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