British Guideline on the Management of Asthma
Aims
• Review of current SIGN/BTS guidelines
– Diagnosing Asthma
– Stepwise management of Asthma
– Managing Acute Asthma
– When to admit
Age Groups
• Children
• Adults
Diagnostic Algorithms
• Clinical features– Increase/decrease the probability of Asthma
• Diagnostic probability– Low, intermediate and high.
Clinical features & Probability
• Increase– Wheeze, cough, shortness of
breath, tight chest.– Worse at night/morning– Triggers
• Exercise,allergen,cold air, drugs
– Atopy– FH asthma/atopy– Widespread wheeze– Response to treatment– Unexplained low FEV1 or
eosinophilia
• Decrease– No interval symptoms– Cough only– Moist cough– Hyperventilation symptom– Normal examination– Normal PF/spirometry– No response to Rx– Cardiac disease– Voice disturbance– Significant smoking history
Management
• Non-pharmacological– Breast feeding– Avoidance of tobacco smoke– Weight reduction
• Pharmacological
Pharmacological Management
• Aim for complete control– No daytime symptoms, no night time awakening, no
need for rescue meds, no exacerbations, normal activity, normal lung function.
• Stepwise approach– Start at most appropriate step– Early control– Maintain by stepping up or down
Stepwise Management in Adults
Management in Children 5-12 yrs
Management in Children <5 yrs
Management of Acute Asthma
Management of Acute Asthma
• Assessment– Clinical features– PEF– Pulse oximetry– Blood gases (ABG)– Chest X-ray
• Not routine– Suspected pneumothorax, consolidation, life threatening,
failure to respond, requiring ventilation
Management of Acute Asthma• Moderate
– PEFR >50-75%– No severe features
• Severe– PEFR 33-50%– RR ≥ 25 (adult), >30 (>5yrs), >40 (2-5yrs)– HR ≥ 110 (adult), >125 (>5yrs), >140 (2-5yrs)– Unable to complete sentences or feed
• Life threatening– PEFR <33%– SpO2 <92%– Silent chest, cyanosis, exhaustion, altered consciousness
Management of Acute Asthma• Oxygen
– Hypoxic patients – aim 94-98%– Drive nebulisers with oxygen
2 agonist bronchodilators– As early as possible– Consider continuous nebulisers if poor initial response
• Oral steroids
• Ipratropium bromide
• IV magnesium sulphate– Poor response to 2 agonist or life threatening
• IV salbutamol/aminophylline - Paediatrics
Admission criteria - Adults
• Life threatening– Immediately
• Severe– If any features of severe attack after initial
treatment
Admission criteria - Children
• Severe of life threatening– Immediately
• Moderate– No improvement after 10 puffs of 2 agonist
Difficult Asthma
• Persistent symptoms or frequent exacerbations despite step 4 or 5– Confirm diagnosis– Consider poor compliance– Consider psychosocial assessment
Conclusion
• Asthma is frequently under treated
• Use current guidelines to aid diagnosis and help in acute and chronic management
• If patients are not responding as you would expect– Is the diagnosis right?– Are they taking the appropriate medication?– Are psychological or social factors hindering
management?