This Guidelines summary is part of a series of summaries of the British Thoracic Society/Scottish Intercollegiate Guidelines Network guideline 158: British guideline on the diagnosis and management of asthma.
This summary focuses on recommendations for the management of asthma in adults, including diagnosis, monitoring, pharmacological management, and management of acute asthma. For the complete set of recommendations, please refer to the full guideline.
Follow the links for summaries of BTS/SIGN recommendations on the diagnosis and management of asthma in the following groups:
Grades of recommendation
The grade of recommendation relates to the strength of the supporting evidence on which the evidence is based. It does not reflect the clinical importance of the recommendation.
[A] At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results.
[B] A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1.
[C] A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++.
[D] Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+.
[✓] Recommended best practice based on the clinical experience of the guideline development group.
For the full key of evidence statements and recommendations, please see the full guideline.
Compare the results of diagnostic tests undertaken whilst a patient is asymptomatic with those undertaken when a patient is symptomatic to detect variation over time [C].
Initial structured clinical assessment
The predictive value of individual symptoms or signs is poor, and a structured clinical assessment including all information available from the history, examination and historical records should be undertaken. Factors to consider in an initial structured clinical assessment include:
More than one of the symptoms of wheeze, breathlessness, chest tightness and cough occurring in episodes with periods of no (or minimal) symptoms between episodes. For example:
- a documented history of acute attacks of wheeze, triggered by viral infection or allergen exposure with symptomatic and objective improvement with time and/or treatment
- recurrent intermittent episodes of symptoms triggered by allergen exposure as well as viral infections and exacerbated by exercise and cold air
- in adults, symptoms triggered by taking non-steroidal anti-inflammatory medication or beta blockers.
An historical record of significantly lower FEV₁ or PEF during symptomatic episodes compared with asymptomatic periods provides objective confirmation of the obstructive nature of the episodic symptoms.
Wheeze confirmed by a healthcare professional on auscultation
It is important to distinguish wheezing from other respiratory noises, such as stridor or rattly breathing.
Repeatedly normal examination of chest when symptomatic reduces the probability of asthma.
Evidence of diurnal variability
Symptoms which are worse at night or in the early morning.
Personal history of an atopic disorder (ie eczema or allergic rhinitis) or a family history of asthma and/or atopic disorders, potentially corroborated by a previous record of raised allergen-specific IgE levels, positive skin-prick tests to aeroallergens or blood eosinophilia.
Absence of symptoms, signs or clinical history to suggest alternative diagnoses (including but not limited to COPD, dysfunctional breathing, obesity).
Assess probability of asthma based on initial structured clinical assessment
Please refer to the full guideline for recommendations on high, intermediate, and low probability of asthma.
Diagnostic indications for referral
At any point in the diagnostic algorithm, there may be a need for referral for additional investigations and/or specialist advice. Some key indications for referral to specialist care are given below.
Refer for additional investigation and specialist advice if:
- Diagnosis unclear
- Suspected occupational asthma (symptoms that improve when patient is not at work, adult-onset asthma and workers in high-risk occupations)
- Poor response to asthma treatment
- Severe/life-threatening asthma attack
‘Red flags’ and indicators of other diagnoses
- Prominent systemic features (myalgia, fever, weight loss)
- Unexpected clinical findings (eg crackles, clubbing, cyanosis, cardiac disease, monophonic wheeze or stridor)
- Persistent non-variable breathlessness
- Chronic sputum production
- Unexplained restrictive spirometry
- Chest X-ray shadowing
- Marked blood eosinophilia
Patient anxiety or need for reassurance
The core components of an asthma review that should be assessed and recorded on at least an annual basis are current symptoms, future risk of attacks, management strategies, and supported self management [✓].
Monitoring current asthma symptom control
When asking about asthma symptoms, use specific questions, such as the Royal College of Physicians ‘3 Questions’ or questions about reliever use, with positive responses prompting further assessment with a validated questionnaire to assess symptom control [✓].
Please refer to the full guideline for recommendations on assessing risk of future asthma attacks.
Supported self management
Please refer to the full guideline for recommendations on supported self management (including personalised asthma action plans [PAAPs]).
Please refer to the full guideline for recommendations on non-pharmacological management (including primary and secondary prevention).
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 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.
See above for summary of pharmacological management in adults.
See next page for summary of pharmacological management in adults.
Approach to management
1. Start treatment at the level most appropriate to initial severity.
2. Achieve early control.
3. 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 [✓].
Intermittent reliever therapy
Prescribe an inhaled short-acting β₂ agonist as short-term reliever therapy for all patients with symptomatic asthma [A].
Regular preventer therapy
Inhaled corticosteroids are the recommended preventer drug for adults for achieving overall treatment goals [A].
Give inhaled corticosteroids initially twice daily (except ciclesonide which is given once daily) [A].
Once-a-day inhaled corticosteroids at the same total daily dose can be considered if good control is established [A].
Clinicians should be aware that higher doses of inhaled corticosteroids may be needed in patients who are smokers or ex-smokers [B].
A summary table categorising inhaled corticosteroids by dose in adults for different types of inhaler is included in the full guideline (Table 12) and is available to download separately from the asthma guideline web page at www.sign.ac.uk.
Initial add-on therapy
Before initiating a new drug therapy practitioners should recheck adherence and inhaler technique and eliminate trigger factors.
The first choice of add-on therapy to inhaled corticosteroids in adults is an inhaled long-acting β₂ agonist, which should be considered before increasing the dose of inhaled corticosteroid [A].
In efficacy studies, where there is generally good adherence, there is no difference in efficacy in giving inhaled corticosteriod and a long-acting β₂ agonist in combination or in separate inhalers. In clinical practice, however, it is generally considered that combination inhalers aid adherence and also have the advantage of guaranteeing that the long-acting β₂ agonist is not taken without the inhaled corticosteroid.
Combination inhalers are recommended to:
- guarantee that the long-acting β₂ agonist is not taken without inhaled corticosteroid [✓]
- improve inhaler adherence [✓].
Additional controller therapies
If control remains poor on low-dose (adults) inhaled corticosteroids plus a long-acting β₂ agonist, recheck the diagnosis, assess adherence to existing medication and check inhaler technique before increasing therapy.
If asthma control remains suboptimal after the addition of an inhaled long-acting β₂ agonist then [D]:
- increase the dose of inhaled corticosteroids from low dose to medium dose in adults if not already on these doses.
- consider adding a leukotriene receptor antagonist.
All patients whose asthma is not adequately controlled on recommended initial or additional controller therapies should be referred for specialist care [✓].
- 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 [✓].
- 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 three 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 adding one of the following therapies:
- leukotriene receptor antagonists [A]
- long-acting β₂ agonists [A]
- sodium cromoglicate or nedocromil sodium [C]
- theophyllines [C].
Immediately prior to exercise, inhaled short-acting β₂ agonists are the drug of choice [A].
Technique and training
Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique [B].
β₂ agonist delivery
Adults with mild and moderate asthma attacks should be treated with a pMDI + spacer with doses titrated according to clinical response [A].
In adults, a pMDI ± spacer is as effective as any other hand-held inhaler, but patients may prefer some types of DPI [A].
Inhaled corticosteroids for stable asthma
In adults, a pMDI ± spacer is as effective as any DPI. [A]
- 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 the 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 in adults
Assessment of severe asthma
Healthcare professionals must be aware that patients with severe asthma and one or more adverse psychosocial factors are at risk of death [B].
For management of acute asthma in adults in general practice see algorithm below.
For management of acute asthma in adults in general practice see previous page.
Please refer to the full guideline for the full recommendations on assessment and management of severe asthma.
Want to learn more about this guideline?
Read the related Guidelines in Practice article
British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN) British guideline on the management of asthma. Edinburgh: SIGN; July 2019. (SIGN publication no. 158). Available at: www.sign.ac.uk/media/1048/sign158.pdf. The copyright of Scottish Intercollegiate Guidelines Network (SIGN) guidelines is retained by SIGN. Subject to Copyright Statement (see www.sign.ac.uk/copyright-statement.html)
All SIGN guidelines are subject to regular review and may be updated or withdrawn. SIGN accepts no responsibility for the use of its content in this product/publication.
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