3Applies to all children Applies to children 5-12 Applies to children under 5 GeneralApplies only to adults



DIAGNOSIS IN ADuLTS

INITIAL ASSESSMENT

The diagnosis of asthma is based on the recognition of a characteristic pattern of symptoms and signs

and the absence of an alternative explanation for them. The key is to take a careful clinical history.

CLINICAL FEATuRES THAT INCREASE THE PROBABILITy OF ASTHMA

CLINICAL FEATuRES THAT LOWER THE PROBABILITy OF ASTHMA

* A normal spirogram/spirometry when not symptomatic does not exclude the diagnosis of asthma.

Repeated measurements of lung function are often more informative than a single assessment.

More than one of the following symptoms: wheeze, breathlessness,chest tightness and cough, particularly if:

~ symptoms worse at night and in the early morning

~ symptoms in response to exercise, allergen exposure and cold air

~ symptoms after taking aspirin or beta blockers

History of atopic disorder Family history of asthma and/or atopic disorder Widespread wheeze heard on auscultation of the chest Otherwise unexplained low FEV1 or PEF (historical or serial readings) Otherwise unexplained peripheral blood eosinophilia

Prominent dizziness, light-headedness, peripheral tingling Chronic productive cough in the absence of wheeze or breathlessness Repeatedly normal physical examination of chest when symptomatic

Voice disturbance Symptoms with colds only Significant smoking history (ie > 20 pack-years) Cardiac disease Normal PEF or spirometry when symptomatic*

D Spirometr is the preferred initial test to assess the presence and severit of airflow obstrction.

Base initial diagnosis on a careful assessment of symptoms and a measure of airflow obstruction:

in patients with a high probabilit of asthma move straight to a trial of treatment. Reservefurther testing for those whose response to a trial of treatment is poor.

in patients with a low probabilit of asthma, whose symptoms are thought to be due to analternative diagnosis, investigate and manage accordingly. Reconsider the diagnosis of

asthma in those who do not respond.

the preferred approach in patients with an intermediate probabilit of having asthma is to carryout further investigations, including an explicit trial of treatments for a specified period,

before confirming a diagnosis and establishing maintenance treatment.


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Clinical assessment including spirometry

(or PEF if spirometry not available)

Continue

treatment

Assess compliance and

inhaler technique.

Consider furtherinvestigation and/or referral

Continue

treatment

Further investigation.

Consider referral

HIGH PROBABILITY

diagnosis of asthma

likely

LOW PROBABILITY

other diagnosis likely

Response? Response?

Investigate/

treat other

condition

Trial of

treatment

Yes No No Yes

Presentation with suspected asthma

FEV1/ FVC

0.7

INTERMEDIATE

PROBABILITY

diagnosis uncertain

Presentation with suspected asthma in adults




NON-PHARMACOLOGICAL MANAGEMENT

There is a common perception amongst patients and carers that there are numerous environmental, dietary and

other triggers of asthma and that avoiding these triggers will improve asthma. Evidence that non-pharmacological

management is effective can be difficult to obtain and more studies are required.

PROSPECTS FOR THE PRIMARy PREVENTION OF ASTHMA

Research Findings Recommendation

Allergen avoidance There is no consistent evidence ofbenefit from domestic aeroallergenavoidance.

Insufficient evidence to makea recommendation.

Breastfeeding Evidence of protective effect in relationto early asthma.

Breast feeding shold be encoragedfor its man benefits, and as it ma also

have a potential protective effect inrelation to earl asthma.

Modified milkformlae

Trials of modified milk formulae havenot included sufficiently long followup to establish whether there is anyimpact on asthma.

In the absence of any evidence of benefitfrom the use of modified infant milkformulae it is not possible to recommendit as a strategy for preventing childhood

asthma.

Ntritionalspplementation

There is limited, variable qualityevidence investigating the potentialpreventative effect of fish oil, seleniumand vitamin E intake during pregnancy.

There is insufficient evidence to make anyrecommendations on maternal dietarysupplementation as an asthma preventionstrategy.

Immnotherap More studies are required to establishwhether immunotherapy might have arole in primary prophylaxis.

No recommendation can be made at present.

Microbial exposre This is a key area for further work withlonger follow up to establish outcomes

in relation to asthma.

There is insufficient evidence to indicate thatthe use of dietary probiotics in pregnancy

reduces the incidence of childhood asthma.Avoidance of

tobacco smoke

Studies suggest an association between

maternal smoking and an increasedrisk of infant wheeze.

Parents and parents-to-be shold be

advised of the man adverse effects thatsmoking has on their children incldingincreased wheezing in infanc andincreased risk of persistent asthma.

DIETARy MANIPuLATION


Fish oils and fattacid

Results from studies are inconsistentand further research is required.

No recommendation for use.

ElectroltesLimited intervention studies suggesteither negligible or minimal effects.

No recommendation can bemade at present.

Weight redction Studies show an association between

increasing body mass index andsymptoms of asthma.

Weight redction is recommended in

obese patients with asthma to promotegeneral health and to improve asthmacontrol.

C

C

C




PROSPECTS FOR THE SECONDARy PREVENTION OF ASTHMA


Air polltion Studies suggest an association betweenair pollution and aggravation ofexisting asthma.

Further research is required on the role ofindoor pollutants in relation to asthma.

Hose dst mites Measures to decrease house dust mitesreduce the numbers of house dustmites, but do not have an effect onasthma severity.

In committed families, multipleapproaches to reduce exposure to housedust mite may help.

Pets There are no controlled trials on thebenefits of removing pets from thehome. If you havent got a cat, andyouve got asthma, you probablyshouldnt get one.

No recommendation can be made at present.

Smoking Direct or passive exposure to cigarettesmoke adversely affects quality of

life, lung function, need for rescuemedications and long term control

with inhaled steroids.

Parents with asthma shold be advisedabot the dangers to themselves and

their children with asthma and offeredappropriate spport to stop smoking.

Immnotherap Allergen specific immunotherapy

is beneficial in the management ofpatients with allergic asthma.

Immnotherap can be considered in

patients with asthma where a clinicallsignificant allergen cannot be avoided.The potential for severe allergicreactions to the therap mst be flldiscssed with patients.

COMPLEMENTARy AND ALTERNATIVE MEDICINES

Research Findings RecommendationAcpnctre Research studies have not

demonstrated a clinically valuable

benefit and no significant benefits inrelation to lung function.

Insufficient evidence to make arecommendation.

Bteko techniqe The Buteyko breathing techniquespecifically focuses on control ofhyperventilation. Trials suggest benefitsin terms of reduced symptoms andbronchodilator usage but no effect onlung function.

Bteko breathing techniqe ma beconsidered to help patients to controlthe smptoms of asthma.

Famil therap May be a useful adjunct to medicationin children with asthma.

In difficult childhood asthma, there maybe a role for family therapy as an adjunct

to pharmacotherapy.

Herbal andChinese Medicines

Trials report variable benefits. Insufficient evidence to make arecommendation.

Homeopath Studies looking at individualisedhomeopathy are needed.

Insufficient evidence to make arecommendation.

Hpnosis andrelaxation therapies

No evidence of efficacy. Musclerelaxation could conceivably benefitlung function in patients with asthma.

Larger blinded trials are neededbefore a recommendation can be made.

Ionisers Air ionisers are of no benefit inreducing symptoms.

Air ionisers are not recommended forthe treatment of asthma.

Phsical exercisetherap

Studies suggest that such interventionsmake one fitter, but there is no effecton asthma

No evidence of specific benefit.

C

B

B

A



Regular review of patients as treatment is stepped down is important. When deciding whichdrug to step down first and at what rate, the severity of asthma, the side effects of thetreatment, time on current dose, the beneficial effect achieved, and the patients preference

should all be taken into account.

Patients should be maintained at the lowest possible dose of inhaled steroid. Reduction ininhaled steroid dose should be slow as patients deteriorate at different rates. Reductions

should be considered every three months, decreasing the dose by approximately 25-50%

each time.

PHARMACOLOGICAL MANAGEMENT

Until May 2009 all doses of inhaled steroids were referenced against beclometasone (BDP) given via

CFC-MDIs. As BDP CFC is now unavailable, the reference inhaled steroid will be the BDP-HFA product,

which is available at the same dosage as BDP-CFC. Adjustments to doses will have to be made for otherinhaler devices and other corticosteroid molecules.

STEPPING DOWN

EXERCISE INDUCED ASTHMA

A

A

CA

C

C

A

CA

C

If exercise is a specific problem in patients taking inhaled steroids who are otherwise well

controlled, consider adding one of the following therapies:

leukotriene receptor antagonists long-acting 2 agonists

chromones oral 2 agonists theophyllines.

A A

COMBINATION INHALERS

In efficacy studies, where there is generally good compliance, there is no difference in efficacy in

giving inhaled steroid and a long-acting 2 agonist in combination or in separate inhalers. In clinical

practice, however it is generally considered that combination inhalers aid compliance and also havethe advantage of guaranteeing that the long-acting 2 agonist is not taken without the inhaled steroids.

The aim of asthma management is control of

the disease. Complete control is defined as:

no daytime symptoms

no night time awakening due to asthma no need for rescue medication no exacerbations no limitations on activity including exercise normal lung function (in practical terms

FEV1 and/or PEF >80% predicted or best)

minimal side effects from medication.

THE STEPWISE APPROACH

1. Start treatment at the step most appropriateto initial severity.

2. Achieve early control

3. Maintain control by:

stepping up treatment as necessary stepping down when control is good.

For most patients, exercise-induced asthma is an expression of poorly controlled asthma andregular treatment including inhaled steroids should be reviewed.

vised

009

Combination inhalers are recommended to:

guarantee that the long-acting 2

agonist is not taken without inhaled steroid improve inhaler adherence.

Before initiating a new drug therapypractitioners should check compliance

with existing therapies, inhaler technique

and eliminate trigger factors.

Immediately prior to exercise, inhaled short-acting 2 agonists are the drug of choice.


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Inha

ledshor

t-ac

ting

2

agon

istasre

qu

ire

d

ST

EP

1

Mildinterm

ittentasthma

Addinha

ledstero

id200-8

00

mcg

/day

*

400mcgisan

appropriate

startingdoseformanypatients

Star

ta

tdoseo

finha

led

stero

idapprop

riateto

sever

ityo

fdis

ease.

STE

P2

Regularprev

entertherapy

1.

Addinha

ledlong-ac

ting

1.

Addinha

ledl

ong-ac

ting

2

agon

ist(LA

BA)

2.

Assesscon

tro

lo

fast

hma:

g

oo

dresponse

to

LABA-continueLABA

b

enetfrom

LABAbut

con

tro

lst

ill

ina

dequa

te

-continueLABAand

increaseinh

aledsteroid

doseto800

mcg/day*(if

notalreadyonthisdose)

n

oresponse

toLABA

-stopLABAandincrease

inhaledsteroidto800

mcg/day.*I

fcontrol

stillinadequ

ate,

institute

trialofother

therapies,

leukotrienereceptor

antagonistorSR

theophylline

1.

Addinha

ledlong-ac

ting

STEP

3

Initialadd-o

ntherapy

Consi

der

trialsof

:

i

ncreasinginha

ledsteroid

upto2000mcg/day*

a

dditionofafo

urthdrug

e.g.

leukotriene

receptor

antagonist,SRtheophylline,

2agonisttable

t

STEP

4

Persistentpoo

rcontrol

Use

da

ilys

tero

idta

blet

inlowestdoseproviding

adequatecontrol

Maintainhighdose

inhaled

steroidat2000mcg/day*

Considerothertrea

tmentsto

minimisetheuseofsteroid

tablets

Referpatientforspecialistcare

STEP5

Continuousorfrequent

useoforalsteroids

MO

VEDOWNTOFINDANDMA

INTAINLOWESTCONTROLL

INGSTEP

*BDPorequ

iva

len

t

Pa

tien

tss

hou

ldstart

trea

tmen

ta

tthestepmos

tappropria

tetothe

initialseve

rityo

fthe

irast

hma.

Chec

kconcordancean

dreconsi

der

diagn

osis

ifresponse

totrea

tmen

tisunex

pec

tedlypoor.

MOVEUPTOIMP

ROVECONTROLASNEEDED

SYMPTOMS

vs

TREATMENT

Summary of stepwise management in adults



14/28

Inhaledshor

t-acting2

agonistasre

quired

ST

EP

1

Mildinterm

ittentasthma

Addinhaledsteroid200-400

mcg/day*(oth

erpreventer

drugifinhaled

steroidcannot

beused)200m

cgisan

appropriatesta

rtingdosefor

manypatients

Startatdoseo

finhaled

steroidapprop

riateto

severityofdis

ease.

STE

P2

Regularprev

entertherapy

1.

Addinhaledlong-acting

1.

Addinhaled

long-acting2

agonist(LAB

A)

2.

Assesscontr

olofasthma:

g

oodresponsetoLABA

-continue

LABA

b

enetfro

mL

ABAbut

controlstillinadequate

-continue

LABAand

increasein

haledsteroid

doseto400mcg/day*(if

notalready

onthisdose)

n

oresponsetoLABA

-stopLABAandincrease

inhaledste

roidto400

mcg/day.*

Ifcontrol

stillinadeq

uate,

institute

trialofothertherapies,

leukotrienereceptor

antagonist

orSR

theophylline

1.


STEP

3

Initialadd-o

ntherapy

Increaseinhaled

steroidupto

800mcg/day*

STEP

4

Persistentpoo

rcontrol

Usedailysteroidtablet

inlowestdoseproviding

adequatecontrol

Maintainhighdose

inhaled

steroidat800mcg/day*

Refertorespiratory

paediatrician

STEP5

Continuousorfrequent

useoforalsteroids

MO

VEDOWNTOFINDANDMA


INGSTEP

*BDPorequivalent

MOVEUPTOIMP

ROVECONTROLASNEEDED

SYMPTOMS

vs

TREATMENT

Patientsshouldstarttreatmentatthestepmos

tappropriatetothe

initialseve

rityoftheirasthma.

Checkconcordanceandreconsider

diagn

osisifresponsetotreatmentisunex

pectedlypoor.

Summary of stepwise management in children aged 5-12 years

10 Applies to all children Applies to children 5-12 Applies to children under 5 GeneralApplies only to adults


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Inhaledshort-acting2

agonistasrequired

STEP

1

Mildintermittentasthma

Addinhaledsteroid200-400

mcg/day*

orleukotriene

receptor

antagonistifinhaled

steroid

cannotbe

used.

Startatdoseofinhaled

steroidappropriateto

severityofdisease.

STEP

2

Regularpreventertherapy

1.


Inthosechildrentaking

inhaledsteroids200-400

mcg/dayconsideraddition

ofleukotrienereceptor

antagonist.

Inthosechildrentaking

aleukotrienereceptor

antagonistalonereconsider

additionofaninhaledsteroid

200-400mcg/day.

Inchildrenunder2years

considerproceedingtostep

4.

1.


STEP

3

Initialadd-ontherapy

Refertorespiratory

paediatrician.

STEP

4

Persistentpoorcontrol

SYMPTOMS

vs

TREATMENT

MO

VEDOWNTOFINDANDMA


INGSTEP

*BDPorequivalent

Highernominaldo

sesmayberequiredifdrugdelivery

isdifcult

MOVEUPTOIMP

ROVECONTROLASNEEDED

Patientsshouldstarttreatmentatthestepmos

tappropriatetothe

initialseve

rityoftheirasthma.

Checkconcordanceandreconsider

diagn

osisifresponsetotreatmentisunex

pectedlypoor.

Summary of stepwise management in children less than 5 years




INHALER DEVICES

TECHNIQuE AND TRAINING

PRESCRIBING DEVICES

2 AGONIST DELIVERy

ACuTE ASTHMA

STABLE ASTHMA

CFC PROPELLANT PMDI VS HFA PROPELLANT PMDI

INHALED STEROIDS FOR STABLE ASTHMA

INHALER DEVICES IN CHILDREN uNDER 5

In young (0-5 years) children, little or no evidence is available on which to base recommendations.

A A B Children and adlts with mild and moderate exacerbations of asthma shold be treatedb pMDI + spacer with doses titrated according to clinical response.

A In children aged 5-12, pMDI + spacer is as effective as an other hand held inhaler.

A +-In adlts pMDI spacer is as effective as an other hand held inhaler, bt patients maprefer some tpes of DPI.

A In children aged 5-12 ears, pMDI + spacer is as effective as an DPI.

A +-In adlts, a pMDI spacer is as effective as an DPI.

AA

A

Salbtamol HFA can be sbstitted for salbtamol CFC at 1:1 dosing. HFA BDP pMDI (Qvar) ma be sbstitted for CFC BDP pMDI at 1:2 dosing. This

ratio does not appl to reformlated HFA BDP pMDIs. Flticasone HFA can be sbstitted for flticasone CFC at 1:1 dosing.

B Prescribe inhalers onl after patients have received training in the se of the device andhave demonstrated satisfactor techniqe.

The choice of device may be determined by the choice of drug If the patient is unable to use a device satisfactorily, an alternative should be found The patient should have their ability to use an inhaler device assessed by a competent health

care professional

The medication needs to be titrated against clinical response to ensure optimum efficacy Reassess inhaler technique as part of structured clinical review.

In children aged 0-5 years, pMDI and spacer are the preferred method of delivery of2 agonistsor inhaled steroids. A face mask is required until the child can breathe reproducibly using the

spacer mouthpiece. Where this is ineffective a nebuliser may be required.



MANAGEMENT OF ACuTE ASTHMA IN ADuLTS

ACuTE SEVERE

Any one of:

PEF 33-50% best or predicted respiratory rate 25/min

heart rate 110/min

inability to complete sentences in one breath

NEAR FATAL

Raised PaCO2 and/or requiring mechanical

ventilation with raised inflation pressures

increasing symptoms PEF >50-75% best or predicted

no features of acute severe asthma

MODERATE EXACERBATION LIFE THREATENING

In a patient with severe asthma any one of: PEF



Give spplementar oxgen to allhpoxaemic patients with acte asthma

to maintain an SpO2level of of 94-98%.

Lack of plse oximetr shold notprevent the se of oxgen.

In hospital, amblance and primarcare, neblised 2 agonist

bronchodilators shold be driven boxgen.

The absence of spplemental oxgenshold not prevent neblised therap

being given if indicated.

CRITERIA FOR ADMISSION

MANAGEMENT OF ACuTE ASTHMA IN ADuLTS

B Admit patients with an featre of a life threatening or near fatal attack.

B Admit patients with an featre of a severe attack persisting after initial treatment.

C Patients whose peak flow is greater than 75% best or predicted one hor after initial treatmentma be discharged from ED, nless there are other reasons wh admission ma be appropriate.

STEROID THERAPy IPRATROPIuM BROMIDE

A Give steroids in adeqate doses in all casesof acte asthma.

B Add neblised ipratropim bromide (0.5mg 4-6 horl) to 2agonist treatment

for patients with acte severe or lifethreatening asthma or those with a poor

initial response to 2agonist therap.

OTHER THERAPIES REFERRAL TO INTENSIVE CARE

Refer any patient:

requiring ventilatory support with acute severe or life threatening asthma,failing to respond to therapy, evidenced by:

- deteriorating PEF

- persisting or worsening hypoxia- hypercapnea

- ABG analysis showing pH or H+

- exhaustion, feeble respiration

- drowsiness, confusion, altered conscious state

- respiratory arrest

B Consider giving a single dose of IVmagnesim slphate for patients with:

acte severe asthma who have not hada good initial response to inhaled

bronchodilator therap

life threatening or near fatal asthma.

B Rotine prescription of antibiotics is notindicated for patients with acte asthma.

Continue prednisolone 40-50 mg daily for

at least five days or until recovery.

IV magnesium sulphate (1.2-2 g IV infusion

over 20 minutes) should only be usedfollowing consultation with senior medical

staff.

TREATMENT OF ACuTE ASTHMA

OXyGEN 2 AGONIST BRONCHODILATORS

A use high dose inhaled 2agonists as firstline agents in acte asthma and administeras earl as possible. Reserve intravenos 2

agonists for those patients in whom inhaled

therap cannot be sed reliabl.

A In patients with severe asthma that ispoorl responsive to an initial bolsdose of 2agonist, consider continos

neblisation with an appropriate nebliser.

In acute asthma with life threateningfeatures the nebulised route (oxygen-driven)

is recommended.

C

A

C

vised

009



OXyGEN

2 AGONIST BRONCHODILATORS


MANAGEMENT OF ACuTE ASTHMA IN CHILDREN AGED OVER 2 yEARS

LIFE THREATENING

SpO2140 (2 to 5 years)

Respiration >30 breaths/min (>5 years) or>40 (2 to 5 years)

The following clinical signs shold be recorded:

Plse rate - increasing tachycardia generally denotes worsening asthma; a fall in heart rate in life

threatening asthma is a pre-terminal event Respirator rate and degree of breathlessness - ie too breathless to complete sentences in onebreath or to feed

use of accessor mscles of respiration - best noted by palpation of neck muscles Amont of wheezing - which might become biphasic or less apparent with increasing airways

obstruction

Degree of agitation and conscios level - always give calm reassurance

NB Clinical signs correlate poorl with the severit of airwas obstrction. Some children with acteasthma do not appear distressed.

CRITERIA FOR ADMISSION

B Consider intensive inpatient treatment for children with SpO2



STEROID THERAPy

OTHER THERAPIES

MANAGEMENT OF ACuTE ASTHMA IN CHILDREN AGED OVER 2 yEARS

MANAGEMENT OF ACuTE ASTHMA IN CHILDREN AGED uNDER 2 yEARS


The assessment of acute asthma in early childhood can be difficult Intermittent wheezing attacks are usually due to viral infection and the response to asthma

medication is inconsistent The differential diagnosis of symptoms includes:

- aspiration pneumonitis- pneumonia

- bronchiolitis

- tracheomalacia- complications of underlying conditions such as congenital anomalies and cystic fibrosis

Prematurity and low birth weight are risk factors for recurrent wheezing

2 AGONIST BRONCHODILATORS

STEROID THERAPy

A Give prednisolone earl in the treatment of acte asthma attacks.

A If smptoms are refractor to initial 2 agonist treatment, add ipratropim bromide (250 mcg/dose mixed with the neblised 2 agonist soltion).

A

C Aminophlline is not recommended in children with mild to moderate acte asthma Consider aminophlline in an HDu or PICu setting for children with severe or life

threatening bronchospasm nresponsive to maximal doses of bronchodilators pls steroids.

B Oral 2 agonists are not recommended for acte asthma in infants.

A For mild to moderate acte asthma, a pMDI+spacer is the optimal drg deliver device.

B Consider steroid tablets in infants earl in the management of moderate to severe episodes ofacte asthma in the hospital setting.

B Consider inhaled ipratropim bromide in combination with an inhaled 2 agonist for moresevere smptoms.

Repeated doses of ipratropium bromide should be given early to treat children poorly responsive

to 2 agonists.

Use a dose of 20 mg prednisolone for children aged 2 to 5 years and a dose of 30 - 40 mg forchildren >5 years. Those already receiving maintenance steroid tablets should receive 2 mg/

kg prednisolone up to a maximum dose of 60 mg Repeat the dose of prednisolone in children who vomit and consider IV steroids Treatment for up to three days is usually sufficient, but the length of course should be tailored

to the number of days necessary to bring about recovery. Weaning is unnecessary unless the

course of steroids exceeds 14 days.

Do not give antibiotics routinely in the management of acute childhood asthma.

Steroid tablet therapy (10 mg of soluble prednisolone for up to three days) is the preferred steroidpreparation for use in this age group.



ASTHMA IN ADOLESCENTS

Adolescents are defined by the World Health Organisation (WHO) as young people between the ages10 and 19 years of age.

Key elements of working effectively with adolescents in the transition to adulthood include:

seeing them on their own, separate from their parents/carers, for part of the consultation, and discussing confidentiality and its limitations.

Clinicians seeing adolescents with any cardio-respiratory symptoms should consider asking aboutsymptoms of asthma.

DIAGNOSIS AND ASSESSMENT

Symptoms and signs of asthma in adolescents are no different from those of other age groups.

Exercise-related wheezing and breathlessness are common asthma symptoms in adolescents but

only a minority show objective evidence of exercise-induced bronchospasm. Other causes such ashyperventilation or poor fitness can usually be diagnosed and managed by a careful clinical assessment.

Qestionnaires The asthma control questionnaire has been validated forchildren up to 16 years.

Qalit of life measres QoL scales (such as AQLQ12+) can be used.

Lng Fnction Tests of airflow obstruction and airway responsivenessmay provide support for a diagnosis of asthma but most

adolescents with asthma will have normal lung function.

Bronchial hper-reactivit A negative response to an exercise test is helpful in excludingasthma in children with exercise related breathlessness.

Anxiet and depressive disorders Major depression, panic attacks and anxiety disorder arecommoner in adolescents with asthma and make asthmasymptoms more prominent.

Brief screening questionnaires for anxiety and depression mayhelp identify those with significant anxiety and depression.


Research finding Recommendation

Tobaccosmoking and

environmental

exposre totobacco smoke

(ETS)

Passive and active smokingare significantly risk factors

for asthma and wheezing in

adolescents.

Adolescents with asthma (and their parents andcarers) should be encouraged to avoid exposureto ETS and should be informed about the risks and

urged not to start smoking.

Adolescents with asthma should be asked if theysmoke personally. If they do and wish to stop,they should be offered advice on how to stop and

encouraged to use local NHS smoking cessation

services.

Complementarand alternative

medicine (CAM)

CAM use in adolescentswith asthma appears to be

widespread and may be amarker for non-adherence

Healthcare professionals should be aware thatCAM use is common in adolescents and shouldask about its use.

New2011

PREVALENCE OF ASTHMA IN ADOLESCENCE

Asthma is common in adolescents but is frequently undiagnosed because of under-reporting ofsymptoms.



PHARMACOLOGICAL MANAGMENT

Specific evidence about the pharmacological management of adolescents with asthma is limited and

is usually extrapolated from paediatric and adult studies. Pharmacological management of asthma iscovered on pages 8-11.

Specific evidence about inhaler device use and choice in adolescents is also limited. Inhaler devices

are covered on page 12.

Research finding Recommendation

Inhaler devices Adolescents may becompetent at using their

inhaler devices, but theiradherence to treatment

may be affected by other

factors such as preference.

Adolescent preference for inhaler device should betaken into consideration as a factor in improvingadherence to treatment.

As well as checking inhaler technique it is importantto enquire about factors that may affect inhaler device

use in real life settings such as school.

Consider prescribing a more portable device (as analternative to a pMDI with spacer) for delivering

bronchodilators when away from home.

ORGANISATION AND DELIVERy OF CARE

Schools as a setting for healthcare deliver and asthma edcation

LONG TERM OuTLOOK AND ENTRy INTO THE WORK PLACE

Young adults with asthma have a low awareness of occupations that might worsen asthma (eg,

exposure to dusts, fumes, spray, exertion and temperature changes, see page 23).

Clinicians should discuss future career choices with adolescents with asthma and highlightoccupations that might increase susceptibility to work related asthma symptoms.

Transition to adlt based health care

Transition to adult services is important for all adolescents with asthma, irrespective of the asthmaseverity. Transition should be thought of as a process and not just the event of transfer to adult

services. It should begin early, be planned and involve the young person and be both age and

developmentally appropriate. In the UK, general guidance on transition is available from the RCPCHand DOH websites.

PATIENT EDuCATION AND SELF-MANAGEMENT

Effective transition care involves preparing adolescents with asthma to take independent responsibilityfor their own asthma management. Clinicians need to educate adolescents to manage as much of

their asthma care as they are capable of doing while supporting parents gradually to hand overresponsibility for management to their child.

Adherence

When asked, adolescents with asthma admit their adherence with asthma treatment and with

asthma trigger avoidance is often poor. Strategies to improve adherence in emphasise the importance of focusing on the individual and

their lifestyle and using individualised asthma planning and personal goal setting

Integration of school based clinics with primary care services is essential.

B Peer-led interventions for adolescents in the school setting shold be considered.

B School based clinics ma be considered for adolescents with asthma to improve attendance.



ASTHMA IN PREGNANCy

ACuTE ASTHMA IN PREGNANCy

DRuG THERAPy IN PREGNANCy

DRuG THERAPy IN BREASTFEEDING MOTHERS

MANAGEMENT DuRING LABOuR

Several physiological changes occur during pregnancy which could worsen or improve asthmaPregnancy can affect the course of asthma and asthma can affect pregnancy outcomes

D Women with asthma shold be advised of the importance of good control of their asthmadring pregnanc to avoid problems for both mother and bab.

C use long acting 2 agonists as normal use inhaled steroids as normal use oral and intravenos theophllines as normal.

C use steroid tablets as normal when indicated for severe asthma. Steroid tablets shold never bewithheld becase of pregnanc.

D Lekotriene antagonists ma be contined in women who have demonstrated significantimprovement in asthma control with these agents prior to pregnanc not achievable with other

medications.

C Give drg therap for acte asthma as for the non-pregnant patient, inclding sstemic steroidsand magnesim slphate.

D Acte severe asthma in pregnanc is an emergenc and shold be treated vigorosl inhospital

Deliver high flow oxgen immediatel to maintain satration 94-98%.

CD If anaesthesia is reqired, regional blockade is preferable to general anaesthesia use prostaglandin F2 with extreme cation becase of the risk of indcing

bronchoconstriction.

C Encorage women with asthma to breast feed use asthma medications as normal dring lactation.

C Monitor pregnant women with moderate/severe asthma closel to keep their asthma wellcontrolled.

Advise women who smoke about the dangers for themselves and their babies and giveappropriate support to stop smoking.

Continuous fetal monitoring is recommended for severe acute asthma For women with poorly controlled asthma there should be close liaison between the

respiratory physician and obstetrician, with early referral to critical care physicians for women

with acute severe asthma

Advise women:- that acute asthma is rare in labour

- to continue their usual asthma medications in labour

Women receiving steroid tablets at a dose exceeding prednisolone 7.5 mg per day for > 2weeks prior to delivery should receive parenteral hydrocortisone 100 mg 6-8 hourly during

labour

In the absence of acute severe asthma, reserve caesarean section for the usual obstetric

indications.

B use short acting 2 agonists as normal dring pregnanc.

evised

2009

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DIFFICuLT ASTHMA

Difficlt asthma is defined as persistent smptoms and/or freqent exacerbations

despite treatment at step 4 or 5

ASSESSING DIFFICuLT ASTHMA

FACTORS THAT CONTRIBuTE TO DIFFICuLT ASTHMA

POOR ADHERENCE

PSyCHOSOCIAL FACTORS

MONITORING AIRWAy RESPONSE

DPatients with difficlt asthma shold be sstematicall evalated, inclding:

confirmation of the diagnosis of asthma identification of the mechanism of persisting smptoms and assessment of adherence with

therap.

D This assessment shold be facilitated throgh a dedicated mltidisciplinar difficlt asthmaservice, b a team experienced in the assessment and management of difficlt asthma.

C Poor adherence with maintenance therap shold be considered as a possible mechanism indifficlt asthma.

C Healthcare professionals shold be aware that difficlt asthma is commonl associated withcoexistent pschological morbidit.

D Assessment of coexistent pschological morbidit shold be performed as part of a difficltasthma assessment - in children this ma inclde a pschosocial assessment of the famil.

B In patients with difficlt asthma, consider monitoring indced sptm eosinophil conts togide steroid treatment.



ORGANISATION AND DELIVERy OF CARE

ROuTINE PRIMARy CARE

STRuCTuRED REVIEW

ACuTE EXACERBATIONS

PATIENT SuBGROuPS

A All people with asthma shold have access to primar care services delivered b doctors andnrses with appropriate training in asthma management.

B Consider carring ot rotine reviews b telephone for people with asthma.

A In primar care, people with asthma shold be reviewed reglarl b a nrse or doctorwith appropriate training in asthma management. The review shold incorporate a written

action plan.

C General practices shold maintain a register of people with asthma Clinical review shold be strctred and tilise a standard recording sstem

B Feedback of adit data to clinicians shold link gidelines recommendations to management of

individal patients.

D Healthcare professionals who provide asthma care shold have heightened awareness of thecomplex needs of ethnic minorities, sociall disadvantaged grop, adolescents, the elderl and

those with commnication difficlties.

C Manage hospital inpatients in specialist rather than general nits.

B Clinicians in primar and secondar care shold treat asthma according to recommendedgidelines.

A Discharge form hospital or ED shold be a planned, spervised event which incldes self-management planning. It ma safel take place as soon as clinical improvement is apparent.

A All people attending hospital with acte exacerbations of asthma shold be reviewed b aclinician with particlar expertise in asthma management, preferabl within 30 das.



PATIENT EDUCATION

CONCORDANCE AND COMPLIANCE

Ask open-ended questions like If we could make one thing better for your asthma

what would it be? This may help to elicit a more patient-centred agenda

Make it clear you are listening and responding to the patients concerns and goals

Reinforce practical information and negotiated treatment plans with written instruction

Consider reminder strategies

Recall patients who miss appointments

ASTHMA ACTION PLANS SELF-MANAGEMENT IN PRACTICE

Written personalised action plans as part ofself-management education have been shown

to improve health outcomes for people withasthma

The Be in Control asthma action plan from

Asthma UK can be downloaded direct from thetheir website: www.asthma.org.uk/control

It can also be obtained by contacting AsthmaUK directly 0800 121 6255.

Introduce personalised action plans as part of a structured educational discussion.A

PRACTICAL TIPS FOR IMPROVING COMPLIANCE

A Patients with asthma should be offered self-management education that focuses onindividual needs, and be reinforced by a written personalised action plan

Prior to discharge, in-patients should receive written personalised action plans, given by

clinicians with expertise in asthma management.

B Initiatives which encourage regular, structured review explicitly incorporating self managementeducation should be used to increase ownership of personalised action plans.

A hospital admission represents a window of opportunity to review self-management skills. No

patient should leave hospital without a written personalised action plan and the benefit may

be greatest at first admission. An acute consultation offers the opportunity to determine what action the patient has already

taken to deal with the exacerbation. Their self-management strategy may be reinforced or

refined and the need for consolidation at a routine follow up considered A consultation for an upper respiratory tract infection, or other known trigger, is an

opportunity to rehearse self-management in the event of their asthma deteriorating Brief simple education linked to patient goals is most likely to be acceptable to patients.

Provide simple, verbal and written instructions and information on drug treatment for patients and

carers.

Computer repeat-prescribing systems provide a useful index of compliance.



OCCuPATIONAL ASTHMA

1.At

least1in10casesofneworreappearanceofchildhoodasthmainadultlifeareattributabletooccupation.

2.En

quireofadultpatientswithrhinitisorasthmaabouttheirjobandthematerials

withwhichtheywork.

3.Rhino-conjunctivitismayprecedeIgE-ass

ociatedoccupationalasthma;therisko

fdevelopingasthmabeinghighestinth

eyearaftertheonsetofrhinitis.

4.Th

eprognosisofoccupationalasthmaisimprovedbyearlyidentificationandear

lyavoidanceoffurtherexposuretoitsc

ause

5.Confirmadiagnosissupportedbyobjectivecriteriaandnotonthebasisofacom

patiblehistoryalonebecauseofthepo

tentialimplicationsforemployment.

6.Ar

rangeforworkerswhomyoususpectofhavingwork-relatedasthmatoperform

serialpeakflowmeasurementsatleas

tfourtimesaday.

WORK-RELATEDASTHMAANDRHINITIS:CASEFINDINGANDMANAGEME

NTINPRIMARYCARE

Dosymptomsimprove

whenawayfromwork

ordeterioratew

henatwork?

GuidelinesfortheIdentification,

ManagementandPrevention

ofOccupationalAsthmaww

w.bohrf.org.u

k/content/asthm

a.h

tm

BritishOccupationalHealthResearchFoundation

,6StAndrewsPlace,RegentsPark,LondonNW14LB

Hasanoccupationalcauseofsymptomsbeen

exclud

ed?1,2

No

Yes

No

Yes

Yes

ASTHMA

RHINITI

Hasthe

patient

developed

asthma?

b

aking

p

astrymaking

s

praypainting

laboratoryanimalwork

h

ealthcare

d

entalcare

foodprocessing

w

elding

s

oldering

m

etalwork

w

oodwork

c

hemicalprocessing

textile,plasticsandrubbermanufacture

farmingandotherjobswithexposuretodustsandfumes

Highriskwork

2i

nc

ludes:

Non-occupationaldisease

Continuetreatment

Possiblework-relatedasthma

Referquicklytoachestphysician

oroccupationalphysician

4,5

ArrangeserialPEFmeasurements6

Possiblework-relatedrhinitis

Refertoa

nallergyspecialistoroccupationalphysician

Monitor

forthedevelopmentofasthmasymptoms

3


28/28

British Thoracic Societ,17 Doughty Street, London WC1N 2PLwww.brit-thoracic.org.uk

Scottish Intercollegiate Gidelines Network

Elliott House, 8 -10 Hillside Crescent, Edinburgh EH7 5EAwww.sign.ac.uk

Asthma nice guidlines.pdf

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