g logo ipb green

Summary of the management of asthma in adults (from the British guideline on the management of asthma)

mcq thumb

Read this summary and then ‘Test and reflect’ using our multiple-choice questions.
Earn 0.5 CPD credits for reading the summary and an additional 0.5 CPD credits for completing the multiple-choice questions.

Diagnosis

  • Undertake a structured clinical assessment to assess the initial probability of asthma. This should be based on:
    • a history of recurrent episodes (attacks) of symptoms, ideally corroborated by variable peak flows when symptomatic and asymptomatic
    • symptoms of wheeze, cough, breathlessness and chest tightness that vary over time
    • recorded observation of wheeze heard by a healthcare professional
    • personal/family history of other atopic conditions (in particular, atopic eczema/dermatitis, allergic rhinitis)
    • no symptoms/signs to suggest alternative diagnoses
  • In patients with a high probability of asthma:
    • record the patient as likely to have asthma and commence a carefully monitored initiation of treatment (typically 6-weeks of inhaled corticosteroids)
    • assess the patient’s status with a validated symptom questionnaire, ideally corroborated by lung function tests (forced expiratory volume in the first second [FEV1] at clinic visits or by domiciliary serial peak flows)
    • with a good symptomatic and objective response to treatment, confirm the diagnosis of asthma and record the basis on which the diagnosis was made
    • if the response is poor or equivocal, check inhaler technique and adherence, arrange further tests and consider alternative diagnoses

 

Diagnostic algorithm



  • If there is a low probability of asthma and/or an alternative diagnosis is more likely, investigate for the alternative diagnosis and/or undertake or refer for further tests of asthma
  • Spirometry, with bronchodilator reversibility as appropriate, is the preferred initial test for investigating intermediate probability of asthma in adults
  • In patients with an intermediate probability of asthma and airways obstruction identified through spirometry, undertake reversibility tests and/or a monitored initiation of treatment assessing the response to treatment by repeating lung function tests and objective measures of asthma control
  • In patients with an intermediate probability of asthma and normal spirometry results, undertake challenge tests and/or measurement of FeNO to identify eosinophilic inflammation

Monitoring

  • Closer monitoring of individuals with poor lung function and with a history of asthma attacks in the previous year should be considered
  • Symptomatic asthma control is best assessed using directive questions such as the Royal College of Physicians' (RCP) '3 questions', or the Asthma Control Questionnaire or Asthma Control Test
  • In adults the following factors should be monitored and recorded in primary care:
    • symptomatic asthma control
    • lung function assessed by spirometry or by peak expiratory flow (PEF)
    • asthma attacks, oral corticosteroid use and time off work since last assessment
    • inhaler technique
    • adherence
    • bronchodilator reliance
    • possession of and use of a self-management plan/personal action plan

Supported self-management

  • All people with asthma (and/or their parents or carers) should be offered self-management education which should include a written personalised asthma action plan and be supported by regular professional review
  • Written personalised asthma action plans may be based on symptoms and/or peak flow
  • Strategies that have been used to support effective self-management include:
    • the use of proactive triggers to ensure routine reviews
    • structured protocols for asthma reviews
    • support of community pharmacists
    • routine mailing of educational resources
    • telephone calls to provide ongoing support and advice
    • IT-based education and monitoring
    • involvement of community workers to support clinical teams in deprived and/or ethnic minority communities

Non-pharmacological management

  • Parents with asthma should be advised about the dangers, to themselves and to their children with asthma, of smoking, and be offered appropriate support to stop smoking
  • Weight-loss interventions (including dietary and exercise-based programmes) can be considered for overweight and obese adults with asthma to improve asthma control
  • Breathing exercise programmes (including physiotherapist-taught methods) can be offered to people with asthma as an adjuvant to pharmacological treatment to improve quality of life and reduce symptoms

Pharmacological management

Summary of management in adults

 

  • The aim of asthma management is control of the disease. Complete control of asthma is defined as:
    • no daytime symptoms
    • no night-time awakening due to asthma
    • no need for rescue medication
    • no asthma attacks
    • 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

Approach to management

  • Start treatment at the level most appropriate to the initial severity
  • Achieve early control
  • Maintain control by:
    • increasing treatment as necessary
    • decreasing treatment when control is good
  • Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique, and eliminate trigger factors
  • Anyone prescribed more than one shortacting bronchodilator inhaler device a month should be identified and have their asthma assessed urgently and measures taken to improve asthma control if this is poor
  • Combination inhalers are recommended to:
    • guarantee that the long-acting β2 -agonist is not taken without inhaled corticosteroid
    • improve inhaler adherence

Decreasing treatment

    • Regular review of patients as treatment is decreased is important. When deciding which drug to decrease first and at what rate, the severity of asthma, the side-effects of the treatment, time on current dose, the beneficial effect achieved, and the patient’s preference should all be taken into account

 

Table 1: Categorisation of inhaled corticosteroids (ICS) by dose—adults*,
ICSDose
Low dose Medium dose High dose
PRESSURISED METERED DOSE INHALERS (pMDI)
Beclometasone dipropionate
Non-proprietary 100 µg two puffs twice a day 200 µg two puffs twice a day 200 µg four puffs twice a day
Clenil modulite 100 µg two puffs twice a day 200 µg two puffs twice a day 250 µg two puffs twice a day or
250 μg four puffs twice a day
Qvar (extrafine) Qvar Autohaler Qvar Easi-Breathe 50 µg two puffs twice a day 100 µg two puffs twice a day 100 µg four puffs twice a day
Ciclesonide
Alvesco aerosol inhaler 80 µg two puffs once a day 160 µg two puffs once a day
Fluticasone propionate
Flixotide Evohalerr 50 µg two puffs twice a day 125 µg two puffs twice a day 250 µg two puffs twice a day
DRY POWDER INHALERS (DPI)
Beclometasone
Non-proprietary Easyhaler 200 µg one puff twice a day 200 µg two puffs twice a day
Asmabec 100 µg one puff twice a day 100 µg two puffs twice a day
Budesonide
Non-proprietary Easyhaler 100 µg two puffs twice a day 200 µg two puffs twice a day 400 µg two puffs twice a day
Budelin Novolizer 200 µg two puffs twice a day 200 µg four puffs twice a day
Pulmicort Turbohaler 100 µg two puffs twice a day or
200 µg one puff twice a day
200 µg two puffs twice a day or
400 µg one puff twice a day
400 µg two puffs twice a day
Fluticasone propionate
Flixotide Accuhaler 100 µg one puff twice a day 250 µg one puff twice a day 500 µg one puff twice a day
Mometasone
Asmanex Twisthaler 200 µg one puff twice a day 400 µg one puff twice a day
COMBINATION INHALERS
Beclometasone dipropionate (extrafine) with formoterol
Fostair (pMDI) 100 µg/6 µg one puff twice a day 100 µg/6 µg two puffs twice a day 200 µg/6 µg two puffs twice a day
Fostair (NEXThaler) 100 µg/6 µg one puff twice a day 100 µg/6 µg two puffs twice a day 200 μg/6 μg two puffs twice a day
Budesonide with formoterol
DuoResp Spiromax 200 µg/6 µg one puff twice a day 200 µg/6 µg two puffs twice a day or
400 µg/12 µg one puff twice a day
400 µg/12 µg two puffs twice a day
Symbicort Turbohaler 100 µg/6 µg two puffs twice a day or
200 µg/6 µg one puff twice a day
200 µg/6 µg two puffs twice a day or
400 µg/12 µg one puff twice a day
400 µg/12 µg two puffs twice a day
Fluticasone propionate with formoterol
Flutiform 50 µg/5 µg two puffs twice a day 125 µg/5 µg two puffs twice a day 250 µg/10 µg two puffs twice a day
Fluticasone propionate with salmeterol
Seretide Accuhaler 100 µg/50 µg one puff twice a day 250 µg/50 µg one puff twice a day 500 µg/50 µg one puff twice a day
Seretide Evohaler 50 µg/25 µg two puffs twice a day 125 µg/25 µg two puffs twice a day 250 µg/25 µg two puffs twice a day
Fluticasone furoate with vilanterol
Relvar 92 µg/22 µg one puff once a day 184 µg/22 µg one puff once a day
* It is the editorial policy of Guidelines not to use proprietary drug or device names, however, an exception has been made in this case to aid discrimination between different devices containing the same drug and/or propellant
Different products and doses are licensed for different age groups and some may be applicable to older children. Prior to prescribing, the relevant summary of product characteristics (SPC) should be checked (www.medicines.org.uk/emc)
Medium doses should only be used after referral of patient to secondary care.

 

  • Patients should be maintained at the lowest possible dose of inhaled corticosteroid. Reduction in inhaled corticosteroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every 3 months, decreasing the dose by approximately 25-50% each time

Exercise-induced asthma

  • For most patients, exercise-induced asthma is an expression of poorly controlled asthma and regular treatment, including inhaled corticosteroids, should be reviewed
  • If exercise is a specific problem in patients taking inhaled corticosteroids who are otherwise well controlled, consider the following therapies:
    • leukotriene receptor antagonists
    • long-acting β2 -agonists
    • sodium cromoglicate or nedocromil sodium
    • oral β2 -agonists
    • theophyllines
  • Immediately prior to exercise, inhaled short-acting β2 -agonists are the drug of choice

Inhaler devices

Technique and training

  • Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique

β2 -agonist delivery

  • Acute asthma: adults with mild and moderate asthma attacks should be treated with a pMDI + spacer with doses titrated according to clinical response
  • Stable asthma: a pMDI ± spacer is as effective as any other hand-held inhaler, but patients may prefer some types of DPI

Inhaled corticosteroids for stable asthma

  • A pMDI ± spacer is as effective as any DPI

Prescribing devices

  • 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 the prescribed inhaler device (particularly for any change in device) assessed by a competent healthcare professional
  • The medication needs to be titrated against clinical response to ensure optimum efficacy
  • Reassess inhaler technique as part of structured clinical review
  • Generic prescribing of inhalers should be avoided as this might lead to people with asthma being given an unfamiliar inhaler device which they are not able to use properly
  • Prescribing mixed inhaler types may cause confusion and lead to increased errors in use. Using the same type of device to deliver preventer and reliever treatments may improve outcomes

Management of acute asthma

Initial assessment

  • Moderate asthma:
    • increasing symptoms
    • PEF >50–75% best or predicted
    • no features of acute severe asthma
  • Acute severe asthma, any one of:
    • PEF 33–50% best or predicted
    • respiratory rate >=25/min
    • heart rate >=110/min
    • inability to complete sentences in one breath
  • Life-threatening asthma, in a patient with severe asthma any one of:
    • PEF <33% best or predicted
    • SpO2 <92%
    • PaO2 <8 kPa
    • normal PaCO2 (4.6–6.0 kPa)
    • silent chest
    • cyanosis
    • poor respiratory effort
    • arrhythmia
    • exhaustion
    • altered conscious level
    • hypotension
  • Near fatal asthma:
    • raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

Criteria for admission

  • Admit patients with any feature of a:
    • life-threatening or near-fatal asthma attack
    • severe asthma attack persisting after initial treatment
  • Patients whose peak flow is greater than 75% best or predicted 1 hour after initial treatment may be discharged from emergency department unless they meet any of the following criteria, when admission may be appropriate:
    • still have significant symptoms
    • concerns about adherence
    • living alone/socially isolated
    • psychological problems
    • physical disability or learning difficulties
    • previous near-fatal asthma attack
    • asthma attack despite adequate dose steroid tablets prior to presentation
    • presentation at night
    • pregnancy

Treatment of acute asthma

  • Oxygen:
    • give controlled supplementary oxygen to all hypoxaemic patients with acute severe asthma titrated to maintain an SpO2 level of 94–98%
    • do not delay oxygen administration in the absence of pulse oximetry but commence monitoring of SaO2 as soon as it becomes available
  • β2 -agonist bronchodilators:
    • use high-dose inhaled β2 -agonists as first-line agents in patients with acute asthma and administer as early as possible. Reserve intravenous β2 -agonists for those patients in whom inhaled therapy cannot be used reliably
    • in patients with acute asthma with lifethreatening features the nebulised route (oxygen-driven) is recommended
    • in patients with severe asthma that is poorly responsive to an initial bolus dose of β2 -agonist, consider continuous nebulisation with an appropriate nebuliser
  • Steroid therapy:
    • give steroids in adequate doses to all patients with an acute asthma attack
    • continue prednisolone (40–50 mg daily) for at least 5 days or until recovery
    • do not stop inhaled corticosteroids during prescription of oral corticosteroids

Referral to intensive care or high-dependency units

  • Refer any patient:
    • requiring ventilatory support
    • with acute severe or life-threatening asthma, failing to respond to therapy, as evidenced by:
      • deteriorating PEF
      • persisting or worsening hypoxia
      • hypercapnia
      • arterial blood gas analysis showing ↓pH, or ↑H+ concentration
      • exhaustion, feeble respiration
      • drowsiness, confusion, altered conscious state
      • respiratory arrest

Follow-up

  • It is essential that the patient's primary care practice is informed within 24 hours of discharge from the emergency department or hospital following an asthma attack
  • Follow-up after treatment or discharge from hospital:
    • GP review within 2 working days
    • monitor symptoms and PEF
    • check inhaler technique
    • written asthma action plan
    • modify treatment according to guidelines for chronic persistent asthma
    • address potentially preventable contributors to admission
Now Test and Reflect: view our multiple choice questions

full guidelines available from...
www.sign.ac.uk/guidelines/fulltext/153/index.html

British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. September 2016.
Reproduced with kind permission from SIGN.
Additional content on: asthma in pregnancy, asthma in adolescents, and occupational asthma is available online at Guidelines.co.uk
First included: June 2003.

g logo gip purple

Read the Guidelines in Practice article A structured approach is key to diagnosing asthma for more information on implementing the BTS/SIGN British guideline on the management of asthma
in adults and children