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Asthma
LastrevisedinDecember2013
Backtotop
Changes
LastrevisedinDecember2013
December2013minorupdate.AbrokenlinktotheChildren'sAsthmaControlTesthasbeenfixed.
July2013minorupdate.LinkstotheDVLAwebsitehavebeenupdated.
June2013minorupdate.The2013QOFoptionsforlocalimplementationhavebeenaddedtothistopic[BMAandNHSEmployers,2013
(/asthma#!references/297181)].
May2013minorupdate.Minorchangetothetexttoimprovetheclarityofhowtomanagepeoplewhoareawaitinghospitaladmission.
February2013minorupdate.The2013QIPPoptionsforlocalimplementationhavebeenaddedtothistopic[NICE,2013
October2012minorupdate.The2012QIPPoptionsforlocalimplementationhavebeenaddedtothistopic[NPC,2012
March2012minorupdate.The2012/2013QOFindicatorshavebeenaddedtothistopic[BMAandNHSEmployers,2012
(/asthma#!references/297181)].IssuedinApril2012.
February2012minorupdate.Arecommendationtoadvisepeopleinhalingterbutalineviaaturbohalertorinsetheirmouthaftereachuseto
minimizesystemicadverseeffectshasbeenadded,followinganupdatetothemanufacturer'sSummaryofProductCharacteristics[ABPIMedicines
Compendium,2011b(/asthma#!references/297181)].IssuedinMarch2012.
November2011minorupdate.TheblacktrianglehasbeenremovedfromSereventEvohaler(salmeterolcfcfreeinhaler)prescriptionshave
beenamendedtoreflectthis.IssuedinDecember2011.
June2011annualupdatesfromtheBritishguidelineonthemanagementofasthma:anationalclinicalguidelinebySIGN/BTSarenowincluded
[SIGNandBTS,2011(/asthma#!references/297181)].IssuedinJune2011.
May2011minorupdate.The2011/2012QOFindicatorsandthe2010/2011QIPPoptionsforlocalimplementationhavebeenaddedtothistopic
[BMAandNHSEmployers,2011(/asthma#!references/297181)NPC,2011(/asthma#!references/297181)].IssuedinJune2011.
April2011minorupdate.PulmicortpMDIinhalershavebeenremovedfromthistopicastheyhavebeendiscontinued.IssuedinJune2011.
March2011topicstructurerevisedtoensureconsistencyacrossCKStopicsnochangestoclinicalrecommendationshavebeenmade.
February2011minorupdate.Therangeofdrypowderinhalerdevicesincludedasprescriptionshasbeenupdated.IssuedinFebruary2011.
December2010minorupdate.TheFlixotideDiskhaler(fluticasone)rangehasbeendiscontinued.Theprescriptionhasbeenremoved.Issuedin
December2010.
October2010minorupdate.InformationonfitnesstodrivefromtheDriverandVehicleLicensingAgency'sguidanceformedicalpractitioners,Ata
glanceguidetothecurrentmedicalstandardsoffitnesstodrivehasbeenadded[DVLA,2010(/asthma#!references/297181)].IssuedinNovember
2010.
September2010minorupdate.TheMedicinesandHealthcareproductsRegulatoryAgencyhasissuesaremindertoprescribersthat,formost
children,adailydoseof24microgramsformoterolissufficient[MHRA,2010(/asthma#!references/297181)].IssuedinSeptember2010.
March2010minorupdate.AllstrengthsofBeclazoneinhalershavebeendiscontinued.Prescriptionsremoved.Foradviceregardingswitching
fromCFCbeclometasonetoCFCfreebeclometasone,seethesectionWhatdoseofinhaledcorticosteroidshouldIprescribe?
(/asthma#!prescribinginfosub:4).IssuedinMarch2010.

January2010minorupdate.Ciclesonide(Alvesco)isnolongerablacktriangleproduct.Minoradditiontotextregardingdruginteractionswith
theophylline.IssuedinJanuary2010.
December2009minorupdate.ClenilModulite(beclometasoneCFCfree)isnolongerablacktriangleproduct.Prescriptionupdated.Issuedin
December2009.
November2009minorupdate.TheSupportingevidencesectiononSymbicortSmart(/asthma#!supportingevidence1:7)hasbeenrewordedto
makeitclearthatthedatasummarizedarefromasingleCochranereview.IssuedinNovember2009.
August2009minorupdate.TheannualupdatesfromtheBritishguidelineonthemanagementofasthma:anationalclinicalguidelineby
SIGN/BTSarenowincluded[SIGNandBTS,2008b(/asthma#!references/297181)].IssuedinAugust2009.
May2009updatedtoincludeinformationandprescriptionsforbudesonideCFCfreepMDI.TheNebuhalerspacerdevicehasbeendiscontinued.
TheprescriptionhasbeenreplacedwiththeNebuChamberspacerdevice.IssuedinJune2009.
April2009minorupdate.TheQualityandOutcomesFramework(QOF)indicatorsforstoppingsmokingthatrelatetoasthmahavebeenaddedto
theGoalsandoutcomemeasuressection.IssuedinMay2009.
February2009minorupdate.Flixotide50microgramdiskhalerandallstrengthsoftheAerobecbreathactuatedinhalerhavebeen
discontinued.Prescriptionsremoved.IssuedMarch2009.
August2008updatetothediagnosisandassessmentsectionsfollowingthepublicationoftheBritishguidelineonthemanagementofasthma:a
nationalclinicalguidelinebySIGN/BTS[SIGNandBTS,2008a(/asthma#!references/297181)].IssuedinNovember2008.
March2008minorupdatetoincludeadvicefromtheMedicinesandHealthcareproductsRegulatoryAgency(MHRA)regardingtheuseofshort
actingbeta2agonistsinpeoplewhohaveahistoryofheartdisease.IssuedinMarch2008.
SeptembertoDecember2007convertedfromCKSguidancetoCKStopicstructure.Theevidencebasehasbeenreviewedindetail,and
recommendationsaremoreclearlyjustifiedandtransparentlylinkedtothesupportingevidence.
ThisCKStopicincludesrevisionsinthe2007updatetotheSIGN/BTSBritishGuidelineontheManagementofAsthma.
Previouschanges Backtotop
June2007updated.Nebuhalerdiscontinued.PrescriptionsreplacedwithNebuhaler+mask,whichcontinuestobeavailable.IssuedinJune
2007.
May2007updated.BecotideandBeclofortediscontinued.Prescriptionsremoved.IssuedinMay2007.
March2007updated.PrescriptionsanddosinginformationforClenilModulite(CFCfreebeclometasone)andCFCfreeformoterolincluded.
Informationonspacerdevicecompatibilitiesalsoupdated.IssuedinMarch2007.
JulySeptember2006updated.ValidatedinDecember2006andissuedinJanuary2007.
ThisguidanceisbasedontheScottishIntercollegiateGuidelinesNetworkandBritishThoracicSocietyguidelinesonthemanagementofasthma
[SIGNandBTS,2005(/asthma#!references/297181)].AstheSIGNandBTSguidelinewasnotupdatedin2006,therearenomajorchangesto
recommendations.Theguidancehasbeenrestructuredwiththeadditionofanoverviewsection,andrecentsafetyinformationondrugshasbeen
added.Someminortechnicalandevidenceinformationhasnotbeenupdatedduetotimerestraintsthesewillbeaddressedinthenextupdate(due
tocommenceinJuly2007).
July2006minorupdate.AllstrengthsofVentodisks(salbutamoldrypowderDiskhaler)willbediscontinuedfromtheendofSeptember2006
andprescriptionshavebeenremoved.IssuedinJuly2006.
April2006minorupdate.PrescriptionsforCFCfreenedocromilandsalmeterolpressurizedmetereddoseinhalershavereplacedthoseforCFC
containinginhalers.InformationonchangingtoCFCfreeinhalersincludedinMedicinesManagement.IssuedinMay2006.
January2006minorupdate.Volumaticspacerdevicereintroducedandprescriptionsincludedterbutalinepressurizedmetereddoseinhalers
havebeendiscontinuedandprescriptionsremoved.IssuedinFebruary2006.
August2005updatedtoincluderevisionsinthe2005updatetotheSIGN/BTSBritishGuidelineontheManagementofAsthma,andthenew
CMOrecommendationsonthepneumococcalimmunizationprogramme.Volumaticspacerdevicediscontinuedandprescriptionsremovedadvice
forusingalternativespacerdevicesincluded.ValidatedinSeptember2005andissuedinNovember2005.
August2004updatedtoincluderevisionsinthe2004updatetotheSIGN/BTSBritishGuidelineontheManagementofAsthma.Validatedin
September2004andissuedinNovember2004.
April2003reviewed.ValidatedinSeptember2003andissuedinOctober2003.ThisguidancesupersedestheCKSguidanceAsthmaage
under5years,whichhasbeenwithdrawn.
April2002reviewedandupdatedtoincorporateInhalerdevicesforroutinetreatmentofchronicasthmainolderchildren(aged515years),
technologyappraisalguidanceno.38,issuedbytheNationalInstituteforHealthandCareExcellence(April2002).
April1999reviewed.ValidatedinJuly1999andissuedinAugust1999.
June1998written.
Backtotop
Update
Newevidence Backtotop
Evidencebasedguidelines
Guidelinespublishedsincethelastrevisionofthistopic:
Bateman,E.D.,Hurd,S.S.,Barnes,P.J.,etal.(2008)Globalstrategyforasthmamanagementandprevention:GINAexecutivesummary.
EuropeanRespiratoryJournal31(1),143178.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18166595)][FreeFulltext
(http://erj.ersjournals.com/content/31/1/143.full)]
Dombrowski,M.P.,Schatz,M.,andACOGCommitteeonPracticeBulletinsObstetrics(2008)ACOGpracticebulletin:clinicalmanagement
guidelinesforobstetriciangynecologistsnumber90,February2008:asthmainpregnancy.ObstetricsandGynecology111(2Pt1),457464.
[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18238988)]
ICSI(2010)Diagnosisandtreatmentofasthma.InstituteforClinicalSystemsImprovementwww.icsi.org(http://www.icsi.org)[FreeFulltext
(http://www.icsi.org/guidelines_and_more/gl_os_prot/respiratory/asthma__outpatient/asthma__diagnosis_and_outpatient_management_of_12572.html)
NationalHeart,Lung,andBloodInstituteandNationalAsthmaEducationandPreventionProgram(2007)Expertpanelreport3:guidelinesforthe
diagnosisandmanagementofasthma.NationalInstitutesofHealth.www.nhlbi.nih.gov(http://www.nhlbi.nih.gov)[FreeFulltext
(http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm)]
VA/DoDManagementofAsthmaWorkingGroup(2009)Managementofasthmainchildrenandadults.DepartmentofVeteransAffairsand
DepartmentofDefense(US).www.healthquality.va.gov(http://www.healthquality.va.gov)[FreeFulltext
(http://www.healthquality.va.gov/guidelines/CD/asthma/)]
Consensusstatementspublishedsincethelastrevisionofthistopic:
Bacharier,L.B.,Boner,A.,Carlsen,K.H.,etal.(2008)Diagnosisandtreatmentofasthmainchildhood:aPRACTALLconsensusreport.Allergy
63(1),534.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18053013)][FreeFulltext(http://onlinelibrary.wiley.com/doi/10.1111/j.1398
9995.2007.01586.x/full)]
Tarlo,S.M.,Balmes,J.,Balkissoon,R.,etal.(2008)Diagnosisandmanagementofworkrelatedasthma:AmericanCollegeofChestPhysicians
Consensusstatement.Chest134(3Suppl),1S41S.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18779187)][FreeFulltext
(http://journal.publications.chestnet.org/article.aspx?articleid=1044851&issueno=3_suppl)]
NICEhasproducedanevidencesummaryonnewmedicinesforasthma:
NICE(2013)ESNM22:Asthma:beclometasone/formoterol(Fostair)formaintenanceandrelievertreatment.NationalInstituteforHealthandCare
Excellence.www.nice.org.uk(http://www.nice.org.uk)[FreeFulltext(http://publications.nice.org.uk/esnm22asthmabeclometasoneformoterol
fostairformaintenanceandrelievertreatmentesnm22)]
NICE(2014)ESNM35:Asthma:fluticasonefuroate/vilanterol(RelvarEllipta)combinationinhaler.NationalInstituteforHealthandCare
Excellence.www.nice.org.uk(http://www.nice.org.uk)[FreeFulltext(http://publications.nice.org.uk/esnm34asthmafluticasonefuroatevilanterol
relvarelliptacombinationinhaleresnm34/keypointsfromtheevidence)]
HTAs(HealthTechnologyAssessments)
NICEhealthtechnologyappraisalspublishedsincethelastrevisionofthistopic.
NICE(2007)Inhaledcorticosteroidsforthetreatmentofchronicasthmainchildrenundertheageof12years.NICEtechnologyappraisalguidance
131.NationalInstituteforHealthandCareExcellence.www.nice.org.uk(http://www.nice.org.uk)[FreeFulltext(http://www.nice.org.uk/ta131)]
NICE(2008)Inhaledcorticosteroidsforthetreatmentofchronicasthmainadultsandinchildrenaged12yearsandover.NICEtechnology
appraisalguidance138.NationalInstituteforHealthandCareExcellence.www.nice.org.uk(http://www.nice.org.uk)[FreeFulltext
(http://www.nice.org.uk/guidance/TA138)]
NICE(2010)Omalizumabforthetreatmentofseverepersistentallergicasthmainchildrenaged6to11years.NICEtechnologyappraisal
guidance201.NationalInstituteforHealthandCareExcellence.www.nice.org.uk(http://www.nice.org.uk)[Freefulltext
(http://guidance.nice.org.uk/TA201)]
Healthtechnologyassessmentspublishedsincethelastrevisionofthistopic.
CADTH(2009)Longactingbeta2agonistandinhaledcorticosteroidcombinationtherapyforadultpersistentasthma:systematicreviewofclinical
outcomesandeconomicevaluation.Technologyreportnumber122.CanadianAgencyforDrugsandTechnologiesinHealth.www.cadth.ca
(http://www.cadth.ca)[FreeFulltext(http://www.cadth.ca/en/products/healthtechnologyassessment/publication/941)]
Main,C.,Shepherd,J.,Anderson,R.,etal.(2008)Systematicreviewandeconomicanalysisofthecomparativeeffectivenessofdifferentinhaled
corticosteroidsandtheirusagewithlongactingbeta2agonistsforthetreatmentofchronicasthmainchildrenundertheageof12years.Health
TechnologyAssessment12(20),1174.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18485272)][FreeFulltext
(http://www.hta.ac.uk/project/1524.asp)]
Economicappraisals
Economicappraisalspublishedsincethelastrevisionofthistopic:
Norman,G.,Faria,R.,Paton,F.,etal.(2013)Omalizumabforthetreatmentofseverepersistentallergicasthma:asystematicreviewand
economicevaluation.HealthTechnologyAssessment17(52),1342.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/24267198)][FreeFulltext
(http://www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0011/93197/FullReporthta17520.pdf)]
Systematicreviewsandmetaanalyses
Systematicreviewspublishedsincethelastrevisionofthistopic:
Abramson,M.J.,Puy,R.M.,andWeiner,J.M.(2010)Injectionallergenimmunotherapyforasthma(CochraneReview).TheCochraneLibrary.
Issue8.JohnWiley&Sons,Ltd.www.thecochranelibrary.com(http://www.thecochranelibrary.com)[FreeFulltext
(http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001186.pub2/abstract)]
Adams,N.,Lasserson,T.J.,Cates,C.J.,andJones,P.W.(2007)Fluticasoneversusbeclomethasoneorbudesonideforchronicasthmainadults
andchildren(CochraneReview).TheCochraneLibrary.Issue4.JohnWiley&Sons,Ltd.www.thecochranelibrary.com
(http://www.thecochranelibrary.com)[FreeFulltext(http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002310.pub4/abstract)]
Adams,N.P.,Bestall,J.C.,Jones,P.,etal.(2008)Fluticasoneatdifferentdosesforchronicasthmainadultsandchildren(CochraneReview).The
CochraneLibrary.Issue4.JohnWiley&Sons,Ltd.www.thecochranelibrary.com(http://www.thecochranelibrary.com)[FreeFulltext
Adams,N.P.,Bestall,J.C.,Lasserson,T.J.,etal.(2008)Fluticasoneversusplaceboforchronicasthmainadultsandchildren(CochraneReview).
TheCochraneLibrary.Issue4.JohnWiley&Sons,Ltd.www.thecochranelibrary.com(http://www.thecochranelibrary.com)[FreeFulltext
Adeniyi,F.B.andYoung,T.(2012)Weightlossinterventionsforchronicasthma(CochraneReview).TheCochraneLibrary.Issue7.JohnWiley&
Sons,Ltd.www.thecochranelibrary.com(http://www.thecochranelibrary.com)[FreeFulltext
Allen,S.,Britton,J.,LeonardiBee,J.(2009)Associationbetweenantioxidantvitaminsandasthmaoutcomes:systematicreviewandmeta
analysis.Thorax64(7),610619.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19406861)]
Arnold,E.,Clark,C.E.,Lasserson,T.J.,andWu,T.(2008)Herbalinterventionsforchronicasthmainadultsandchildren(CochraneReview).The
Bahadori,K.,DoyleWaters,M.M.,Marra,C.,etal.(2009)Economicburdenofasthma:asystematicreview.BMCPulmonaryMedicine9(1),24.
[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19454036)][FreeFulltext(http://www.biomedcentral.com/14712466/9/24)]
Bailey,E.J.,Kruske,S.G.,Morris,P.S.,etal.(2008)Culturespecificprogramsforchildrenandadultsfromminoritygroupswhohaveasthma
(CochraneReview).TheCochraneLibrary.Issue2.JohnWiley&Sons,Ltd.www.thecochranelibrary.com(http://www.thecochranelibrary.com)
[FreeFulltext(http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006580.pub4/abstract)]
Bateman,E.,Nelson,H.,Bousquet,J.,etal.(2008)Metaanalysis:effectsofaddingsalmeteroltoinhaledcorticosteroidsonseriousasthma
relatedevents.AnnalsofInternalMedicine149(1),3342.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18523132)][FreeFulltext
(http://annals.org/article.aspx?articleid=741442)]
Beggs,S.,Foong,Y.C.,Le,H.C.T.,etal.(2013)Swimmingtrainingforasthmainchildrenandadolescentsaged18yearsandunder(Cochrane
Review).TheCochraneLibrary.Issue4.JohnWiley&Sons,Ltd.www.thecochranelibrary.com(http://www.thecochranelibrary.com)[FreeFulltext
Blake,K.andLima,J.(2011)Asthmainsicklecelldisease:implicationsfortreatment.Anemia2011,740235.[Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/21490765)][FreeFulltext(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065846/)]
Bonini,M.,DiMambro,C.,Calderon,M.A.,etal.(2013)Beta2agonistsforexerciseinducedasthma(CochraneReview).TheCochraneLibrary.
Boyd,M.,Lasserson,T.J.,McKean,M.C.,etal.(2009)Interventionsforeducatingchildrenwhoareatriskofasthmarelatedemergency
departmentattendance(CochraneReview).TheCochraneLibrary.Issue2.JohnWiley&Sons,Ltd.www.thecochranelibrary.com
Bravata,D.M.,Gienger,A.L.,Holty,J.E.,etal.(2009)Qualityimprovementstrategiesforchildrenwithasthma:asystematicreview.Archivesof
PediatricsandAdolescentMedicine163(6),572581.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19487615)][FreeFulltext
(http://archpedi.jamanetwork.com/article.aspx?articleid=381649)]
Brozek,J.L.,Kraft,M.,Krishnan,J.A.,etal.(2012)Longactingbeta2agoniststepoffinpatientswithcontrolledasthma:systematicreviewwith
metaanalysis.ArchivesofInternalMedicine172(18),13651375.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/22928176)]
Bruurs,M.L.,vanderGiessen,L.J.,andMoed,H.(2013)Theeffectivenessofphysiotherapyinpatientswithasthma:asystematicreviewofthe
literature.RespiratoryMedicine107(4),483494.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/23333065)]
CastroRodriguez,J.A.andRodrigo,G.J.(2009)Efficacyofinhaledcorticosteroidsininfantsandpreschoolerswithrecurrentwheezingand
asthma:asystematicreviewwithmetaanalysis.Pediatrics123(3),e519e525.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19254986)][Free
Fulltext(http://pediatrics.aappublications.org/content/123/3/e519.full)]
CastroRodriguez,J.A.andRodrigo,G.J.(2009)Theroleofinhaledcorticosteroidsandmontelukastinchildrenwithmildmoderateasthma:
resultsofasystematicreviewwithmetaanalysis.ArchivesofDiseaseinChildhood95(5),365370.[Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/19946008?
itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=92)]
CastroRodriguez,J.A.andRodrigo,G.J.(2012)Asystematicreviewoflongactingbeta2agonistsversushigherdosesofinhaledcorticosteroids
inasthma.Pediatrics130(3),e650e657.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/22926172)]
Cates,C.J.andCates,M.J.(2008)Regulartreatmentwithsalmeterolforchronicasthma:seriousadverseevents(CochraneReview).The
(http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006363/frame.html)]
Cates,C.J.,andLasserson,T.J.(2010)Regulartreatmentwithformoterolandaninhaledcorticosteroidversusregulartreatmentwithsalmeterol
andaninhaledcorticosteroidforchronicasthma:seriousadverseevents(CochraneReview).TheCochraneLibrary.Issue1.JohnWiley&Sons,
Ltd.www.thecochranelibrary.com(http://www.thecochranelibrary.com)[FreeFulltext
Cates,C.J.,Lasserson,T.J.,andJaeschke,R.(2009)Regulartreatmentwithformoterolandinhaledsteroidsforchronicasthma:seriousadverse
events(CochraneReview).TheCochraneLibrary.Issue2.JohnWiley&Sons,Ltd.www.thecochranelibrary.com
(http://www.thecochranelibrary.com)[FreeFulltext(http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006924/frame.html)]
Cates,C.J.,Lasserson,T.J.andJaeschke,R.(2009)Regulartreatmentwithsalmeterolandinhaledsteroidsforchronicasthma:seriousadverse
effects(CochraneReview).TheCochraneLibrary.Issue3.JohnWiley&Sons,Ltd.www.thecochranelibrary.com
Cates,C.J.andLasserson,T.J.(2009)Combinationformoterolandinhaledsteroidversusbeta2agonistasreliefmedicationforchronicasthmain
adultsandchildren(CochraneReview).TheCochraneLibrary.Issue1.JohnWiley&Sons,Ltd.www.thecochranelibrary.com
Cates,C.J.andLasserson,T.J.(2009)Combinationformoterolandbudesonideasmaintenanceandrelievertherapyversusinhaledsteroid
maintenanceforchronicasthmainadultsandchildren(CochraneReview).TheCochraneLibrary.Issue2.JohnWiley&Sons,Ltd.
www.thecochranelibrary.com(http://www.thecochranelibrary.com)[FreeFulltext
Cates,C.J.andLasserson,T.J.(2009)Regulartreatmentwithformoterolversusregulartreatmentwithsalmeterolforchronicasthma:serious
adverseevents(CochraneReview).TheCochraneLibrary.Issue4.JohnWiley&Sons,Ltd.www.thecochranelibrary.com
Chauhan,B.F.,Chartrand,C.,andDucharme,F.M.(2012)Intermittentversusdailyinhaledcorticosteroidsforpersistentasthmainchildrenand
adults(CochraneReview).TheCochraneLibrary.Issue12.JohnWiley&Sons,Ltd.www.thecochranelibrary.com
Chauhan,B.F.,BenSalah,R.AndDucharme,F.M.(2013)Additionofantileukotrieneagentstoinhaledcorticosteroidsinchildrenwithpersistent
asthma(CochraneReview).TheCochraneLibrary.Issue10.JohnWiley&Sons,Ltd.www.thecochranelibrary.com
Cramer,H.,Posadzki,P.,Dobos,G.andLanghorst,J.(2014)Yogaforasthma:asystematicreviewandmetaanalysis.AnnalsofAllergy,Asthma
andImmunologyepubaheadofprint.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/24726198)]
deAguiar,M.M.,daSilva,H.J.,Rizzo,J.A.,etal.(2013)Inhaledbeclomethasoneinpregnantasthmaticwomenasystematicreview.Allergologia
etimmunopathologiaepubaheadofprint.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/23830308)]
Ducharme,F.M.,Lasserson,T.J.,andCates,C.J.(2011)Additiontoinhaledcorticosteroidsoflongactingbeta2agonistsversusantileukotrienes
forchronicasthma(CochraneReview).TheCochraneLibrary.Issue5.JohnWiley&Sons,Ltd.www.thecochranelibrary.com
(http://www.thecochranelibrary.com)[FreeFulltext(http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD003137/frame.html)]
Eijkemans,M.,Mommers,M.,Draaisma,J.M.,etal.(2012)Physicalactivityandasthma:asystematicreviewandmetaanalysis.PLoSOne7(12),
e50775.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/23284646)][FreeFulltext
(http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0050775)]
ElZein,M.,Parent,M.E.,Benedetti,A.,andRousseau,M.C.(2009)DoesBCGvaccinationprotectagainstthedevelopmentofchildhoodasthma?
Asystematicreviewandmetaanalysisofepidemiologicalstudies.InternationalJournalofEpidemiology39(2),469486.[Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/19822573)][FreeFulltext(http://ije.oxfordjournals.org/content/39/2/469.long)]
Eneli,I.U.,Skybo,T.,andCamargo,C.A.(2008)Weightlossandasthma:asystematicreview.Thorax63(8),671676.[Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/18663068)]
Ernst,E.(2009)Spinalmanipulationforasthma:asystematicreviewofrandomisedclinicaltrials.RespiratoryMedicine103(12),17911795.
Etminan,M.,Sadatsafavi,M.,Jafari,S.,etal.(2009)Acetaminophenuseandtheriskofasthmainchildrenandadults:asystematicreviewand
metaanalysis.Chest136(5),13161323.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19696122)][FreeFulltext
(http://journal.publications.chestnet.org/article.aspx?articleid=1090147)]
Everhart,R.S.andFiese,B.H.(2008)Asthmaseverityandchildqualityoflifeinpediatricasthma:asystematicreview.PatientEducationand
Counseling75(2),162168.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19036553)]
Frois,C.,Wu,E.Q.,Ray,S.,andColice,G.L.(2009)Inhaledcorticosteroidsorlongactingbetaagonistsaloneorinfixeddosecombinationsin
asthmatreatment:asystematicreviewoffluticasone/budesonideandformoterol/salmeterol.ClinicalTherapeutics31(12),27792803.[Abstract
Gao,J.,Gao,X.,Li,W.,etal.(2008)Observationalstudiesontheeffectofdietaryantioxidantsonasthma:ametaanalysis.Respirology13(4),
528536.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18410255)]
GarciaMarcos,L.,CastroRodriguez,J.A.,Weinmayr,G.,etal.(2013)InfluenceofMediterraneandietonasthmainchildren:asystematicreview
andmetaanalysis.PediatricAllergyandImmunology24(4),330338.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/23578354)]
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Gotzche,P.C.andJohansen,H.K.(2008)Housedustmitecontrolmeasuresforasthma(CochraneReview).TheCochraneLibrary.Issue2.John
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reviewandmetaanalysisofrandomizedcontrolledtrials.Allergy69(4),510516.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/24571355)]
Hart,K.,Weatherall,M.,Shirtcliffe,P.,andBeasley,R.(2009)Frequencyofdosingandcomparativedosesofmometasonefuroate:ameta
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Jaeschke,R.,O'Byrne,P.M.,Mejza,F.,etal.(2008)Thesafetyoflongactingbetaagonistsamongpatientswithasthmausinginhaled
corticosteroids.AmericanJournalofRespiratoryandCriticalCareMedicine178(10),10091016.[Abstract
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Jia,C.E.,Zhang,H.P.,Lv,Y.,etal.(2013)TheAsthmaControlTestandAsthmaControlQuestionnaireforassessingasthmacontrol:systematic
reviewandmetaanalysis.JournalofAllergyandClinicalImmunology131(3),695703.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/23058645)]
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AsthmaandAllergy2012(5),2126.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/22791994)][FreeFulltext
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Lasserson,T.J.,Cates,C.J.,Ferrara,G.,andCasali,L.(2008)Combinationfluticasoneandsalmeterolversusfixeddosecombinationbudesonide
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Zairina,E.,Stewart,K.,Abramson,M.JandGeorge,J.(2014)Theeffectivenessofnonpharmacologicalhealthcareinterventionsforasthma
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Zhang,J.,Li,X.,Xu,J.,andErnst,E.(2012)Laseracupunctureforthetreatmentofasthmainchildren:asystematicreviewofrandomized
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CurrentMedicineResearchandOpinion28(11),17911798.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/22970659)]
Zhou,Y.,Yang,M.,andRongDong,B.(2012)Monosodiumglutamateavoidanceforchronicasthmainadultsandchildren(CochraneReview).
Primaryevidence
Randomizedcontrolledtrialspublishedsincethelastrevisionofthistopic:
Abramson,M.J.,Schattner,R.L.,Sulaiman,N.D.,etal.(2010)Dospirometryandregularfollowupimprovehealthoutcomesingeneralpractice
patientswithasthmaorCOPD?Aclusterrandomisedcontrolledtrial.MedicalJournalofAustralia193(2),104109.[Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/20642418)][FreeFulltext(https://www.mja.com.au/journal/2010/193/2/dospirometryandregularfollow
improvehealthoutcomesgeneralpractice)]
AmericanLungAssociationAsthmaClinicalResearchCenters(2009)Efficacyofesomeprazolefortreatmentofpoorlycontrolledasthma.New
EnglandJournalofMedicine360(15),14871499.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19357404)][FreeFulltext
(http://content.nejm.org/cgi/content/full/360/15/1487)]
Chang,A.B.,Clark,R.,Sloots,T.P.,etal.(2008)A5versus3daycourseoforalcorticosteroidsforchildrenwithasthmaexacerbationswhoare
nothospitalised:arandomisedcontrolledtrial.MedicalJournalofAustralia189(6),306310.[Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/18803532?dopt=Abstract)][FreeFulltext(https://www.mja.com.au/journal/2008/189/6/5versus3day
courseoralcorticosteroidschildrenasthmaexacerbationswhoare)]
deJongste,J.C.,Carraro,S.,Ho,W.C.,etal.(2009)Dailytelemonitoringofexhalednitricoxideandsymptomsinthetreatmentofchildhood
asthma.AmericanJournalofRespiratoryandCriticalCareMedicine179(2),9397.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18931330)]
[FreeFulltext(http://www.atsjournals.org/doi/full/10.1164/rccm.2008071010OC)]
Haldar,P.,Brightlin,C.E.,Hargadon,B.,etal.(2009)Mepolizumabandexacerbationsofrefractoryeosinophilicasthma.NewEnglandJournalof
Medicine360(10),973984.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19264686)][FreeFulltext
Holbrook,J.T.,Wise,R.A.,Gold,B.D.etal.(2012)Lansoprazoleforchildrenwithpoorlycontrolledasthma:arandomizedcontrolledtrial.JAMA
307(4),373381.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/22274684?dopt=Abstract)]
HowdenChapman,P.,Pierse,N.,Nicholls,S.,etal.(2008)Effectsofimprovedhomeheatingonasthmaincommunitydwellingchildren:
randomisedcontrolledtrial.BMJ337,a1411.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18812366)][FreeFulltext
Janson,S.L.,McGrath,K.W.,Covington,J.K.,etal.(2009)Individualizedasthmaselfmanagementimprovesmedicaladherenceandmarkersof
asthmacontrol.JournalofAllergyandClinicalImmunology123(4),840846.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19348923)][FreeFull
text(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729175/)]
Kerwin,E.M.,Oppenheimer,J.J.,LaForce,C.,etal.(2009)Efficacyandtolerabilityofoncedailybudesonide/formoterolpressurizedmetereddose
inhalerinadultsandadolescentswithasthmapreviouslystablewithtwicedailybudesonide/formoteroldosing.AnnalsofAllergy,Asthmaand
Immunology103(1),6272.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19663129)]
Lanier,B.,Bridges,T.,Kulus,M.,etal(2009)Omalizumabforthetreatmentofexacerbationsinchildrenwithinadequatelycontrolledallergic(IgE
mediated)asthma.JournalofAllergyandClinicalImmunology124(6),12101216.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19910033)]
LemanskeJr,R.F.,Mauger,D.T.,Sorkness,C.A.,etal.(2010)Stepuptherapyforchildrenwithuncontrolledasthmawhilereceivinginhaled
corticosteroids.NewEnglandJournalofMedicine362(11),975985[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/20197425)][FreeFulltext
(http://www.nejm.org/doi/full/10.1056/NEJMoa1001278#t=article)]
Lenney,W.,McKay,A.,TudurSmith,C.,etal.(2013)ManagementofAsthmainSchoolAgeChildrenonTherapy(MASCOT):arandomised,
doubleblind,placebocontrolled,parallelstudyofefficacyandsafety.HealthTechnologyAssessment17(4),1218.[Abstract
Mancuso,C.A.,Choi,T.N.Westermann,H.,etal.(2012)Increasingphysicalactivityinpatientswithasthmathroughpositiveaffectandself
affirmation:arandomizedtrial.ArchivesofInternalMedicine172(4),337343.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/22269593)]
Nair,P.,Pizzichini,M.M.,Kjarsgaard,M.,etal.(2009)Mepolizumabforprednisonedependentasthmawithsputumeosinophilia.NewEngland
JournalofMedicine360(10),985993.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19264687)][FreeFulltext
Oborne,J.,Mortimer,J.,Hubbard,R.B.,etal.(2009)Quadruplingthedoseofinhaledcorticosteroidtopreventasthmaexacerbations:a
randomized,doubleblind,placebocontrolled,parallelgroup,clinicaltrial.AmericanJournalofRespiratoryandCriticalCareMedicine180(7),598
602.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19590019)][FreeFulltext(http://www.atsjournals.org/doi/full/10.1164/rccm.2009040616OC)]
Ryan,D.,Price,D.,Musgrave,S.D.,etal.(2012)Clinicalandcosteffectivenessofmobilephonesupportedselfmonitoringofasthma:multicentre
randomisedcontrolledtrial.BMJ344,e1756.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/22446569)][FreeFulltext
Schuh,S.,Willan,A.R.,Stephens,D.,etal.(2009)Canmontelukastshortenprednisolonetherapyinchildrenwithmildtomoderateacuteasthma?
Arandomizedcontrolledtrial.JournalofPediatrics155(6),795800.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19656525)]
Skoner,D.P.,Maspero,J.,Banerji,D.,andCiclesonidePediatricGrowthStudyGroup(2008)Assessmentofthelongtermsafetyofinhaled
ciclesonideongrowthinchildrenwithasthma.Pediatrics121(1),e114.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18070931)][FreeFulltext
(http://pediatrics.aappublications.org/cgi/content/full/121/1/e1)]
Strunk,R.C.,Bacharier,L.B.,Phillips,B.R.,etal.(2008)Azithromycinormontelukastasinhaledcorticosteroidsparingagentsinmoderateto
severechildhoodasthmastudy.JournalofAllergyandClinicalImmunology122(6),11381144.[Abstract
Strunk,R.C.,Sternberg,A.L.,Szefler,S.J.,etal.(2009)Longtermbudesonideornedocromiltreatment,oncediscontinued,doesnotalterthe
courseofmildtomoderateasthmainchildrenandadolescents.JournalofPediatrics154(5),682687.[Abstract
Szefler,S.J.,Mitchell,H.,Sorkness,C.A.,etal.(2008)Managementofasthmabasedonexhalednitricoxideinadditiontoguidelinebased
treatmentforinnercityadolescentsandyoungadults:arandomisedcontrolledtrial.Lancet372(9643),10651072.[Abstract
Thomas,M.,McKinley,R.K.,Mellor,S.,etal.(2009)Breathingexercisesforasthma:arandomisedcontrolledtrial.Thorax64(1),5561.[Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/19052047)][FreeFulltext(http://thorax.bmj.com/content/64/1/55.long)]
Turpeinen,M.,Nikander,K.,Pelkonen,A.S.,etal.(2008)Dailyversusasneededinhaledcorticosteroidformildpersistentasthma(theHelsinki
earlyinterventionchildhoodasthmastudy).ArchivesofDiseaseinChildhood93(8),654659.[Abstract
Vempati,R.,Bijlani,R.L.,andDeepak,K.K.(2009)Theefficacyofacomprehensivelifestylemodificationprogrammebasedonyogainthe
managementofbronchialasthma:arandomizedcontrolledtrial.BMCPulmonaryMedicine9(1),37.[Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/19643002)][FreeFulltext(http://www.biomedcentral.com/14712466/9/37)]
Vuillermin,P.J.,Robertson,C.F.,Carlin,J.B.,etal.(2010)Parentinitiatedprednisoloneforacuteasthmainchildrenofschoolage:randomised
controlledcrossovertrial.BMJ340,c843.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/20194353)][FreeFulltext
Wechsler,M.E.,Kunselman,S.J.,Chinchilli,V.M.,etal.(2009)Effectofbeta2adrenergicreceptorpolymorphismonresponsetolongactingbeta2
agonistinasthma(LARGEtrial):agenotypestratified,randomised,placebocontrolled,crossovertrial.Lancet374(9703),17541764.[Abstract
Wright,G.R,Howieson,S.,McSharry,C.,etal.(2009)Effectofimprovedhomeventilationonasthmacontrolandhousedustmiteallergenlevels.
Allergy64(11),16711680.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/19650848)][FreeFulltext
(http://onlinelibrary.wiley.com/doi/10.1111/j.13989995.2009.02098.x/full)]
Observationalstudiespublishedsincethelastrevisionofthistopic:
Bakhireva,I.N.,Schatz,M.,Jones,K.L.,etal.(2008)Asthmacontrolduringpregnancyandtheriskofpretermdeliveryorimpairedfetalgrowth.
AnnalsofAllergy,Asthma&Immunology101(2),137143.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18727468)]
Busse,W.W.,Morgan,W.J.,Gergen,P.J.,etal.(2011)Randomizedtrialofomalizumab(AntiIgE)forasthmaininnercitychildren.NewEngland
(http://www.nejm.org/doi/full/10.1056/NEJMoa1009705)]
deVries,F.,Setakis,E.,Zhang,B.,andvanStaa,T.P.(2010)Longactingbeta2agonistsinadultasthmaandthepatternofriskofdeathand
severeasthmaoutcomes:astudywiththeGeneralPracticeResearchDatabase.EuropeanRespiratoryJournal36(3),494502.[Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/20351036)][FreeFulltext(http://erj.ersjournals.com/content/36/3/494.long)]
Kelly,H.W.,vanNatta,M.L.,Covar,R.A.,etal.(2008)Effectoflongtermcorticosteroiduseonbonemineraldensityinchildren:aprospective
longitudinalassessmentinthechildhoodasthmamanagementprogram(CAMP)study.Pediatrics122(1),e53e61.[Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/18595975)][FreeFulltext(http://pediatrics.aappublications.org/cgi/content/full/122/1/e53)]
Lapi,F.,Kezouh,A.,Suissa,S.,andErnst,P.(2013)Theuseofinhaledcorticosteroidsandtheriskofadrenalinsufficiency.EuropeanRespiratory
Journal42(1),7986.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/23060630)]
Lin,S.,Munsie,J.P.,HerdtLosavio,M.L.,etal.(2012)Maternalasthmamedicationuseandriskofselectedbirthdefects.Pediatrics129(2),e316
e324.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/22250027?dopt=Abstract)]
Mai,X.M.,Langhammer,A.,Chen,Y.,etal.(2013)CodliveroilintakeandincidenceofasthmainNorwegianadultstheHUNTstudy.Thorax
68(1),2530.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/22977130)]
Martinez,F.D.,Chinchilli,V.M.,Morgan,W.J.,etal.(2011)Useofbeclomethasonedipropionateasarescuetreatmentforchildrenwithmild
persistentasthma(TREXA):arandomised,doubleblind,placebocontrolledtrial.Lancet377(9766),650657.[Abstract
Price,D.,Musgrave,S.,Wilson,E.,etal.(2011)Apragmaticsingleblindrandomisedcontrolledtrialandeconomicevaluationoftheuseof
leukotrienereceptorantagonistsinprimarycareatsteps2and3ofthenationalasthmaguidelines(ELEVATEstudy).HealthTechnology
Assessment15(21),1132.[FreeFulltext(http://www.hta.nhs.uk/project/1204.asp)]
Price,D.,Musgrave,S.D.,Shepstone,L.,etal.(2011)Leukotrieneantagonistsasfirstlineoraddonasthmacontrollertherapy.NewEngland
(http://www.nejm.org/doi/full/10.1056/NEJMoa1010846#t=article)]
Ramsay,C.F.,Pearson,D.,Mildenhall,S.andWilson,A.M.(2010)Oralmontelukastinacuteasthmaexacerbations:arandomised,doubleblind,
placebocontrolledtrial.Thorax66(1),711.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/20956393)]
Risnes,K.R.,Belanger,K.,Murk,W.andBracken,M.B.(2010)Antibioticexposureby6monthsandasthmaandallergyat6years:findingsina
cohortof1401USchildren.AmericanJournalofEpidemiology173(3),310318.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/21190986)][Free
Fulltext(http://aje.oxfordjournals.org/content/173/3/310.long)]
Shaaban,R.,Zureik,M.,Soussan,D.,etal.(2008)Rhinitisandonsetofasthma:alongitudinalpopulationbasedstudy.Lancet372(9643),1049
Stern,D.A.,Morgan,W.J.,Halonen,M.,etal.(2008)Wheezingandbronchialhyperresponsivenessinearlychildhoodaspredictorsofnewly
diagnosedasthmainearlyadulthood:alongitudinalbirthcohortstudy.Lancet372(9643),10581064.[Abstract
Tata,L.J.,Lewis,S.A.,McKeever,T.M.,etal.(2008)Effectofmaternalasthma,exacerbationsandasthmamedicationuseoncongenital
malformationsinoffspring:aUnitedKingdompopulationbasedstudy.Thorax63(11),981987.[Abstract
To,T.,Gershon,A.,Wang,C.,etal.(2007)Persistenceandremissioninchildhoodasthma:apopulationbasedasthmabirthcohortstudy.
ArchivesofPediatricsandAdolescentMedicine161(12),11971204.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18056566)][FreeFulltext
(http://archpedi.amaassn.org/cgi/content/full/161/12/1197)]
Vestergaard,P.,Rejnmark,L.,andMosekilde,L.(2007)Fractureriskinpatientswithchroniclungdiseasestreatedwithbronchodilatordrugsand
inhaledandoralcorticosteroids.Chest132(5),15991607.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/17890464)][FreeFulltext
Wu,A.C.,Tantisira,K.,Li,L.,etal.(2012)EffectofvitaminDandinhaledcorticosteroidtreatmentonlungfunctioninchildren.AmericanJournalof
RespiratoryandCriticalCareMedicine186(6),508513.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/22798322)]
Posthocanalysisofrandomizedcontrolledtrialspublishedsincethelastrevisionofthistopic:
Barr,R.G.,Kurth,T.,Stampfer,M.J.,etal.(2007)Aspirinanddecreasedadultonsetasthma:randomizedcomparisonsfromthephysicians'health
study.AmericanJournalofRespiratoryandCriticalCareMedicine175(2),120125.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/17068328?
dopt=Abstract)][FreeFulltext(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1899281/)]
Kurth,T.,Barra,R.G.,Ganziano,J.M.,andBuring,J.(2008)RandomisedaspirinassignmentandriskofadultonsetasthmaintheWomen's
HealthStudy.Thorax63(6),514418.[Abstract(http://www.ncbi.nlm.nih.gov/pubmed/18339679)][FreeFulltext
Newpolicies Backtotop
Nonewnationalpoliciesorguidelinessince1September2007.
Newsafetyalerts Backtotop
InSeptember2010,theMedicinesandHealthcareproductsRegulatoryAgency(MHRA)issuedadvicetoprescribersthatthebenefitsofusinglong
actingbeta2agonists(inconjunctionwithinhaledcorticosteroids)inchildrenoutweighanyapparentrisks.However,prescribersareadvisedthata
dailydoseof24microgramsformoterolshouldbesufficientformostchildren,particularlyyoungeragegroups.Higherdosesshouldbeusedrarely,
andonlywhencontrolisnotmaintainedonthelowerdose.
Reference:MHRA(2010)Longacting2agonists:reminderforuseinchildrenandadults.DrugSafetyUpdate4(2),H2.[FreeFulltext
(http://www.mhra.gov.uk/Publications/Safetyguidance/DrugSafetyUpdate/CON093877)]
On31March2009allstockofNebuChamberspacerdevices(forusewithPulmicortinhalers)wererecalledbyAstraZenecabecauseofreports
thatthemouthpiececouldbeattachedthewrongway.Thisisclinicallysignificantbecausethemouthpiececontainsaonewayvalve.Patientsshould
beremindedthatthefrostedendofthemouthpiecemustbeattachedtothespacer.
Reference:MHRA(2009)Class2DrugAlert(actionwith48hours):AstraZenecaUKLtdNebuChamberDevice(InhalationAid)EL(09)A/09.
MedicinesandHealthcareproductsRegulatoryAgency.www.mhra.gov.uk(http://www.mhra.gov.uk)[FreeFulltext
(http://www.mhra.gov.uk/Publications/Safetywarnings/Drugalerts/CON041523)]
Changesinproductavailability Backtotop
Pulmicort(budesonide)100and200microgramsperdosemetereddoseinhalershavebeendiscontinued(March2011).
AllstrengthsoftheFlixotidediskhalerhavenowbeendiscontinued(December2010).StocksarelikelytobeexhaustedbyMarch2011.
TheFlixotide50microgramdiskhalerandallstrengthsoftheAerobecbreathactuatedinhalerhavebeendiscontinued.
AbudesonideCFCfreeinhaler(Pulmicort)hasbeenlaunched.
TheNebuhalerspacerdevice(forusewithPulmicort)hasbeenreplacedbytheNebuChamberspacerdevice.
Backtotop
Goals
Theaimofasthmamanagementiscontrolofthediseasewithminimalsideeffects.Controlofthediseaseisdefinedas[SIGNandBTS,
2011(/asthma#!references/297181)]:
Nodaytimesymptoms
Nonighttimeawakeningduetoasthma
Noneedforrescuemedicine
Noexacerbations
Nolimitationsonactivityincludingexercise
Normallungfunction(inpracticaltermsforcedexpiratoryvolumein1second(FEV1)and/orpeakexpiratoryflowrate(PEF),greaterthan80%
predicted(ortheperson'sbestvalueifunabletoattainthis)
Backtotop
QOFindicators
Table1.IndicatorsfromtheQualityandOutcomesFramework(QOF)forasthmainthenewGeneralMedicalServices(GMS)contract.
Qualityindicator Points Threshold
AST001Thecontractorestablishesandmaintainsaregisterofpatientswithasthma,excludingpatientswithasthmawho 4
havebeenprescribednoasthmarelateddrugsinthepreceding12months
AST002Thepercentageofpatientsaged8oroverwithasthma(diagnosedonorafter1April2006),ontheregister,with 15 4580%
measuresofvariabilityorreversibilityrecordedbetween3monthsbeforeandanytimeafterdiagnosis
AST004Thepercentageofpatientswithasthmaaged14oroverwhohavenotattainedtheageof20,ontheregister,in 6 4580%
whomthereisarecordofsmokingstatusinthepreceding12months
AST003Thepercentageofpatientswithasthma,ontheregister,whohavehadanasthmareviewinthepreceding12months 20 4570%
thatincludesanassessmentofasthmacontrolusingthe3RCPquestions
SMOK002Thepercentageofpatientswithanyoranycombinationofthefollowingconditions:CHD,PAD,strokeorTIA, 25 5090%
hypertension,diabetes,COPD,CKD,asthma,schizophrenia,bipolaraffectivedisorderorotherpsychoseswhosenotes
recordsmokingstatusinthepreceding12months
SMOK005Thepercentageofpatientswithanyoranycombinationofthefollowingconditions:CHD,PAD,strokeorTIA, 25 5696%
hypertension,diabetes,COPD,CKD,asthma,schizophrenia,bipolaraffectivedisorderorotherpsychoseswhoarerecorded
ascurrentsmokerswhohavearecordofanofferofsupportandtreatmentwithinthepreceding12months
Datafrom:[BMAandNHSEmployers,2013(/asthma#!references/297181)]
Backtotop
QIPPOptionsforlocalimplementation
Highdoseinhaledcorticosteroidsinasthma
Reviewtheuseofinhaledcorticosteroids(ICS)routinelyinpatientswithasthma.
StepdownthedoseanduseofICSwhereclinicallyappropriateinpatientswithasthma.
[NICE,2013(/asthma#!references/297181)]
Backtotop
Definition
Whatisasthma?
Asthmaisachronicinflammatoryconditionoftheairways,thecauseofwhichisnotcompletelyunderstood.Theairwaysarehyper
responsiveandconstricteasilyinresponsetoawiderangeofstimuli.Thismayresultincoughing,wheezing,chesttightness,andshortnessof
breath:
Narrowingoftheairwaysisusuallyreversible(eitherspontaneouslyorwithmedication),leadingtointermittentsymptoms,butinsomepeople
withchronicasthma,theinflammationmayleadtoirreversibleairflowobstruction.
Asthmacanvarymarkedlyinseverity,clinicalcourse,andresponsetotreatment.
Acuteasthmaexacerbationisatermusedtodescribeonsetofsevereasthmasymptoms.
Workaggravatedasthmaispreexistingasthmathatisaggravatednonspecificallybydustandfumesatwork.
Occupationalasthmaisasthmaduetoexposuretospecificsubstancesatwork.
Exerciseinducedasthmaisasthmabroughtonbyphysicalexertion.Formostpeople,itisanindicationofpoorlycontrolledasthma.
[NewmanTaylor,2003(/asthma#!references/297181)SIGNandBTS,2011(/asthma#!references/297181)]
Backtotop
Prevalence
Howcommonisasthma?
ThemostrecentreportbyAsthmaUKstatesthat5.2millionpeopleintheUKhaveasthma[AsthmaUK,2006(/asthma#!references/297181)].
Theprevalenceofasthmahasincreasedinmostcountriessincethe1970s.Levelsmayhaveplateauedinsomedevelopedcountries[Anderson,
2005(/asthma#!references/297181)Rees,2006(/asthma#!references/297181)].
ThenumberofadultswithasthmaintheUKhasincreasedby400,000sincethelastauditofUKasthmain2001[AsthmaUK,2006
Theproportionofadolescentsaged1314yearsreportingwheezeintheprevious12monthsinWesternEuropewas14.3%,andtheproportion
reportingsevereasthmawas6.2%.Severeasthmawasdefinedasmorethanfourattacksofwheeze,ormorethanoneattackofwheezeatnight
disturbingsleep,ormorethanoneattackofwheezeaffectingspeechintheprevious12months[Laietal,2009(/asthma#!references/297181)].
Theproportionofchildreninwhomasthmawasdiagnosedincreasedfrom4%to10%between1964and1989[KeeleyandMcKean,2006
(/asthma#!references/297181)].Afurtherstudyfoundariseintheprevalenceofasthmaticsymptomsbetween1988and2003[Burretal,2006
Incontrast,selfreportedsymptomsofasthmainchildren1314yearsofagedecreasedbyabout20%intheUKbetween1995and2002
[Anderson,2005(/asthma#!references/297181)].
Inearlychildhood,asthmaismorecommoninboysthaningirls,butbyadulthood,thesexratioisreversed.Themechanismforthisisnotclear
[deMarcoetal,2000(/asthma#!references/297181)Nicolaietal,2003(/asthma#!references/297181)].Approximately60%ofadultswith
asthmaintheUKarewomen[AsthmaUK,2006(/asthma#!references/297181)].
Morethan4.1millionGPconsultationsforasthmaoccureachyear[AsthmaUK,2006(/asthma#!references/297181)].
Eachyear,aGPwith2000patientswillseeapproximately85peoplewithasthma,andeachofthesewillconsultthreetimesonaverage
[McCormicketal,1995(/asthma#!references/297181)].
About2%ofadultsconsulttheirGPannuallywithasthma[McCormicketal,1995(/asthma#!references/297181)].
Occupationalasthmamayaccountfor915%ofadultonsetasthma.Itisreportedtobethemostcommonindustriallungdiseaseinthedeveloped
world[SIGNandBTS,2011(/asthma#!references/297181)].
Backtotop
Riskfactors
Whataretheriskfactorsforasthma?
Variousriskfactorsmayincreasethelikelihoodofdevelopmentorpersistenceofasthma:
Familyhistoryofatopicdisease(forexampleasthma,eczema,allergicrhinitis,orallergicconjunctivitis).
Coexistenceofatopicdisease.
Malesex(forprepubertalasthma)andfemalesex(forpersistenceofasthmafromchildhoodtoadulthood).
Bronchiolitisininfancy.
Parentalsmoking,includingperinatalexposuretotobaccosmoke.
Lowbirthweight(associatedwithintrauterinegrowthretardation).
Prematurebirth(especiallyinextremepreterminfantswhorequiredventilatorysupport,withconsequentchroniclungdiseaseofprematurity).
[SIGNandBTS,2011(/asthma#!references/297181)]
Backtotop
Complicationsandprognosis
Complications Backtotop
Death:morethan1400peoplediedofasthmaintheUKin2002.Onaverage,onepersondiesofasthmaevery7hours[AsthmaUK,2006
(/asthma#!references/297181)].Asthmaaccountsforoneofevery250deathsworldwide[Rees,2006(/asthma#!references/297181)].
Respiratorycomplications:pneumonia,pulmonarycollapse(atelectasiscausedbymucuspluggingoftheairways),respiratoryfailure,
pneumothorax,andstatusasthmaticus(repeatedasthmaattackswithoutrespite,ornonresponsetoappropriatetreatment).
Growthandpubertaldelayinchildrenmaybeadirectresultofchronicdiseaseorsecondarytouseofinhaledcorticosteroidsorrepeatedshort
coursesofsystemicsteroids.Thegrowthsuppressiveeffectsofthelattermayberelativelyshortlived[Wolthers,2002
(/asthma#!references/297181)Doull,2004(/asthma#!references/297181)].
Impairedqualityoflifemayresultfromsuboptimalcontrolofasthma.Thismayinclude:
Fatigue.
Underperformanceandtimeoffschoolorwork.Asthmaaccountsforatleast12.7millionworkdayslosteachyearintheUK[AsthmaUK,2006
Psychologicalproblems,includingstress,anxiety,anddepression[OpolskiandWilson,2005(/asthma#!references/297181)].Childrenmay
experiencesocialexclusionbecausetheycannotparticipateinactivitiesandsports.
[SIGNandBTS,2011(/asthma#!references/297181)]
Prognosis Backtotop
Malechildrenaremorelikelytogrowoutofasthmainthetransitiontoadulthood[SIGNandBTS,2011(/asthma#!references/297181)].
Theearliertheonsetofasthma,thebettertheprognosismostchildrenwhopresentunder2yearsofagebecomeasymptomaticbymidchildhood
(611yearsofage)[SIGNandBTS,2011(/asthma#!references/297181)].
However,earlyonsetasthmainatopicchildrenmaybeassociatedwithaworseprognosis[Warner,PersonalCommunication,2006
TheMelbourneEpidemiologicalStudyofChildhoodAsthmawasa19641999longitudinalstudythatsuggestedthatinmostchildrenwithasthma,
significantwheezingcontinuedintoadultlife,andthemoresevereorfrequentthesymptomsinchildhood,themorelikelythatsymptomscontinued
[Phelanetal,2002(/asthma#!references/297181)Horaketal,2003(/asthma#!references/297181)]:
Thisstudyrecruitedchildrenatage7yearsandfollowedthemupthroughadolescencetoadulthood.Theproportionofpeoplewithnorecent
asthmaincreasedsteadilyfrom20%atage14yearsto40%atage42years.
Episodicasthmainchildhoodtendstoresolveinadolescenceandearlyadulthood.
Thestudyconcludedthatthepatternofasthmaduringchildhoodpredictsoutcomeinlaterlife,althoughthisisnotentirelyreliable.
Ofnote,changesindiseaseprevalence,environmentalfactors,andtreatmentstrategiesoverthestudymayaffecttheinterpretationof
longitudinaldata[Robertson,2002(/asthma#!references/297181)].
Backtotop
Diagnosis
HowdoIknowmypatienthasit?
Initially,decidehowlikelyitisthatapersonhasasthma.
Forchildren,basethisdecisiononrecognizingfeaturesthatincreaseordecreasetheprobabilityofasthma.Formoreinformation,see
Probabilityofasthmainchildren(/asthma#!diagnosissub:1).
Foradults,basethisdecisiononrecognizingfeaturesthatincreaseordecreasetheprobabilityofasthmaandspirometry
(/asthma#!diagnosissub:3).Formoreinformation,seeProbabilityofasthmainadults(/asthma#!diagnosissub:2).
Thenuseclinicaljudgementtocategorizethepersonintooneofthreegroups:
Highprobability:diagnosisofasthmalikely.
Intermediateprobability:diagnosisuncertainandinsufficientevidenceatfirstconsultationtomakeafirmdiagnosis,butnofeaturestosupport
analternativediagnosis.
Lowprobability:diagnosisotherthanasthmalikely.
Forpeoplewithanintermediateandhighprobabilityofasthma,manageassuspectedasthma(toconfirmorrefutethediagnosis).Formore
information,seeScenario:Newpresentationofasthma(/asthma#!scenario).
Forpeoplewithalowprobabilityofasthmaconsideranalternativediagnosis.
Occupationalasthmaisdiagnosedwhenthediagnosisofasthmaisconfirmed,therelationshipbetweenasthmaandworkexposureismade,
andaspecificcauseisidentified.
Exerciseinducedasthmaisusuallydiagnosedbasedonsymptomsrelatedtoexercise.
Peoplewithexerciseinducedasthmareportsymptomssuchascoughingandwheezingafter510minutesofexerciseorforupto12hours
afterfinishingexercise.Thesymptomsaregenerallyworsewhenbreathingcoldordryair(outdoors),orwithlongerdurationorhigherintensity
ofexercise.
Basisforrecommendation Backtotop
ThisrecommendationisbasedonaBritishguidelineonthemanagementofasthma:anationalclinicalguideline,fromtheScottishIntercollegiate
GuidelinesNetworkandtheBritishThoracicSociety[SIGNandBTS,2011(/asthma#!references/297181)].
Backtotop
Probabilityofasthmainchildren
Whatfeaturesincreaseordecreasetheprobabilityofasthmainchildren?
Featuresthatincreasetheprobabilityofasthmainchildreninclude:
Morethanoneofthefollowingsymptoms:wheeze,cough,difficultybreathing,chesttightness.Suchsymptomsparticularlyindicateasthmaif
they:
Arefrequentandrecurrent.
Areworseatnightandintheearlymorning.
Occurinresponseto,orareworseafter,exerciseorothertriggerssuchasexposuretopets,coldordampair,orwithemotionsorlaughter.
Occurevenwhenthepersonhasnotgotacold(coryzalillness).
Personalhistoryofanotheratopicdisorder(hayfever,eczema).
Familyhistoryofasthmaand/oratopicdisorder.
Widespreadwheeze(bilateral,predominantlyexpiratory).
Theabsenceofwheezedoesnotruleoutasthma.Inseverecases,chestwallmovementmaybereducedonbothsides,andwheezemay
notbeaudible.
Prolongedexpiration.
Increasedrespiratoryrate.
Featuresthatlowertheprobabilityofasthmainchildreninclude:
Symptomswithcolds(coryzalillness)only.
Isolatedcoughintheabsenceofwheezeordifficultybreathing.
Historyofmoistcough.
Prominentdizziness,lightheadedness,peripheraltingling.
Clinicalfeaturespointingtoanalternativediagnosis(/asthma#!diagnosissub:5).
Repeatedlynormalphysicalexaminationofthechestwhensymptomatic.
Backtotop
Probabilityofasthmainadults
Whatfeaturesincreaseordecreasetheprobabilityofasthmainadults?
Featuresthatincreasetheprobabilityofasthmainadultsinclude:
Morethanoneofthefollowingsymptoms:wheeze,breathlessness,chesttightness,andcough,particularlyifthey:
Areworseatnightandintheearlymorning.
Occurinresponsetoexercise,allergenexposure,andcoldair.
Occuraftertakingaspirinorbetablockers.
Historyofatopicdisorder.
Theabsenceofwheezedoesnotruleoutasthma.Inseverecases,chestwallmovementmaybereducedonbothsides,andwheezemay
notbeaudible.
Featuresthatlowertheprobabilityofasthmainadultsinclude:
Prominentdizziness,lightheadedness,peripheraltingling.
Chronicproductivecoughintheabsenceofwheezeorbreathlessness.
Voicedisturbance.
Symptomswithcoldsonly.
Significantsmokinghistory(greaterthan20packyears).
Cardiacdisease.
Repeatedlynormalphysicalexaminationofthechestwhensymptomatic.
Clinicalfeaturesofanalternativediagnosis(/asthma#!diagnosissub:6).
Backtotop
Spirometry
WhenshouldIinvestigatewithspirometry?
Spirometryisthepreferredmethodtodemonstrateairwayobstructionbecause:
Itmoreclearlyidentifiesairwayobstructionthanpeakexpiratoryflow(PEF),andtheresultsarelessdependentoneffort.
PEFvariabilitycanbeincreasedinpeoplewithconditionscommonlyconfusedwithasthma.
PEFshouldonlybeusedifspirometryisunavailable.
Inviewofthepotentialrequirementfortreatmentovermanyyears,itisimportanteveninrelativelyclearcutcases,totrytoobtainobjective
supportforthediagnosisofasthma.
Adults
Performspirometryonalladultstoassessforthepresenceandseverityofairwayobstruction.
Airwayobstructionisconfirmedwhenforcedexpiratoryvolumein1second(FEV1)/ForcedVitalCapacity(FVC)ratioislessthan0.7.
Whetherornotspirometryshouldhappenbeforestartingtreatmentdependsonthecertaintyoftheinitialdiagnosisandtheseverityofthe
presentingsymptoms.
Normalspirometryobtainedwhenapersonisasymptomaticdoesnotexcludeadiagnosisofasthma.Repeatedassessmentandmeasurement
maybenecessary.
Children
Spirometryisrecommendedforchildrenwithanintermediateprobabilityofasthmaiftheyareabletoperformthetest(usuallyolderthan5years).
Spirographsrequirecalibrationtoallowaccurateinterpretationoftheresults(forexampleRosenthalnormalvaluesbasedonthechild'ssexand
height).Healthcareprofessionalsrequiretrainingonhowtocalibrateandinterprettheresultsfromaspirogram.CKSrecommendthatadvice
shouldbesoughtregardingcarryingoutspirometryinchildrenandinterpretingtheresults,unlessthehealthcareprofessionalhasreceivedthe
appropriatetraining.
Measuringlungfunctioninyoungchildrenisdifficultandnotusuallypossibleinchildrenunder5yearsofage.
Normalresultsobtainedwhenthechildisasymptomaticdonotexcludeadiagnosisofasthma.
Backtotop
Triggerfactors
Whatarethetriggerfactors?
Respiratoryinfections,mostcommonlyviruses.Fungi,bacteria,orparasitesmayberesponsibleinsomepeople.
Allergens,suchaspollen,dustmites,andfeatheredorfurryanimals.
Airborneirritants,suchascigarettesmoke,irritantdusts,coldair,vapoursandfumes,atmosphericpollution.
Weatherchanges,suchascoldair.
Exercise.
Emotionalfactors,suchasstressorlaughing.
Gastrooesophagealrefluxdisease.
Allergicrhinitisandsinusitis.
Occupationalsensitizers,suchasisocyanates.
Drugs,suchasnonsteroidalantiinflammatorydrugsandbetablockers.
Foodscontainingsulphites,suchasbeer,wine,andshrimps.
ThisinformationisbasedonaBritishguidelineonthemanagementofasthma:anationalclinicalguideline,fromtheScottishIntercollegiate
GuidelinesNetworkandtheBritishThoracicSociety[SIGNandBTS,2011(/asthma#!references/297181)]andastrategyforasthmamanagement
andpreventionfromtheGlobalInitiativeforAsthma[GINA,2006(/asthma#!references/297181)].
Backtotop
Differentialdiagnosisinchildren
Whatelsemightitbeinchildren?
Inyoungchildrenwithepisodicbreathlessness,wheeze,andcough,themostlikelyalternativediagnosistoasthmaisviralinducedwheeze.
Othercausesofpersistentsymptomsofbreathlessness,wheeze,orcough:
Allergicbronchopulmonaryaspergillosis,allergicalveolitis,hypersensitivitypneumonitis,polyarteritisnodosa.
Cysticfibrosis,chroniclungdisease,ciliarydyskinesia,developmentalanomaly(vascularring)andothermalformationsaffectingairwaycalibre,
bronchopulmonarydysplasia.
Laryngealdisorder,laryngotracheomalacia,tracheooesophagealfistula.
Gastrooesophagealrefluxdiseasewithorwithoutaspiration,swallowingproblemswithaspiration.
Congestiveheartfailure,pulmonarythromboembolism,sarcoidosis.
Tumour,lymphomawithsuperiorvenacavaobstruction,neuromusculardisorder,immunedeficiency.
Psychogeniccough.
Othercausesofacuteonsetofbreathlessness:
Inhaledforeignbody.
Viralassociatedwheezeofinfancy,bronchiolitis,pneumonia,croup,bronchitis,pertussis.
Sinusitis.
Postnasaldrip.
Bronchiectasis.
Postinfectionsyndrome(bronchiolitisobliterans).
Tuberculosis.
Histoplasmosis.
Backtotop
Differentialdiagnosisinadults
Whatelsemightitbeinadults?
Inadults,alternativediagnosescanbeclassifiedaccordingtothepresenceorabsenceofairwaysobstruction:
Conditionswithoutairwaysobstruction:
Chroniccoughsyndromes
Hyperventilationsyndrome
Vocalcorddysfunction
Rhinitis
Gastrooesophagealreflux
Heartfailure
Pulmonaryfibrosis
Conditionswithairwaysobstruction:
Chronicobstructivepulmonarydisease
Bronchiectasis
Inhaledforeignbody
Obliterativebronchiolitis
Largeairwaystenosis
Lungcancer
Sarcoidosis
Mayalsobeassociatedwithnonobstructivespirometry.
Backtotop
Scenario:Newpresentationofasthma
Agefrom1monthonwards
Managingchildrenwithsuspectedasthma Backtotop
Managingchildrenwithalowprobabilityofasthma Backtotop
HowshouldImanagechildrenwithalowprobabilityofasthma?
Consideranalternativediagnosis,orrefertosecondarycareforfurtherinvestigations.
ThisrecommendationisbasedontheBritishguidelineonthemanagementofasthma:anationalclinicalguideline[SIGNandBTS,2011
Managingchildrenwithahighprobabilityofasthma Backtotop
HowshouldImanagechildrenwithahighprobabilityofasthma?
Startatrialofasthmatreatmentfor23months.Thechoiceoftreatmentdependsontheseverityandfrequencyofsymptoms.Formore
information,seeStartingasthmatreatment(/asthma#!scenariorecommendation:5).
Ifresponseisgood,continuetreatment.
Ifresponseispoor:
Assesscomplianceandinhalertechnique.
Considercheckingairwayreversibility,orrefertosecondarycareforadditionaltests(/asthma#!scenariorecommendation:21).
TheserecommendationsarebasedontheBritishguidelineonthemanagementofasthma:anationalclinicalguideline[SIGNandBTS,2011
Managingchildrenwithanintermediateprobability(cannotperformairwayobstructiontests) Backtotop
HowshouldImanagechildrenwithanintermediateprobabilityofasthmawhocannotperformairwayobstructiontests?
Thefollowingoptionsmaybetrieddependingonthefrequencyandseverityofsymptoms:
Watchfulwaitingreviewthechildafteratimeintervalagreedwiththeparentsorcarers.Inchildrenwithmild,intermittentwheezeandother
respiratorysymptomswhichoccuronlywithviralupperrespiratorytractinfections,itisreasonabletogivenospecifictreatmentandthenreview
thechild.
Startatrialofasthmatreatmentfor23months.Thechoiceoftreatmentdependsupontheseverityandfrequencyofsymptoms:
Ifresponseispoor,assesscomplianceandinhalertechnique,andconsiderreferralforAdditionaltestsinsecondarycare
(/asthma#!scenariorecommendation:21).
Ifitisunclearwhetherachildhasimproved,carefulobservationduringatrialoftreatmentwithdrawalmayclarifywhethertheyhave
respondedtoasthmatreatment.
(/asthma#!references/297181)]:
Measuringlungfunctioninyoungchildrenisdifficultandnotusuallypossibleinchildrenyoungerthan5yearsofage.
Althoughatrialoftreatmentwithinhaledororalsteroidsisoftenusedtomakeadiagnosisthereislittleobjectiveevidencetosupportthis
approachinchildrenwhopresentwithahistoryofrecurrentwheeze.
Managingchildrenwithanintermediateprobabilityofasthma(canperformairwayobstructiontests) Backtotop
HowshouldImanagechildrenwithanintermediateprobabilityofasthmawhocanperformairwayobstructiontests?
Checkforairwayobstructionusingspirometry:
Spirometryshouldbedonebyatrainedhealthcareprofessionalifthisisnotpossible,seekadvice.
Normalspirometryresultsobtainedwhenthechildisasymptomaticdonotexcludeadiagnosisofasthma.Repeatedmeasurementsoflung
functionmaybemorehelpfultointerpretthanasinglemeasurement.
Ifthereisnoevidenceofairwayobstruction,considerreferringforAdditionaltestsinsecondarycare(/asthma#!scenariorecommendation:21).
Ifthereisevidenceofairwayobstruction,assessforreversibilitytoeitherbronchodilatortherapy(forexamplesalbutamol400microgramsvia
metereddoseinhalerandspacer)and/ortoatrialofasthmatreatmentfor23months:
Ifthereissignificantreversibility(greaterthan12%increaseinforcedexpiratoryvolumein1second[FEV1]),orifthereisasignificantincrease
inpeakexpiratoryflowrateafterabronchodilator,adiagnosisofasthmaisprobable.Continuetotreatasasthma.Thechoiceofasthma
treatment(forexampleinhaledshortactingbeta2agonistorinhaledcorticosteroid)dependsontheseverityandfrequencyofsymptoms.For
moreinformation,seeStartingasthmatreatment(/asthma#!scenariorecommendation:5).
Ifthereisnosignificantreversibility(lessthan12%increaseinFEV1),andatrialoftreatmentisnotbeneficial,refertosecondarycarefor
additionaltests(/asthma#!scenariorecommendation:21).
Ifitisunclearwhetherachildhasimprovedonatrialofasthmatreatment,carefulobservationduringatrialoftreatmentwithdrawalmayclarify
whethertheyhaverespondedtoasthmatreatment.
Inchildren,testsofairwayobstruction(spirometryormeasuringpeakexpiratoryflow)mayprovidesupportforadiagnosisofasthma.
Spirographsrequirecalibrationtoallowaccurateinterpretationoftheresults(forexampleRosenthalnormalvaluesbasedonthechild'ssexand
height).Healthcareprofessionalsrequiretrainingonhowtocalibrateandinterprettheresultsfromaspirogram.CKSrecommendthatadvice
shouldbesoughtregardingcarryingoutspirometryinchildrenandinterpretingtheresults,unlessthehealthcareprofessionalhasreceived
appropriatetraining.
Althoughatrialoftreatmentwithinhaledororalsteroidsisoftenusedtomakeadiagnosisthereislittleobjectiveevidencetosupportthis
approachinchildrenwhopresentwithahistoryofrecurrentwheeze.
Startingasthmatreatment Backtotop
HowshouldIstarttreatmentforasthma?
Explainthatlifestyle(/asthma#!scenariorecommendation:22)changesandmedicationaremeanttocontrolasthmasymptomsandpreventan
exacerbation.
Explainthedifferencebetweenrelieverandpreventivetherapy,anddemonstratehowtouseinhalersandspacerdevices
Prescribeaneffectivedeliverydevice(/asthma#!scenariorecommendation:12)onthebasisofconvenience,cost,andsuitability.
Prescribeashortactingbeta2agonist(/asthma#!prescribinginfosub)foruseasrequiredtotreatdaytimesymptoms(twiceweeklyorlessoften)of
shortduration(lastingonlyafewhours).
Prescribearegularinhaledcorticosteroid(/asthma#!prescribinginfosub:2)withtheshortactingbeta2agonistifsymptomsareatleastthreetimes
weekly,orwakingthepersononenightweekly.
Prescribeapeakflowmeterandrecordtheperson'sbestpeakexpiratoryflowratereading.Advisemonitoringduringanexacerbation,worsening
symptoms,oramedicationchange.Regularmonitoringofpeakexpiratoryflowisnolongeradvisedasitdoesnotprovideadditionalbenefitwhen
addedtoasymptombasedmanagementstrategy.
Provideeducation(/asthma#!scenariorecommendation:23)aboutasthma,suchashowtomonitorsymptomsandrecognizeanexacerbation.
Additionalinformation Backtotop
Demonstratehowtouseinhalersandspacerdevices.Askthepersontorepeatthetechniquebacktoyou.Formoreinformationonhowtouse
inhalers(withdemonstrations),seewww.asthma.org.uk(http://www.asthma.org.uk)orwww.ginasthma.org(http://www.ginasthma.org).
Encouragemonitoringofasthmacontrolonthebasisofsymptoms[SIGNandBTS,2011(/asthma#!references/297181)]:
Symptomsthatworsenatnight,orexerciseinducedasthma,maysuggestpoorasthmacontrol.Thefrequencyofshortactingbeta2agonistuse
isausefulguidetoasthmacontrol.Ideally,peopleshouldnotbeusingrelievermedicationincontrolledasthma.
Donotrecommendroutinemonitoringofpeakexpiratoryflowrate(PEFR)unlessthepersonhassevereasthmaorapoorperceptionof
bronchoconstriction[SIGNandBTS,2011(/asthma#!references/297181)].However,encouragemeasuringPEFRaspartofaself
managementprogramme:lossofasthmacontrolmaybeassessedbysymptomsorbymeasuringPEFRorboth[SIGNandBTS,2011
Ideally,recordPEFRannuallyinchildrenwhilsttheyarestillgrowing[PinnockandShah,2007(/asthma#!references/297181)].
Ashortactingbeta2agonistshouldbestartedonanasrequiredbasisformild,intermittentsymptoms.Peopleshouldhavenormallungfunction
andnonocturnalawakening.Whensymptomsaremorefrequentorareworsening,peoplerequiretreatmentatalevelbasedontheseverityof
symptoms.SeeScenario:Uncontrolledasthmaoncurrenttreatment(/asthma#!scenario:1).
Measuringpeakexpiratoryflowrate(PEFR):TheguidelinedevelopmentgroupfortheBritishguidelineonthemanagementofasthma:a
nationalclinicalguidelinecommentedthatstudiesinchildrenhaveshownthatroutineserialmeasurementsofPEFRdonotprovideadditional
usefulinformationwhenaddedtoasymptombasedmanagementstrategy[SIGNandBTS,2011(/asthma#!references/297181)].
Shortactingbronchodilators:inhaledshortactingbeta2agonistsarethepreferredtreatmentforrapidsymptomrelief.Theevidence
(/asthma#!supportingevidence1:1)suggeststhatshortactingbeta2agonistshaveaquickeronsetofactionandfeweradverseeffectsthanother
relieverdrugs(inhaledanticholinergics,shortactingoralbeta2agonists,andshortactingtheophylline).Anasrequiredregimenisatleastas
effectiveasregularuseinpeoplewithasthma[GINA,2006(/asthma#!references/297181)].
Managingadultswithsuspectedasthma Backtotop
Managingadultswithalowprobabilityofasthma Backtotop
HowshouldImanageadultswithalowprobabilityofasthma?
Consideranalternativediagnosis,orrefertosecondarycareforfurtherinvestigations.
ThisrecommendationisbasedontheBritishguidelineonthemanagementofasthma:anationalclinicalguideline[SIGNandBTS,2011
Managingadultswithahighprobabilityofasthma Backtotop
HowshouldImanageadultswithahighprobabilityofasthma?
Startatrialofasthmatreatmentfor23months.Thechoiceoftreatmentdependsontheseverityandfrequencyofsymptoms.Formore
information,seeStartingasthmatreatment(/asthma#!scenariorecommendation:10).
Ifresponseispoor:
Assesscomplianceandinhalertechnique.
Considercheckingairwayreversibility(/asthma#!scenarioclarification:1)(inadditiontospirometryattheinitialdiagnosis),orrefertosecondary
careforadditionaltests(/asthma#!scenariorecommendation:21).
Assessingadultsforairwayreversibility Backtotop
Assessforcedexpiratoryvolumein1second(FEV1)and/orsymptomsbeforeand15minutesafterinhalationofashortactingbeta2agonist
(salbutamol400microgramsbymetereddoseinhalerdeliveredviaaspacer,or2.5mgbynebulizer)atthetimeofassessment.Agreaterthan
400mLimprovementinFEV1stronglysuggestsunderlyingasthma.
Ifresponsetoinhaledsalbutamolisincomplete,assessFEV1aftereitherinhaledcorticosteroids(beclometasoneequivalent200microgramstwice
dailyfor68weeks)ororalprednisolone(30mg/dayfor14days).
Managingadultswithanintermediateprobabilityofasthma Backtotop
HowshouldImanageadultswithanintermediateprobabilityofasthma?
Ifthepersonhasanintermediateprobabilityofasthma,considerperformingareversibility(/asthma#!scenarioclarification:2)test(inadditionto
spirometryattheinitialdiagnosis)and/oratrialoftreatmentfor23months:
Ifatrialoftreatmentisoffered,thechoiceoftreatmentdependsontheseverityandfrequencyofsymptoms(seeStartingasthmatreatment
(/asthma#!scenariorecommendation:10)).
Ifareversibilitytestshowssignificantreversibility(agreaterthan400mLimprovementinforcedexpiratoryvolumein1second[FEV1]),starta
trialofasthmatreatment.
Ifareversibilitytestshowsnoreversibility(lessthan400mLimprovementinFEV1),considerreferringtosecondarycareforadditionaltests
Ifatrialofasthmatreatmenthasbeenstartedand:
Responseisgood,continuetreatment.
Responseispoor,checkforreversibility.Ifthereisinsignificantreversibility,considerreferringtosecondarycareforadditionaltests
(/asthma#!scenariorecommendation:21).Ifthereissignificantreversibility,assesscomplianceandinhalertechnique.
Assessingadultsforairwayreversibility Backtotop
Assessforcedexpiratoryvolumein1second(FEV1)and/orsymptomsbeforeand15minutesafterinhalationofashortactingbeta2agonist
(salbutamol400microgramsbymetereddoseinhalerdeliveredviaaspacer,or2.5mgbynebulizer)atthetimeofassessment.Agreaterthan
400mLimprovementinFEV1stronglysuggestsunderlyingasthma.
Ifresponsetoinhaledsalbutamolisincomplete,assessFEV1aftereitherinhaledcorticosteroids(beclometasoneequivalent200microgramstwice
dailyfor68weeks)ororalprednisolone(30mg/dayfor14days).
Startingasthmatreatment Backtotop
HowshouldIstarttreatmentforasthma?
Explainthatlifestyle(/asthma#!scenariorecommendation:22)changesandmedicationaremeanttocontrolasthmasymptomsandpreventan
exacerbation.
Explainthedifferencebetweenrelieverandpreventivetherapy,anddemonstratehowtouseinhalersandspacerdevices
Prescribeaneffectivedeliverydevice(/asthma#!scenariorecommendation:12)onthebasisofconvenience,cost,andsuitability.
Prescribeashortactingbeta2agonist(/asthma#!prescribinginfosub)foruseasrequiredtotreatdaytimesymptoms(twiceweeklyorlessoften)of
shortduration(lastingonlyafewhours).
Prescribearegularinhaledcorticosteroid(/asthma#!prescribinginfosub:2)withtheshortactingbeta2agonistifsymptomsareatleastthreetimes
weekly,orwakingthepersononenightweekly.
Prescribeapeakflowmeter,recordtheperson'sbestpeakexpiratoryflowratereading,andadvisemonitoringduringanexacerbation,worsening
symptoms,oramedicationchange.Regularmonitoringofpeakexpiratoryflowisnolongeradvisedasitdoesnotprovideadditionalbenefitwhen
addedtoasymptombasedmanagementstrategy.However,adultswithseverediseaseorwhohaveapoorperceptionofbronchoconstrictionmay
benefitfromregularpeakexpiratoryflowratemonitoring.
Provideselfmanagementinformation(/asthma#!scenariorecommendation:23)aboutasthma,suchashowtomonitorsymptomsandrecognizean
exacerbation.
Demonstratehowtouseinhalersandspacerdevices.Askthepersontorepeatthetechniquebacktoyou.Formoreinformationonhowtouse
inhalers(withdemonstrations),seewww.asthma.org.uk(http://www.asthma.org.uk)orwww.ginasthma.org(http://www.ginasthma.org).
Encouragemonitoringofasthmacontrolonthebasisofsymptoms[SIGNandBTS,2011(/asthma#!references/297181)]:
Symptomsthatworsenatnight,orexerciseinducedasthma,maysuggestpoorasthmacontrol.Thefrequencyofshortactingbeta2agonistuse
isausefulguidetoasthmacontrol.Ideally,peopleshouldnotbeusingrelievermedicationincontrolledasthma.
Donotrecommendroutinemonitoringofpeakexpiratoryflowrate(PEFR)unlessthepersonhassevereasthmaorapoorperceptionof
bronchoconstriction[SIGNandBTS,2011(/asthma#!references/297181)].However,encouragemeasuringPEFRaspartofaself
managementprogramme:lossofasthmacontrolmaybeassessedbysymptomsorbymeasuringPEFRorboth[SIGNandBTS,2011
Ashortactingbeta2agonistshouldbestartedonanasrequiredbasisformild,intermittentsymptoms.Peopleshouldhavenormallungfunction
andnonocturnalawakening.Whensymptomsaremorefrequentorareworsening,peoplerequiretreatmentatalevelbasedontheseverityof
symptoms.SeeScenario:Uncontrolledasthmaoncurrenttreatment(/asthma#!scenario:1).
Measuringpeakexpiratoryflowrate(PEFR):TheguidelinedevelopmentgroupfortheBritishGuidelineontheManagementofAsthma:a
nationalclinicalguidelinecommentedthatinmostadultswithasthma,symptombasedmonitoringisadequate[SIGNandBTS,2011
Shortactingbronchodilators:inhaledshortactingbeta2agonistsarethepreferredtreatmentforrapidsymptomrelief.Theevidence
(/asthma#!supportingevidence1:1)suggeststhatshortactingbeta2agonistshaveaquickeronsetofactionandfeweradverseeffectsthanother
relieverdrugs(inhaledanticholinergics,shortactingoralbeta2agonists,andshortactingtheophylline).Anasrequiredregimenisatleastas
effectiveasregularuseinpeoplewithasthma[GINA,2006(/asthma#!references/297181)].
Keyprescribinginformation Backtotop
Choosingadeliverydevice Backtotop
WhichdeliverydeviceshouldIprescribe?
Whenchoosinganinhalerdeviceforapersonwithasthma,consider:
Theavailabilityofthedruganddoseinthespecificdevice.
Theabilityofthepersontodevelopandmaintainaneffectivetechniquewiththespecificdevicethismaydependonsuchfactorsasage,
dexterity,coordination,andinspiratoryflow.
Thesuitabilityofthedevicetotheperson's(andcarer's)lifestyles,consideringsuchfactorsasportabilityandconvenience.
Theperson'spreferenceforandwillingnesstouseaparticulardevice.
Costchoosethedevicewiththelowestoverallcost(takingintoaccountdailyrequireddoseandproductpriceperdose).
Goodtechniqueisessentialinensuringthecorrectuseofinhalerdevices.Onlyprescribeinhalersafterthepersonusingthem(ortheircarer)has
receivedtrainingintheuseofthedeviceandhasdemonstratedacceptabletechnique.
Awidevarietyofdevices,masks,andspacersareusedtodeliverinhaleddrugs,including:
Pressurizedmetereddoseinhalers.
Breathactuatedmetereddoseinhalers.
Drypowderinhalers.
Spacerdeviceswithavarietyofdifferentvolumes.
Facemaskswithavarietyofdesigns.
Nebulizers,drivenbyairoroxygen.
Forafulllistofavailabledevices,seeBNF(http://www.evidence.nhs.uk/formulary/bnf/current).
Prescribersshouldfamiliarizethemselveswithaselectionofthesedevicessotheycaninform,supervise,andassistpatientsappropriately.
Drypowderdevicesandbreathactuatedmetereddoseinhalersrequireaninspiratoryflowofatleast30L/mintoactivatethedevice.Somefrail
peopleandyoungerchildrencannotconsistentlyachievetherequiredminimuminspiratoryflowrate[NICE,2002(/asthma#!references/297181)].
Table1(/asthma#!scenarioclarification:4/491792)showssuggestedminimumagerequirementsforthecorrectuseofinhaleddrugdelivery
devices.
Table1.Agerequirementsforcorrectuseofinhalerdeliverydevices.
Deliverysystem Minimumage
pMDI >5years
pMDIwithspacer >4years
pMDIwithspacerandmask 4yearsoryounger
Breathactuatedmetereddoseinhaler >5years
Drypowderinhaler 5yearsorolder
pMDI=pressurizedmetereddoseinhaler.
Anumberoffactorsguidingthechoiceofinhalerdevicehavebeenidentifiedintheliterature[MeReC,2002(/asthma#!references/297181)Dolovich
etal,2005(/asthma#!references/297181)SIGNandBTS,2011(/asthma#!references/297181)].
Systematicreviewshavefoundnoevidencethatalternativeinhalerdevicesareclinicallymoreeffectivethanstandardpressurizedmetereddose
inhalers(pMDIs)fordeliveringbeta2agonistbronchodilatorsorinhaledcorticosteroids[Brocklebanketal,2001(/asthma#!references/297181)
Rametal,2001(/asthma#!references/297181)].Onthisbasis,ifusedcorrectly,pMDIsarethemostcosteffectiveinhalerdevices:
Studiesoftenselectforpeoplewhocanuseeachofthedevicesappropriately,ortheyprovideintensivetrainingtoensurethattheappropriate
techniqueisused[Dolovichetal,2005(/asthma#!references/297181)].Therefore,inpractice,efficacymaydifferamongindividuals.
Deliverysystemsforadults Backtotop
Whichdeliverysystemisrecommendedforadults?
Apressurizedmetereddoseinhaler(pMDI)withorwithoutaspacerdevice(/asthma#!scenariorecommendation:17)isrecommendedfor
deliveryofinhaledcorticosteroidsandbronchodilatorsinadults,providedthatthepersoncanusethemethodadequately.
Adrypowderinhaler(DPI)orabreathactuatedmetereddoseinhalermaybemoreacceptabletopeoplewhoareunableorunwillingtousea
standardpMDIandspacer:
Becauselargevolumespacerdevicesarenoteasilyportable,aDPIorabreathactuatedmetereddoseinhaler(whicharesmallerand
thereforemoreportable)maybeappropriateforbronchodilator(reliever)useduringthedayorwhentravelling.
Usingsuchadeviceforportablebronchodilationdoesnotnecessitateuseofthesamedeviceforinhaledcorticosteroidtreatmentorfor
bronchodilatortreatmentathome.
Nebulizersarerarelyrequiredfortheroutinemanagementofasthmainprimarycare:
Ifavailable,anebulizermaybeusedinasevereexacerbationofasthmaforthecombineddeliveryofshortactingbronchodilatorsand
anticholinergicdrugs.
Goodevidencefromsystematicreviewsshowsthat,whenusedcorrectly,pressurizedmetereddoseinhalers(pMDIs)andalternativeinhalerdevices
donotdifferclinicallyineffectiveness[Brocklebanketal,2001(/asthma#!references/297181)Rametal,2001(/asthma#!references/297181)].The
pMDIsaregenerallylessexpensivethanalternativeinhalerdevices.
Upto70%ofpeoplecannotuseapMDIcorrectly.Acommonproblemisthetimingofactuationwithinspiration[GiraudandRoche,2002
(/asthma#!references/297181)Molimardetal,2003(/asthma#!references/297181)].UseofaspacerwithapMDIlargelyovercomesproblems
withpoortechnique.
Deliverysystemforchildren5to15years Backtotop
Whichdeliverysystemisrecommendedforchildrenaged5to15years?
Apressurizedmetereddoseinhaler(pMDI)withasuitablespacerdeviceisrecommendedforthedeliveryofinhaledcorticosteroids.
Ifthechild'suseofthepMDIandspacerislikelytobesopoorastoundermineeffectiveasthmacontrol,consideralternativedevices(e.g.dry
powderinhaler[DPI]orbreathactuatedmetereddoseinhaler[MDI]),bearinginmindtheneedtominimizetheadverseeffects
(/asthma#!prescribinginfosub:5)ofcorticosteroids.
Forbronchodilators,considerawiderrangeofdevices(forexampleDPI,breathactuatedMDI),whichallowformorefrequentspontaneoususe
andgreaterportability.
TheserecommendationsarebasedontheNationalInstituteforHealthandCareExcellenceguidanceInhalerdevicesforroutinetreatmentofchronic
asthmainolderchildren(aged515years),andarebasedonfindingsfromlimitedevidence,clinicalopinion,andpharmacologicalconsiderations
[NICE,2002(/asthma#!references/297181)].
Deliverysystemforchildrenunder5years Backtotop
Whichdeliverysystemisrecommendedforchildrenyoungerthan5years?
Apressurizedmetereddoseinhaler(pMDI)plussuitablespacerdevice,withafacemaskwherenecessary,isrecommendedforthedeliveryof
inhaledcorticosteroidandbronchodilatorsinchildrenyoungerthan5years.
Afacemaskisrequireduntilthechildcanbreathereproduciblyusingthespacermouthpiece.Mostchildrenolderthan3yearscanusea
mouthpiece.
Ifthisisnotclinicallyeffectiveforthechild,considernebulizedtherapy.Fewchildrenyoungerthan5yearscanuseadrypowderinhaler
adequately.
TheserecommendationsarebasedontheNationalInstituteforHealthandCareExcellence,Guidanceontheuseofinhalersystemsinchildren
undertheageof5yearswithchronicasthma,andarebasedonlimitedevidencefromsmall,poorqualitystudies[NICE,2000
Whentouseaspacerdevice Backtotop
Whenshouldaspacerdevicebeused?
Alargevolumespacerisrecommendedfortheadministrationofinhaledcorticosteroidsinallchildrenyoungerthan16years,andforgivinghigh
dosesofinhaledcorticosteroids(>800microgramsofbeclometasoneorequivalentdaily)inadults.
Considerspacerdevicesforpeoplewhohavedifficultycoordinatingactuationofapressurizedmetereddoseinhalerwithinhalation.
Useapressurizedmetereddoseinhalerplusalargevolumespacerdeviceasanalternativetoanebulizerinanacuteexacerbationofasthma.
SeeScenario:Acuteasthmaexacerbation(/asthma#!scenario:3)formoreinformation.
Byfilteringoutlargerparticles,largevolumespacerdevicesreduceoropharyngealdepositionofthedrugandtheamountofdrugabsorbedfromthe
gastrointestinaltractatalldoses[DTB,2000(/asthma#!references/297181)].Thisisparticularlyimportantforinhaledcorticosteroidsbecause:
Reducingoropharyngealdepositionofinhaledcorticosteroidsdecreasestheincidenceoflocaladverseeffects,suchasoralcandidiasis.
Reducingtheamountofdrugabsorbedfromthegutreducestheriskofsystemicadverseeffects.
Choiceofspacerdevice Backtotop
WhichspacerdeviceshouldIprescribe?
Wherepossible,prescribethespacerthatthemanufacturerrecommendsassuitableforusewiththeparticularpressurizedmetered
doseinhaler.
Table1(/asthma#!scenariorecommendation:17/491803)showswhichspacerdevicesarecompatiblewithwhichpressurizedmetereddose
inhalers.
Table1.Specificcompatibilitiesofpressurizedmetereddoseinhalers(pMDIs)andspacerdevices.
pMDI Spacer
recommended
Bronchodilator Corticosteroid
Airomir(salbutamol)Atrovent(ipatropium) Qvar(beclometasone)Alvesco(ciclesonide) AeroChamberPlus
VentolinEvohaler(salbutamol)SerevntEvohaler ClenilModulite(beclometasone)FlixotideEvohaler Volumatic

(salmeterol) (fluticasone)
Datafrom:[BNF53,2007(/asthma#!references/297181)]
TheCommitteeontheSafetyofMedicineshasraisedconcernsthatdrugdeliverytothelungmaybechangedifalternativespacerdevicesareused
[MHRA,2006b(/asthma#!references/297181)].Thisismostlikelytobeclinicallysignificantwithhighdoseinhaledcorticosteroids.
Adviceonusingaspacerdevice Backtotop
WhatadviceshouldIgiveregardingusingthespacerdevice?
Drugsshouldbeadministeredassingleactuationsintothespacerandinhaledwithminimumdelayaftereachactuation,repeatinguntilthe
prescribednumberofpuffshasbeengiven.Thecanistershouldbeshakenbetweenactuations.
Whenmultiplepuffsarebeinggiven,asduringexacerbations,thereshouldbeashortpausebetweenpuffstoavoidhyperventilation.
Spacerdevicesshouldbewashedbeforetheyarefirstused,andonceamonththereafter.Theyshouldbereplacedevery612months.
Plasticorpolycarbonatespacers(includingVolumatic,AeroChamber,andNebuhaler)shouldbewashedinwashingupliquidandallowedto
airdry(withoutrinsingorwiping).Anyresidualdetergentshouldbewipedfromthemouthpiece.
Thisrecommendationisbasedonexpertopinioninareviewarticle[DTB,2000(/asthma#!references/297181)].
Multipleactuationsofthemetereddoseinhalerintothespacerbeforeinhalationmayreducetheproportionofthedruginhaled[DTB,2000
Staticchargebuildsuponthewallsofthespacer,potentiallyreducingtheoutputofmedicationfromthespacer.Washingthespacerasadvised
reducesthischargeforatleast4weeks,increasingthedeliveryofdrugtothelungs[DTB,2000(/asthma#!references/297181)].
Roleofcombinationinhalers Backtotop
Whatistheroleofcombinationinhalersinasthma?
Ingeneral,inhaledcorticosteroid/longactingbeta2agonist(LABA)combinationinhalersarerecommendedinpreferencetoaninhaledsteroidand
alongactingbeta2agonistinseparateinhalers.Combinationinhalersshouldbeusedinpeoplewhoarestabilizedonthecomponentdrugsinthe
samedoseratio.Acombinationinhalerisrecommendedto:
Guaranteethatthelongactingbeta2agonistisnottakenwithoutaninhaledsteroid.
Improveadherence.
ThreecombinedproductsareavailableintheUK:
Symbicortisacombinationofbudesonideandformoteroldeliveredasadrypowderinhaler.
Seretideisacombinationoffluticasoneandsalmeterolandisdeliveredbyadrypowderinhalerorpressurizedmetereddoseinhaler(pMDI).
FostairisacombinationofbeclometasoneandformoteroldeliveredasaCFCfreepMDI.Itislicensedforuseonlyinadultsaged18years
andolder.ItisnotdoseequivalenttobeclometasonedeliveredbyCFCpMDIFostair100/6maybesubstitutedforClenilModulite(CFCfree
beclometasonepMDI)at1:2dosing.
TheSymbicortSMARTregimen(acombinationinhalerasmaintenanceandrelievertherapy)maybeconsideredinadultswhorespondtoLABAs
butstillhaveinadequatecontroloftheirasthma(step3).
Providedadherenceisgood,efficacyandadverseeffectsdonotdifferaccordingtowhetherinhaledcorticosteroids(ICS)andlongactingbeta2
agonists(LABA)formaintenancetherapyaregivenincombinationorinseparateinhalers[SIGNandBTS,2011(/asthma#!references/297181)].
Inclinicalpractice,however,combinationinhalersmayimproveadherence.CombinationinhalersarethereforerecommendedbytheNational
InstituteforHealthandClinicalExcellence[NICE,2008(/asthma#!references/297181)]andtheMedicinesandHealthcareproductsRegulatory
Agency[MHRA,2008(/asthma#!references/297181)]asthey:
Guaranteethatthelongactingbeta2agonistisnottakenwithoutaninhaledcorticosteroid.Thereisthereforealowerriskofseriousasthma
relatedadverseeffects,whichcanoccurwhenaLABAinhalerisusedonitsown.
Improveadherencetodrugtreatment,asfewerinhalationsandinhalerdevicesareneeded[Currieetal,2005(/asthma#!references/297181)].
However,nodirectevidencesubstantiatesthistheory.
Themaindisadvantageofthecombinationinhalersisthatthedosesofthecomponentdrugscannotbeindividuallytitratedwithoutchangingthe
inhaler(e.g.duringsteppinguporsteppingdownofICS).Thisismoreeasilydonewithseparateinhalers.
Thereisevidence(/asthma#!supportingevidence1:7)thatusingthecombinationinhaler,Symbicort(budesonideandformoterol)asa
maintenanceandrelievertherapy(SymbicortSMART)issimilarlyeffectivetoconventionalmethodsatreducingexacerbationratesinpeoplewith
moderatetosevereasthmasymptoms.ItisrecommendedforuseasStep3oftheBritishguidelineonthemanagementofasthma:anational
clinicalguideline[SIGNandBTS,2011(/asthma#!references/297181)].
Referral Backtotop
Whenisareferralrecommendedinpeoplewithasthma?
Thedecisiontoreferisinfluencedbylocalreferralpathways,theindividual,andtheexperienceoftheprimaryhealthcareprovider.
Inadditiontorespiratoryphysiciansandpaediatricianswithaspecialistinterestinrespiratorymedicine,suchspecialistsasdietitians,
physiotherapists,occupationaltherapists,andrespiratorynursespecialistsmaybeinvolvedinthemanagementofasthmaatanystage.
Admitorreferadultsforspecialistassessmentorfurtherinvestigationinthefollowingsituations:
Thediagnosisisunclearorindoubt:
Unexpectedclinicalfindings(forexamplecrackles,clubbing,cyanosis,cardiacdisease).
Persistentnonvariablebreathlessness.
Monophonic,unilateralorfixedwheezeorstridor.
Persistentchestpainoratypicalfeatures.
Prominentsystemicfeatures(forexampleweightloss,myalgia,fever).
Persistentcoughorsputumproduction.
Spirometricorpeakexpiratoryflowmeasurementsthatdonotfittheclinicalpicture(forexampleunexplainedrestrictivespirometry).
Suspectedoccupationalasthma.
Nonresolvingpneumonia.
Inadequateresponsetomaximumguidelinetreatment.
Admitorreferchildrenforspecialistassessmentorfurtherinvestigationinthefollowingsituations:
Thediagnosisisunclearorindoubt(theyoungerthechild,themoredifficultitistobesurethatwheezingisduetoasthma):
Unexpectedclinicalfindings(forexampleabnormalvoice,focalchestsigns,dysphagia,inspiratorywheeze,stridor).
Symptomspresentfrombirth,orperinatallungproblem.
Excessivevomitingorposseting.
Severeupperrespiratorytractinfection.
Persistentproductivecough.
Familyhistoryofunusualchestdisease.
Failuretothrive.
Parentalanxiety.
Inadequateresponsetomaximumguidelinetreatment,particularlyiforalcorticosteroidsareneededfrequently,oruseofthemaximumdoseof
inhaledcorticosteroids.
Theurgencyofareferraltosecondarycareoradmissiontohospitalshouldbeappropriatetotheclinicalsituation.
Forindicationsofwhentoadmitsomeonewithanacuteexacerbationofasthma,seeWhentoadmittohospital
(/asthma#!scenariorecommendation:54)inScenario:Acuteasthmaexacerbation(/asthma#!scenario:3).
Additionaltestsinsecondarycare Backtotop
Whatadditionaltestsareavailableinsecondarycare?
Othertestsavailableinsecondarycareinclude:
Indirecttestingforbronchoconstriction,forexamplemorethan15%decreaseintheforcedexpiratoryvaluein1secondafter6minutesof
running.
Testingforbronchialhyperresponsivenessusinghistamineormethacholine.
Lifestyleadvice Backtotop
Selfmanagementinformation Backtotop
Whatinformationisneededinselfmanagementeducationandactionplans?
Giveallpeoplewithasthmaselfmanagementeducationandawrittenactionplan.
Ateachreview,repeateducationandadviseon:
Takingmedicationandavoidingknowntriggerfactors(/asthma#!diagnosissub:4).
Recognizingpoorasthmacontrol(worseningsymptomsorpeakflowreadings)andearlysignsofanexacerbation(suddenpersistentworsening
symptoms).
Presentingforfollowupannuallyormorefrequentlyifsymptomsarenotcontrolled.
Atypicalasthmaactionplanshouldinclude:
Whentoincreasetreatment(asdefinedbysymptomsorpeakexpiratoryflowrate).
Howtochangetreatmentincaseofdeteriorationandwhentogobacktomaintenancemedication.
Whentoseekmedicalhelp.
Tailorselfmanagementeducationandwrittenactionplanstotheneedsoftheindividual.Suchplansmaybeparticularlyhelpfulinsomehighrisk
peoplewithahistoryofinsidiousdeteriorationofasthma,poorperceptionofdeterioratingbreathing,andpooradherencetomedication,andin
peoplewithfrequentexacerbations.Providesuchpeoplewitha'crashcourse'oforalcorticosteroidsandinstructions,preferablyinwriting,on
whentostarttreatment:
Advisepeoplethatpoorasthmacontrolmaybesuggestedby:
Worseningsymptoms(cough,wheeze,breathlessness),especiallyatnightorduringexercise.
Worseningpeakexpiratoryflowrate(PEFR)comparedwithpreviousreadings.
AdvisepeoplewithworseningsymptomsforacoupleofdaysoradecreaseinPEFRtoinitiatetheirpersonalizedactionplan.Thisplanshould
bebasedontheperson'scurrentmedication,history,andseverityofanexacerbation.Considerthefollowingapproach:
Ifaperson'sPEFRis>75%(bestorpredicted),adviseregularuseofashortactingbeta2agonistfor12daysuntilsymptomsimprove.If
thereisnobenefit,startacourseoforalprednisolone.
Ifaperson'sPEFRis5075%(bestorpredicted),advisestartingacourseoforalprednisolonewithregularuseoftheirshortactingbeta2
agonist.Ifnobenefitisseenafter12days,seekmedicalhelp.
Ifaperson'sPEFRis<50%,advisestartingacourseoforalprednisolonealongwithregularuseoftheirshortactingbeta2agonistandseek
medicalhelp.
ExamplesofasthmaactionplansareavailableonlinefromtheNationalAsthmaCampaign(www.asthma.org.uk(http://www.asthma.org.uk)).
Studiesvarywidelyinpopulations,setting,anddiseaseseverity.Oneapproachcannotbeassumedtobesuccessfulinallcircumstances.Less
evidence(/asthma#!supportingevidence1:8)isavailablefromprimarycaresettings,andresultsarelessconsistent.Overall,selfmanagement
educationpackagesappeartobeeffective,butnooneindividualcomponentisconsistentlyshowntobeeffectiveinisolation.Aconsistentfinding
inmanystudieshasbeenimprovementsinpeople'sselfefficacy,knowledge,andconfidence[SIGNandBTS,2011
Increasinglowdoseinhaledcorticosteroids(ICS)byasmuchasfourfoldatthebeginningofanexacerbationmaybesuitableforsomepeopleon
lowdosesofmaintenanceICS,butdoublingICSduringanexacerbationhasnotbeenshowntoprovidebenefitandisnolongerrecommended
[SIGNandBTS,2011(/asthma#!references/297181)].
Smoking Backtotop
Smoking:WhatadviceshouldIgivesomeonewithasthma?
Advisesmokerswithasthmatostopsmokingandprovidethemwiththeappropriatehelp.Formoreinformation,seetheCKStopiconSmoking
cessation(/smokingcessation).
Advisepeoplewithasthmato,asfaraspossible,avoidexposuretotobaccosmoke.Forparentswhosmokeandhaveachildwithasthma,this
meanseitherstoppingsmoking(thebestoption),ornotsmokinginthesameroomasthechild(or,preferably,notsmokinginthehouse).
Parentsandparentstobewhosmokeshouldbeadvisedaboutthemanyadverseeffectsofsmokingonthemselvesandtheirchildren.They
shouldbeofferedappropriatesupporttostopsmoking.
Theevidence(/asthma#!supportingevidence1:9)suggeststhatexposuretotobaccosmokeinthehomecontributestoincreasedwheezingin
infancy,increasedriskofpersistentasthma,increasedseverityofchildhoodasthma,andthatstartingsmokingasateenagerincreasestherisk
thatasthmawillpersist.Activesmokinginasthmaresultsinworseningsymptomsanddeclineinlungfunction,anditmayinhibittheshortterm
responsetoinhaledororalcorticosteroids(althoughthemechanismofthiseffectisnotcertain)[Thomsonetal,2004
Vaccinations Backtotop
Vaccinations:WhatadviceshouldIgivesomeonewithasthma?
Adviseallpeoplewithasthmaandparentslookingafterchildrenwithasthmathataninfluenzaandapneumococcalvaccinationisadvisableif
asthmaissevereandrequireshospitaladmissionorfrequentuseofcorticosteroids.
Influenzavaccinationisrecommendedforallpeopleolderthan6monthswhohaverequiredhospitaladmissionforanexacerbationofasthma,or
whoneedcontinuousorfrequentlyrepeateduseofinhaledororalcorticosteroids.Formoreinformation,seetheCKStopiconImmunizations
seasonalinfluenza(/immunizationsseasonalinfluenza).
Pneumococcalvaccinationisrecommendedinthefollowinggroups:
People(ofanyage)whoseasthmaissoseverethattheyrequirecontinuousorfrequentrepeateduseoforalcorticosteroids(i.e.atadose
equivalentto20mgormoreofprednisolonedaily).
Childrenweighinglessthan20kg,adoseprednisoloneof1mgormoreperkilogrambodyweightperday,formorethanamonth.
Notethatpneumococcalvaccineisnowpartofthechildhoodimmunizationprogrammeseewww.dh.gov.uk
(http://www.dh.gov.uk/en/PublicationsAndStatistics/LettersAndCirculars/ProfessionalLetters/ChiefPharmaceuticalOfficerLetters/DH_4137173).
Formoreinformation,seetheCKStopiconImmunizationspneumococcal(/immunizationspneumococcal).
Theserecommendationsarebasedongovernmentpolicyasdiscussedinthe'GreenBook',publishedbytheDepartmentofHealth[DH,2006a
Ayearlyinfluenzavaccinationdoesnotappeartoprotectpeoplefromexacerbationsorimproveasthmacontrol[GINA,2006
Allergenavoidance Backtotop
Allergenavoidance:WhatadviceshouldIgivesomeonewithasthma?
Adviseallpeoplewithasthmaandparentslookingafterchildrenwithasthmatoavoid(ifpossible)knowntriggerfactors,especiallyattimeswhen
asthmaispoorlycontrolled.
Advisealladultstoreportpromptlyanyworseningasthmacontrolduringwork.
Thepersonwithasthmashouldidentifytriggerfactors(/asthma#!diagnosissub:4),wherepossible,bynotingworseningsymptomsordecreasing
peakexpiratoryflowrates(PEFR)duringexposuretocertainsituations.Sometriggerscannotbeavoided(forexampleairpollution,weather,viral
illness),butattimesofpoorasthmacontrol,itisprudenttodosoifpossible.Uncontrolledasthmaismoresensitivetopossibletriggerfactors.
Dustmites:sensitizationtohousedustmiteisanimportantriskfactorforthedevelopmentofasthma,howeverintheabsenceofbenefitfrom
domesticaeroallergenavoidance,itisnotpossibletorecommenditasastrategyforpreventingchildhoodasthma.Overall,measurestodecrease
housedustmiteshavenotbeenshowntohaveaneffectonasthmaseverity.Ifahouseholdmembershowsevidenceofhousedustmiteallergy
andwishestotrymiteavoidance,strategiesincludecompletebarrierbedcoveringsystems,ensuringthatsusceptiblechildrendonotsleepina
lowerbunkbed,removalofcarpetsorsofttoysfrombeds,hightemperaturewashingofbedlinen,applicationofacaricides(chemicalagentsthat
killmites)tosoftfurnishings,andgoodventilation.
Animalallergens,particularlycatanddogallergens,arepotentinducersofasthmasymptoms.Manyexpertsrecommendtheremovalofpets
fromthehomeofallergicpeoplewithasthma,butthereportedeffectsareinconsistent.
Foodandfoodadditives(forexamplesulphitesfoundinwine,beer,processedpotatoes,shrimps)asanexacerbatingfactorforasthmaare
uncommonandoccurprimarilyinyoungchildren.Donotrecommendfoodavoidanceunlessthereisaprovenallergy,andthenonlywiththe
supervisionofadietitian,especiallyinchildren.
Airpollutants(ozone,nitrogenoxide,acidicaerosols)andoccasionalweatherchangeshavebeenassociatedwithasthmasymptomsand
exacerbations,althoughthereisnoevidencetosupportalinkbetweenexposuretoairpollutantsandtheinductionofallergy.Thereisnoneedto
recommendavoidanceinpeoplewithstableasthma.Advisepeoplewithpoorlycontrolledasthmawhoaretroubledbyoutdoortriggerstominimize
exposure,suchasbynotdoingstrenuousexerciseorsmokingincoldweather,lowhumidity,ortimesofhighairpollution.
Anoccupationaltriggerwillusuallyworsenasthmaatwork,andimprovementswilloccurwhenthepersonisawayfromtheworkenvironment.
Identifypeoplewithoccupationaltriggersearlyandreferthemtoarespiratoryspecialist.
Allergenavoidance:theevidence(/asthma#!supportingevidence1:9)thatreducingallergenexposurecanreducemorbidityandmortalityis
tenuous.Inuncontrolledstudies,childrenandadultshaveshownsomebenefitfromexposuretoverylowallergenenvironments.However,the
benefitscannotbenecessarilyattributedtoallergenavoidance.Larger,welldesignedstudiesofcombinedallergenavoidancestrategiesin
differentgroupsareneeded[GINA,2006(/asthma#!references/297181)SIGNandBTS,2011(/asthma#!references/297181)].
Weightreduction,dietandexercise Backtotop
Weightreduction,diet,andexercise:WhatadviceshouldIgivesomeonewithasthma?
Adviseoverweightpeoplethatahealthydietandregularexercisewillhelpwithweightreductionandimproveasthmacontrol:
Advisepeople(ifpossible)totake30minutesofexercisetoincreasetheirheartrateatleastfivetimesweekly.Formoreinformationonweight
loss,seetheCKStopiconObesity(/obesity).
Exercisenospecificexerciseregimencanberecommendedapartfromthatneededtoadoptahealthierlifestyle(30minutesofexerciseto
increaseheartrateatleastfivetimesweekly).Advisepeopleaboutprecautionsagainstexerciseinducedasthma.SeeScenario:Managementof
exerciseinducedasthma(/asthma#!scenario:4).
Dietnospecificdietaryrecommendationcanbegiventopeoplewithasthmaapartfromabalanceddiet,oralowfatdietforpeopleneedingto
loseweight.Observationalstudiesinbothadultsandchildrenhaveconsistentlyshownthatahighintakeoffreshfruitandvegetablesisassociated
withlessasthmaandbetterlungfunction.Nointerventionstudieshaveyetbeenreported.
Weightreduction,diet,andexercise:theevidence(/asthma#!supportingevidence1:9)islimitedandbasedonsmallnumbersofpeoplewith
asthma.Weightreductionappearstoimproveasthmacontrol,lungfunction,andsymptomsinobesepeople.However,noconvincingtrial
evidenceshowsthatanyspecificdietorspecificexerciseregimenimprovesasthmacontrolorsymptoms[GINA,2006
(/asthma#!references/297181)SIGNandBTS,2011(/asthma#!references/297181)].
Comorbidities Backtotop
Comorbidities:WhatadviceshouldIgivesomeonewithasthma?
Adviseallpeoplewithasthmaandparentslookingafterchildrenwithasthmatoreportsymptomsofconditionsthatcouldworsenasthma,suchas
rhinitis,sinusitis,gastrooesophagealrefluxdisease,andsleepapnoea.
Explainthatsuchsymptomsasfacialpain,nasalsymptoms,indigestion,andsnoringsuggestcoexistingconditionsthatmayworsenasthmaand
needtreatment.
Associatedconditions,suchassinusitis,rhinitis,andgastrooesophagealrefluxdisease,worsenasthmacontrol.However,thereisno
conclusiveevidence(/asthma#!supportingevidence1:9)thatmanagingtheseconditionsresultsinsignificantclinicalimprovementsinasthma
symptoms.
Driving Backtotop
Driving:WhatadviceshouldIgivesomeonewithasthma?
Forbothgroup1(carormotorcycle)orgroup2(lorryorbus)entitlement:
TheDriverandVehicleLicensingAgency(DVLA)neednotbeeninformedunlessattacksareassociatedwithdisablinggiddiness,fainting,or
lossofconsciousness.
IftheDVLAneedtobenotified,advisethepersonthatitistheirresponsibilitytodoso.
ThelatestinformationfromtheDVLAregardingmedicalfitnesstodrivecanbeobtainedatwww.gov.uk/government/publications/ataglance
(https://www.gov.uk/government/publications/ataglance).
ThisinformationonmedicalrulesisfromtheDriverandVehicleLicensingAgency'sguidanceformedicalpractitioners,Ataglanceguidetothe
currentmedicalstandardsoffitnesstodrive[DVLA,2011(/asthma#!references/297181)].
Backtotop
Scenario:Uncontrolledasthmaoncurrenttreatment
Managementinchildunder5years Backtotop
Childrenunder5yearsofagewithuncontrolledsymptomsoncurrenttreatment:HowdoImanage?
Adjusttreatmentusingthestepwiseapproachoutlinedbelow.
Beforestartinganewdrugorsteppinguptreatment,confirmwiththeparentstheirunderstandingoftheroleoftreatment,adherencetotreatment,
inhalertechnique,andappropriateeliminationoftriggerfactors(/asthma#!diagnosissub:4).
Chooseaneffectivedeliverydevice(/asthma#!scenariorecommendation:12)onthebasisofconvenience,cost,andsuitability:
Step1:Prescribeashortactingbeta2agonist(/asthma#!prescribinginfosub)toallchildren,forrapidsymptomrelief.
Step2:Considerstartinganinhaledcorticosteroid(/asthma#!prescribinginfosub:2)(ICS)atadose(/asthma#!prescribinginfosub:4)thatis
appropriatefortheseverityofsymptoms(usuallyequivalenttobeclometasoneCFCfreeasClenilModulite200to400micrograms/day).
IndicationsforICSinclude:
Havingsymptomsthreetimesweeklyormore,or
Awakeningwithsymptomsonenightweeklyormore,or
Havinganexacerbationinthelast2years,or
Usinginhaledshortactingbeta2agonistthreetimesweeklyormore.
IfICSarenottoleratedorarecontraindicated,considerstartingaleukotrienereceptorantagonistatstep2(butdosoonlyinchildrenaged2
5years).
Step3:IfthechildstillhassymptomswhileusingregularICS(equivalenttoClenilModulite[beclometasoneCFCfree]400micrograms/day),
consider:
Forchildrenyoungerthan2years:movetostep4.
Forchildrenaged25years:initiateatrialofaleukotrienereceptorantagonist(/asthma#!prescribinginfosub:12)ifasthmaremains
inadequatelycontrolled,movetostep4.
Step4:Refertoapaediatricianwithknowledgeaboutrespiratorydiseases.
Offerselfmanagementinformation(/asthma#!scenariorecommendation:23),includingwrittenactionplansfocusingonthechild'sandthefamily's
needs.
Inhaledcorticosteroidsshouldbeusedtwiceaday,atthelowestdosethatmaintainseffectivecontrolofasthma.Higherdosesmaybeneeded
inyoungchildrentoensureadequatedrugdelivery.
Leukotrienereceptorantagonists:montelukastistheonlydruginthisclassthatislicensedforuseinchildren25yearsofage.
Chooseaneffectivedeliverysystemonthebasisofavailability,thechild'sabilitytousethedevice,convenience,andcost.Fordetails,see
Deliverysystemforchildrenunder5years(/asthma#!scenariorecommendation:15).
Evidenceislimitedforalltypesoftreatmentforasthmainchildrenyoungerthan5yearscomparedwitholderchildrenandadults.
Inhaledcorticosteroids(ICS):theevidence(/asthma#!supportingevidence1:2)nowsuggeststhatICSaresafeandeffectiveinyoungerchildren.
Theseagentsarebeneficialeveninmildasthma,butthereisnobenefitinstartingtreatmentatveryhighdosesandthensteppingdown.Concerns
remainabouttheadverseeffects(/asthma#!prescribinginfosub:2)ofICSinchildren.
Managementinchild512years Backtotop
Childrenaged512yearswithuncontrolledsymptomsoncurrenttreatment:HowdoImanage?
Beforestartinganewdrugorsteppinguptreatment,confirmwiththeparentstheirunderstandingoftheroleoftreatment,adherencetotreatment,
Step1:Prescribeashortactingbeta2agonist(/asthma#!prescribinginfosub)toallchildrenwithasthma,forrapidsymptomrelief.
Step2:Considerstartinganinhaledcorticosteroid(/asthma#!prescribinginfosub:2)(ICS)atadosemostappropriatetotheseverityof
symptomsforbeclometasoneCFCfreeasClenilModulitethisis200to400micrograms/day.Indicationsinclude:
Awakeningwithsymptomsonenightaweekormore,or
Havinganexacerbationinthepast2years,or
Usingtheirinhaledbeta2agonistthreetimesweeklyormore.
IfICStherapyisnottolerated,considerstartingaleukotrienereceptorantagonist(/asthma#!prescribinginfosub:12)orcromones
(/asthma#!prescribinginfosub:15).Longactingbeta2agonists(LABA)shouldonlybeprescribedwithanICSandthereforeshouldnotbe
consideredanalternativetoICS.
Step3:ConsiderstartingLongactingbeta2agonists(/asthma#!prescribinginfosub:7)(LABA)ifsymptomsarestilluncontrolledwhenusingan
ICSat400micrograms/day:
IfthechildhasagoodresponsetotheLABAwithadequatesymptomcontrol,continuetheLABAandcurrentdoseoftheICS.Consider
prescribingacombinationinhaler.
IfthechildhasagoodresponsetotheLABAbutsymptomcontrolisstillinadequate,andthechildisreceiving400micrograms/dayofan
ICS,continuetheLABAandgotostep4.
IfthechilddoesnotrespondtoLABA,stoptheLABA.Ifthesymptomcontrolisinadequateandthechildisreceiving400micrograms/dayof
anICS,thenconsideranalternativeaddontreatment,suchasaleukotrienereceptorantagonist(/asthma#!prescribinginfosub:12)or
modifiedreleasetheophylline(/asthma#!prescribinginfosub:10),beforemovingtostep4.
Step4:ConsiderincreasingtheICStothemaximumrecommendeddailydose.ForbeclometasoneCFCfreeasClenilModulitethis
is800micrograms/day.ChildrenunderspecialistcaremaybenefitfromatrialofadoseofICSabove800microgramsadaybeforemovingto
step5.
Step5:Refertoapaediatricianwithknowledgeofrespiratorymedicine.Continuousorfrequentuseoforalcorticosteroidsmaybeneeded.
Omalizumab(/asthma#!scenarioclarification:7/491855)maybeinitiatedbysomespecialistsforchildrenwithsevere,persistent,allergic
asthma.
Offerselfmanagementinformation(/asthma#!scenariorecommendation:23),includingwrittenactionplansfocusingontheindividual'sneeds.
Thedurationofatrialofaddontherapydependsonthedesiredoutcome.Atrialofdaystoweeksmaybesufficientforsymptomrelief,whilstit
maytakeweekstomonthsforbenefitstobeseeninexacerbationrates.Formostpreventivetherapies,improvementsbeginwithindays,butthe
fullbenefitmayonlybeevidentafter3or4months,especiallyinsevereandchronicallyundertreateddisease[GINA,2006
Shortactingbeta2agonistsmaybeneededonaregularbasistoprovidetemporaryreliefofuncontrolledsymptoms.Theaimistostoptheneed
forrelievermedicationbyusingadequatepreventivetherapy.
Inhaledcorticosteroidsareusuallyprescribedatthelowestdoseneededtoachievecontrol.
Inhaledlongactingbeta2agonists:whenstartingtherapywiththesedrugs,itmaybemorepracticaltoprescribeseparateinhalerstoallow
titrationofdoses,andseparateinhalersmakeiteasiertostepdowntreatmentifsymptomsimprove.However,acombinationinhalershouldbe
consideredoncethedosehasbeentitratedasthiswillensurethatalongactingbeta2agonistisnottakenwithoutaninhaledcorticosteroid.
Leukotrienereceptorantagonistsmaybepreferredovermodifiedreleasetheophyllinebecausetheyhavefeweradverseeffects.
Oralcorticosteroids(daily)areanoptionforchildrenwhoseasthmaremainsinadequatelycontrolledafterstep4,buttheyshouldnotbe
prescribedwithoutspecialistadvice.
Omalizumab:isanoptionasaddontherapytoinhaledcorticosteroidsinchildrenwithmoderatetosevereasthmabutthisshouldonlybe
prescribedonspecialistadvice.OmalizumabisahumanisedmonoclonalantibodymanufacturedbyrecombinantDNAtechnology.Itisgivenby
subcutaneousinjectionandislicensedforuseinpeopleagedover6years[ABPIMedicinesCompendium,2010(/asthma#!references/297181)].
ItisaBlackTriangleproductsubjecttointensivemonitoringbytheMedicinesandHealthcareproductsRegulatoryAgency(MHRA).
Forsteps2,3,and4,thebenefitsoftreatmentintrialsarebasedonimprovementsinsymptomsandlungfunction,reducedexacerbations,anda
goodsafetyprofile.TheBritishThoracicSocietybasedtheiraddonregimensonextrapolatedevidencefromtrialsofaddontherapytoinhaled
corticosteroids(ICS)andonpreviousguidelines.Fewclinicaltrialsinspecificpatientgroupsareavailabletoguidemanagement.
Inhaledcorticosteroids(ICS):Theevidence(/asthma#!supportingevidence1:2)suggeststhatICSarethemosteffectivepreventivetreatment
forallpeoplewithasthma.Nevertheless,thereareconcernsaboutlocalandsystemicadverseeffects(/asthma#!prescribinginfosub:2)when
ICSareusedinhighdoses.Clinicaltrialsshownodifferenceinefficacy(providedadherenceisgood)betweengivinginhaledcorticosteroids
andlongactingbeta2agonistsincombinationorinseparateinhalers.Inclinicalpractice,however,combinationinhalersmayimprove
compliance.CombinationinhalersarethereforerecommendedbytheNationalInstituteforHealthandCareExcellence[NICE,2008
(/asthma#!references/297181)]andtheMedicinesandHealthcareproductsRegulatoryAgency[MHRA,2008(/asthma#!references/297181)]
asthey:
Guaranteethatthelongactingbeta2agonistisnottakenwithoutaninhaledcorticosteroid.
Aidadherence.
Althoughtherearenocontrolledtrials,expertopinionintheBritishguidelineonthemanagementofasthma:anationalclinicalguidelineisthat
childrenofallageswhoarebeingtreatedatstep4maybenefitfromatrialofICSabovethemaximumrecommendeddosebeforemovingto
step5,providedthisisinitiatedbyaspecialist[SIGNandBTS,2011(/asthma#!references/297181)].
Longactingbeta2agonists(LABA):Theevidence(/asthma#!supportingevidence1:3)suggeststhataddingaLABAprovidesbetterasthma
controlthanincreasingICSabove400micrograms.InchildrenthedoseatwhichaddontherapyappearstobemorebeneficialiswhenICS
exceed400micrograms/day(beclometasoneequivalent).UseofaLABAalone(withoutICS)appearstobeassociatedwithincreasedriskof
asthmarelateddeath.Largerprospectivestudiesareneededtoconfirmthesefindings.
Leukotrienereceptorantagonists(LTRA):Theevidence(/asthma#!supportingevidence1:4)suggeststhatleukotrienereceptorantagonists
improveasthmasymptomsandlungfunctionwhenaddedtoICS,buttheydonotprovidegreaterbenefitthanincreasingICSalone.
Theophylline:Theevidence(/asthma#!supportingevidence1:5)suggeststhatincreasingtheICSdoseprovidesbetterasthmacontrolthanadding
intheophylline.Comparisonstudieswithotheraddontherapiesarelimited,buttheophyllineappearstohaveaworseadverseeffectprofilethan
otherdrugs.
Cromones:Limitedandinconclusiveevidence(/asthma#!supportingevidence1:6)suggeststhatcromonesmayprovidesomebenefitincontrolling
asthmasymptoms.
Omalizumab:Useofomalizumabhasbeenstudiedinchildrenaged512yearsandhasbeenshowntosignificantlyreduceclinicallysignificant
exacerbations.Mostchildrenstudiedweretakinglongactingbeta2agonistsoraleukotrieneantagonist.Omalizumabshouldonlybeadministered
underdirectmedicalsupervisionbecauseoftheriskofanaphylaxiswhichhasbeenreportedafterthefirstdoseandalsoafter1year[SIGNand
BTS,2011(/asthma#!references/297181)].
Managementinpeopleover12years Backtotop
Peopleover12yearsofagewithuncontrolledsymptomsoncurrenttreatment:HowdoImanage?
Beforestartinganewdrugorsteppinguptreatment,confirmwiththepersontheirunderstandingoftheroleoftreatment,adherencetotreatment,
Step1:Prescribeashortactingbeta2agonist(/asthma#!prescribinginfosub)toallpeoplewithasthma,forrapidsymptomrelief.
Step2:Considerstartinganinhaledcorticosteroid(/asthma#!prescribinginfosub:2)(ICS)atadosemostappropriatetotheseverityof
symptoms(forbeclometasoneCFCfreeasClenilModulitethisis200to800micrograms/day,with400micrograms/daybeingappropriatefor
mostpeopleolderthan12years).UsehalfthedoseforQvar.Indicationsinclude:
Awakeningwithsymptomsonenightweeklyormore,or
Havinganexacerbationinthepast2years,or
Usinginhaledbeta2agonistthreetimesweeklyormore.
IfICSarenottolerated,considerstartingaleukotrienereceptorantagonist(/asthma#!prescribinginfosub:12)orcromone
(/asthma#!prescribinginfosub:15).Longactingbeta2agonists(LABA)shouldonlybeprescribedwithanICSandthereforeshouldnotbe
consideredanalternativetoICS.
Step3:Considerstartingalongactingbeta2agonist(/asthma#!prescribinginfosub:7)(LABA)ifsymptomsarestilluncontrolledwiththeICS
(irrespectiveofthedoseused):
IfthepersonhasagoodresponsetotheLABAwithadequatesymptomcontrol,continuetheLABAandcurrentdoseoftheICS.Consider
usingacombinationinhaler.
IfthepersonhasagoodresponsetotheLABAbutcontrolremainsinadequate,continuetheLABA,butincreaseICSupto
800micrograms/day(halfthedoseforQvar).Ifthepersonisreceiving800micrograms/dayandcontrolremainspoor,movetostep4.
IfthepersondoesnotrespondtoLABA,stopLABAtherapyandincreaseICSupto800micrograms/day(unlessthepersonisalready
receivingthisdosage).Ifcontrolremainspoor,consideranalternativeaddontreatment,suchasaleukotrienereceptorantagonist
(/asthma#!prescribinginfosub:12)ormodifiedreleasetheophylline(/asthma#!prescribinginfosub:10),beforemovingtostep4.
TheSymbicortSMARTregimen(abudesonide/formoterolcombinationinhalerusedasapreventerandreliever)isanalternativein
selectedadults(18yearofageandolder)whorespondtoaLABAbutarepoorlycontrolled,orinadultswhoaretakinganICSalone(above
400micrograms/day)butarepoorlycontrolled.Theregularmaintenancedoseofbudesonideshouldnotbedecreased,andmaybe
budesonide200or400microgramstwiceaday,dependingonsymptomseverity.IfthepersonregularlyusesSymbicortasarelieveronce
adayormore,reviewtreatment.
PeopleusingtheSymbicortSMARTregimenshouldbeadvisedtocontinueusingtheinhalerregularlytwiceaday,aswellaswhen
required.CarefulexplanationisneededaboutwhySymbicortcanbeusedasarelieveraswellasapreventer,andwhyitisimportantto
arrangeareviewifSymbicortregularlyneedstobeusedasareliever(toreviewcontrolofasthmaandtheriskofdoserelatedadverse
effects).
Step4:Ifcontrolisstillinadequate,eitherincreaseICStothemaximumdose(forbeclometasoneCFCfreeasClenilModulite,thisis
2000micrograms/day)orconsiderstartingafourthdrugthatthepersonisnotalreadyusing,suchasaleukotrienereceptorantagonist
(/asthma#!prescribinginfosub:12),modifiedreleasetheophylline(/asthma#!prescribinginfosub:10),oranoralmodifiedreleasebeta2agonist.
Step5:Refertoaspecialistinrespiratorymedicine.Considerstoppinganyaddontherapy(orreducingtheICSdose)iftheseoptionsare
ineffective,whilstreferringtoaspecialist.
Offerselfmanagementinformation(/asthma#!scenariorecommendation:23),includingwrittenactionplansfocusingontheindividual'sneeds.
Thedurationofatrialofaddontherapydependsonthedesiredoutcome.Atrialofdaystoweeksmaysufficeforsymptomrelief,whilstitmay
takeweekstomonthsforbenefittobeseeninexacerbationrates.Formostpreventivetherapies,improvementsbeginwithindays,butthefull
benefitmayonlybeevidentafter3or4months,especiallyinsevereandchronicallyundertreateddisease[GINA,2006
Shortactingbeta2agonistsmaybeneededonaregularbasistoprovidetemporaryreliefofuncontrolledsymptoms.Theaimistostoptheneed
forrelievermedicationbyusingadequatepreventivetherapy.
Inhaledcorticosteroidsareusuallyprescribedatthelowestdoseneededtoachievecontrolandarerarelynottolerated.
Inhaledlongactingbeta2agonists(LABA):whenstartingtherapywithLABA,itmaybemorepracticaltoprescribeseparateLABAandICS
inhalerstoallowtitrationofdoses.However,acombinationinhalershouldbeconsideredoncethedosehasbeentitratedasthiswillensurethata
longactingbeta2agonistisnottakenwithoutaninhaledcorticosteroid.
Leukotrienereceptorantagonistsmaybepreferredtomodifiedreleasetheophyllineororalmodifiedreleasebeta2agonistbecausetheyare
associatedwithfeweradverseeffects.Inpracticemodifiedreleasetheophyllineandoralmodifiedreleasebeta2agonistsarenotroutinely
prescribedinprimarycare.
Oralcorticosteroidsareanoptionforpeoplewhoseasthmaremainsinadequatelycontrolledafterstep4,buttheyshouldnotbeprescribed
withoutspecialistadvice.
Forsteps2,3,and4,thebenefitsoftreatmentintrialsarebasedonimprovementsinsymptomsandlungfunction,reducedexacerbationsand
agoodsafetyprofile.TheBritishThoracicSocietybasedtheiraddonregimensonextrapolatedevidencefromtrialsofaddontherapytoICS
andonpreviousguidelines.Fewclinicaltrialsareavailableinspecificpatientgroupstoguidespecificmanagement.
Inhaledcorticosteroids(ICS):Theevidence(/asthma#!supportingevidence1:2)suggeststhatICSarethemosteffectivepreventivetreatment
forallpeoplewithasthma.Nevertheless,thereareconcernsaboutlocalandsystemicadverseeffects(/asthma#!prescribinginfosub:2)when
ICSareusedinhighdoses.
Longactingbeta2agonists(LABA):Theevidence(/asthma#!supportingevidence1:3)suggeststhataddingaLABAcontrolsasthmabetter
thanincreasingtheICSdose.UseofLABAalone(withoutICS)appearstobeassociatedwithanincreasedriskofasthmarelateddeath.
Clinicaltrialsshownodifferenceinefficacy(providedadherenceisgood)betweengivinginhaledcorticosteroidsandlongactingbeta2agonists
incombinationorinseparateinhalers.Inclinicalpractice,however,combinationinhalersmayimprovecompliance.Combinationinhalersare
thereforerecommendedbytheNationalInstituteforHealthandCareExcellence[NICE,2008(/asthma#!references/297181)]andthe
MedicinesandHealthcareproductsRegulatoryAgency[MHRA,2008(/asthma#!references/297181)]asthey:
Guaranteethatthelongactingbeta2agonistisnottakenwithoutaninhaledcorticosteroid.
Aidadherence.
Leukotrienereceptorantagonists:Theevidence(/asthma#!supportingevidence1:4)suggeststhattheseagentsimproveasthmasymptoms
andlungfunctionwhenaddedtoICShowever,theydonotprovideanygreaterbenefitthanincreasingICSalone.
Theophylline:Theevidence(/asthma#!supportingevidence1:5)suggeststhatincreasingtheICSdoseprovidesbetterasthmacontrolthan
addingintheophylline.Comparisonstudieswithotheraddontherapyarelimited,buttheophyllineappearstohaveaworseadverseeffect
profilethanotherdrugsused.
Cromones:Limitedandinconclusiveevidence(/asthma#!supportingevidence1:6)suggestthatcromonesmayprovidesomebenefitin
controllingasthmasymptoms.
Alwaysreferpeopletoaspecialistbeforestartingtherapywithoralcorticosteroids,astheyrequireclosemonitoringforsuchadverseeffectsas
hypertension,diabetes,reducedgrowth(inchildren),andcataracts.
Combinationinhalers:evidence(/asthma#!supportingevidence1:7)indicatesthatusingthecombinationinhalerSymbicort(budesonideand
formoterol)asamaintenanceandrelievertherapy(SymbicortSMART)maybesimilarlyeffectivetoconventionalmethodsatreducing
exacerbationratesinpeoplewithmoderatetosevereasthma.
Followup Backtotop
Whatfollowupisneededinsomeonewithasthma?
Reviewapersonwithstableasthmaatleastonceayear.Morefrequentfollowupmaybeneededaftertheinitialdiagnosis,forexample
reassesswithin23months,whenthereisachangetomedication,orinpeoplewithsevereasthma,poorlungfunctionorrecurrentexacerbations.
Considermonitoringpeoplewithpoorlungfunctionandwithahistoryofexacerbationsinthepreviousyearmoreoften.
Whenassessingasthmacontrol:
Usespecific(closed)questions,becausebroadnonspecificquestionsmayunderestimatesymptoms.
Inadults,useaquestionnairesuchasTheRoyalCollegeofPhysicians3questions(/asthma#!scenarioclarification:9)ortheAsthmaControl
Questionnaire(http://erj.ersjournals.com/content/14/4/902.full.pdf+html)orAsthmaControlTest
(http://www.asthma.org.uk/applications/control_test/).
Inchildren,useasymptomscoresuchastheAsthmaControlQuestionnaire(http://erj.ersjournals.com/content/14/4/902.full.pdf+html)orthe
Children'sAsthmaControlTest(http://www.asthmacontroltest.com/worldmap_children/worldmap_child.htm).
Askaboutsymptomsduringthedaydifficultysleepingandtheimpactofasthmaonsuchactivitiesasexercise,work,school,and
psychologicalwellbeinginthepastweekormonth.
Assesslungfunctionusingspirometryorpeakexpiratoryflowrateandcomparewiththepreviouslyrecordedvalue.Reducedlungfunctionmay
indicatecurrentbronchoconstrictionoralongtermdeteriorationinlungfunction.Carryoutadetailedassessmentiftherehasbeenareduction
inlungfunction.
Updatethebestpeakflowexpiratoryrateinadultseveryfewyearsandmoreofteningrowingchildren.
Askaboutpastexacerbationsandtheirfrequency,andwhetheroralcorticosteroidsorhospitaladmissionwasneeded.
Askaboutpossibletriggerfactors(/asthma#!diagnosissub:4),suchasexercise,work,andallergens.
Askaboutotherconditionsthatareknowntocoexistwithasthmaandaggravatesymptoms,forexample,allergicrhinitis,sleepapnoea,and
gastrooesophagealrefluxdisease.
Lookforsignsofcomplications(/asthma#!backgroundsub:4)whichmaynecessitatereferraltoaspecialist.
Inchildren,monitorgrowth(heightandweightcentile)annually.
Reviewasthmamedication:
Askabouttheuseofrelievermedication,anybenefitsseenwithchangesinmedication,andadherencewithtreatment(whichcanbeassessed
byreviewingprescriptionrefillfrequency).
Assessinhalertechnique.Reinforcethecorrectuseofinhalersateachreview.Askthepersontoshowyouhowtheyusetheirinhaler,and
correctanyproblemsbydemonstratingthetechniqueandhavingthepersonrepeatitbacktoyou.Formoreinformationonhowtouseinhalers
(withdemonstrations),seewww.asthma.org.uk(http://www.asthma.org.uk)orwww.ginasthma.org(http://www.ginasthma.org).
Askaboutsmokinghabitsinadultsandadolescents,andinchildrenaskaboutexposuretotobaccosmoke.Encouragepeoplewithasthmaor
parentsofchildrenwithasthmatostopsmoking.
Reviewselfmanagementinformation(/asthma#!scenariorecommendation:23)andmakeanynecessarychangestowrittenactionplans.
Discussfuturecareerchoiceswithadolescents,andhighlightoccupationsthatmightincreasetheriskofdevelopingoccupational
asthma.Theseincludeforestryworkers,chemicalworkers,plasticsandrubberworkers,metalworkers,welders,textileworkers,electricaland
electronicproductionworkers,storageworkers,farmworkers,waiters,cleaners,painters,dentalworkers,andlaboratorytechnicians.
TheRoyalCollegeofPhysicians3questions Backtotop
The'RoyalCollegeofPhysicians(RCP)3questions'issimpletouseineverydayclinicalpractice.Answering'no'toallthreequestionsis
consistentwithcontrolledasthma.
Table1.RoyalCollegeofPhysicians''threequestions'forassessingasthmacontrol.
Inthelastweek/month: Yes No
Haveyouhaddifficultysleepingbecauseofyourasthmasymptoms(includingcough)? 1 0
Haveyouhadyourusualasthmasymptomsduringtheday(e.g.cough,wheeze,chesttightness,orbreathlessness)? 1 0
Hasyourasthmainterferedwithyourusualactivities(e.g.housework,work,school)? 1 0
3questionsscore(03)
Thisscoreshouldbeusedonlyforpeoplewhoareatleast16yearsoldandafterthediagnosisofasthmahasbeenestablished[Pearsonand
Bucknall,1999(/asthma#!references/297181)SIGNandBTS,2011(/asthma#!references/297181)].
Theaimofastructuredreviewistoassesshowwellaperson'sasthmaiscontrolledandtoidentifypossibletriggersofpoorcontrol.Then,if
needed,treatmentcanbechanged(steppedup,downorchanged)tohelpoptimizecontrolandreduceexacerbationsandhospitalizations.
Currentcontrolisthebestpredictorforfutureexacerbations.ExpertopinionintheBritishguidelineonthemanagementofasthma:anational
clinicalguidelineisthatforagivenlevelofsymptomspeoplewithpoorlungfunctionandahistoryofrecentexacerbationsmaybeatincreasedrisk
offutureexacerbations[SIGNandBTS,2011(/asthma#!references/297181)].
Asthmamorbidityquestionnaires:Questionnaireshavebeendevelopedtostandardizetheassessmentofasthmasymptomcontrol.Asking
peopleaboutasthmasymptomsandtheireffectsoneverydaylifeisimportanttoimproveasthmamanagement[Rees,2006
Askclosedquestions.Askinggeneralquestionssuchas'howisyourasthmatoday?'islikelytogenerateanonspecificreply.Closed
questionsaremorelikelytoresultinusefulinformation[SIGNandBTS,2011(/asthma#!references/297181)].ExpertopinionintheBritish
guidelineonthemanagementofasthma:anationalclinicalguidelineisthatitisbesttouseavalidatedquestionnaire[SIGNandBTS,2011
(/asthma#!references/297181)].Monitoringpeakexpiratoryflowrateinadditiontomonitoringsymptomshasnotbeenshowntoimprove
asthmacontrolwiththepossibleexceptionofadultswhohaveseverediseaseorwhohaveapoorperceptionofbronchoconstriction.
The'RoyalCollegeofPhysicians3questions'hasnotbeenwellvalidatedinadultsandhasnotbeenvalidatedinchildren.However,its
simplicityisattractiveforclinicalpractice.TheQualityandOutcomesFrameworkforGMScontract2012/2013alsosuggestsuseofthis
questionnaireasaneffectivewayofassessingasthmasymptoms[BMAandNHSEmployers,2012(/asthma#!references/297181)].
TheAsthmaControlQuestionnairehasbeenwellvalidatedinadultsandchildrenagedover5years.
TheAsthmaControlTesthasbeenvalidatedinadultsandchildrenagedover3years.
Structuredreviews:Theevidenceshowsthatpeoplehavefewerexacerbations,haveimprovedsymptoms,andmisslessschoolorworkifthey
undergostructuredasthmareviews,especiallyiftheassessmentsaredonebytrainedprofessionals.Telephoneconsultationsmaybeaseffective
asfacetofaceconsultations[PinnockandShah,2007(/asthma#!references/297181)].
Assessinglungfunction:Reducedlungfunctioncomparedtopreviouslyrecordedvaluesmayindicatecurrentbronchoconstrictionoralongterm
declineinlungfunctionandshouldpromptdetailedassessment[SIGNandBTS,2011(/asthma#!references/297181)].Expertopinioninthe
Britishguidelineonthemanagementofasthma:anationalclinicalguidelinerecommendsthatapersonalbestpeakflowexpiratoryrateshouldbe
measuredoncetreatmenthasbeenoptimisedandupdatedeveryfewyearsinanadultandmorefrequentlyinachild[SIGNandBTS,2011
Inhalertechnique:ExpertopinionintheBritishguidelineonthemanagementofasthma:anationalclinicalguidelinerecommendsthatinhalers
shouldonlybeprescribedafterthepersonhasreceivedtrainingintheuseoftheinhalerdeviceandhasdemonstratedsatisfactorytechnique
Comorbidities:Gastrooesophagealrefluxdisease,allergicrhinitis,obesity,andobstructivesleepapnoeahavebeenreportedingreater
proportionsofpeoplewithdifficulttotreatasthma.Itisimportanttorecognizesuchconditionsbecausetheyappeartoaggravateasthma
symptomsandneedtreatment.However,todate,noevidenceindicatesthattreatingtheseconditionsimprovesasthmacontrol[GINA,2006
Smoking:Smokingmaycausepoorasthmacontrol.Pastsmokingcanbeassociatedwithpoorcontrolduetofixedairwayobstruction,andcurrent
smokingreducestheeffectivenessofinhaledandoralcorticosteroids[GINA,2006(/asthma#!references/297181)].
Monitoringgrowthinchildren:ExpertopinionintheBritishguidelineonthemanagementofasthma:anationalclinicalguidelinerecommendsto
monitorgrowth(heightandweightcentile)annually[SIGNandBTS,2011(/asthma#!references/297181)].
Selfmanagementinformation:ExpertopinionintheBritishguidelineonthemanagementofasthma:anationalclinicalguidelinerecommends
thatallpeoplewithasthmashouldbeofferedselfmanagementeducationandshouldalsohaveapersonalisedactionplan[SIGNandBTS,2011
Discussingtheriskofoccupationalasthmawithadolescents:Thisrecommendationandtheoccupationslistedarebasedonexpertopinionin
theBritishguidelineonthemanagementofasthma:anationalclinicalguideline[SIGNandBTS,2011(/asthma#!references/297181)].
Referral Backtotop
Prominentsystemicfeatures(forexampleweightloss,myalgia,fever).
Spirometricorpeakexpiratoryflowmeasurementsthatdonotfittheclinicalpicture,forexampleunexplainedrestrictivespirometry.
Failuretothrive.
Parentalanxiety.
Additionaltestsinsecondarycare Backtotop
Othertestsavailableinsecondarycareinclude:
Indirecttestingforbronchoconstriction,forexamplemorethan15%decreaseintheforcedexpiratoryvaluein1secondafter6minutesof
running.
Testingforbronchialhyperresponsivenessusinghistamineormethacholine.
symptoms).
medicalhelp.
Smoking Backtotop
Theserecommendationsarebasedongovernmentpolicyasdiscussedinthe'GreenBook',publishedbytheDepartmentofHealth[DH,2006b
needtreatment.
Associatedconditions,suchassinusitis,rhinitis,andgastrooesophagealrefluxdisease,worsenasthmacontrol.However,thereisnoconclusive
evidence(/asthma#!supportingevidence1:9)thatmanagingtheseconditionsresultsinsignificantclinicalimprovementsinasthmasymptoms.
Driving Backtotop
Backtotop
Scenario:Controlledasthmaoncurrenttreatment
Managementofcontrolledasthma Backtotop
Childrenandadultswithcontrolledsymptomsoncurrenttreatment:HowdoImanage?
DoNOTstepdowntreatmentforpeoplewhohaveongoingsymptoms(/asthma#!diagnosissub)orneedinhaledshortactingbeta2agonists,and
thosewhohavehadarecentexacerbation.
Ifapersonhascontrolledsymptoms,considerthefollowingapproachtostepdowntreatment:
Makesurethepersonfeelsthattheirasthmaiscontrolledandthattheyarewillingtotrystepdowntreatment.
Reducethedoseofinhaledcorticosteroidsslowly.Theusualprotocolistodecreasethedoseby25%to50%per3monthvisit.Explainthe
potentialforworseningsymptomsandtheincreasedriskofanexacerbation.
Somechildrenwithmilderasthmaandaclearseasonalpatterntotheirsymptomsmaytolerateamorerapiddosereductionduringtheir'good'
season.
Reviewthepersononaregularbasispromotelifestyleadvice(/asthma#!scenariorecommendation:44),assessforworseningsymptoms,and
considerincreasingmedicationiftheperson'sasthmadeteriorates.
Ifsteppingdownisnotpossible,andthepersonisstableonaninhaledcorticosteroidandalongactingbeta2agonist,considerprescribinga
combinationinhaler(/asthma#!scenariorecommendation:19).
Discussthereasonforreducingmedication(tominimizeadverseeffects),andalwaystaketheperson'spreferenceintoconsideration.
Updatetheperson'swritten'actionplan'andreinforcehowtorecognizeandmanageanacuteexacerbation(/asthma#!scenario:3).
Tailorthemanagementtotheindividual,onthebasisoftheircombinationofdrugsandthedosesneededtoachieveasthmacontrol:
Ifapersonisonacombinationofinhaledcorticosteroids(ICS)andaddontherapy,slowlyreducetheICStothelowestdosepossibleifasthma
controlismaintainedconsiderstoppingaddontherapy.Someexperts(althoughthereisnoclearevidencetodoso)recommenddiscontinuing
anyregularuseofabetaagonist(shortorlongacting)beforereducingtheinhaledcorticosteroiddosebelow400microgramsdaily.
PreventiveICStreatmentmaypossiblybestoppedifasthmaremainscontrolledonthelowestpossibledoseandsymptomsdonotrecurforone
year.
(/asthma#!references/297181)]andguidelinesfromtheGlobalInitiativeforAsthma[GINA,2006(/asthma#!references/297181)]:
Thereducedneedformedicationoncecontrolisachievedisnotfullyunderstood.Possibilitiesincludeareversaloflongterminflammationinthe
airwaysorspontaneousimprovementaspartofthecyclicalnaturalhistoryofasthma[GINA,2006(/asthma#!references/297181)].
Fewstudieshaveinvestigatedthemostappropriatewayofsteppingdowntreatment.Onestudyinadultswithstableasthmawhousedatleast
900microgramsofinhaledcorticosteroidsdailyshowedthatthedosecouldbehalvedevery3monthswithnosignificantdeteriorationin
symptoms[SIGNandBTS,2011(/asthma#!references/297181)].
symptoms).
medicalhelp.
Smoking Backtotop
needtreatment.
symptoms.
Driving Backtotop
Followup Backtotop
Whatfollowupisneededinsomeonewithasthma?
Reviewapersonwithstableasthmaatleastonceayear.Morefrequentfollowupmaybeneededaftertheinitialdiagnosis,forexample
reassesswithin23months,whenthereisachangetomedication,orinpeoplewithsevereasthma,poorlungfunctionorrecurrentexacerbations.
Somepeoplemaynotwishtoattendforregularreview.Astructuredinterviewbytelephonemaybeanalternativeapproach.Ideally,candidates
shouldhavestableasthma,andfacetofacecontactshouldbeencouragedatalaterdatetoassesstheirinhalertechnique.
Reviewasthmacontrol:
Whenassessingasthmacontrolusespecific(closed)questionsbecausebroadnonspecificquestionsmayunderestimatesymptoms.
Responsescanberecordedeasilyandcanformthebasisofasymptomdiary.
Inadults,useaquestionnairesuchasTheRoyalCollegeofPhysicians3questions(/asthma#!scenarioclarification:13)ortheAsthmaControl
Questionnaire(http://erj.ersjournals.com/content/14/4/902.full.pdf+html)orAsthmaControlTest
(http://www.asthma.org.uk/applications/control_test/).
Inchildren,useasymptomscoresuchastheAsthmaControlQuestionnaire(http://erj.ersjournals.com/content/14/4/902.full.pdf+html)orthe
Children'sAsthmaControlTest(pdf)(http://www.nationaljewish.org/NJH/media/pdf/pdfChildhood_ACT.pdf).
Askaboutsymptoms,duringthedaydifficultysleepingandtheimpactofasthmaonsuchactivitiesasexercise,work,orschoolinthepast
weekormonth.
Assesslungfunctionusingspirometryorpeakexpiratoryflowrateandcomparewiththepreviouslyrecordedvalue.Reducedlungfunctionmay
indicatecurrentbronchoconstrictionoralongtermdeteriorationinlungfunction.Carryoutadetailedassessmentiftherehasbeenareduction
inlungfunction.
Updatethebestpeakflowexpiratoryrateinadultseveryfewyearsandmoreofteningrowingchildren.
Askaboutpastexacerbationsandtheirfrequency,andwhetheroralcorticosteroidsorhospitaladmissionwasneeded.
Askaboutpossibletriggerfactors(/asthma#!diagnosissub:4)suchasexercise,work,andallergens.
Askaboutotherconditionsthatareknowntocoexistwithasthmaandaggravatesymptoms,forexampleallergicrhinitis,sleepapnoea,and
gastrooesophagealrefluxdisease.
Lookforsignsofcomplications(/asthma#!backgroundsub:4)whichmaynecessitatereferraltoaspecialist.
Inchildren,monitorgrowth(heightandweightcentile)annually.
Reviewasthmamedication:
Askabouttheuseofrelievermedication,anybenefitsseenwithchangesinmedication,andadherencewithtreatment.
Assessinhalertechnique.Reinforcethecorrectuseofinhalersateachreview.Askthepersontoshowyouhowtheyusetheirinhaler,and
correctanyproblemsbydemonstratingthetechniqueandhavingthepersonrepeatitbacktoyou.Formoreinformationonhowtouseinhalers
(withdemonstrations),seewww.asthma.org.uk(http://www.asthma.org.uk)orwww.ginasthma.org(http://www.ginasthma.org).
Askaboutsmokinghabitsinadultsandadolescents,andinchildrenaskaboutexposuretotobaccosmoke.Encouragepeoplewithasthmaor
parentsofchildrenwithasthmatostopsmoking(/asthma#!scenariorecommendation:46).
ReviewSelfmanagementinformation(/asthma#!scenariorecommendation:45)andmakeanynecessarychangestowrittenactionplans.
Discussfuturecareerchoiceswithadolescents,andhighlightoccupationsthatmightincreasetheriskofdevelopingoccupational
asthma.Theseincludeforestryworkers,chemicalworkers,plasticsandrubberworkers,metalworkers,welders,textileworkers,electricaland
electronicproductionworkers,storageworkers,farmworkers,waiters,cleaners,painters,dentalworkers,andlaboratorytechnicians.
TheRoyalCollegeofPhysicians3questions Backtotop
The'RoyalCollegeofPhysicians(RCP)3questions'issimpletouseineverydayclinicalpractice.Answering'no'toallthreequestionsis
consistentwithcontrolledasthma.
Table1.RoyalCollegeofPhysicians''threequestions'forassessingasthmacontrol.
Inthelastweek/month: Yes No
Haveyouhaddifficultysleepingbecauseofyourasthmasymptoms(includingcough)? 1 0
Haveyouhadyourusualasthmasymptomsduringtheday(e.g.cough,wheeze,chesttightness,orbreathlessness)? 1 0
Hasyourasthmainterferedwithyourusualactivities(e.g.housework,work,school)? 1 0
3questionsscore(03)
Thisscoreshouldbeusedonlyforpeoplewhoareatleast16yearsoldandafterthediagnosisofasthmahasbeenestablished[Pearsonand
Bucknall,1999(/asthma#!references/297181)SIGNandBTS,2011(/asthma#!references/297181)].
Theaimofastructuredreviewistoassesshowwellaperson'sasthmaiscontrolledandtoidentifypossibletriggersofpoorcontrol.Then,if
needed,treatmentcanbechanged(steppedup,downorchanged)tohelpoptimizecontrolandreduceexacerbationsandhospitalizations.
Currentcontrolisthebestpredictorforfutureexacerbations.ExpertopinionintheBritishguidelineonthemanagementofasthma:anational
clinicalguidelineisthat,foragivenlevelofsymptoms,peoplewithpoorlungfunctionandahistoryofrecentexacerbationsmaybeatincreased
riskoffutureexacerbations[SIGNandBTS,2011(/asthma#!references/297181)].
Asthmamorbidityquestionnaires:Questionnaireshavebeendevelopedtostandardizetheassessmentofasthmasymptomcontrol.Asking
peopleaboutasthmasymptomsandtheireffectsoneverydaylifeisimportanttoimproveasthmamanagement[Rees,2006
Askclosedquestions.Askinggeneralquestionssuchas'howisyourasthmatoday?'islikelytogenerateanonspecificreply.Closedquestions
aremorelikelytoresultinusefulinformation[SIGNandBTS,2011(/asthma#!references/297181)].ExpertopinionintheBritishguidelineon
themanagementofasthma:anationalclinicalguidelineisthatitisbesttouseavalidatedquestionnaire[SIGNandBTS,2011
(/asthma#!references/297181)].Monitoringpeakexpiratoryflowrateinadditiontomonitoringsymptomshasnotbeenshowntoimprove
asthmacontrolwiththepossibleexceptionofadultswhohaveseverediseaseorwhohaveapoorperceptionofbronchoconstriction.
The'RoyalCollegeofPhysicians3questions'hasnotbeenwellvalidatedinadultsandhasnotbeenvalidatedinchildren.However,its
simplicityisattractiveforclinicalpractice.TheQualityandOutcomesFrameworkforGMScontract2012/2013alsosuggestsuseofthis
questionnaireasaneffectivewayofassessingasthmasymptoms[BMAandNHSEmployers,2012(/asthma#!references/297181)].
TheAsthmaControlQuestionnairehasbeenwellvalidatedinadultsandchildrenagedover5years.
TheAsthmaControlTesthasbeenvalidatedinadultsandchildrenagedover3years.
Structuredreviews:Theevidenceshowsthatpeoplehavefewerexacerbations,haveimprovedsymptoms,andmisslessschoolorworkifthey
undergostructuredasthmareviews,especiallyiftheassessmentsaredonebytrainedprofessionals.Telephoneconsultationsmaybeaseffective
asfacetofaceconsultations[PinnockandShah,2007(/asthma#!references/297181)].
Assessinglungfunction:Reducedlungfunctioncomparedtopreviouslyrecordedvaluesmayindicatecurrentbronchoconstrictionoralongterm
declineinlungfunctionandshouldpromptdetailedassessment[SIGNandBTS,2011(/asthma#!references/297181)].Expertopinioninthe
Britishguidelineonthemanagementofasthma:anationalclinicalguidelinerecommendsthatapersonalbestpeakflowexpiratoryrateshouldbe
measuredoncetreatmenthasbeenoptimisedandupdatedeveryfewyearsinanadultandmorefrequentlyinachild[SIGNandBTS,2011
Inhalertechnique:ExpertopinionintheBritishguidelineonthemanagementofasthma:anationalclinicalguidelinerecommendsthatinhalers
shouldonlybeprescribedafterthepersonhasreceivedtrainingintheuseoftheinhalerdeviceandhasdemonstratedsatisfactorytechnique
Comorbidities:Gastrooesophagealrefluxdisease,allergicrhinitis,obesity,andobstructivesleepapnoeahavebeenreportedingreater
proportionsofpeoplewithdifficulttotreatasthma.Itisimportanttorecognizesuchconditionsbecausetheyappeartoaggravateasthma
symptomsandneedtreatment.However,todate,noevidenceindicatesthattreatingtheseconditionsimprovesasthmacontrol[GINA,2006
Smoking:Smokingmaycausepoorasthmacontrol.Pastsmokingcanbeassociatedwithpoorcontrolduetofixedairwayobstruction,andcurrent
smokingreducestheeffectivenessofinhaledandoralcorticosteroids[GINA,2006(/asthma#!references/297181)].
Monitoringgrowthinchildren:ExpertopinionintheBritishguidelineonthemanagementofasthma:anationalclinicalguidelinerecommendsto
monitorgrowth(heightandweightcentile)annually[SIGNandBTS,2011(/asthma#!references/297181)].
Selfmanagementinformation:ExpertopinionintheBritishguidelineonthemanagementofasthma:anationalclinicalguidelinerecommends
thatallpeoplewithasthmashouldbeofferedselfmanagementeducationandshouldalsohaveapersonalisedactionplan[SIGNandBTS,2011
Discussingtheriskofoccupationalasthmawithadolescents:Thisrecommendationandtheoccupationslistedarebasedonexpertopinionin
theBritishguidelineonthemanagementofasthma:anationalclinicalguideline[SIGNandBTS,2011(/asthma#!references/297181)].
Backtotop
Scenario:Acuteasthmaexacerbation
Assessment Backtotop
Whatassessmentisrecommendedduringanexacerbationofasthma?
Askaboutpossibletriggerfactors(/asthma#!diagnosissub:4),suchasarecentupperrespiratorytractinfection.
Askaboutthetypeanddurationofsymptoms,whattreatmenthasbeenstarted(ifany),andwhethertreatmenthasimprovedsymptoms.
Assesstheseverityoftheexacerbation:
Lookforsignsofexhaustion(inabilitytocompletesentences)andcyanosis(bluishlipsorextremities).
Examinetheperson'schestandrecordtherespiratoryrate,pulse,andbloodpressure.
Recordthepeakexpiratoryflowrate(ifthepersonisoldenoughtocomply)andusethebestofthreerecordingstogradetheseverityofthe
attackonthebasisoftheperson'sbestorpredictedvalue:
Moderate:morethan5075%.
Acutesevere:3350%.
Lifethreatening:<33%.
Measureaperson'soxygensaturationinroomairusingpulseoximetry(ifavailable).
Askaboutdepression,alcoholmisuse,poorcompliancewithmedication,socialisolationandanypreviousexacerbations.Togetherwiththe
severityoftheexacerbation,thiswillhelptodeterminetheriskofdeathandtheneedforhospitaladmission
Symptomsareamoresensitivemeasurethanpeakexpiratoryflowrate(PEFR)oftheonsetofanexacerbation,astheincreaseinsymptoms
usuallyprecedesthedeteriorationinPEFR.Symptomsvaryamongindividualsandageranges.Nosymptomorsignalone(ortogether)isspecific,
andtheirabsencedoesnotexcludeasevereexacerbation.
Signstolookforandrecordinclude:
Pulserate(increasingsuggestsworseningasthma,whilstadecreaseindicatesalifethreateningsituation).
Respiratoryrateanduseofaccessorymuscles.
Degreeofwheeze(lessapparentwithincreasingobstruction).
Degreeofagitationandconsciousness.
Peakexpiratoryflowrateisamorereliableindicatorofseveritythansymptoms.UseapredictedPEFRvalueonlyiftheperson'srecent(within2
years)bestPEFRisunknown.Ideally,usetheperson'sownpeakflowmeterorasimilartype.
Pulseoximetrymaynotbeavailableinprimarycare,especiallyforyoungchildren.
Whendecidingtoadmit(/asthma#!scenariorecommendation:54)someonetohospital,assesstheseverityofthiscurrentexacerbationandalso
reviewtheperson'shistory.Iftheyhaveanyassociatedmedical,behavioural,orpsychosocialfactorsthatareofconcern,lowerthethresholdfor
admission.
UsethecriteriainTable1(/asthma#!scenarioclarification:14/491944)togradeandrecordtheseverityofanasthmaexacerbation.
Table1.Levelsofseverityofacuteasthmaexacerbation.
Levelof Criteria
severity
Nearfatal Respiratoryacidosis(increasedarterialcarbondioxide)and/orrequiringmechanicalventilationwithincreasedinflationpressures
Life Anyoneofthefollowinginsomeonewithsevereasthma:
threatening
Peakexpiratoryflowrate<33%ofbestorpredictedOxygensaturation<92%Silent BradycardiaDysrhythmiaHypotension
chestCyanosisFeeblerespiratoryeffort ExhaustionConfusionComa
Acute Anyoneof:Peakexpiratoryflowrate3350%ofbestorpredictedRespirationrate:25yearsold:40breaths/min512yearsold:
severe 30breaths/min>12yearsold:25breaths/minPulse:25yearsold:140beats/min512yearsold:125beats/min>12years
old:110beats/minInabilitytocompletesentencesinonebreathUseofaccessoryneckmuscles(inchildren)
Moderate IncreasingsymptomsPeakexpiratoryflowrate>5070%ofbestorpredictedNofeaturesofacutesevereasthma
asthma
exacerbation
Brittle Type1:widevariabilityinpeakexpiratoryflowratedespiteintensivetherapy(i.e.>40%diurnalvariationfor>50%ofthetimeover
asthma >150days)Type2:suddensevereattacksdespiteapparentlywellcontrolledasthma
Caution:peoplewithsevereorlifethreateningattackssometimesdonotappeartobedistressedandmaynothaveallthefeatureslisted.Agitation
andbehaviouralchangesinachildmaybeasignofhypoxia.Considertheoccurrenceofanyfeatureasanalertforthepresenceofsevereorlife
threateningasthma[SIGNandBTS,2011(/asthma#!references/297181)].
Triggerfactors:theevidence(/asthma#!supportingevidence1:11)fromsmallcasecontrolledstudiesshowsthatsensitizationandexposureto
allergens(housedustmites,cats,dogs)andrespiratoryvirusesareindependentlyandsynergisticallyassociatedwithasthmaexacerbations
[Greenetal,2002(/asthma#!references/297181)].Theroleofatypicalbacteriaismuchlesscertain[GINA,2006(/asthma#!references/297181)].
Symptoms:earlyintervention(viaanactionplan)atsignsofapossibleexacerbationisessential,asmost(8892%)asthmaattackssevere
enoughtorequirehospitaladmissiondeveloprelativelyslowly,over6hoursormore.Inonestudy,morethan80%developedover48hours[SIGN
andBTS,2011(/asthma#!references/297181)].
Peakexpiratoryflowrateimprovesrecognitionofasthmaseverityandhelpswithdecisionsaboutmanagementathomeorinhospital.Themost
clinicallyusefulvalueispeakexpiratoryflowratemeasuredasapercentageoftheperson'sbest[SIGNandBTS,2011
Pulseoximetrycanhelpdiagnoselifethreateningasthmaifaperson'ssaturationisbelow92%.Aprospectivestudy(n=1184)ofchildrenaged
217yearssuggestedthatlowoxygensaturationpredictshospitaladmission,butnospecificcutoffvalueissufficientlyaccurateforclinical
decisionmaking[Keaheyetal,2002(/asthma#!references/297181)].
Whentoadmittohospital Backtotop
Whenishospitaladmissionrequired?
Admitallpeoplewithalifethreatening(/asthma#!scenariorecommendation:53/311072)asthmaexacerbation(peakexpiratoryflowrate[PEFR]
usually<33%bestorpredictedand/oroxygensaturation<92%).
Admitpeoplewithasevere(/asthma#!scenariorecommendation:53/311072)asthmaexacerbation(PEFRusually3350%bestorpredicted)who
donotrapidlyrespondtoinitialtreatmentorwhohaveafactorthatwarrantsalowerthresholdforadmission.
Admitpeoplewithamoderate(/asthma#!scenariorecommendation:53/311072)asthmaexacerbation(PEFRusually>50%bestorpredicted)who
haveafactorthatwarrantsalowerthresholdforadmission.
Thefollowingfactorsshouldlowerthethresholdforadmission:
Peopleunder18years.
Poorconcordance.
Personlivesalone.
Psychologicalproblemssuchasdepression,andalcoholordrugmisuse.
Physicalorlearningdisability.
Previousnearfatalattackorbrittleasthma.
Persistentexacerbationdespiteanadequatedoseoforalcorticosteroidsbeforepresentation.
Presentationatnightorintheafternoon.
Pregnancy.
Somepeoplewithamoderatetosevereexacerbation(andnoriskfactorsforalowerthresholdofadmission)maybemanagedinprimarycare
onlyiftheyshowagoodresponsetoinitialtreatment.Theprimaryhealthcareprofessionalneedstomakethatdecisiononanindividualbasis.
Theirdecisionshouldbebasedontheknowledgeofthepersonandhowquicklytheyrespondtoinitialtreatment.Ifthehealthcareprofessional
hasanydoubt,doesnothavetheappropriatefacilitiestoassessandmonitortreatmentresponse,orcannotsafelyfollowuptheindividual,
admissiontohospitalisneededforfurtherassessment.
Determinewhetherapersonisatfurtherriskofdeteriorationordeathbyassessingtheirmedical,behavioural,andpsychosocialhistory.SeeTable
1(/asthma#!scenarioclarification:15/491894).
Table1.Importantfactorsinnearfatalorfatalasthmaexacerbation.
Medicalriskfactors Behaviouralorpsychosocialriskfactors
Previousnearfatalepisodeofasthma(i.e.previousventilationorrespiratory Noncompliancewithtreatmentormonitoring
acidosis)
Previoushospitaladmissionforasthma,especiallywithinthepastyear Failuretoattendappointments,orpreviousselfdischarge
fromhospital
Requiresthreeormoreclassesofasthmamedication Psychiatricillnessorlearningdifficulties,denial
Heavyuseofbeta2agonist Misuseofalcoholordrugs
Repeatedattendanceataccidentandemergencyunitforasthma,especiallywithin Currentorrecentmajortranquillizeruse
thepastyear
'Brittle'asthma Incomeoremploymentproblems,socialisolation
Severedomestic,marital,orlegalstress,childabuse
Obesity
Datafrom:[SIGNandBTS,2011(/asthma#!references/297181)]
Casecontrolledstudieshaveshownthatpeoplewhodieofasthmaattacksorhavenearfatalattacksaremorelikelytohaveassociatedadverse
behaviouralorpsychologicalfeatures.Deathswerealsorelatedtoinadequateuseoforalcorticosteroidsandpoorfollowup.
Peoplewhodieofasthmaarealsolikelytohavehadseveredisease,poorcompliancewithmedication,ahospitaladmissionorvisittoanaccident
andemergencydepartmentforasthmainthepreviousyear,orapreviousnearfatalattack.
Anoxygensaturation(SpO2)oflessthan92%isassociatedwithariskofhypercapnoea,whichisafeatureoflifethreateningasthma.
Hypercapnoeacanonlybedetectedbyarterialbloodgasmeasurement,notbypulseoximetry.
Managingpeopleneedingadmission Backtotop
Childrenandadultswhoneedadmissiontohospital:HowdoImanage?
Organizeurgenthospitaladmission.
Givehighflowoxygen(4060%)withatightfittingmask.Ifpulseoximetryisavailable,adjusttheflowratetomaintainanoxygensaturationof94
98%.
Giveashortactinginhaledbeta2agonist:
Forlifethreateningasthma,giveviaanebulizer,ifavailable.Repeatevery2030minutesaccordingtoclinicalresponse.
Ideally,nebulizersshouldbeoxygendriven(flowrateof6L/minusuallyneeded)toavoidworseninghypoxia.
Forsevereattacks,giveviaanebulizer(preferredforchildrenifavailable)oruseapressurizedmetereddoseinhalerwithalargevolume
spacer.
Foranadult,give4puffsinitially,followedby2puffsevery2minutesaccordingtoresponse,upto10puffs.
Forachild,give2puffsevery2minutesaccordingtoresponse,upto10puffs.
Eachpuffshouldbegivenoneatatimeandinhaledwithfivetidalbreaths.
Theaboveprocessmayberepeatedevery1020minutesifclinicallynecessarywhilethepersonisawaitinghospitaladmission.
Formoderateattacks,useapressurizedmetereddoseinhalerwithalargevolumespacer.
Givethefirstdoseofacourseofprednisolone.
Monitorpeakexpiratoryflowrate(ifthepersoncancomply)andoxygensaturation(ifavailable)toassessresponsetotreatment.
Ifthepersondoesnotrespondtoabeta2agonist,considercontinuousnebulizedbeta2agonistsoradditionofipratropiumbromide(viaa
nebulizer).However,aimtogetthepersontohospitalurgently.
Highflowoxygen:thereisverylittleriskofcausinghighcarbondioxideretentionwithhighflowoxygeninpeoplewithasthma(unlikechronic
obstructivepulmonarydisease).Aimtokeeptheperson'soxygensaturationbetween94%and98%(measuredbypulseoximetry)bygiving6L/min
ora4060%flowratewhilstenroutetohospital.
Inhaledshortactingbeta2agonist:
Inlifethreateningasthma,theagentshouldbedeliveredideallybyahighflowoxygendrivennebulizer.Ifanoxygendrivennebulizeris
unavailable,deliverbyairdrivennebulizer(althoughbealertthatoxygendesaturationmayoccur).Continuousnebulizationispreferredin
severeobstruction,butnotallnebulizersystemscandothis.
Insevereasthma,theagentshouldbedeliveredbyhighflowoxygendrivennebulizer(preferredforchildren)orpressurizedmetereddose
inhalerwithalargevolumespacer.Ifmultiplepuffsareneeded,theyshouldbegivenassinglepuffsintothespacerandinhaledwithfivetidal
breathsaftereach,repeatinguntiltheprescribednumberofpuffshasbeengiven.Ashortpausebetweenpuffsmaybenecessarytoavoid
hyperventilation.
Inmoderateasthma,theagentshouldbedeliveredbypressurizedmetereddoseinhalerwithalargevolumespacer.
Oralcorticosteroidsshouldbegivenassoonaspossible.Oraladministrationisaseffectiveastheintravenousroute,providedthatmedication
canbeswallowed.Ifmedicationcannotbeswallowed,considerintramuscularmethylprednisolone160mgasanalternativetoacourseoforal
prednisolone.
Table1.Dosesofnebulizedbronchodilatorsusedinacutesevereexacerbationofasthma.
Drug 25yearsold 612yearsold(higherdoseformoresevere) >12yearsold
Salbutamol 2.5mg 2.55mg 5mg
Terbutaline 5mg 510mg 10mg
Ipratropium(every4to6hours) 250micrograms 250micrograms 500micrograms
Whenusingintermittentnebulization,repeatbeta2agonistadministrationevery1020minutes.Whenusingacontinuousnebulizer,givethe
tabulateddosesofbeta2agonistover3060minutes[SIGNandBTS,2011(/asthma#!references/297181)].
TheserecommendationsarebasedontheBritishguidelineonthemanagementofasthma:anationalclinicalguideline.Becausemostofthestudies
weresmall,haddiversedesigns,andinvolvedpeopleinsecondarycaresettings,itisdifficulttogeneralizefindingstoprimarycare[SIGNandBTS,
Ifapersondoesnotrespondtoinitialtreatment,themainaimistogetthepersontohospitalurgentlyforfurthersupport,suchasintravenous
medicationandpossiblyventilation.
Oxygen:peoplewithasevereasthmaattackarehypoxaemicthisshouldbecorrectedurgentlywithhighflowoxygen.Limitedevidence(one
randomizedcontrolledtrial,n=74adults)showsthat100%oxygenmayworsencarbondioxideretention,andimprovepeakexpiratoryflowrateto
alesserextent,comparedwith28%oxygen[Rodolfoetal,2005(/asthma#!references/297181)].
Inhaledbeta2agonistsquicklycorrectbronchospasmwithveryfewadverseeffects.Theevidence(/asthma#!supportingevidence1:12)suggests
salbutamolandterbutalinedonotdifferinefficacy.Deliveryviaapressurizedmetereddosedinhalerwithalargevolumespacerappearstobeas
effectiveasdeliveryviaanebulizer.Continuousnebulizationisatleastaseffectiveasbolusnebulizationinrelievingacuteasthma.However,
continuousnebulizationappearstobemoreeffectivethanbolusnebulizationinasthmathatissevereorunresponsivetotreatment[SIGNand
Inhaledipratropiumbromide:theevidence(/asthma#!supportingevidence1:12)suggeststhatcombiningnebulizedipratropiumbromidewith
nebulizedbeta2agonistsinanacuteattackmayleadtoafasterrecoveryandshorterdurationofadmission[SIGNandBTS,2011
Managingpeoplenotneedingadmission Backtotop
Childrenandadultsnotneedingadmissiontohospital:HowdoImanage?
Prescribeashortcourseoforalprednisolone(seeTable1(/asthma#!scenarioclarification:17/492005)fordoses).Theusualdoseforsomeonenot
takingaregularcorticosteroidis:
Child<2years:10mgonceadayfor3days
Child25years:20mgonceadayfor3days
Child612years:3040mgonceadayfor3days
Adultorchild>12years:4050mgonceadayfor5days
Donotprescribeantibioticsroutinely,unlesssymptomsandsignssuggestabacterialinfection.
Advisetheperson(orparentofachild)tousetheirshortactingbeta2agonistviaalargevolumespacer.
Foranadult,give4puffsinitially,followedby2puffsevery2minutesaccordingtoresponse,upto10puffs.
Forachild,give2puffsevery2minutesaccordingtoresponse,upto10puffs.
Eachpuffshouldbegivenoneatatimeandinhaledwithfivetidalbreaths.Repeatevery1020minutesaccordingtoclinicalresponse.
Aftertheshortactingbeta2agonisthasbeengiven(upto10puffs),advisetheperson(orparentofachild):
Toreturntousingtheirshortactingbeta2agonistasrequired,uptofourtimesaday(notexceeding4hourlyuse).
Tomonitortheirpeakexpiratoryflowrate(PEFR)andsymptoms.Ifsymptomsworsen,orPEFRdecreasesafterstartingtreatment,theyshould
seekfurthermedicaladvice.
Considerinitiatingmontelukastinchildrenagedover2yearswithmildasthmaearlyaftertheonsetofsymptoms.
Followup(/asthma#!scenariorecommendation:65)aperson(ideally)within24hours,orsooneriftheydeteriorate,andwithin1weekafteran
exacerbation.
Peoplewhoseconditiondeterioratesdespitetreatmentnormallyneedadmissiontohospital.Ideally,allpeopleshouldbefollowedupafteran
exacerbationbytelephoneor,preferably,inperson.
Inhaledbeta2agonistscanbeusedonaregularbasistoalleviatepersistentsymptomsduringanexacerbation.Manypeoplemayhavealready
implementedthisprocedureaspartoftheiractionplan.
Oralcorticosteroidsshouldbegivenforatleast5daysinadults,whilst3daysisusuallysufficientforchildren.Nevertheless,thelengthofa
courseshouldbetailoredtothenumberofdaysnecessarytobringaboutrecovery.Thebenefitsofcorticosteroidscanoccurwithin34hours,and
mostpeopledonotneedtaperingofthedoseattheendofsuchashortcourse.
Thedoseofinhaledcorticosteroids(ICS)doesnotneedtobeincreasedduringanexacerbation,andpeopleshouldremainontheirusualdose.
TreatmentwithICSshouldnotbeusedasanalternativetooralcorticosteroids.
Antibiotics:explaintotheindividualthatmostexacerbationsofasthmaarenotcaused(/asthma#!diagnosissub:4)byabacterialinfectionand
antibioticswillnothastenrecovery.Ifapersonhasaproductivecoughandelevatedbodytemperature,consideranalternativediagnosissee
Differentialdiagnosisinadults(/asthma#!diagnosissub:6)andDifferentialdiagnosisinchildren(/asthma#!diagnosissub:5).
Table1.Doseoforalprednisoloneusedinacutesevereexacerbationofasthma.
Doseoforalprednisolone(once <2yearsold 25yearsold 612yearsold >12yearsold

daily)
Peoplenottakingregularoral 10mg 20mg 3040mg 4050mg*

corticosteroid
Peopletakingregularoralcorticosteroid 2mg/kg(maximum 2mg/kg(maximum 2mg/kg(maximum 2mg/kg(maximum

40mg) 60mg) 60mg) 60mg)
*Inpractice,manyhealthcareprofessionalsprescribe30mg/day.Datafrom:[BNF53,2007(/asthma#!references/297181)BNFforChildren,
2007(/asthma#!references/297181)SIGNandBTS,2011(/asthma#!references/297181)]
Oralcorticosteroids:theevidence(/asthma#!supportingevidence1:13)showsthatoralcorticosteroidsreducemortality,relapse,subsequent
hospitaladmission,andrequirementforbeta2agonisttherapy.Theearlieroralcorticosteroidsaregiveninanacuteattack,thebettertheoutcome.
Largerdosesthanthosestatedintherecommendationdonotappeartoprovideanyadditionalbenefit.
Inhaledcorticosteroids:noevidence(/asthma#!supportingevidence1:14)indicatesthatdoublingthedoseofinhaledcorticosteroidsiseffectivein
treatingacutesymptomsofasthma[SIGNandBTS,2011(/asthma#!references/297181)].
Antibiotics:theevidence(/asthma#!supportingevidence1:11)suggeststhatwhenaninfectionprecipitatesanexacerbationofasthma,itislikelyto
beviral.Theroleofbacterialinfectionshasbeenoverestimated[SIGNandBTS,2011(/asthma#!references/297181)].
Montelukast:AnupdatetotheBritishGuidelineontheManagementofAsthma:anationalclinicalguidelinestatesthatthereisevidence
(/asthma#!supportingevidence1:15)thatinitiatingoralmontelukastearlyaftertheonsetofacuteasthmainchildrenagedover2yearscanresultin
decreasedasthmasymptomsandlessneedforsubsequenthealthcareattendances.Thereisnoclearevidencetosupporttheuseoforal
montelukastinmoderateorsevereasthma,butonlyinmildasthma[SIGNandBTS,2011(/asthma#!references/297181)].
symptoms).
medicalhelp.
Smoking Backtotop
(/asthma#!references/297181)]
needtreatment.
symptoms.
Driving Backtotop
Followup Backtotop
Whatfollowupisrecommendedafteranexacerbationofasthma?
Somepeoplemaynotneedfollowupduringamildexacerbation.However,iftherearesignsofdeterioration,reviewisnecessarytodetermine
whetheradmission(/asthma#!scenariorecommendation:54)tohospitalisappropriate.
Sometimesattendingforfollowupmaybeimpractical.Consideratelephoneconsultationtoreviewthepersonearly,andscheduleaclinic
consultationforalaterdatetoassessinhalertechniqueandperformanexamination.
Peoplewhohavebeendischargedfromhospitalorfromanemergencydepartmentshouldbefollowedup:
Inprimarycarewithin2daysofdischarge.
Byarespiratoryspecialistinabout1month.
Assesstheexacerbation:
Askaboutthedurationandseverityoftheexacerbationcomparedwithanypreviousepisodes.Recordthenumberofexacerbationsand
hospitaladmissions.
Identifypossibletriggerfactors(/asthma#!diagnosissub:4),suchasexercise,work,orallergens.
Optimizetreatment:
Askaboutcompliancewithtreatmentbeforetheexacerbationandreviewtheperson'sinhalertechnique.
Provideadviceonlifestyle,vaccinations,diet,exercise,andsmoking.Ifthepersonorparentofthechildsmokes,advisethemtostop.
Considersteppingup(/asthma#!scenario:1)treatmentbyincreasinginhaledcorticosteroidsoraddinginnewpreventivetherapy.
Reviewselfmanagementeducationandwrittenactionplan:
Reviewtheperson'sunderstandingofhowtorecognizeanexacerbationandwhattodoattheearlysignsofanexacerbation(increasebeta2
agonistandstartoralcorticosteroids).
Reinforceunderstandingbyupdatingthewrittenactionplan.
(/asthma#!references/297181)].Manyfollowupstudieshaveinvolvedsmallnumbersofpeople,mainlyinasecondarycaresetting,andfollowup
wasdonebyspecialistsusingdifferentmethods.Evidenceisscantonfollowinguppeoplewhohavenotbeenadmittedtohospital.
Followupisnecessaryafteranexacerbation,astheevidencesuggeststhatmorethan15%ofpeoplewillhavearelapsewithin2weeks[SIGN
andBTS,2011(/asthma#!references/297181)].Thefollowupprocessshouldaimtoidentifyapossiblecauseoftheexacerbationsothat
strategiestopreventfurtherexacerbationscanbedeveloped.
Followupafterdischargefromhospitalandemergencydepartments:thisrecommendationisbasedonexpertopinionintheBritishGuidelineon
theManagementofAsthma:anationalclinicalguidelinewhichrecommendsthatifthepersonrequiresadmissionforanexacerbationofasthma
thentheperson'sprimarycarepracticeshouldbeinformedwithin24hoursofdischargefromhospital,preferablybyfaxoremailtotheperson
responsibleforasthmacarewithinthepractice.Theyalsorecommendthatthepersonshouldbeassessedbyeitherarespiratoryphysicianora
hospitalspecialistasthmanurseabout1monthafteradmission[SIGNandBTS,2011(/asthma#!references/297181)].
Theevidence(/asthma#!supportingevidence1:8)suggeststhatfollowupafteranexacerbationwhichinvolvesprovidingselfmanagement
educationandawrittenactionplanmayreducehospitalreadmissionsandimprovesymptomcontrolandselfmanagementofasthma.Outcomes
appeartodifferlittlebytheplaceorpersonnelinvolved[BernardBonninetal,1995(/asthma#!references/297181)Nathanetal,2006
Backtotop
Scenario:Managementofexerciseinducedasthma
Managingexerciseinducedasthma Backtotop
Exerciseinducedasthma:HowdoImanage?
Ifexerciseinducedasthmaisasymptomofpoorasthmacontrol,manageitasuncontrolledasthma(/asthma#!scenario:1).
Ifapersonhasotherwisewellcontrolledasthma,butfindsexerciseinducedasthmatobeaproblem:
Adviseshortburstactivities,exercisinginhumidenvironments,andbreathingthroughthenosetoavoidhyperventilation.
Prescribeuseofashortactingbeta2agonist(/asthma#!prescribinginfosub)1015minutesbeforethestartofexerciseandafter2hoursof
prolongedexercise,orafterexercisehasfinished.
Ifexerciseinducedsymptomspersistdespiteuseofashortactingbeta2agonist(adequatedosagewithgoodconcordance):
Considerstartinganinhaledcorticosteroid(/asthma#!prescribinginfosub:2).
Iftheindividualisstillsymptomaticdespiteusinganinhaledcorticosteroid,considerprescribingalongactingbeta2agonist
(/asthma#!prescribinginfosub:7)orleukotrienereceptorantagonist(/asthma#!prescribinginfosub:12)forregularuse.
Otheroptions,suchastheophylline(/asthma#!prescribinginfosub:10),sodiumcromoglicate,ornedocromilsodium
(/asthma#!prescribinginfosub:15),andoralmodifiedreleasebeta2agonist(/asthma#!prescribinginfosub)(adultsonly)canbeusedbutareless
effectiveinexerciseinducedasthma.
Ifthepersondoesnotrespondtotreatmentandexerciseinducedasthmaisstillproblematic(especiallyinathletes),considerreferraltoa
respiratoryspecialist.
Confirming(/asthma#!diagnosissub)thediagnosisofexerciseinducedasthmacanbedifficult:
Askaboutacough(usuallystarting610minutesafterthestartofexercise)andassociatedchesttightness(upto12hoursafterwards).Some
peoplemayhavesymptomsstartingafterexercise.
Askaboutothersymptomsnotrelatedtoexercise,suchasnocturnalcough,wheeze,orbreathlessness,thatmightindicatepoorlycontrolled
asthma.
Givethepersonapeakflowdiaryandaskthemtomeasuretheirpeakflowbeforeand5minutesafterexercisetohelpsupportthediagnosis.
Verylittleevidence(/asthma#!supportingevidence1:16)supportstheuseofanymedicationinexerciseinducedasthmainchildrenyoungerthan5
years.Mostoftheevidenceisfrompoorqualitytrialsinvolvingsmallnumbersofpeoplewithorwithoutpoorlycontrolledasthma,andusing
differentdosesofmedicationoverdifferentdurations.
Exerciseinducedasthmaisoftenanindicationofpoorlycontrolledasthma.Ifcontrolofasthmaisimproved,thesymptomsofexerciseinduced
asthmawillusuallycease.
Inhaledshortactingbeta2agonistsarethemosteffectivetherapyforpreventionofexerciseinducedasthma.Regularuseoffersnoadvantage
overasrequiredregimens,andmayresultintolerance[SIGNandBTS,2011(/asthma#!references/297181)].
Longactingbeta2agonists,leukotrienereceptorantagonists,andcromonesaremoreeffectivethanplaceboincontrollingexerciseinduced
asthmainsmallrandomizedcontrolledtrials,buttheyarenomoreeffectivethanshortactingbeta2agonists[SIGNandBTS,2011
symptoms).
medicalhelp.
Smoking Backtotop
needtreatment.
symptoms.
Driving Backtotop
Backtotop
Scenario:Suspectedoccupationalasthma
Agefrom12yearsonwards
Managingoccupationalasthma Backtotop
Suspectedoccupationalasthma:HowdoImanage?
Referanyindividualwithsuspectedoccupationalasthmatoarespiratoryspecialistforconfirmation.
Suspectoccupationalasthmainadultswhodevelopedasthmainadulthoodorhavearecurrenceofchildhoodasthmaandhave:
Asthmasymptomsthatarebetterondaysawayfromworkoronholidays.
Ahighriskoccupation,suchaspaintsprayers,bakersandpastrymakers,nurses,chemicalworkers,animalhandlers,welders,foodprocessing
workers,andtimberworkers.
Askthepersontokeepapeakflowdiary,recordingtheirpeakflowatworkandawayfromworktoshowthespecialist.
Workaggravatedasthmaoccurswhenpreexistingasthmaisaggravatedbynonspecificdustorfumesatwork.Incontrast,occupationalasthma
ispreexistingasthmawhichbecomesadditionallysensitizedtoanoccupationalagent.
Referpeoplewithsuspectedoccupationalasthmatotheoccupationalhealthserviceattheworkplace(ifavailable)orarespiratoryspecialist.
Occupationalasthmaisdiagnosedinsecondarycarewhenallthefollowingaretrue:
Thediagnosis(/asthma#!diagnosissub)ofasthmaisconfirmed.
Arelationshipbetweenasthmaandworkexposuresisconfirmed,forexample,by:
Serialmeasurementsofpeakexpiratoryflowrateathomeandatwork(atleastthreeseriesofconsecutivedaysatworkwiththreeperiods
awayfromwork,atleastfourevenlyspacedreadingsperday,andatleast3daysineachconsecutiveworkperiod).
Specificandnonspecificbronchialprovocationtests.
Aspecificcauseisidentified.
Followingconfirmation,thepersonshouldrelocateawayfromexposureassoonaspossible,andideallywithin12monthsofthefirstworkrelated
symptomsofasthma.Sometimes,substitutionofthehazardmaybeanalternativeoption.
Childrenmaybeaffectedbyoccupationalallergensbroughthomebytheirparents.
Moreinformationandacomputertoolforanalysingdataareavailablefromwww.occupationalasthma.com(http://www.occupationalasthma.com/).
Theaimofmanagementistoidentifythecause,toremovetheworkerfromexposure,andforthepersontohaveworthwhileemployment.Early
identificationandavoidanceoftheexposureoffersthebestchanceofcompleterecovery.Studieshaveshownthattheprognosisisworsefor
peoplewhoremainexposedafter1yearofsymptomscomparedwiththoseremovedearlier.
History:askingaboutsymptomsimprovingawayfromworkismoresensitivethanaskingaboutworseningsymptomsatwork,asmanysymptoms
deteriorateinthehoursafterworkorduringsleep.However,thesequestionsarenotspecificforoccupationalasthmaandalsoidentifypeoplewith
asthmaduetoagentsathome(whomayimproveonholidays)andthosewhodomuchlessphysicalactivityawayfromwork.
Investigations:serialpeakflowmeasurementsarethemostsensitiveandspecificinitialinvestigation.Lungfunctiontestsawayfromworkmay
havefalsenegativeresults.Specificbronchialprovocationtestingisthegoldstandard,butfewfacilitiesintheUKdosuchtesting.Mostcasesof
occupationalasthmacanbediagnosedinsecondarycarewithoutsuchatest.
symptoms).
medicalhelp.
Smoking Backtotop
needtreatment.
symptoms.
Driving Backtotop
Backtotop
Scenario:Pregnancyandbreastfeeding
Agefrom12yearsto60years(Female)
Pregnancyorbreastfeeding Backtotop
Womenwhoarepregnantorbreastfeedingwithasthma:HowdoImanage?
Manageawomanwhoispregnantlikeanyotherindividualwithasthma:
Continuetheuseofallmedicationasnormalinpregnancy,butdonotstartleukotrienereceptorantagonists(/asthma#!prescribinginfosub:12).
However,ifthewomanisalreadytakingaleukotrienereceptorantagonistanditisconsideredessential,continuetreatment.
Advisewomenthatthebenefitsoftreatmentwithoralcorticosteroidsforanacuteattackoutweightherisks.
Advisewomenwhosmokeaboutthedangersthatsmokingposestothemselvesandtheirchildren.Giveappropriatesupportforstopping
smoking.
Encouragewomenwithasthmatobreastfeedtheirbabiesanduseasthmamedicationsasnormalduringbreastfeeding.
Therisksfromuncontrolledasthmaaremuchgreaterthantherisksfromasthmatreatmentsduringpregnancy.
Therisksofuncontrolledasthmainpregnancyincludehyperemesis,hypertension,preeclampsia,vaginalhaemorrhage,complicatedlabour,
fetalgrowthrestriction,pretermbirth,increasedperinatalmortality,andneonatalhypoxia[Schatzetal,1990(/asthma#!references/297181)
Perlowetal,1992(/asthma#!references/297181)Demissieetal,1998(/asthma#!references/297181)Dombrowskietal,2004
Womenwhohaveasevereexacerbationofasthmaduringpregnancyareatasignificantlyincreasedriskofhavingalowbirthweightbaby
comparedwithwomenwithoutasthma[Murphyetal,2006(/asthma#!references/297181)].
Incontrast,ifasthmaiswellcontrolledthroughoutpregnancythereislittleornoincreasedriskofadversematernalorfetalcomplications[Schatz
etal,1988(/asthma#!references/297181)Schatzetal,1995(/asthma#!references/297181)].
Acasecontrolstudyincluding2460infantsexposedtoshortactingbeta2agonistsfoundnoincreasedriskofcongenitalmalformationin
exposedinfants[Dombrowskietal,2004(/asthma#!references/297181)].
Ametaanalysisoffourstudiesofinhaledcorticosteroiduseinpregnancyshowednoincreaseintherateofmajormalformations,preterm
delivery,lowbirthweightorpregnancyinducedhypertension[Rahimietal,2006(/asthma#!references/297181)].AlargeUKpopulationbased
casecontrolstudyfoundnoincreasedriskofmajorcongenitalmalformationsinchildrenofwomenreceivingasthmatreatmentwithinhaledbeta2
agonistsandinhaledcorticosteroidsintheyearbeforeorduringpregnancy[Tataetal,2008(/asthma#!references/297181)].
Asystematicreviewofstudiesincluding190exposuretolongactingbeta2agonistsdemonstratednoincreasedriskofcongenital
malformations,pretermdeliveryorpereclampsia[GluckandGluck,2005(/asthma#!references/297181)].
Oralcorticosteroidsarenotteratogenic,althoughthereareconflictingdataonwhetheroralcorticosteroidsareassociatedwithoralclefts.Expert
opinionisthattheassociationisnotdefiniteand,evenifitisreal,thebenefittothemotherandherbabyofusingcorticosteroidstotreata
potentiallylifethreateningdisease,justifytheiruseinpregnancy[Schatzetal,1990(/asthma#!references/297181)].
Leukotrienereceptorantagonistsshouldnotbestartedduringpregnancybecausedataontheirsafetyinpregnantorbreastfeedingwomenare
limited[SIGNandBTS,2011(/asthma#!references/297181)].
Intwosmallprospectivestudiesnoincreaseintheratesofcongenitalmalformation,pretermbirth,orlowbirthweightwasfound[Schaeferet
al,2007(/asthma#!references/297181)].
Therehavebeenseveralcasereportsoflimbdefectsinwomentakingaleukotrienereceptorantagonistduringpregnancy,butacausal
relationshiphasnotbeenestablished[Schaeferetal,2007(/asthma#!references/297181)].
Referral Backtotop
Prominentsystemicfeatures,forexampleweightloss,myalgia,fever.
Spirometricorpeakexpiratoryflowmeasurementsthatdonotfittheclinicalpicture,forexampleunexplainedrestrictivespirometry.
Failuretothrive.
Parentalanxiety.
Backtotop
Shortactingbeta2agonists
Prescribingashortactingbeta2agonist Backtotop
WhatdoIneedtoknowwhenprescribingashortactingbeta2agonist?
Inhaledshortactingbeta2agonistsshouldbeusedasrequiredunlessanindividualhasshowntobenefitfromregularuse:
Asrequireduseofshortactingbeta2agonistsisatleastaseffectiveasregularadministration[SIGNandBTS,2011
(/asthma#!references/297181)]andislesslikelytoresultintolerance.
Inhaledshortactingbeta2agonistshaveminimaladverseeffects.Overusecancausetremor,tension,headache,musclecramps,andpalpitations
[BNF53,2007(/asthma#!references/297181)].Hypokalaemiamayresultfromhighdosesofinhaledbeta2agonists(ororalbeta2agonists)this
maybepotentiatedbyconcomitanttreatmentwiththeophylline,corticosteroids,diuretics,andbyhypoxia.TheCommitteeontheSafetyof
Medicineshasadvisedthatplasmapotassiumshouldbemonitoredinpeoplewithsevereasthma[CSM,1990(/asthma#!references/297181)].
Thereissomeevidencefrompostmarketingdataandpublishedliteratureofmyocardialischaemiaassociatedwithshortactingbeta2agonists.
TheMHRAhasissuedadvicethatpeoplewithahistoryofheartdisease,includinganginaorrhythmdisturbance,shouldseekmedicaladviceif
symptomssuchasshortnessofbreathorchestpainoccur,asthesemayindicateworseningheartdisease[MHRA,2007
Backtotop
Inhaledcorticosteroids
Choosinganinhaledsteroid Backtotop
Whichinhaledcorticosteroid?
Thevariousinhaledcorticosteroids(ICS)donotseemtodifferinefficacy(assumingapotencyratioofbeclometasoneandfluticasoneof2:1).
Adverseeffectsareclasseffectsanddonotdiffersignificantlybetweenthedifferentinhaledcorticosteroids(ICS)ateitherloworhighdoses.
IncreaseddosesofICSareassociatedwithanincreasedriskoflocalandsystemicadverseeffects.Thereisevidencethatprovidedthe
recommendeddoseisused,ICSareeffectiveandsafeinchildrenagedunder5years[SIGNandBTS,2011(/asthma#!references/297181)].
CKSrecommendsbeclometasone,budesonide,orfluticasonebecausetheyareavailableinarangeofformulationsatdifferentdosesandfora
rangeofages.
Ciclesonide(availableasapressurizedmetereddoseinhaler)andmometasone(availableasadrypowderinhaler)areoncedailyalternatives.
Neitherdrugislicensedforchildrenyoungerthan12years.Mometasonehasblacktrianglestatusandfurtherpostmarketingdataareneededto
confirmitssafety.
Dose Backtotop
Usethelowestdoseofinhaledcorticosteroid(ICS)thatmaintainseffectivecontrolofasthma.
StartICSatadoseappropriatetotheseverityofsymptoms[SIGNandBTS,2011(/asthma#!references/297181)]:
SuitablestartingdosesforbeclometasoneCFCfreeasClenilModuliteare:
Age>12years:200microgramstwicedaily.
Age512years:100microgramstwicedaily.
Age<5years:100microgramstwicedailyhigherdosesmayberequiredtoensureadequatedrugdelivery.
IfbeclometasoneCFCfreeisstartedasQvarusehalfthedoselistedabove(licensedonlyforage>12years).
Table1(/asthma#!prescribinginfosub:4/309739)andTable2(/asthma#!prescribinginfosub:4/309739)showcomparabletotaldailydosesof
ICS.
HigherdosesofICSmaybeneededinpeoplewhosmoke.Atlowdoses,smokerswithmildpersistentasthmaarelesssensitivethannon
smokerstothetherapeuticeffectsofICStreatment.ThisdisparityisreducedathighdosesofICS[Tomlinsonetal,2005
TreatmentwithICSshouldinitiallybetwiceaday(exceptciclesonide,whichislicensedforonceadayuse)[SIGNandBTS,2011
MostICSareslightlymoreeffectivewhenusedtwiceratherthanonceaday,butpeoplewithmilderdiseasemayusethemonceaday.Thereis
littleevidenceofbenefitforadministrationmorefrequentlythantwiceaday.
OncedailyinhalationofICSatthesametotaldailydose,withintheproductlicense,maybeconsideredifgoodcontrolisestablished.
PrescribeCFCfreebeclometasoneinhalersbybrandname(ClenilModuliteorQvar)[MHRA,2006a(/asthma#!references/297181)].Theyare
notequivalentandmustnotbeinterchanged.
WhenchangingfromaCFCpMDItoaCFCfreepMDI[BNF53,2007(/asthma#!references/297181)SIGNandBTS,2011
ClenilModulitemaybesubstitutedforbeclometasoneCFCpMDIat1:1dosing.
QvarmaybesubstitutedforbeclometasoneCFCpMDIat1:2dosingifasthmaiswellcontrolled,butconsider1:1dosingifasthmaispoorly
controlled.Monitorthepersoncloselytoensurethatadequatecontrolismaintained.
Clarification/Additionalinformation
ComparabledosesofinhaledcorticosteroidsareshowninTable1(/asthma#!prescribinginfosub:4/309739)(adultsandchildren>12yearsofage)
andTable2(/asthma#!prescribinginfosub:4/309739)(children).
Beclometasoneinhalersthatcontainchlorofluorocarbons(CFC)havebeenphasedoutandarenolongeravailable.
Table1.Recommendeddailydosesofinhaledcorticosteroiddeliveredbypressurizedmetereddoseinhaler(pMDI)foradultsandchildrenaged12
yearsofageorolder.Dosageadjustmentmaybenecessaryforalternativedevices.
pMDI Age Doseofinhaledcorticosteroid

(Years)
Lowdose Usualstartdose(step Highdose(step3) Maximumdose
2)
ClenilModulite(beclometasone >12 100microgramstwice 200microgramstwice 400microgramstwice 1000microgramstwice

CFCfree) daily daily daily daily
Qvar(beclometasoneCFCfree)* >12 50microgramstwice 100microgramstwice 200microgramstwice 400microgramstwice
daily daily daily daily
Fluticasone >12 50microgramstwice 100microgramstwice 250microgramstwice 500microgramstwice

daily daily daily daily
*WhenconvertingfromCFCbeclometasonetoQvar,doublethedoseinthetableifcontrolofasthmaispoor.Notethatthisdoesnotapplyto
ClenilModulite,whichisequipotent.Themaximumlicenseddailydoseoffluticasoneforadultsis2000micrograms.TheCommitteeonSafetyof
Medicines(CSM)hasadvisedthatdosesoffluticasoneabove1000microgramsadayshouldonlybeprescribedforadultswithsevereasthma,and
shouldonlybeinitiatedbyaphysicianwithaspecialinterestinasthma[CSM,2001(/asthma#!references/297181)]
Table2.Recommendeddailydosesofinhaledcorticosteroiddeliveredbypressurizedmetereddoseinhaler(pMDI)forchildren<12yearsofage.
Dosageadjustmentmaybenecessaryforalternativedevices.
pMDI Age Doseofinhaledcorticosteroid

(years)
Lowdose Ususalstartdose Highdose(step3) Maximumdose
(step2)
ClenilModulite(Beclometasone 511 50microgramstwice 100micrograms 200micrograms 400microgramstwicedaily

CFCfree) daily twicedaily twicedaily (unlicensed)
<5 50microgramstwice 100micrograms 200microgramstwicedaily

daily twicedaily
Qvar(BeclometasoneCFC <12 Unlicensedforchildrenundertheageof12

free)*
Budesonide 511 50microgramstwice 100micrograms 200micrograms 400microgramstwicedaily

daily twicedaily twicedaily
<5 50microgramstwice 100micrograms 200microgramstwicedaily

daily twicedaily
BudesonideCFCfree 511 100micrograms 100micrograms 200micrograms 400microgramstwicedaily

oncedaily twicedaily twicedaily
25 100micrograms 100micrograms 200microgramstwicedaily

oncedaily twicedaily
<2 Unlicensedforchildren<2years
Fluticasone 511 25microgramstwice 50microgramstwice 100micrograms 200microgramstwicedaily

daily daily twicedaily
4 25microgramstwice 50microgramstwice 100microgramstwicedaily

daily daily
<4 Unlicensedforchildren<4years
*WhenconvertingfromCFCbeclometasonetoQvar,doublethedoseinthetableifcontrolofasthmaispoor.Notethatthisdoesnotapplyto
ClenilModulite,whichisequipotent.Inchildrenunder5yearsofage,doseshigherthan200microgramstwiceadayofbeclometasone(or
equivalentICS)shouldonlybeusedunderspecialistsupervision.
Adverseeffects Backtotop
Whataretheadverseeffectsofinhaledcorticosteroidsandhowcantheybemanaged?
Takeintoaccounttheuseofothersystemicortopicalcorticosteroidswhenassessingrisk.
Elderlypeopleandchildrenmaybeparticularlysusceptibletoadverseeffects.
Localadverseeffects:
Oralcandidiasis,soremouth,dysphonia,andhoarsenessarecommonlyrecognizedproblemswithinhaledcorticosteroid(ICS)use,especially
inhighdoses:
Forpeopleusingapressurizedmetereddoseinhaler,theseeffectsmaybereducedbyusingalargevolumespacerdevice(whichreduces
oropharyngealdepositionbyfilteringoutlargerparticles)[DTB,2000(/asthma#!references/297181)RPSGB,2006
OralcandidiasiscanbeminimizedbyrinsingthemouthwithwaterafterICSinhalation.
Oropharyngealdepositionishighwithdrypowderinhalersandautohalers.
Systemicadverseeffectsadults:
Osteoporosis:thereareconcernsthatinhaledcorticosteroidsmayaffectbonemineraldensity,particularlywhengiveninhighdosesforlong
periods,buttheevidenceregardingthisisconflicting[SIGNandBTS,2011(/asthma#!references/297181)]:
InpeoplewhorequirehighdosesofICSforprolongedperiodsoftime,generalmeasurestocounteractosteoporosis(suchasregularexercise,
smokingcessation,andadequatedietarycalcium)areprudent.
Adrenalsuppression:evidenceindicatesthathighdosesofICS(equivalentto1.5mg/dayCFCcontainingbeclometasone)resultinsignificant
adrenalsuppression[EBM,1999(/asthma#!references/297181)].Theriskofadrenalinsufficiencyisdoserelatedandislargelyduetouseoforal
corticosteroids,althoughinhaledcorticosteroidsmayhaveaneffectwhentheyaretakenathigherdoses[Mortimeretal,2006
Titratethedoseofinhaledsteroidtothelowestdoseatwhicheffectivecontrolofasthmaismaintained[SIGNandBTS,2011
Systemicadverseeffectschildren:
TheCommitteeonSafetyofMedicineshas'stronglyadvisedthatthepaediatriclicenseddosesofallinhaledcorticosteroidsshouldnotbe
exceeded'[CSM,2002(/asthma#!references/297181)].UsethelowestdoseofICSthatwillmaintaindiseasecontrol.Ifadequatecontrolisnot
achieved,considerusingaddonagentsratherthanincreasingthedoseofICS[SIGNandBTS,2011(/asthma#!references/297181)].
Childhoodgrowth:someinitialslowingofgrowthmayoccurinchildrenwhohaveusedICS,butfinaladultheightdoesnotappeartobeaffected
[ChildhoodAsthmaManagementProgramResearchGroup,2000(/asthma#!references/297181)MeReC,2002(/asthma#!references/297181)]:
AllchildrenreceivingprolongedtreatmentwithICSshouldhavetheirheightregularlyandaccuratelymonitoredusingagrowthchart[CSM,
1998(/asthma#!references/297181)].Anyslowingofgrowthshouldpromptareductionindoseifpossible,orreferraltoaspecialist,orboth.
Bonemineraldensity:onelongtermstudyinchildrenwithchronicasthmatreatedwithICSsuggestsnoadverseeffectofICSonbonemineral
densityinchildren[AgertoftandPedersen,2000(/asthma#!references/297181)].Furtherlongtermstudiesareneededtoconfirmthis.However,
expertssuggestthatwithcarefulICSdoseadjustment,thisriskislikelytobeoutweighedbytheabilityofICStoreducetheneedformultiple
coursesoforalcorticosteroids[Kellyetal,2008(/asthma#!references/297181)].
Veryrarelypsychiatricdisordersincludingpsychomotorhyperactivity,sleepdisorders,anxiety,depression,aggression,andbehaviouralchanges
(predominantlyinchildren),havebeenreported[ABPIMedicinesCompendium,2011a(/asthma#!references/297181)].
Acuteadrenalcrisis:inasmallnumberofchildren,dosesofinhaledICSatorabove400microgramsperdayofbeclometasonehavebeen
associatedwithgrowthfailureandadrenalsuppression.TheexactdoseanddurationofICStreatmenttoputachildatriskofadrenalinsufficiency
isunknown,butitislikelytobe1000microgramsormoreofbeclometasoneorequivalentdaily[SIGNandBTS,2011
Specificwrittenadviceaboutsteroidreplacementintheeventofasevereintercurrentillnessshouldbepartofthemanagementplanfor
childrentreatedwith800microgramsormoreofbeclometasoneorequivalentdaily.
Anychildreceivingthisdoseshouldbeunderthecareofaspecialistpaediatricianforthedurationofthetreatment.
Consideruseofasteroidtreatmentcard.
Considerthepossibilityofadrenalinsufficiencyinanychildmaintainedoninhaledsteroidspresentingwithshockordecreasedconsciousness:
Checkserumbiochemistryandbloodglucoselevelsurgently.
Considerwhetherintramuscularhydrocortisoneisrequired.
Adviceforpatients Backtotop
Advisepeoplethatsmokingcanreducetheeffectivenessofinhaledcorticosteroids(ICS)[SIGNandBTS,2011(/asthma#!references/297181)].
Advisepeopletorinsetheirmouthwithwater(orcleanchildren'steeth)afterinhalationofadoseofICStoreducetheriskoforalcandidiasis[BNF
53,2007(/asthma#!references/297181)].
Adviseongeneralmeasurestocounteractosteoporosis(suchasregularexercise,smokingcessation,andadequatecalciumintake)inpeople
usinghighdosesofICSforprolongedperiods.
Adviseparentstoimmediatelyreportnonspecificsymptoms,suchasanorexia,abdominalpain,weightloss,tiredness,headache,nausea,
vomiting,decreasedconsciousness,hypoglycaemia,andseizures,inchildrenusinghighdosesofICS(400microgramsormoreperdayof
beclometasone).
Consideruseofasteroidtreatmentcard:
Peopleusingprolongedhighdoses(offlabelhighdoses,ormaximumdosesinconjunctionwithoralcorticosteroids)ofICSshouldbegivena
steroidtreatmentcardwhichgivesguidanceonminimizingriskandprovidesdetailsofprescriber,drug,dosage,anddurationoftreatment
[CHM,2006(/asthma#!references/297181)].
Backtotop
Longactingbeta2agonists
Prescribingalongactingbeta2agonist Backtotop
WhatdoIneedtoknowwhenprescribingalongactingbeta2agonist?
Thelongactingbeta2agonists(LABAs),salmeterolandformoterol,arewelltoleratedandhavefewadverseeffects.
TherehasbeenconcernregardingLABAsandanincreaseinasthmarelatedadverseevents.Onthebasisofcurrentevidence
(/asthma#!supportingevidence1:3),theMedicinesandHealthcareproductsRegulatoryAgencyhasissuedthefollowingrecommendations[MHRA,
Longactingbeta2agonists(LABAs)shouldnotbeprescribedforsomeonewhoisnotalreadyusinganinhaledcorticosteroid.
InhaledcorticosteroidtreatmentshouldnotbestoppedwhilstthepersonisusingaLABA.
PeoplewithacutelydeterioratingasthmashouldnotbestartedonLABAtherapy.
Peopleshouldbemonitoredclosely,especiallyduringthefirst3monthsoftreatment.
TreatmentwithLABAsshouldbecontinuedonlyiftheyhaveshownbenefit.
Steppingdowntherapyshouldbeconsideredwhengoodlongtermasthmacontrolhasbeenachieved.
Salmeterolhasasloweronsetofactionthansalbutamolorterbutalineandshouldnotbeusedtorelieveanacuteexacerbationofasthma[BNF
53,2007(/asthma#!references/297181)].
Adailydoseof24microgramsformoterolshouldbesufficientformostchildren,particularlyyoungeragegroups.Higherdosesshouldbeused
rarely,andonlywhencontrolisnotmaintainedonthelowerdose[MHRA,2010(/asthma#!references/297181)].
Basisforrecommendation
Therehasbeenconcernregardingthesafetyoflongactingbeta2agonist(LABA)therapy.
TheSalmeterolMultiCentreAsthmaResearchTrial(SMART)[Nelsonetal,2006(/asthma#!references/297181)]wasalargerandomized
controlledtrial(n=26,355)thatcomparedsalmeterolwithplaceboinolderchildrenandadults.Thestudywasstoppedprematurelybecausethe
incidenceofasthmarelatedadverseeffects(suchassevereasthmaexacerbationsandasthmarelateddeaths)washigherinpeoplewhohad
usedsalmeterolwithoutaninhaledcorticosteroid(ICS):
TheriskofadverseeffectswashigherinAfricanAmericanpeoplethaninthewhitepopulation.
Theauthorscouldnotdeterminewhetherthenegativeoutcomesinthetrialwereduetothephysiologicaleffectofthedrug,geneticfactors,
behaviouralfactors,orcombinationsofthesefactors.
Ametaanalysispooledtheresultsfrom19trials(n=33,826includingtheSMARTstudy),andsimilarlyconcludedthatLABAtherapyincreases
severeandlifethreateningasthmaexacerbations,andriskofasthmarelateddeath[Salpeteretal,2006(/asthma#!references/297181)].
Usingalongactingbeta2agonist Backtotop
Advisepeoplewhoarestartingtreatmentwithalongactingbeta2agonist(LABA)toreportanydeteriorationinsymptoms[BNF53,2007
AdvisepeopleusingaLABAthattheymustnotstopusingtheirinhaledcorticosteroid(ICS).
Advisepeoplewhohavebeenprescribedsalmeterolthattheyshouldnotuseittorelieveanacuteasthmaattack.
Advisepeoplewhoareinhalingterbutalineusingaturbohalertorinsetheirmouthaftereachuse.Afractionofthedosewillalwaysbedepositedin
themouthandrinsingthemouthwillminimizetheamountofterbutalineabsorbedsystemically[ABPIMedicinesCompendium,2011b
Backtotop
Theophylline
Prescribingissues Backtotop
Themarginbetweentherapeuticandtoxicdosesoftheophyllineisnarrow.Mostpeoplerequireplasmaconcentrationsbetween10and20mg/L
forsatisfactorybronchodilation,althoughalowerconcentrationmaybeeffective.
Onceamaintenancedosehasbeenreached,checkserumtheophyllineconcentrationevery6to12months,orifthepersonisexperiencing
adverseeffectsthatmightsuggesttoxicity[UKMI,2002(/asthma#!references/297181)].
Adverseeffects,includingnausea,vomiting,tremor,palpitations,andarrhythmias,canoccuratplasmaconcentrationsof1020mg/L.The
frequencyandseverityofadverseeffectsincreasewithconcentrationsgreaterthan20mg/L.
Serumlevelsoftheophyllineareincreased(becauseofanincreaseinthehalflifeoftheophylline)inpeoplewithheartfailureorhepatic
impairment,inelderlypeople,andbydrugsthatinhibithepaticenzymes(forexamplecimetidine,ciprofloxacin,erythromycin,fluvoxamine,St
John'sWort):
Ifpeoplewhosediseaseisstableduringtheophyllinetherapybegintotakeoneofthesedrugs,areductionofthetheophyllinedoseis
recommended.
Serumlevelsoftheophyllinearedecreased(becauseofadecreaseinthehalflifeoftheophylline)inpeoplewhosmoke,inchronicalcohol
misuse,andbydrugsthatinducehepaticenzymes(forexamplephenytoin,carbamazepine,rifampicin):
Ifpeoplewhosediseaseisstableduringtheophyllinetherapybegintotakeoneofthosedrugs,thetheophyllinedosemayneedtobeincreased.
Ifpeoplewhosediseaseisstableduringtheophyllinetherapystopsmoking,plasmalevelsoftheophyllinemayincrease,andareductionin
dosemaybenecessary.
Whenprescribingtheophylline,thebrandshouldbespecifiedontheprescription.Becauseofdifferencesinbioavailabilityamongbrands,
peopleshouldbemaintainedonthesamebrandoftheophylline.
Backtotop
Leukotrienereceptorantagonists
Prescribingaleukotrienereceptorantagonist Backtotop
Theleukotrienereceptorantagonistsmontelukastandzafirlukastarewelltoleratedandhavefewclassrelatedadverseeffects[GINA,2006
Zafirlukasthasbeenassociatedwithlivertoxicity.Ifclinicalsymptomsorsignssuggestiveofliverdysfunctionoccur(forexampleanorexia,
nausea,vomiting,rightupperquadrantpain,fatigue,lethargy,flulikesymptoms,enlargedliver,pruritus,orjaundice),stopzafirlukastand
immediatelymeasureserumtransaminases(inparticular,serumalanineaminotransferase).Routinemonitoringofliverfunctionisnot
recommended[ABPIMedicinesCompendium,2004(/asthma#!references/297181)].
Useinchildren:montelukastistheonlyleukotrienereceptorantagonistlicensedforuseinchildren(aged6monthsandolder).Apaediatric
granuleformulationisavailable,whichcanbeswallowedormixedwithcoldorroomtemperaturesoftfoodandtakenimmediately[ABPIMedicines
Compendium,2007(/asthma#!references/297181)].
Useinpregnancy:donotstartaleukotrienereceptorantagonistduringpregnancy.However,ifawomanisalreadytakingaleukotrienereceptor
antagonistanditisconsideredessential,treatmentcanbecontinuedduringpregnancy[SIGNandBTS,2011(/asthma#!references/297181)].
Intwosmallprospectivestudiesnoincreaseintheratesofcongenitalmalformation,pretermbirth,orlowbirthweightwasfound.Therehave
beenseveralcasereportsoflimbdefectsinwomentakingaleukotrienereceptorantagonistduringpregnancy,butacausalrelationshiphasnot
beenestablished[Schaeferetal,2007(/asthma#!references/297181)].
Adviceforpatients Backtotop
Advisepeopletakingzafirlukasttoseekmedicaladviceintheeventofpersistentnausea,vomiting,malaise,orjaundice[BNF53,2007
Advisethepersonthatmontelukastshouldnotbeusedtorelievesymptomsofanacuteasthmaexacerbation.
Backtotop
Cromones
Cromones(sodiumcromoglicateandnedocromilsodium)
Adviceforusinganinhaledcromone Backtotop
Advisepeoplethatinhaledsodiumcromoglicateornedocromilsodiumshouldbeusedregularly,usuallyfourtimesaday.
Cromoneinhalersshouldnotbeusedtorelieveanacuteattackofasthma.
Ifinhalationofthedrypowderformofsodiumcromoglicatecausesbronchospasm,advisethepersontousetheirshortactingbeta2agonist
inhaler(salbutamolorterbutaline)afewminutespriortousingthesodiumcromoglicateinhaler.
Backtotop
Oralcorticosteroids
Prescribingoralcorticosteroids Backtotop
Adverseeffectsareuncommonwithinfrequent,shortcoursesoforalcorticosteroids.
Table1inmanagingpeoplenotneedingadmission(/asthma#!scenariorecommendation:56)showsthedoseoforalprednisolonerecommendedin
anacuteexacerbationofasthma:
Inadults,oralcorticosteroidsshouldbecontinuedforatleast5days,untilrecovery.
Inchildren,oralcorticosteroidsshouldbecontinuedforatleast3days,untilrecovery.
Prescribesolubleprednisolonetabletsforchildrenwhocannotswallowtablets.
Repeatthedoseofprednisoloneinchildrenwhovomit.
Afterrecoveryfromtheacuteexacerbation,therapywithprednisolonecanbestoppedabruptly,withouttaperingthedose,unlessthecoursewas
longerthan3weeksorthepersonwaspreviouslyreceivingmaintenanceoralcorticosteroidtreatment.
Adverseeffects Backtotop
Whataretheadverseeffectsofcontinuousorfrequentuseoforalcorticosteroidsandhowcantheybemanaged?
Theriskandseverityofadverseeffectswithoralcorticosteroidsincreasewiththedoseandthedurationoftreatment.Peoplereceivinglongterm
oralcorticosteroids(morethan3months)orthoseneedingfrequentcoursesofanoralcorticosteroid(threetofourperyear)areatriskofsystemic
adverseeffects.
Systemicadverseeffectsincludeosteoporosis,hypertension,diabetes,hypothalamicpituitaryadrenalaxissuppression,weightgain,cataracts,
glaucoma,skinthinning,easybruising,andmuscleweakness.
Aimtoprevent,minimize,orquicklydetectadverseeffectsoflongtermcorticosteroids.Generalandlifestylerecommendationstominimize
adverseeffectsincludethefollowing:
Encourageadequatedietarycalciumintakeandgoodnutrition.
Maintainnormalbodyweightwherepossible.
Adviseonsmokingcessation.
Adviseonmoderatealcoholconsumption.
Encouragephysicalexercisewithinthelimitsimposedbytheunderlyingdisease.
Performafallsriskassessment,whereappropriate,andadvisethoseatincreasedriskoffracturesfromfalling.
Monitor,prevent,andtreatthesystemicadverseeffectsofcontinuousorfrequentcoursesoforalcorticosteroids:
Bloodpressure:monitorregularlyandtreatifnecessary.
Diabetesmellitus:screenregularlyandtreatifnecessary.
Osteoporosis:seetheCKStopiconOsteoporosispreventionoffragilityfractures(/osteoporosispreventionoffragilityfractures)fordetailson
whentoprescribeprophylacticbisphosphonatetherapy.
Growthsuppression:recordheightofchildrenregularlyandaccurately.
Cataracts:screenchildrenperiodicallythroughcommunityoptometricservices.
Childrenwhofrequentlyusecoursesoforalcorticosteroidsshouldhaveregularchecksforsignsofadrenalsuppression.Refertoapaediatrician
whocanarrangeSynacthentesting,whereappropriate.
Documenttheperson'shistoryofchickenpox(fataldisseminatedchickenpoxmayoccurinnonimmunepeople).Adviseallpeoplewithoutahistory
ofchickenpoxwhoaretakingsystemicprednisolonetoavoidclosecontactwithpeoplewhohavechickenpoxorshingles,andtoseekurgent
medicaladviceiftheyareexposed.
Backtotop
Stableasthma
Evidenceonstableasthma
Shortactingbeta2agonists Backtotop
Evidenceonshortactingbeta2agonists
Thereisnoclinicallysignificantdifferencebetweenregularorasrequiredshortactingbeta2agonistsintermsoflungfunction,useof
relievermedication,exacerbationrates,orqualityoflife:
Onesystematicreview(searchdate2002,22crossoverrandomizedcontrolledtrials[RCTs]andeightparallelgroupRCTs)examinedregular
versusasrequireduseofshortactingbeta2agonistsinasthmacontrol.Moststudiesdidnotallowconcomitantuseofinhaledcorticosteroids,and
onlydatafromthecrossoverstudiesweresuitableforpooling.Thereviewfoundnodifferenceinmorningpeakflowrates,butregularuse
improvedeveningpeakflowrates,reduceddiurnalvariation,andreducedtheneedforrelievermedication.However,theclinicalrelevanceof
theseresultsisuncertain,becauseexacerbationrates,andqualityoflifescoresdidnotdifferandoneRCT(n=117)showedbettersymptom
controlover24hourswithasrequiredusethanwithregularuse.Insomestudies,regularusewasassociatedwithdeteriorationofairway
responsivenessafterstoppingmedication,increasedallergeninducedbronchoconstriction,andtremor[Rodolfoetal,2005
Inhaledcorticosteroids Backtotop
Evidenceoninhaledcorticosteroids
ICSversusplacebo:
Onesystematicreview(searchdate1999,12randomizedcontrolledtrials[RCTs],n=647)andsevensubsequentRCTs(sixRCTs,n=1210
oneRCT,n=7241)involvedbudesonide.Onesystematicreview(searchdate2004,sevenRCTs,n=1043)involvedfluticasone(100or
200micrograms/day).Onesystematicreview(searchdate2003,10RCTs,n=1458)examinedbeclometasoneandsevenRCTs(n=2788)
examinedtriamcinolone,flunisolide,mometasone,andciclesonide.AllstudiesinvolvedpeoplewithmildasthmaandshowedthatICSimproved
lungfunction,improvedasthmasymptoms,andreducedtheneedforbronchodilatortherapycomparedwithplacebo.Onlythefluticasone
systematicreviewshowedthatfluticasonesignificantlyincreasedtheriskoforalcandidiasiscomparedwithplacebo(2%versus0.5%RR3.45,
95%CI1.29to9.26).Theotherreviewsmayhavebeenunderpoweredtodetectaclinicallyimportantdifference[Rodolfoetal,2005
ICSversusshortactingbeta2agonist:
Onesystematicreview(nosearchdate,fiveRCTs[ofwhichtwocomparedbeta2agonists],n=141)showedthatICSsignificantlyimproved
lungfunctioncomparedwithbeta2agonists.Noinformationwasprovidedonadverseeffects[Rodolfoetal,2005
ICSversussodiumcromoglicate:
ACochranereview(searchdateFebruary2004)included17trials(n=1279children>2yearsofage)andeighttrials(n=321adults)of
peoplewithmoderatetosevereasthmathatmadeheadtoheadcomparisonsofICSagainstsodiumcromoglicate.Inhaledcorticosteroidswere
superiortosodiumcromoglicateforalloutcomes,suchasreducedexacerbationrates(primaryoutcome),asthmasymptomscores,peakflow
rates,andneedforrescuemedicationinchildrenandadults(secondaryoutcomes).Adverseeffectsdidnotdifferbetweengroups,although
inconsistentreportingandlackoflongtermfollowuppreventdrawingfirmconclusionsaboutsafety.Theresultsaregeneralizable,butthe
studiesdidnotinvolveinfantsyoungerthan2yearsandolderpeople(>65years)[Guevaraetal,2006(/asthma#!references/297181)].
ICSversusleukotrienereceptorantagonists:
Asystematicreview(13RCTs,12inadults,oneinchildren)inpeoplewithmildtomoderateasthmacomparedICS(dosesequivalentto
beclometasone,400micrograms/day)withleukotrienereceptorantagonists.Inhaledcorticosteroidsweremoreeffectiveatreducing
exacerbations,nocturnalawakenings,useofrescuebeta2agonists,anddayswithsymptoms.Adverseeffectsdidnotdifferbetweengroups,
butmorepeopleintheleukotrienereceptorantagonistgroupwithdrewbecauseofpoorasthmacontrol[Ducharme,2003
AnRCT(n=994)randomizedchildren614yearsofagewithmildpersistentasthmatoreceiveinhaledfluticasone,100microgramstwice
daily,ororalmontelukast,5mgoncedaily,for1year.TheresultsfavouredICSovermontelukast.TheICSgrouphadmorerescuefreedays
(mean86.7%versus84%)thisresultwasstatisticallysignificantlyinfavouroffluticasonebutisofquestionableclinicalsignificance.The
fluticasonegrouphadalowerproportionofchildrenrequiringsystemiccorticosteroidsandalowerproportionwithasthmaattack[Garcia
Garciaetal,2005(/asthma#!references/297181)].
Fluticasoneversushydrofluoroalkane134a(HFA)beclometasonedipropionate:
ACochranereview(searchdateJanuary2007)involvingeightRCTs(n=1260,onlyonestudyinvolvingchildren)showednostatistically
significantdifferencebetweenbothICSonlungfunctionover6to12weeks.However,thisshouldnotbetakenasequivalence,asthedata
availablecouldnotexcludeameaningfulbenefitoffluticasoneoverHFAbeclometasonedipropionate.Dataonexacerbationrates,symptom
scores,andrescuemedicationusewereverylimited,butoverall,nodifferenceswerereported.Adverseeffectsdidnotdifferbetweengroups,
andveryfewadverseeffectswererecorded,whichmayduetotheshortdurationofmanyofthestudies.Thesefindingscannotbegeneralized
tochildrenorpeoplewithapoorinhalertechnique.Furtherresearchisneededtovalidatetheeffectsreportedinthesestudies[Lassersonetal,
2006(/asthma#!references/297181)].
Longactingbeta2agonists Backtotop
Evidenceonlongactingbeta2agonists
LABAversusplacebo:
Fourrandomizedcontrolledtrials(RCTs)(n=2063)inpeoplewithpersistentasthmanotcontrolledwithbeclometasone,200to2000
micrograms/day,showedthattheadditionofsalmeterolorformoterolimprovedpeakexpiratoryflowrate,forcedexpiratoryvolumein1second
(FEV1)andreducednightawakeningcomparedwithplacebo.Thestudiesinvolvingsalmeterolalsoshowedimprovementsinqualityoflife
scorescomparedwithplacebo.Intheformoteroltrials,symptomswereimprovedsignificantlyat6months.However,exacerbationratesdidnot
differbetweengroupsinanyRCT[Rodolfoetal,2005(/asthma#!references/297181)].
Asystematicreview(searchdateJune2004,26RCTs[eightonchildren,18onadults])randomizedpeopletoanICSalone(beclometasone,
200to400g/dayorequivalent)oranICSwithLABAs(formoterolorsalmeterol).Mosttrialslasted4monthsorless.TheadditionofLABA
reducedriskofexacerbationsrequiringsystemicsteroids(NNT18,95%CI13to33),andincreasedtheproportionofsymptomfreedaysby
17%(95%CI12to22)in6trials,increasedtheproportionofrescuefreedaysby19%(95%CI12to26)intwotrials,andreduceduseof
rescueshortactingbeta2agonistsby0.7puff/day(95%CI1.2to0.2puff/day)[NiChroininetal,2005(/asthma#!references/297181)].A
laterCochranereviewsupportsthebenefitsofLABAtherapyintermsoflungfunction,fewersymptoms,lessuseofrescuemedication,and
improvedqualityoflifescorecomparedwithplacebo.However,theriskofexacerbationsinchildrenmayhavebeenincreasedthisfinding
needsfurtherconfirmation[Waltersetal,2007(/asthma#!references/297181)].
Inasystematicreview(searchdateJuly2005)oftenparallelgrouprandomizedtrials,twostudiesshowedthatinadults,theadditionofaLABA
toICSallowsreductionoftheICSdose.Thegroupsdidnotsignificantlydifferintheratesofsevereexacerbationsrequiringoralcorticosteroids
andwithdrawalduetoworseningasthma,andLABAtherapywasassociatedwithsignificantimprovementsinFEV1,peakexpiratoryflowrate,
andpercentageofrescuefreedays[Gibsonetal,2005(/asthma#!references/297181)].
LABAversusincreasingICS:
Asystematicreview(searchdateJuly2005,30RCTs,n=9509,children>2yearsofage[threetrials]andadults[27trials])compareda
combinationofLABAplusICSwithahigherdoseofICS.Thecombinationregimensignificantlyincreasedsymptomfreedaysby12%(eight
trials),reduceddaytimeuseofrescuebeta2agonistsby1puff/day(fourtrials),andreducedtherateofwithdrawalsowingtopoorasthma
control(20trials).Thegroupsdidnotsignificantlydifferintherateofexacerbationsrequiringsystemicsteroids(15trials)oroveralladverse
events(15trials).TremorwastheonlysignificantadverseeffectthatwasincreasedwithLABAtherapy(10trials)[Greenstoneetal,2005
Onesystematicreview(searchdate1999,nineRCTs)andeightadditionalRCTsfoundthataddingLABA(salmeterolorformoterol)toICS
improvedlungfunctionandsymptomscomparedwithincreasingtheICSdose.AdditionofLABAreducedexacerbationrates.However,one
RCTfoundthatincreasingICScomparedwithaddingformoterolsignificantlyreducedsevereexacerbationsat1year[Rodolfoetal,2005
AnRCT(n=1272)showedthatformoterolwasmoreeffectivethandoublingthedoseofbudesonideat1yearforreducingtheriskofsevere
exacerbationsandpoorlycontrolledasthmadays[O'Byrneetal,2001(/asthma#!references/297181)].
LABAversusleukotrienereceptorantagonists:
SevenRCTs(totaln=3943)comparedsalmeterolorformoterolwithleukotrienereceptorantagonists(montelukastorzafirlukast).Allstudies
hadslightlydifferentresults,butoverall,LABAimprovedlungfunctionandsymptomsmorethanleukotrienereceptorantagonists.Oneofthe
largerRCTs(n=1490)showednosignificantdifferenceinasthmaexacerbationsover48weeksbetweenfluticasoneplussalmeteroland
fluticasoneplusmontelukast(19.1%vs.20.1%difference1%,95%CI3.1to+5)[Rodolfoetal,2005(/asthma#!references/297181)].A
recentCochranereview(15RCTs,11RCTsincludedinthemetaanalysis,n=6030)supportsthefindingsofearlyRCTsandaddsthatLABA
lowertheriskofexacerbationsrequiringsystemiccorticosteroids(NNT38topreventoneexacerbationover48weeks,95%CI23to247)
comparedwithleukotrienereceptorantagonists[Ducharmeetal,2006(/asthma#!references/297181)].
LABAversustheophylline:
Asystematicreview(searchdateApril2003,12RCTs)showedLABAtobeatleastaseffectiveastheophyllineinreducingsymptoms(including
nightawakening)andimprovinglungfunction.However,LABAwereassociatedwithlessadverseeffectsthantheophylline.Alatersystematic
review(searchdateNovember2006,13RCTs,n=1344)confirmedthesefindingsandsuggestedthatLABAweremoreeffectivethan
theophyllineinimprovingmorningandeveningpeakexpiratoryflowrate.Salmeteroldecreasedtheneedforshortactingbeta2agonist
comparedwiththeophylline[Teeetal,2007(/asthma#!references/297181)].
LABAadverseeffects:
OneRCT(SalmeterolMulticenterAsthmaResearchTrial[SMART],n=26,355people>12yearsofage)showedthatsalmeterolsignificantly
increasedthenumberofrespiratoryrelateddeaths(RR2.16,95%CI1.06to4.41),asthmarelateddeaths(RR4.37,95%CI1.25to15.3NNH
1315),andcombinedasthmarelateddeathsorlifethreateningexperiences(RR1.71,95%CI1.01to2.89NNH909).MortalityintheRCTwas
verylow:thenumberneededtoharm(oneasthmarelateddeath)was1318(95%CI746to6173)afterameanof7months.Whetherthis
increasedriskrepresentslackofappropriateuseofICS,atreatmenteffect,orgeneticfactorsisnotyetclear[Nelsonetal,2006
(/asthma#!references/297181)].ACochranereview(searchdateOctober2005,67RCTs,n=42,333)highlightsthattheseobservationswere
drawnfromaposthocanalysisandlackthevalidityofpredefineddistinctions.ThereviewalsostatesthatLABAusedinappropriate
candidates,alongwithICS,areverysafe[Waltersetal,2007(/asthma#!references/297181)].
Asystematicreview(19RCTs,n=33,836)includingtheSMARTtrialshowedthatuseofLABA(salmeterolandformoterol)foratleast3months
(range312months)comparedwithplaceboresultedinhospitalizationforasthmaexacerbationin1.72%versus0.6%(NNH89)basedon
metaanalysisof12trials(n=5091),andlifethreateningasthmaexacerbationsin0.32%versus0.17%(NNH666)basedonmetaanalysisof
seventrials(n=29,981).Therewere15versus3asthmarelateddeathsin14trialswithreportedasthmarelateddeaths(NNH1428,95%CI
1000to10,000).Insensitivityanalysisthatassumednodeathsin28additionaltrials,theabsoluteincreaseinriskwas0.06%(NNH1666)
[Salpeteretal,2006(/asthma#!references/297181)].
Leukotrienereceptorantagonists Backtotop
Evidenceonleukotrienereceptorantagonists
LeukotrienereceptorantagonistsversusplaceboinpeopleusingICS:
Asystematicreview(searchdateOctober2003,27RCTs,onlytwotrialsincludedchildren)showedthatadditionofaleukotrienereceptor
antagonisttoICSreducedtheriskofexacerbationsrequiringsystemicsteroids(notstatisticallysignificant),reduceduseofrescueshortacting
beta2agonists(by1puff/week),andimprovedpeakexpiratoryflowrate(by7.7mL/min).Onlythreetrialscomparedadditionofleukotriene
receptorantagonistswithincreasingtheinhaledsteroiddose,andnoconclusionscanbemade[Ducharmeetal,2004
AnRCT(n=455adults)withasthmaandskintestsensitivitytoseasonalaeroallergenswererandomizedtoreceiveoralmontelukast10mgvs.
placebofor3weeksduringtheallergyseason.Thereductionindaytimeasthmasymptomscore(total6points)was0.54pointswith
montelukastand0.34pointswithplacebo,astatisticallysignificant(p=0.002)butnotclinicallyrelevantdifference[Busseetal,2006
AnRCT(n=689childrenaged25years)showedthat12weeksofmontelukast,4mgoncedaily,wasmoreeffectivethanoncedaily
chewableplacebotabletsatimprovingdaytimeasthmasymptoms(59%vs.64%dayswithasthmasymptoms),nocturnalcough,anduseof
beta2agonists(49%vs.55%dayswithbetaagonistuse)anduseoforalsteroids.Nosignificantadverseeffectswerereported[Knorretal,
LeukotrienereceptorantagonistversusdoublingthedoseofICS:
AnRCT(n=889peopleaged1575years)showedthatadditionofmontelukast(10mgoncedaily)anddoublingthedoseofbudesonidewere
equallyeffectivestrategiesinpeoplewhoseasthmawasinadequatelycontrolledwithbudesonide,800micrograms/day,over12weeks.Both
groupsimproved,andmorerapidresponsewasreportedinthemontelukastgroup,butthisfindingwasbasedonpeakflowmeasurements.The
groupsdidnotsignificantlydifferinsymptombasedoutcomes.Thestudywasfundedbythemanufacturerofmontelukast[Rodolfoetal,2005
LeukotrienereceptorantagonistaloneversusICSalone:
Onesystematicreview(searchdate2003,15RCTsinadultsandthreeRCTsinchildren,n=4965)foundthatleukotrienereceptorantagonists
weresignificantlylesseffectivethanICS(beclometasoneandfluticasone)inreducingriskofexacerbationrequiringoralcorticosteroidsand
reducingsymptomfreedaysover4to37weeks.Therewasnodifferenceinhospitaladmissionratesforexacerbations[Rodolfoetal,2005
LeukotrienereceptorantagonistsaloneversusICSplusLABA:
TwoRCTs(n=855adults)showedthatfluticasone(200micrograms/day)plussalmeterol(50mg/day)comparedwithmontelukast(10mg/day)
significantlyincreasedsymptomfreedays,reducedexacerbations,andimprovedlungfunctionandsymptomsat12weeks[Rodolfoetal,2005
Theophylline Backtotop
Evidenceontheophylline
Theevidencefortheophyllineuseinasthmaislimitedandofpoorquality.Resultsofheadtoheadstudiescomparingtheophyllinewith
otheraddontherapiesareinconsistentandrequirefurther,morerobustevaluation.Overall,theophyllineappearstobemorebeneficial
thanplaceboandisatbestsimilarineffectivenesstolongactingbeta2agonists,sodiumcromoglicate,andleukotrienereceptor
antagonists.However,increasingthedoseofinhaledcorticosteroids(ICS)providesbetterasthmacontrolthanaddingintheophyllinein
poorlycontrolledasthma.Inallcomparisonstudies,theophyllineisassociatedwithanincreasedriskofadverseeffects:
Asystematicreview(searchdateMay2006,35randomizedcontrolledtrials[RCTs],n=2754)comparedoralxanthines(forexampletheophylline)
inchildrenaged18monthsto18years[Seddonetal,2006(/asthma#!references/297181)]:
Placebo(18RCTs):xanthineincreasedtheproportionofsymptomfreedaysby8%(95%CI3.4to12.5)anddecreaseduseofrescue
medication,butsymptomscoresandhospitalizationsdidnotsignificantlydiffer.
ICS(fourRCTs):exacerbationswerelessfrequentandsymptomimprovementswerebetterwithICS,andxanthineswereassociatedwithmore
frequentheadachesandnausea.Therewasnosignificantdifferenceinlungfunction.
Regularshortactingbeta2agonists(tenRCTs):theseagentsdidnotsignificantlyaffectsymptomsoruseofrescuemedication.They
reducedhospitalizationsandheadachesbutincreasedtremor.
Sodiumcromoglicate(sixRCTs):nosignificantdifferencesinsymptoms,exacerbations,orrescuemedicationusewereobserved.Xanthines
hadmoregastrointestinaladverseeffects.
ArecentRCT(n=489)randomizedpeoplewithpoorlycontrolledasthmatoplacebo,theophylline300mg/day,ormontelukast10mg/day,for24
weeks.Ratesofepisodesofpoorasthmacontrol,asthmasymptoms,andqualityoflifedidnotdiffersignificantlyamonggroups.Theophyllineand
montelukastprovidedsmallimprovementsintheprebronchodilatorforcedexpiratoryvolumein1second,whichwereofborderlinesignificance.
However,inpeoplenottakingICS,asthmacontrol,symptoms,andlungfunctionimprovedmorewithlowdosetheophyllinethanwithmontelukast
orplacebo[AmericanLungAssociationAsthmaClinicalResearchCenters,2007(/asthma#!references/297181)].
Cromones Backtotop
Evidenceoncromones
Cromonesmaybeofsomebenefitinadultsandchildrenolderthan5yearstohelpwithasthmasymptoms,buttheevidenceis
inconclusive.Sodiumcromoglicateoffersnoclearbenefitinchildrenaged5yearsoryounger[SIGNandBTS,2011
Asystematicreview(24doubleblindrandomizedcontrolledtrials[RCTs],n=1074children)concludedthatsodiumcromoglicatemayhavea
smalloveralltreatmenteffecthowever,thisfindinglackedstatisticalsignificance,andthelikelihoodofpublicationbiaswashigh.Theauthors
concludedthatsodiumcromoglicateshouldnotbeusedasfirstlinetherapyinasthmamanagement[Tascheetal,2000
Asystematicreview(15randomizedcontrolledtrials,n=1422children)concludedthatnedocromilmayreducesymptomsinchildrenwithasthma,
butthelongertermevidenceofsymptombenefitislimitedandinconsistent.Moreevidenceisrequiredonnedocromilcomparedwithinhaled
corticosteroids,whoseefficacyiswellestablishedinasthma.Inshorttermstudies,nedocromilshowedpromisingresultscomparedwithplacebo,
especiallyintermsoflungfunction.However,theprimaryendpointofsymptomfreedayswasinconsistentinthelongertermstudies.Theonly
significantadverseeffectwasunpleasanttaste[SridharandMcKean,2006(/asthma#!references/297181)].
SymbicortSmart Backtotop
EvidenceonSymbicortSmartformaintenanceandrelievertherapyforasthmamanagement
SymbicortSMARTcomparedwithICS+longactingbeta2agonist(adults)
OneCochranesystematicreview(searchdateSeptember2008,fiverandomizedopencontrolledtrials)foundthatSymbicortSMARTwasno
differenttocurrentbestpractice(ICSpluslongactingbeta2agonist)[CatesandLasserson,2009(/asthma#!references/297181)].
Exacerbationsofasthmarequiringtreatmentwithoralcorticosteroids:OR0.83,95%CI0.66to1.03(n=4,470).
Exacerbationsrequiringhospitaladmissions:OR0.59,95%CI0.24to1.45(n=5378).
Therewasnodifferenceintherateoffatalornonfataladverseevents(datafromthreestudies).Theeventratesweretoolowtoruleouta
clinicallysignificantincreaseordecreaseinadverseevents.
AnotherfourstudiescomparingSymbicortSMARTwithcurrentbestpracticearedueforcompletionsoon,andtheresultsfromafurther
4600participantsareawaited.
SymbicortSMARTcomparedwithICSalone(adultsandadolescents)
ThesameCochranesystematicreview(searchdateSeptember2008,threerandomized,doubleblindcontrolledtrials,onerandomizedopen
controlledtrial)foundthatSymbicortSMARTwasnodifferenttoICSaloneforexacerbationsneedinghospitaladmission,buttherewerefewer
exacerbationsrequiringoralcorticosteroids[CatesandLasserson,2009(/asthma#!references/297181)].OnestudycomparedSymbicort
SMARTtothesamedoseofICS.ThreestudiescomparedSymbicortSMARTtoincreaseddoseICS.Patientswerewithdrawnfromtheir
longactingbeta2agonistintheICSarms.Theauthorsarguethatthiscouldhaveledtoanincreaseinearlyexacerbationsinpatientstaking
ICSbecauseanincreaseintheICSdosewouldbeexpectedtotakelongertoworkthanthelongactingbeta2agonistcomponentin
Symbicort.
Exacerbationsofasthmarequiringtreatmentwithoralcorticosteroids:OR0.54,95%CI0.45to0.64(n=4280).
Exacerbationsrequiringhospitaladmission:OR0.56,95%CI0.28to1.09(n=4209).
Therewasnodifferenceintherateoffatalornonfataladverseevents(datafromthreestudies).Theeventratesweretoolowtoruleouta
clinicallysignificantincreaseordecreaseinadverseevents.
Selfmanagementeducationandactionplans Backtotop
Evidenceonselfmanagementeducationandactionplans
Peopleexperienceonethirdtotwothirdsreductioninhospitalizations,emergencydepartmentvisits,misseddaysofwork,andnocturnal
wakening.Implementationofoneselfmanagementprogrammein20peoplepreventsonehospitalization.Lessintensiveinterventions(not
involvingawrittenactionplan)appeartobelesseffective[GINA,2006(/asthma#!references/297181)].
Writtenactionplansimprovehealthoutcomesforpeoplewithasthma,aspartofselfmanagementeducation.Theevidenceisparticularlygood
forpeoplewhohavehadarecentexacerbation[GallefossandBakke,2000(/asthma#!references/297181)Moudgiletal,2000
(/asthma#!references/297181)Coteetal,2001(/asthma#!references/297181)Guevaraetal,2003(/asthma#!references/297181)Gibsonand
Powell,2004(/asthma#!references/297181)Rodolfoetal,2005(/asthma#!references/297181)Rees,2006(/asthma#!references/297181)
SIGNandBTS,2011(/asthma#!references/297181)]:
Asystematicreview(searchdateNovember2004,fourrandomizedcontrolledtrials,n=355)suggestedthatchildrenprefersymptombased
monitoringactionplansoverpeakflowbasedmonitoringactionplans(RR1.21,95%CI1.00to1.46),butparentsshowednopreference.
Exacerbationrates,admissions,schoolabsenteeism,lungfunction,symptomscore,qualityoflife,andwithdrawalsdidnotdiffersignificantly
betweentypesofactionplans[Bhogaletal,2006(/asthma#!references/297181)].
Selfmanagementeducation:
Inchildrenandadolescents,selfmanagementeducationcanreducesymptoms,schoolabsenteeism,andvisitstoemergencytreatment
services[Guevaraetal,2003(/asthma#!references/297181)Bhogaletal,2006(/asthma#!references/297181)].Thereislessevidenceof
benefitofwrittenactionplansforveryyoungchildren[Habyetal,2001(/asthma#!references/297181)Wolfetal,2002
(/asthma#!references/297181)DTB,2005(/asthma#!references/297181)].
Inteenagers,innovativeapproaches,suchaswebbasedorpeerbaseddelivery(atschool),appeartobemoresuccessfulthantraditional
programmes[SIGNandBTS,2011(/asthma#!references/297181)].
Lifestyleinterventions Backtotop
Evidenceonlifestyleinterventions
Theevidenceforlifestyleinterventionsinasthmamanagementisbasedonafewsmallstudies.Mostofthetrialevidenceisinconsistent,
howeversmokingcessation(bytheindividualorparentofachildwithasthma)andweightreduction(inobesepeople)improveasthma
symptoms.Larger,morerobuststudiesofallergenavoidanceareneededtoconfirmbenefit:
Smoking:
Thereisadirectcausalrelationshipbetweenparentalsmokingandlowerrespiratorytractillnessinchildrenupto3yearsofage.Infantswhose
motherssmokearefourtimesmorelikelytodevelopwheezingillnessesinthefirstyearoflife[GINA,2006(/asthma#!references/297181)].
Exposuretotobaccocontributestotheseverityofchildhoodasthma.Averageexposureisassociatedwitha30%increasedriskofasthma
symptoms.Onesmallstudysuggeststhat,bystoppingsmoking,parentscandecreasetheseverityofasthmaintheirchildren[SIGNandBTS,
Vaccinations:
Asystematicreview(searchdateAugust2003,ninerandomizedcontrolledtrials[RCTs])concludedthatevidenceisinsufficienttodetermine
whetherinfluenzavaccinationpreventsexacerbationsinpeoplewithasthma,butinfluenzavaccinationwithinactivevaccinedoesnotcause
exacerbations[Catesetal,2003(/asthma#!references/297181)].
Asystematicreview(searchdate2001September)includingonlyoneRCT(n=30children)ofpoormethodologicalquality(lackofblindingand
inadequateallocationconcealment),showedthatpneumococcalvaccinationdecreasedtheincidenceofacuteasthmaexacerbationsperchild
(fromtentosevenepisodesperyear)inthosewithasthmapronetorecurrentepisodesofotitismedia[Sheikhetal,2002
Allergenavoidance:
Aeroallergenavoidancetrialshaveshowninconsistenteffectsonasthma.Airpollutionmayprovokeoraggravateanacuteasthmaattack,but
thistriggerisminimalcomparedwithaninfectioustrigger[SIGNandBTS,2011(/asthma#!references/297181)].
TwoCochranereviewssuggestthatmeasurestocontrolhousedustmiteallergensdonotappeartobeacosteffectivemethodoftreating
asthma.Studieswereheterogeneousintermsofintervention,andallocationwasnotadequatelyconcealedinsomestudies.Atpresent,thereis
noclearbenefitofhousedustmiteavoidance[Woodcocketal,2003(/asthma#!references/297181)GINA,2006
Resultsofobservationalstudiesareconflictingandhavenotshownthatremovingapetfromthehomeimprovesasthmacontrol[SIGNand
Weightreduction,diet,andexercise:
Anopenstudyoftworandomizedparallelgroupsofobesepeoplewithasthmafoundthatasupervisedweightreductionprogramme
significantlyimprovedlungfunction,symptoms,morbidity,andhealthstatus[SteniusAarnialaetal,2000(/asthma#!references/297181)].A
smallerstudyfoundthatweightlossreducesairwaysobstructionandpeakflowvariabilityinobesepeoplewithasthma[Hakalaetal,2000
ThereisnoconvincingevidencefromCochranereviewstosupporttheuseoffishoilsupplements,saltrestriction,ortartrazineexclusioninthe
managementofasthma[SIGNandBTS,2011(/asthma#!references/297181)].
ACochranereview(13RCTs,n=455)showedthatphysicaltrainingincreasescardiorespiratorycapacitybuthasnoeffectonlungfunctionand
daysofwheezinginpeoplewithasthma.Evidenceisinsufficientontheroleofbreathingexercisesinthemanagementofasthmatorecommend
anyoneparticulartechnique[Rametal,2005(/asthma#!references/297181)].Nevertheless,somesmallstudieshavesuggestedapossible
benefitinasthmasymptomswiththeButeyko[Cooperetal,2003(/asthma#!references/297181)]andPapworth[HollowayandWest,2007
(/asthma#!references/297181)]methodsofbreathing.Thesefindingsneedfurtherconfirmation.
Associatedconditions:
Rhinitis:onestudyshowedthat76%ofpeoplewithasthmahadsymptomsofrhinitis.Halfofthesepeoplesaidtheirrhinitismadetheirasthma
worse[PinnockandShah,2007(/asthma#!references/297181)].Rhinitisusuallycomesbeforeasthma,anditisbothariskfactorforasthma
andisassociatedwithincreasedseverityofthedisease[GINA,2006(/asthma#!references/297181)].Thetreatmentofallergicrhinitishasnot
beenshowntoimproveasthmacontrol[SIGNandBTS,2011(/asthma#!references/297181)].
Gastrooesophagealrefluxdisease:therelationshipofincreasedasthmasymptoms,particularlyatnight,togastrooesophagealreflux
remainsuncertain,althoughtheconditionisthreetimesmoreprevalentinpeoplewithasthmathaninthegeneralpopulation[GINA,2006
(/asthma#!references/297181)].ACochranereview(12RCTs)concludedthatthetreatmentofgastrooesophagealrefluxinpeoplewithasthma
hadnoeffectonasthmasymptomsorlungfunction.Drycoughimproved,althoughthissymptomwasprobablynotduetoasthma[SIGNand
Hayfever:thereisastronglinkbetweenasthmaandhayfever,anddeathsfromasthmainyoungadultspeakduringthepollenseason
[PinnockandShah,2007(/asthma#!references/297181)].
Backtotop
Acuteasthmaexacerbation
Evidenceonacuteasthmaexacerbation
Triggerfactors Backtotop
Evidenceontriggerfactors
Theevidenceontriggerfactorsforexacerbationofasthmacomesfromsmallcasecontrolledstudies.Virusesappeartobeacommon
trigger,whilstbacterialinfectionsareamuchlesscommoncause[GINA,2006(/asthma#!references/297181)SIGNandBTS,2011
Smallcasecontrolledstudiesinchildrenhaveshownrespiratorysyncytialvirustobeassociatedwithwheezingininfancy.Rhinovirus(thecauseof
commoncold)istheprincipalcauseofwheezingandworseningasthmainolderchildrenandadults.Otherviruses,suchasparainfluenzaand
enterovirus,arealsoassociatedwithworseningasthmasymptoms.
Smallcasecontrolledstudieshaveidentifiedatypicalbacteria(ChlamydiapneumoniaeandMycoplasmapneumoniae)asamuchlessfrequent
causeofworseningasthma,buttheirexactroleremainsuncertain.
Inhaledbeta2agonists Backtotop
Evidenceoninhaledbeta2agonists
Moststudiesofinhaledbeta2agonistsweredoneinAccidentandEmergencydepartmentsandinvolvedmonitoringpeopleover16
hoursthefindingsarethereforedifficulttogeneralizetoprimarycare.However,continuousbeta2agonisttreatmentortheadditionof
ipratropiumbromideappearstoreducethenumberofpeoplehospitalizedwithasevereasthmaexacerbation:
Beta2agonistdoseandfrequency:
Arandomizedcontrolledtrial(RCT,n=100)inadultswithacuteasthmashowedthatsixspraysofsalbutamolviaametereddoseinhalerevery
60minuteswassafeandeffective,butsomepeoplewhodidnotrespondinitiallymaybenefitfromtreatment30minutesafterthefirstinhalation.
Treatmentintervalsof60minutes(comparedwith30minutesor120minutes)seemedtoprovideoptimalresultsinmostpeople,and
hospitalizationratesandadverseeventsdidnotdiffer[Karpeletal,1997(/asthma#!references/297181)].
Beta2agonistsviaapressurizedmetereddosedinhalerversusanebulizer:
Asystematicreview(sixRCTs,n=491children<5yearsofage)showedametereddoseinhalerwithaspacertobemoreeffectivethana
nebulizer.Thechildrenwhoreceivednebulizershadhigheradmissionrates[CastroRodriguezandRodrigo,2004
(/asthma#!references/297181)].Childrenarelesslikelytohavetachycardiaandhypoxiawhenusingapressurizedmetereddoseinhalerwith
spacercomparedwithanebulizer[SIGNandBTS,2011(/asthma#!references/297181)].
Continuousversusintermittentbeta2agonists:
Onesystematicreview(searchdate2004,eightRCTs,n=461)foundthatcontinuousnebulizedbeta2agonistssignificantlyreducehospital
admissioncomparedwithintermittentnebulizedbeta2agonists,especiallyinpeoplewithsevereairflowobstruction(RR0.64,95%CI0.50to
0.90).Adverseeffects,suchasheartrateandbloodpressureelevationandtremor,didnotdifferbetweengroups[Rodolfoetal,2005
Ipratropiumbromideaddedtobeta2agonists:
TwosystematicreviewsandonesubsequentRCTfoundthattheadditionofipratropiumbromidetobeta2agonistsinacutesevereasthma
improveslungfunctionandislikelytoreducehospitaladmission[Rodolfoetal,2005(/asthma#!references/297181)].
Oralcorticosteroids Backtotop
Evidenceonoralcorticosteroids
Systemiccorticosteroidsversusplacebo:
Onesystematicreview(searchdate1991,fiveRCTs,n=422)foundthatearlyinterventionwithsystemiccorticosteroids(oral,intravenous,or
intramuscular)significantlyreducedhospitalizationscomparedwithplacebo(OR0.47,95%CI0.27to0.79).Anothersystematicreview(five
RCTs,n=345)showedthatsystemiccorticosteroids(oralorintramuscular)significantlyreducedtherelapserateat710days(RR0.35,95%
CI0.17to0.73NNT13)andhospitalreadmissionwithin7days(RR0.32,95%CI0.11to0.94NNT16)comparedwithplacebo.
Corticosteroidsalsosignificantlyreducedtheuseofbeta2agonists[Rodolfoetal,2005(/asthma#!references/297181)].
Alatersystematicreview(searchdateSeptember2000,12RCTs,n=863)ofcorticosteroidsgivenwithin1hourtopeoplepresentingtothe
emergencydepartmentwithacuteasthmafurthersupportsthesefindings.Earlyadministrationofcorticosteroidssignificantlyreducedadmission
rates(11trialspooledOR0.4,95%CI0.21to0.78NNT8,95%CI5to21),andbenefitsweremorepronouncedforpeoplenotalready
receivingsystemiccorticosteroidsandpeoplewithmoresevereasthma.Oralcorticosteroidswereparticularlyeffectiveinchildren(threeRCTs)
[Roweetal,2001(/asthma#!references/297181)].
Stoppingtreatment:
AsmallRCT(n=35)ofpeopleadmittedtohospitalforasthmawhoweregiven40mgofprednisoloneover10daysshowednodifferencein
morningpeakexpiratoryflowratebetweentaperingover1weekandabruptlystoppingtherapy(p=0.82)[Rodolfoetal,2005
Doseandduration:
ThreesmallRCTsshowednodifferenceindoseandduration(510days)ofcorticosteroidswithregardtolungfunctionandrelapserates.
Nevertheless,allthreeRCTsmayhavelackedthepowertodetectaclinicallyimportantdifference.Theoptimumdoseanddurationislikelyto
dependontheindividual,severityoftheexacerbation,andconcomitantmedication[Rodolfoetal,2005(/asthma#!references/297181)].
Corticosteroidsinchildren:
Asystematicreview(17RCTs)showedoralcorticosteroidstobeeffectiveforoutpatienttreatmentofacuteasthmainchildren.Early
administrationoforalcorticosteroidsappearedtoreducehospitalizations[Rachelefsky,2003(/asthma#!references/297181)].
Asystematicreview(searchdateMay2006,twoRCTs,n=303)showedthatwhenparentsinitiatedoralcorticosteroidtherapyforan
intermittentwheezingillness(asthma,viralwheeze,andpreschoolviralwheeze),therewasnosignificantbenefitintermsofhospital
admissions,symptomscores,bronchodilatoruse,parentalandpatientimpressions,ordayslostfromschool[Vuillerminetal,2006
Inhaledcortisosteroids Backtotop
Evidenceoninhaledcorticosteroids
Inhaledcorticosteroids(ICS)havebeenshowninsmallrandomizedcontrolledtrials(RCTs)toprovidebenefitinasthmamanagementin
termsofreducinghospitaladmissionscomparedwithplacebo.NoconsistentevidenceindicatesthatdoublingthedoseofICSimproves
peakexpiratoryflowrate(PEFR)andsymptomscomparedwithcontinuingtheusualdoseofICS.UseofICSinadditiontooral
corticosteroidsoffersnobenefitinpreventingasthmaexacerbations[Rodolfoetal,2005(/asthma#!references/297181)]:
IncreasingtheICSdoseatearlysignsofanexacerbationdoesnotappeartobenefitmanagementofanexacerbation:
ICSversusplacebo:
Onesystematicreview(searchdateFebruary2005,10RCTs,n=587)inadultsandchildrenattendinganemergencydepartmentshowedthat
ICSreducedhospitaladmission.Subgroupanalysisfoundthatthebenefitwassignificantonlyinpeoplenotreceivingconcomitantoral
corticosteroids(OR0.27,95%CI0.14to0.52).TreatmentwithICSwaswelltolerated,withfewreportedadverseeffects.
AnRCT(n=390)showedthatdoublingthedoseofICSforworseningPEFRandsymptomswasnobetterthancontinuingtherapywiththe
regulardose.Peopleatriskofexacerbationmonitoredtheirmorningpeakflowandsymptomsforupto12months.Theywererandomly
assignedtouseanactiveinhaleroraplaceboinhalerandtodoubletheusualdosefor14daysiftheirPEFRorsymptomsdeteriorated.Results
showednodifferenceinuseoforalcorticosteroids(11%vs.12%)orsymptomscores[Harrisonetal,2004(/asthma#!references/297181)].
ICSplusoralcorticosteroidsversusoralcorticosteroidsalone:
Onesystematicreview(searchdate2003,threeRCTs,n=909)showedthatinadultsattendinganemergencydepartment,relapseratesafter
24daysdidnotdiffersignificantlywitheitherregimen(OR0.68,95%CI0.46to1.02)[Rodolfoetal,2005(/asthma#!references/297181)].
ICSversusoralcorticosteroids:
Onesystematicreview(searchdate2001,fourRCTs,772adultsand22children)showednosignificantdifferenceinrelapseratesat710days
inpeoplereceivingoralprednisoloneorICS(equivalenttobeclometasone,2000micrograms/day)foranacuteasthmaexacerbation(OR1.00,
95%CI0.66to1.52,p=0.88).OnesubsequentRCT(n=40)inadultsdischargedfromhospitalfollowinganexacerbationshowedno
differenceinlungfunctionorsymptomsbetweenoralprednisoloneandinhaledflunisolideat7days.AnadditionalRCT(n=413)showedno
significantdifferenceintreatmentfailurewithoralprednisoloneandhighdoseinhaledfluticasone(2000micrograms/day)inpeoplepresenting
totheirGPforanasthmaexacerbation[Rodolfoetal,2005(/asthma#!references/297181)].
FurthersmallstudieshaveshownconflictingevidenceofICScomparedwithoralcorticosteroidsinchildrenwithacuteasthma.Overall,oral
corticosteroidsappeartobesuperiortoICS,buttrialsareheterogeneous,makingitdifficulttodrawdefiniteconclusions[Schuhetal,2006
Montelukast Backtotop
Thereisevidencefromtwosmallrandomizedtrialsthatmontelukastgiventochildrenagedover2yearswithmildasthmamayreduce
symptomsandsubsequenthospitalattendance.Thereisnoevidenceforitsuseotherthanforamildexacerbationofasthma.
Arandomized,doubleblind,placebocontrolled,parallelgroupstudyincluded51childrenaged25yearswhowereusingashortactingbeta2
agonistintermittentlyandwhohadaclinicalhistoryofintermittentasthma[Harmancietal,2006(/asthma#!references/297181)].Duringanacute
attackthechildrenwererandomizedtoreceivemontelukast(n=25)orplacebo(n=26).Clinicalimprovementwasassessedbyapulmonary
indexscorewhichhadfiveparameters:airentry,wheezing,suprasternalretractions,abdominalbreathing,andoxygensaturation.Thescorewas
measuredathalfhourlyintervalsfor4hours.
After90minutestherewasasignificantimprovementinthepulmonaryindexscoreinthegroupreceivingmontelukast.
Arandomized,doubleblind,placebocontrolled,multicentretrialincluded220childrenwithintermittentasthmawhowererandomizedtoreceive
eithermontelukast(n=107)orplacebo(n=113)duringanacuteexacerbationofasthma[Robertsonetal,2007(/asthma#!references/297181)].
Therewere163exacerbationsofasthmaover12monthsinthegroupreceivingmontelukastand228exacerbationsintheplacebogroup
[Robertsonetal,2007(/asthma#!references/297181)].
Therewasasignificantreductioninnightsawakenedby8.6%(p=0.43),daysofffromschoolby37%(p<0.0001),andparenttimeofffrom
workby33%(p<0.0001).
Arandomized,doubleblind,placebocontrolled,pilotstudyenrolledchildrenaged614yearswhopresentedwithanacuteasthmaexacerbation
ofmoderateseverity(PEFR=4070%ofpredicted)[Nelsonetal,2008(/asthma#!references/297181)].Thechildrenwererandomizedtoreceive
eitheroralmontelukastorplaceboatthebeginningoftheirtreatment.FEV1wasmeasuredbeforethestartoftreatmentandthenhourlyuntil
3hoursposttreatment.
TherewasnoimprovementinFEV1at3hours.
Theauthorsconcludedthatinchildrenwithmoderateasthma,oralmontelukastisunlikelytoresultinimprovementinFEV1.
Backtotop
Exerciseinducedasthma
Evidenceonexerciseinducedasthma
Theevidenceformedicationinexerciseinducedasthmaislimitedtosmallrandomizedcontrolledtrials(RCTs).Differentstudydesigns
anddoseanddurationofmedicationmakeitdifficulttodrawdefiniteconclusions.Overall,shortactingbeta2agonistsappeartobethe
mostcosteffectivetherapyforpreventingsymptomsofexerciseinducedasthma.Veryfewheadtoheadstudieshavebeenconducted,
andnoevidenceisavailableforchildrenyoungerthan5years:
Longactingbeta2agonists(LABAs):insmallRCTs,LABAsweremoreeffectivethanplaceboincontrollingexerciseinducedasthma,butno
moreeffectivethanshortactingbeta2agonists.Thebenefitappearstodecreasewithlongtermuse[SIGNandBTS,2011
AnRCTcrossovertrial(n=24children)showedformoteroltobesimilartoterbutalineinbronchodilatoreffectforexerciseinducedasthma
[Hermansenetal,2006(/asthma#!references/297181)].
AnRCT(n=20adults)comparedsalmeterol(twicedailyfor1month)withplacebo.Allparticipantsunderwent30minutesofexerciseafterthe
morningdoseand9hourslater.Thebenefitsappearedtobeminimalat9hours,especiallyondays14and29[Nelsonetal,1998
Leukotrienereceptorantagonists:mostevidenceisavailableformontelukast.
Whentakenregularly,montelukastappearstobemoreeffectivethanplaceboandatleastaseffectiveasLABAs(especiallyoverthelonger
term)inpreventingexerciseinducedasthma.Montelukastmayprovidesomebenefitinpreventingbronchospasmbyuseofasingledose
beforeexercise,butlargerstudiesareneededtoconfirmthis[Pearlmanetal,2006(/asthma#!references/297181)].
Cromones(nedocromilandsodiumcromoglicate):
Asystematicreview(searchdateSeptember2001,20trials,n=280)showedthatnedocromilgivenbeforeanexercisechallengetestappears
tobeeffectiveatpreventingexerciseinducedasthma,especiallyinpeoplewithmoreseverebronchoconstriction[Spooneretal,2002
Asystematicreview(searchdateMarch2000,eightRCTs,children>6yearsofage)showednosignificantdifferencebetweensodium
cromoglicateornedocromil(atdifferentdoses)inpreventingorreducingexerciseinducedasthmasymptomsforupto2hours[Kellyetal,2000
Backtotop
AsthmaSummary
Asthmaisachronicinflammatoryconditionoftheairways.
Theairwaysarehyperresponsiveandconstricteasilyinresponsetoawiderangeofstimuli.Thismayresultincoughing,wheezing,chest
tightness,andshortnessofbreath.
Narrowingoftheairwaysisusuallyreversible(eitherspontaneouslyorwithmedication),leadingtointermittentsymptoms,butinsomepeople
withchronicasthma,theinflammationmayleadtoirreversibleairflowobstruction.
Asthmaisacommoncondition.AreportbyAsthmaUKstatesthat5.2millionpeopleintheUKhaveasthma.
Theprobabilityofsomeonehavingasthmaisincreasediftheyhave:
Wheeze,breathlessness,chesttightness,andcough,particularlyifsymptomsareworseatnightandintheearlymorningoccurinresponseto
exercise,allergenexposure,andcoldairoccuraftertakingaspirinorbetablockersoccurevenwhenthepersonhasnotgotacold.
Historyofatopicdisorder.
Spirometryshouldbeperformedonalladultstoassessforthepresence,severity,andreversibilityofairwayobstruction.Spirometryis
recommendedforchildrenwherethediagnosisofasthmaisuncertainiftheyareabletoperformthetest(usuallyolderthan5years).
Forpeoplewithanintermediateorhighprobabilityofasthma,atrialoftreatmenttoconfirmthediagnosisshouldbeconsidered.Forpeoplewitha
lowprobabilityofasthma,analternativediagnosisshouldbeconsidered.
Asteppedapproachtothemanagementofchronicasthmaisrecommended.Forpeopleovertheageof5yearsofage:
Step1:occasionalreliefbronchodilatoraninhaledshortactingbeta2agonistasrequired.
Step2:regularinhaledpreventertherapyaninhaledcorticosteroidor,ifaninhaledcorticosteroidisnottolerated,aleukotrienereceptor
antagonistorcromone.
Step3:inhaledcorticosteroidandlongactinginhaledbeta2agonist.Ifsymptomcontrolisinadequatewithalongactinginhaledbeta2agonist,
consideranalternativeaddontreatment,suchasaleukotrienereceptorantagonistormodifiedreleasetheophyllinebeforemovingtostep4.
Step4:highdoseinhaledcorticosteroidandregularbronchodilator.
Step5:regularcorticosteroidtabletsandreferraltoaspecialistinrespiratorymedicine.
Forchildrenunder5years,asteppedapproachisalsorecommended.
Step1:occasionalreliefbronchodilatoraninhaledshortactingbeta2agonistasrequired.
Step2:regularpreventertherapyaninhaledcorticosteroidor,ifaninhaledcorticosteroidisnottolerated,aleukotrienereceptorantagonist
(children25years).
Step3:ifyoungerthan2years,referraltoarespiratorypaediatrician.Forchildrenaged25years,addaleukotrienereceptorantagonist.
Step4:referraltoarespiratorypaediatrician.
Acuteexacerbationsofasthmaaregenerallymanagedwithashortcourseoforalprednisoloneandashortactingbeta2agonist.Hospital
admissionisnecessaryforpeoplewithlifethreateningasthmaorsevereasthmathatdoesnotadequatelyrespondtoinitialtreatment.
Backtotop
HaveIgottherighttopic?
ThisCKStopiccoverstheprimarycaremanagementofacuteandchronicasthmainadultsandchildren.
ThisCKStopicisbasedonthe2011Britishguidelineonthemanagementofasthma:anationalclinicalguidelinefromtheScottishIntercollegiate
GuidelinesNetworkandBritishThoracicSociety[SIGNandBTS,2011(/asthma#!references/297181)].
ThereareseparateCKStopicsonChestinfectionsadult(/chestinfectionsadult),Chronicobstructivepulmonarydisease(/chronicobstructive
pulmonarydisease),andSmokingcessation(/smokingcessation).
ThetargetaudienceforthisCKStopicishealthcareprofessionalsworkingwithintheNHSintheUK,andprovidingfirstcontactorprimaryhealth
care.
Backtotop
Howuptodateisthistopic?
Changes
Update
Backtotop
Goalsandoutcomemeasures
Goals
QOFindicators
QIPPOptionsforlocalimplementation
Backtotop
Backgroundinformation
Definition
Prevalence
Riskfactors
Complicationsandprognosis
Backtotop
Diagnosis
Diagnosisofasthma
Diagnosis
Probabilityofasthmainchildren
Probabilityofasthmainadults
Spirometry
Triggerfactors
Differentialdiagnosisinchildren
Differentialdiagnosisinadults
Backtotop
Management
Scenario:Newpresentationofasthma(/asthma#!scenario):coversthemanagementofadultsandchildrenwithanewpresentationofasthma
andwhohaveahigh,intermediateorlowprobabilityofhavingasthma.
Scenario:Uncontrolledasthmaoncurrenttreatment(/asthma#!scenario:1):covershowtostepupasthmatherapyinadultsandchildren
withuncontrolledasthma.
Scenario:Controlledasthmaoncurrenttreatment(/asthma#!scenario:2):covershowtofollowuppeoplewithasthmaandwhentoconsider
steppingdownasthmatherapy.
Scenario:Acuteasthmaexacerbation(/asthma#!scenario:3):covershowtoassesssomeonewithacuteasthma,whenadmissiontohospital
isrequired,andhowtomanagepeoplewithacuteasthmawhodonotrequirehospitaladmission.
Scenario:Managementofexerciseinducedasthma(/asthma#!scenario:4):coversthemanagementofpeoplewithexerciseinducedasthma.
Scenario:Suspectedoccupationalasthma(/asthma#!scenario:5):coversthemanagementofoccupationalasthma.
Scenario:Pregnancyandbreastfeeding(/asthma#!scenario:6):coversthemanagementofasthmainapregnantorbreastfeedingwoman.
Backtotop
Prescribinginformation
Importantaspectsofprescribinginformationrelevanttoprimaryhealthcarearecoveredinthissectionspecificallyforthedrugsrecommendedinthis
CKStopic.Forfurtherinformationoncontraindications,cautions,druginteractions,andadverseeffects,seetheelectronicMedicinesCompendium
(http://www.medicines.org.uk/emc)(eMC)(http://medicines.org.uk/emc),ortheBritishNationalFormulary
(http://www.evidence.nhs.uk/formulary/bnf/current)(BNF).
Backtotop
Howthistopicwasdeveloped
Backtotop
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Backtotop
Supportingevidence
Stableasthma
Acuteasthmaexacerbation
Exerciseinducedasthma
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Qualityindicator Points Threshold

Airomir(salbutamol)Atrovent(ipatropium) Qvar(beclometasone)Alvesco(ciclesonide) AeroChamberPlus

VentolinEvohaler(salbutamol)SerevntEvohaler ClenilModulite(beclometasone)FlixotideEvohaler Volumatic

Drug 25yearsold 612yearsold(higherdoseformoresevere) >12yearsold

Salbutamol 2.5mg 2.55mg 5mg

Terbutaline 5mg 510mg 10mg

Ipratropium(every4to6hours) 250micrograms 250micrograms 500micrograms

Doseoforalprednisolone(once <2yearsold 25yearsold 612yearsold >12yearsold

Peoplenottakingregularoral 10mg 20mg 3040mg 4050mg*

Peopletakingregularoralcorticosteroid 2mg/kg(maximum 2mg/kg(maximum 2mg/kg(maximum 2mg/kg(maximum

pMDI Age Doseofinhaledcorticosteroid

ClenilModulite(beclometasone >12 100microgramstwice 200microgramstwice 400microgramstwice 1000microgramstwice

Fluticasone >12 50microgramstwice 100microgramstwice 250microgramstwice 500microgramstwice

pMDI Age Doseofinhaledcorticosteroid

ClenilModulite(Beclometasone 511 50microgramstwice 100micrograms 200micrograms 400microgramstwicedaily

<5 50microgramstwice 100micrograms 200microgramstwicedaily

Qvar(BeclometasoneCFC <12 Unlicensedforchildrenundertheageof12

Budesonide 511 50microgramstwice 100micrograms 200micrograms 400microgramstwicedaily

<5 50microgramstwice 100micrograms 200microgramstwicedaily

BudesonideCFCfree 511 100micrograms 100micrograms 200micrograms 400microgramstwicedaily

25 100micrograms 100micrograms 200microgramstwicedaily

Fluticasone 511 25microgramstwice 50microgramstwice 100micrograms 200microgramstwicedaily

4 25microgramstwice 50microgramstwice 100microgramstwicedaily

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