NHS FORTH VALLEY Guideline for the Management of Asthma

Transcription

1 NHS FORTH VALLEY Guideline for the Management of Asthma Date of First Issue 2004 Approved 18/09/2013 Current Issue Date 18/09/2013 Review Date 18/09/2016 Version 3.0 EQIA Yes 15/05/2009 Author / Contact Olwyn Lamont Group Committee NHS Forth Valley Respiratory MCN Steering Group Final Approval This document can, on request, be made available in alternative formats Version 3.0 September 2013 Page 1 of 6 UNCONTROLLED WHEN PRINTED

2 NHS Forth Valley Consultation and Change Record Contributing Authors: Consultation Process: Distribution: Ms Clare Colligan, Clinical Pharmacist Mrs Olwyn Lamont, Lead Respiratory Nurse Dr Dougie Morrison, Lead Respiratory Physician Dr Una MacFadyen, Consultant Paediatrician Maggie MacKinnon, Airways MCN Manager Mrs Nan O Hara, Practice Nurse Facilitator Dr Scott Williams, GP Viewfield Medical Practice, Stirling Dr Stan Wright, Cancer and Palliative Care Physician Dr Melanie Cross, Respiratory Physician Ms Yvonne Kerr, Community Children s Nurse NHS Forth Valley Respiratory MCN Core and Steering Groups To all NHS Forth Valley accessible via the Quality Improvement page on the NHS Forth Valley Intranet and Internet. Educational Launch Evenings to raise awareness invitation to all NHS Forth Valley healthcare professionals involved in the management of asthma. Change Record Date Author Change Version September 2013 Review of guideline changes highlighted in red on index page 1.1 Version 3.0 September 2013 Page 2 of 6 UNCONTROLLED WHEN PRINTED

3 Introduction Welcome to the updated NHS Forth Valley Guideline on the Management of Asthma, which replaces the 2009 guideline. It draws on existing local information and guidelines, and national guidelines (largely the updated joint BTS 1 /SIGN 2 Guideline No101) to provide clinicians with a concise local asthma management plan. The guideline is intended for use by all healthcare professionals in NHS Forth Valley and it is available on the NHS Forth Valley intranet/internet, where it will be regularly updated It is hoped that you will find the materials useful in supporting your patients to take care of their asthma condition and in recording the care which you provide. The guideline includes information on: Diagnosis, assessment, follow-up and disease registers in primary care Referral to secondary care Treatment and prescribing in accordance with the Joint Forth Valley Formulary Inhaler assessment technique Personal Asthma Plan templates Patient information leaflets Patient recall in primary care This guideline is not intended to serve as a standard of care or be applicable in every situation. Decisions regarding the treatment of individual patients must be made by the clinician in light of that patient s presenting clinical condition and with reference to current good medical practice. The guideline steering group is grateful to SIGN who have given permission to reproduce specific information from SIGN No101, which is accurate at the time of review in September Quality Improvement The pack contains information about education, continuing professional development and audit. Please advise the Forth Valley Airways Managed Clinical Network (MCN) of any further resources that you think would be useful: David Munro, Respiratory MCN Manager [email protected] 1 British Thoracic Society 2 Scottish Intercollegiate Guideline Network Version 3.0 September 2013 Page 3 of 6 UNCONTROLLED WHEN PRINTED

4 Guideline Development In 2004, this guideline was developed by the then NHS Forth Valley Airways Group in a multidisciplinary and multi-agency collaborative approach, with the assistance of support services Guideline Update The NHS Forth Valley Respiratory Managed Clinical Network is responsible for reviewing this local guideline and would like to acknowledge the following members who contributed to the development of the 2013 update: Clare Colligan, Clinical Pharmacist, NHS Forth Valley Olwyn Lamont, Lead Respiratory Nurse Specialist, NHS Forth Valley Dr Dougie Morrison, Lead Respiratory Physician, NHS Forth Valley Dr Una MacFadyen, Consultant Paediatrician, NHS Forth Valley David Munro, Respiratory MCN Manager, NHS Forth Valley Nan O Hara, Practice Nurse Facilitator, NHS Forth Valley Dr Scott Williams, GP Viewfield Medical Practice Stirling, NHS Forth Valley Dr Fraser Wood, Consultant Physician, NHS Forth Valley Dr Melanie Cross, Respiratory Physician, NHS Forth Valley Yvonne Kerr, Community Children s Nurse We would also like to acknowledge the WoSCOR MCN for the Understanding Asthma Booklet we recommend, the Attacking Asthma programme for children and parents and for the updated adrenal suppression protocol. The Respiratory MCN meets regularly to discuss respiratory services and patient care. The membership is multidisciplinary and multi-agency and includes representation from specialist healthcare professionals, voluntary organisations, patients and carers. Key Sources of Evidence & Websites Scottish Intercollegiate Guidelines Network and the British Thoracic Society British Guideline on the Management of Asthma (Revised 2012); September 2013 NHS Forth Valley Joint Formulary. m_formulary.asp September 2013 New GMS Contract 2003 Quality and Outcomes Framework. September September 2013 Scottish Programme for Improving Clinical Effectiveness in Primary Care. and September 2013 British Thoracic Society. September 2013 Version 3.0 September 2013 Page 4 of 6 UNCONTROLLED WHEN PRINTED

5 Asthma UK September 2013 National Institute for Clinical Excellence. September 2013 Version 3.0 September 2013 Page 5 of 6 UNCONTROLLED WHEN PRINTED

6 Table of Contents Red print indicates alteration/addition to the policy Title Section Quick Reference Guide 1 Diagnosis of Asthma in Children 2.1 Indications for Referral and Clues to Alternative Diagnoses in Wheezy Children Diagnosis of Asthma in Adults 2.2 Indications for Referral for Specialist Opinion or Further Investigation in Adults Initial Assessment of Asthma Proforma 3.1 Initial Assessment & Diagnosis of Asthma Summary 3.1 Asthma Follow Up Proforma 3.2 Non-pharmacological Management 4 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison 5.1 Stepping Down Treatment in Children Management of Acute Asthma in Children in General Practice 5.2 Management of Acute Asthma in Children in Emergency Department 5.3 Management of Acute Asthma in Children in Hospital 5.4 Drug Preparation Guidance Management of Acute Asthma in Infants Aged <2 years in Hospital 5.5 Adverse Effects of Treatment in Children 5.6 Stepwise Management in Adult Asthma Treatment Cost Comparison 6.1 Stepping Down Treatment in Adults Prescribing Symbicort SMART Treatment of Exacerbations of Asthma in Adults Management of Acute Severe in Adults in General Practice 6.2 Management of Severe Acute Asthma of Adults in Emergency Department 6.3 Inpatient Management of Acute Asthma in Adults 6.4 Severe or Difficult to Manage Asthma in Adults 6.5 Adverse Effects of Treatment in Adults 6.6 Occupational Asthma 6.7 Asthma in Pregnancy 6.8 Exercise Induced Asthma 7 Inhaler Assessment Information 8.1 Peak Expiratory Flow Rate Normal Values 8.2 Asthma Recall Process in Primary Care 9 Self Management and Patient Information 10 Education and Continuing Professional Development 11.1 Organisation and Delivery of Care and Audit 11.2 Version 3.0 September 2013 Page 6 of 6 UNCONTROLLED WHEN PRINTED

7 1 NHS Forth Valley Guideline for the Management of Asthma Quick Reference Guide Diagnosis Patients suspected of having a diagnosis of Asthma should have differential tests undertaken and/or trials of asthma therapy, or referred for specialist opinion. (Section 2) Initial Assessment Once a diagnosis is confirmed, ensure an initial assessment proforma is completed, in the primary care setting. (Section 3.1) Asthma Register in Primary Care Maintain a Register of all patients with a diagnosis of Asthma. Personal Asthma Action Plans Patients with asthma should have a Personal Asthma Plan to facilitate self-management, and locally developed and endorsed templates are available to download online. (Section 7) Treatment Prescribing should be in accordance with the local Joint Formulary. Inhaler technique should be evaluated (Section 8). Guidance on treatment (depending upon age, severity and setting, and including non-pharmacological treatment) is included in the pack. (Sections 4, 5, 6 and 7) Patient Recall in Primary Care A robust system of patient recall should be implemented to facilitate annual review or more frequent follow-up accordingly. Guidance for primary care setting is included. (Section 9) Patient Information/Advice Written information should be provided as part of a continuing education programme, and a series of locally developed and endorsed leaflets are available to download online. (Section 10; Leaflets 1-8) Quality Improvement The pack contains information about Education, CPD and audit. Contract Reporting tools and SPICEpc reports can provide a dataset on asthma indicators in primary care. (Section 11) Patient Follow-up All patients should have at least annual review. Ensure that review data are collated, using the contract compliant proforma in the primary care setting. (Section 3.2) This guidance has been developed by a multidisciplinary and multiagency collaborative approach and is endorsed by the NHS Forth Valley Airways MCN. It is informed by evidence from RCGP SPICEpc, ngms Quality Indicators, SIGN101/BTS British Guideline on the Management of Asthma, 2008 (updated 2012), and current good practice. September 2013

8 2.1 NHS Forth Valley Guideline for the Management of Asthma Diagnosis of Asthma in Children Features that increase the probability of asthma: More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness particularly if these are frequent and recurrent; are worse at night and in the early morning; occur in response to, or are worse after, exercise or other triggers, such as exposure to pets; cold or damp air, or with emotions or laughter; or occur apart from colds: Personal history of atopic disorder Family history of atopic disorder and/or asthma Widespread wheeze heard on auscultation History of improvement in symptoms or lung function in response to adequate therapy Features that lower the probability of asthma: Symptoms with colds only, with no interval symptoms Isolated cough in the absence of wheeze or difficulty breathing History of moist cough Prominent dizziness, light-headedness, peripheral tingling Repeatedly normal physical examination of chest when symptomatic Normal peak expiratory flow (PEF) or spirometry when symptomatic No response to trial of asthma therapy Clinical features pointing to alternative diagnosis N.B. Atopy = eczema, hayfever, rhinitis, allergic conjunctivitis, allergic reactions Presentation with suspected asthma Clinical assessment Consider potential effect of exposure to tobacco smoke High probability: diagn osis of asthma likely Intermediate probability: diagnosis uncertain Low probability: other diagnosis likely Consider referral Trial of treatment Consider tests of lung Investigate/treat +ve -ve function* and other condition atopy Good response Poor response Poor response Good response Continue treatment and find minimum effective dose September 2013 Assess compliance and inhaler technique Consider further investigation and/or specialist referral (see 2.2): Paediatric respiratory clinic or general paediatric clinic Sci gateway Continue treatment *Lung function tests include spirometry before and after bronchodilator (test of airway reversibility) and possible exercise or methacholine challenge (test of airway responsiveness). Most children over the age of 5 can perform lung function tests.

9 2.1.1 NHS Forth Valley Guideline for the Management of Asthma Clues to Alternative Diagnoses in Wheezy Children All respiratory problems are made worse by exposure to tobacco smoke. Clinical Clue Perinatal and Family History Symptoms present from birth or perinatal lung problem Family history of unusual chest disease Possible Diagnosis Cystic fibrosis: chronic lung disease; ciliary dyskinesia; developmental anatomy Cystic fibrosis, congenital lung anomaly; neuromuscular disorder Severe upper tract disease Defect of host defence Symptoms and Signs Persistent wet cough Cystic fibrosis; recurrent aspiration: host defence disorder Excessive vomiting or posseting Reflux (± aspiration) Dysphagia Swallowing problems (± aspiration) Abnormal voice or cry Laryngeal problem Focal signs in the chest Developmental disease; postviral syndrome; bronchiectasis; tuberculosis Inspiratory stridor as well as wheeze Central airway or laryngeal disorder Failure to thrive Cystic fibrosis; host defence defect; gastro-oesophageal reflux Investigations Focal or persistent radiological changes Congenital lung disorder; postinfective disorder; recurrent aspiration; inhaled foreign body; bronchiectasis; cystic fibrosis; tuberculosis Newborn screening for cystic fibrosis may have occasional false negatives when either initial IRT is normal or a rare gene deletion is not detected on molecular genetic testing. Clinical vigilance remains important in diagnosing CF, especially in infants identified as heterozygote. September 2013

10 2.2 NHS Forth Valley Guideline for the Management of Asthma Diagnosis of Asthma in Adults Features that increase the probability of asthma: More than one of the following symptoms: wheeze; breathlessness, chest tightness and cough, particularly if: o symptoms worse at night and early in the morning o symptoms in response to exercise, allergen exposure and cold air o symptoms after taking aspirin or beta blockers History of atopic disorder Family history of asthma and/or atopic disorder Widespread wheeze heard on auscultation of the chest Otherwise unexplained low FEV 1 or PEF (historical or serial readings) Otherwise unexplained peripheral blood eosinophilia Features that lower the probability of asthma: Prominent dizziness, light-headedness, peripheral tingling Chronic productive cough in the absence of wheeze or breathlessness Repeatedly normal physical examination of the chest when symptomatic Voice disturbance Significant smoking history (i.e. >20 pack years) Cardiac disease Normal PEF or spirometry when symptomatic* *A normal spirogram/spirometry when not symptomatic does not exclude the diagnosis of asthma. Repeated measurements of lung function are often more informative than a single assessment. Presentation with suspected asthma Clinical assessment including occupation and spirometry. High probability: diagnosis of asthma likely Intermediate probability: diagnosis uncertain Low probability: other diagnosis likely Trial of treatment FEV 1 /FVC <0.7 FEV 1 /FVC >0.7 Investigate/treat other condition Good response Poor response Poor response Good response Diagnosis confirmed Continue treatment and code diagnosis of Asthma Assess compliance and inhaler technique Consider specialist referral (see 2.2): Continue treatment NHS Forth Valley Respiratory Physicians: September 2013 Sci gateway

11 2.2.1 NHS Forth Valley Guideline for the Management of Asthma Indication Indications for Referral for Specialist Opinion or Further Investigation * in Adults Diagnoses unclear or in doubt Unexpected clinical findings e.g. crackles, clubbing, cyanosis, cardiac disease Unexplained restrictive spirometry Suspected occupational asthma Persistent non-variable breathlessness Monophonic wheeze or stridor Prominent systemic features (myalgia, fever, weight loss) Chronic sputum production CXR shadowing Marked blood eosinophilia (> 1x10 9 /l) Poor response to asthma treatment Severe asthma exacerbation Differential Diagnosis According to the presence or absence of airflow obstruction (FEV1/FVC <0.7) Without Airflow Obstruction Chronic cough syndrome Hyperventilation syndrome Vocal cord dysfunction Heart failure Pulmonary fibrosis With Airflow Obstruction COPD Bronchiectasis* Inhaled foreign body* Obliterative bronchiolitis Large airway stenosis Lung cancer Sarcoidosis* *may also be associated with non-obstructive spirometry Patients presenting atypically or with additional symptoms or signs and are being referred for specialist opinion should have chest x-ray performed prior to referral September 2013

12 3.1 NHS Forth Valley Guideline for the Management of Asthma Initial Assessment and Diagnosis of Asthma Summary of Initial Assessment Form Patient Details Personal details Occupation Pets Exercise tolerance grade Smoking Status Present Symptoms Wheeze, shortness of breath, exercise intolerance, chest tightness, cough. Symptoms worse at night and early morning Symptoms worse with exercise, allergens, cold air, aspirin or Beta-blocker Episodic or persistent Time off work/education in the past year Number of puffs of β 2 agonist daily(if applicable) Trigger Factors URTI, Exercise, Stress, Tobacco, Smoke, Dust, Pollen, Animals, Food, NSAID, Aspirin, Other Medication, Cold Air, Chemicals/irritants/aerosols Relevant atopic history e.g. nasal polyps, hayfever, eczema Family History Relevant Past Medical History Current Medication Examination Height, Weight, Blood pressure, BMI FEV 1 (Expected and Actual) FEV 1 /FVC ratio Date of last chest x-ray and result (if applicable) Inhaler technique (if applicable) Details of contra-indicated drugs Record method of confirmation of diagnosis Checklist Check understanding of asthma Discuss trigger factors and their avoidance Does the patient have a peak flow meter and can they use it competently? Agree and give a personal asthma plan Arrange follow-up appointment September 2013

13 3.1 Initial Assessment & Diagnosis of Asthma Fields marked with an asterisk* ngms contract data Date*..../..../. GP.. Patient details Name DOB..../..../. Gender M F Occupation.... If considering diagnosis of occupational asthma, consider referral to Respiratory Physician Exposed to: Dusts / Chemicals? Yes No Any Better Days? (e.g. away from work, on holiday) Yes No Not Sure Pets? Yes No... Exercise Tolerance Grade: (See classification on page 2 overleaf) Smoking Status*: Never Smoked Ex-smoker No. of years smoking Current Smoker No. per day. Smoking Cessation Advice Given* Yes No Passive Smoking? Yes No If yes, Home Work other e.g (child care). Symptoms Date of Onset:../.../ Episodic Persistent Wheeze S.O.B Chest Tightness Cough Worse at night and early morning Symptoms in response to exercise allergen cold air Symptoms after taking aspirin Beta-blocker Childhood symptoms (if adult) Yes No Time off work/education in past year (days).. Puffs of 2 agonist daily.. not applicable Pre-exercise 2 agonist Yes No Trigger factors and their avoidance discussed*: Yes No Aggravating factors: URTI Exercise Stress Tobacco Smoke Dust Pollen Animals Food Other medication Cold air NSAID Aspirin Chemicals/irritants/aerosols Atopic History: Eczema Hay Fever Nasal Polyps rhinitis conjunctivits Other (e.g. food). Family history of asthma/ atopy Yes No September 2013 Page 1 of 2

14 Relevant Past Medical History Current Medication Drug Strength Dosage Device Examination Height: Weight:. BP: /. BMI: Date of last chest X-ray.../..../ Result... Expected FEV 1*:.. Actual FEV1*:.. FEV1 /FVC:.. Present inhaler device Present Inhaler Technique*: Satisfactory Unsatisfactory Present level of understanding of asthma: Satisfactory Incomplete Information given/accessed: Information Leaflets Websites Diagnosis Confirmed by*: History Follow-up appointment: Y N Wheeze Response to treatment Objective Measurement (See below) Contra-indicated drugs? Blocker Y N Aspirin Y N NSAIDs Y N Other(s) Y N.. Peak Flow Meter (has own device) Y N Personal Asthma Plan agreed? Y N Uses Peak Flow Meter competently Y N Personal Asthma Plan given? Y N Main carer (if applicable).. Others who need to know about asthma and its management.. Objective Diagnostic Measurements 1. Spirometry Reversibility Positive FEV 1 15% (and 200ml) increase after trial of beclomethasone 200mg (or equivalent) twice daily 2. Positive Reversibility Test Salbutamol FEV 1 15% (and 200ml) increase after short acting 2 agonist e.g. Salbutamol 400mcg by MDI and Spacer or 2.5mg by Nebuliser 3. Serial Peak Expiratory Flow Rate 20% diurnal variation on 3 days in a week for 2 weeks on PEF diary twice daily (4 times may be more sensitive) Exercise Tolerance Grading Criteria Grade 1: Asthma but with no limitation of physical activity Grade 2: Asthma with slight limitation of physical activity but by limiting physical activity, can lead a normal social life. Grade 3: Asthma resulting in marked limitation of physical activity. Grade 4: Asthma resulting in being unable to do any physical activity without shortness of breath. September 2013 Page 2 of 2

15 3.2 Asthma Follow- up Fields marked with an asterisk* are ngms contract data Name: DoB:./../.. FOLLOW-UP DATE*: /./... /./... /./... For children read you as the child Symptoms Do you cough, wheeze or get short of breath? Y N Y N Y N In the last week* / month: 1. Have you had difficulty sleeping because of your Asthma symptoms (including cough)? Y Week* Month Week* Month Week* Month N No of nights Y N No of nights Y N No of nights Y N No of nights Y N No of nights Y N No of nights 2. Have you had your usual Asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? Week* Month Week* Month Week* Month Y N Y N Y N Y N Y N No of days No of days No of days No of days No of days Y N No of days 3. Has your asthma interfered with your usual activities (e.g. housework, school/work, etc)? Week* Month Week* Month Week* Month Y N Y N Y N Y N Y N Y N PEFR* Predicted* Best* Actual* Trigger factors and their avoidance discussed* Y N Action. No. of unscheduled asthma appointments*.. Y N Action... Y N Action... Current Asthma Medication No. of puffs of 2 agonist daily No. of short courses of oral steroids since last review Other medication including over the counter Changes in Asthma medication including over the counter September 2013 Page 1 of 2

16 3.2 Asthma Follow- up Fields marked with an asterisk* are ngms contract data Name: DoB:./../.. DATE: /./... /./... /./... Inhaler technique* Assessment Result* Assessment Result* Assessment Result* Satisfactory Unsatisfactory Satisfactory Unsatisfactory Satisfactory Unsatisfactory Action Action Action Steroid Adverse Effects Testing ( For further information please refer to 5.6 for Children or 6.6 for Adults ) Y N N/A Y N N/A Y N N/A Weight / Height* (Annually < 18yrs*) Kg m Kg m Kg m Asthma education/concordance discussed Y N Y N Y N Asthma literature offered Y N Y N Y N Written Personal Asthma Plan Reviewed/Given*? Record the date the plan was last updated* Y N Y N Y N Action Action Action Advised to inform school of plan given/changed Y N N/A Y N N/A Y N N/A Flu Vaccination* Pneumococcal Vaccination* Date:.. / /.. Date:.. / /.. Date:.. / /.. Date:.. / /.. Date:.. / /.. Date:.. / /.. Smoking status* (include passive smoking) Smoking Cessation Advice*? Y N N/A Y N N/A Y N N/A Pregnant Y N N/A Y N N/A Y N N/A Planning pregnancy/ Personal worries /concerns? Y N N/A Y N Y N N/A Y N Y N N/A Y N Is there anything you avoid due to your asthma? Y N.. Y N.. Y N.. Next appointment: Nurse / GP/ Hospital N GP H Date:.. / /... N GP H Date:../ /... N GP H Date:../ /... September 2013 Page 2 of 2

17 4 NHS Forth Valley Guideline for the Management of Asthma Source: SIGN101 Quick Reference Guide. Reproduced with the permission of and thanks to SIGN, and accurate at the time of review in NHS Forth Valley, September 2013 September 2013 Page 1 of 2

18 4 NHS Forth Valley Guideline for the Management of Asthma Families with evidence of dust mite allergy and to wish to try mite avoidance may consider the following: Complete barrier bed-covering systems Removal of carpets Removal of soft toys from bed High temperature washing of bed linen Acaricide to soft furnishings September 2013 Page 2 of 2

19 5.1 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison NB. IN CHILDREN UNDER 5 YEARS MDI AND SPACER ARE DEVICES OF CHOICE Step 4: Persistent Poor Control Increase dose of ICS to 800mcg * /day (with LABA if some response) ENSURE STEROID CARD GIVEN Beclometasone Clickhaler Clenil Modulite Pulvinal Easyhaler + max. licensed dose = 400mcg/day Budesonide Easyhaler Novolizer Turbohaler Fluticasone Accuhaler MDI Combined: Not licensed at this dose of ICS Seretide Accuhaler MDI Symbicort Turbohaler Step 3 : Add-on Therapy 1. Add LABA 2. ICS to 400mcg * /day 3. Combined (400mcg * /day) Consider trial of: Formoterol Turbohaler Foradil Easyhaler Salmeterol Accuhaler MDI Assess control Good control, continue Some response, increase dose of ICS No response, stop LABA Beclometasone Clickhaler Clenil Modulite Pulvinal Easyhaler Salbutamol MDI Easyhaler Accuhaler Easibreathe Pulvinal Clickhaler Beclometasone Clickhaler Clenil Modulite Pulvinal Easyhaler Budesonide Easyhaler Novolizer Turbohaler Fluticasone Accuhaler MDI Step 2: Regular Preventer Therapy 200mcg * / day Budesonide Easyhaler Turbohaler Step 1: Mild Intermittent Asthma Novolizer Refer to Respiratory Paediatrician Fluticasone Accuhaler MDI Seretide MDI 50 Accuhaler 100 Indicated if: Exacerbation of asthma in last 2 years, inhaled 2 agonist > 3x week, symptomatic >3x week or waking one night a week then Rx mcg BDP equivalent, starting at dose appropriate to disease severity continue at lowest effective dose to maintain control Terbutaline Turbohaler Symbicort Turbohaler 100/6 1. LTRA Montelukast Treatment trials of 1-3 months. Discontinue if ineffective. Key 5 5 < Reference: BNF March 2013 Based on usage over 30 days at average doses for each step * BDP Equivalents: 2mcg Beclometasone/Budesonide = 1mcg Fluticasone = 1mcg CFC - Free Beclometasone(QVAR) ) (Costs on step 2 based on 200mcg/day*) Check licensing of medicines in children some drugs listed here are not licensed in all age groups BDP = Beclometasone Diproprionate; ICS = inhaled corticosteroids; MDI = metered dose inhaler; LABA = long acting beta agonist; LTRA = leukotriene receptor antagonist March 2013 Always check inhaler technique and concordance before changing, and remember to Review and Step Down.

20 5.1 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison NB. IN CHILDREN UNDER 5 YEARS MDI AND SPACER ARE DEVICES OF CHOICE Bronchodilators - Cost per Average Child Daily Dose Analysis (equivalent to 400mcg salbutamol daily (cost for 28 days)) Bricanyl Turbohaler Salbutamol Easi-Breathe Airomir Autohaler Asmasal Clickhaler Ventolin Accuhaler Pulvinal Salbutamol Salbutamol Easyhaler Salbulin Novolizer Salbutamol CFC free MDI Cost ( )

21 5.1 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison NB. IN CHILDREN UNDER 5 YEARS MDI AND SPACER ARE DEVICES OF CHOICE Corticosteroid Cost per Average Child Dose Analysis (equivalent to 200mcg BDP equivalents per day (cost per 28 days therapy)) Flixotide Accuhaler Pulmicort Turbohaler Beclometasone Easyhaler Pulvinal Beclometasone Asmabec Clickhaler Flixotide MDI Budesonide Easyhaler Clenil Modulite Cost ( )

22 5.1 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison NB. IN CHILDREN UNDER 5 YEARS MDI AND SPACER ARE DEVICES OF CHOICE Combination Therapy Costs per 28 days (BDP equivalent 400mcg/day) Symbicort 100/6 (2p bd) 30.8 Seretide 100 Accuhaler (1p bd) 16.8 Seretide 50 MDI (2p bd) Cost ( )

23 5.1 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison NB. IN CHILDREN UNDER 5 YEARS MDI AND SPACER ARE DEVICES OF CHOICE Equivalent Inhaled Corticosteroid Doses BECLOMETASONE / dose 100mcg 200mcg QVAR (CFC Free BDP)/dose FLUTICASONE / dose 50mcg 100mcg FLUTICASONE / dose not licensed in children <12 years 50mcg 100mcg BUDESONIDE / dose 100mcg 200mcg 400mcg 50mcg 100mcg FLUTICASONE / dose 50mcg 100mcg 200mcg Titrate the dose of inhaled steroid to the lowest dose at which effective control is maintained

24 5.1.1 NHS Forth Valley Guideline for the Management of Asthma Stepping Down Treatment in Children Patients should be maintained at the lowest possible dose of inhaled steroid. Reduction in inhaled steroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every 3 months, decreasing the dose by approximately 25-50% each time. Decisions on which drug to step down first should be determined by the recorded effect on symptoms. Minimising exposure to steroids is a priority and patient preference should also be considered. Record the rationale for each change of treatment and how response will be monitored. Revise Personal Asthma Plan appropriately for home and school. September 2013

25 5.2 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in General Practice Children Age 2-5 Years Assess Asthma Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features Moderate Exacerbation SpO 2 92% Able to talk Heart rate 130/min Respiratory rate 50/min Severe Exacerbation SpO 2 <92% To breathless to talk Heart rate >130/min Respiratory rate >50/min Use of accessory neck muscles Life Threatening Asthma SpO 2 <92% plus any of: Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis ß 2 agonist 4-6 puffs via spacer ± facemask Consider soluble Prednisolone 20mg Increase ß 2 agonist dose by 2 puffs every 2 minutes up to 10 puffs according to response. If poor response arrange admission Oxygen via face mask 10 puffs of ß 2 agonist (given one at a time single puffs, tidal breathing and inhaled separately) at intervals of minutes or nebulised salbutamol 2.5mg or terbutaline 5mg delivered with oxygen if available Soluble prednisolone 20mg Assess response to treatment 15 minutes ß 2 agonist. after If poor response repeat ß 2 agonist and arrange admission Oxygen via face mask Nebulise with oxygen if available: o Salbutamol 2.5 mg or terbutaline 5mg + o Ipratropium 0.25mg Soluble prednisolone 20mg or IV hydrocortisone 50mg Repeat ß 2 agonist via oxygendriven nebuliser whilst arranging immediate hospital admission Good Response Continue ß 2 agonist via spacer or nebuliser, as needed but not exceeding 4-hourly If symptoms are not controlled repeat ß 2 agonist and refer to hospital Continue prednisolone for up to 3 days Arrange follow-up clinic visit Poor Response Stay with patient until ambulance arrives Send written assessment and referral details Repeat ß 2 agonist via oxygen-driven nebuliser in ambulance September 2013 Lower threshold for admission if: Attack in late afternoon or at night Recent hospital admission or previous severe attack Concern over social circumstances or ability to cope at home

26 5.2 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in General Practice Age > 5 Years Assess Asthma Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features Moderate Exacerbation SpO 2 92% PEF 50% best or predicted Able to talk Heart rate 120/min Respiratory rate 30/min Severe Exacerbation SpO 2 <92% PEF <50% best or predicted Too breathless to talk Heart rate >120/min Respiratory rate >30/min Use of accessory neck muscles Life Threatening Asthma SpO 2 <92% plus any of: PEF <33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis ß 2 agonist 4-6 puffs via spacer ± facemask Consider soluble Prednisolone 30-40mg Increase ß 2 agonist dose by 2 puffs every 2 minutes up to 10 puffs according to response. If poor response arrange admission Oxygen via face mask 10 puffs of ß2agonist (given one at a time single puffs, tidal breathing and inhaled separately) at intervals of minutes or nebulised salbutamol 5mg or terbutaline 10mg Soluble prednisolone 30-40mg Assess response to treatment 15 minutes after ß 2 agonist. If poor response repeat ß 2 agonist and arrange admission Oxygen via face mask Nebulise with oxygen if available: o Salbutamol 5 mg or terbutaline 10mg + o Ipratropium 0.25mg Soluble prednisolone 40mg or IV hydrocortisone 100mg Repeat ß 2 agonist via oxygendriven nebuliser whilst arranging immediate hospital admission Good Response Continue ß 2 agonist via spacer or nebuliser, as needed but not exceeding 4-hourly If symptoms are not controlled repeat ß 2 agonist and refer to hospital Continue prednisolone for up to 3 days Arrange follow-up clinic visit Poor Response Stay with patient until ambulance arrives Send written assessment and referral details Repeat ß 2 agonist via oxygen-driven nebuliser in ambulance September 2013 Lower threshold for admission if: Attack in late afternoon or at night Recent hospital admission or previous severe attack Concern over social circumstances or ability to cope at home

27 5.3 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in Emergency Department Children Age 2-5 Years Assess Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features Moderate Exacerbation SpO2 92% No clinical features of severe asthma Severe Exacerbation SpO 2 <92% in air Too breathless to talk or eat Heart rate >130/min Respiratory rate >50/min Use of accessory neck muscles Life Threatening Asthma SpO 2 <92% plus any of: Silent chest Poor respiratory effort Agitation Altered consciousness or exhaustion Cyanosis Salbutamol 100mcgx10 puffs Give nebulised salbutamol 2.5mg with oxygen as driving gas via spacer + facemask Continue O 2 via face mask/nasal prongs Reassess after 15 minutes Give soluble prednisolone 20mg or IV hydrocortisone 50mg Send U&E and venous gas if IV cannula sited Responding Continue inhaled ß 2 agonist 1-4 hourly Give soluble oral prednisolone 20mg Discharge Plan Continue ß2 agonist 4 hourly prn Consider prednisolone 20mg daily for up to 3 days Advise to contact GP (or NHS 24 if out of hours) if not controlled on above treatment Provide written asthma plan for next days and Asthma UK leaflet After your Child s Asthma Attack Advise avoidance of tobacco smoke exposure Review regular treatment Check inhaler technique Arrange GP follow-up within 3 days September 2013 Not Responding Repeat inhaled ß 2 agonist Give soluble oral prednisolone 20mg Arrange Admission (Lower threshold if concern over social circumstances) If Life Threatening Features Present Discuss with senior clinician and paediatrician Repeat nebulised ß2agonist plus Ipratropium bromide 0. 25mg Consider Portable chest x-ray Capillary blood gases Plus Bolus IV salbutamol 15 mcg/kg over 10 minutes to maximum dose of 250 mcg over 10 minutes (see PICU folder for IV salbutamol monograph) Continuous salbutamol = infusion or nebulised Arrange immediate transfer to HDU if poor response to treatment PEWS every 15 minutes including signs of fatigue Consider discussing with PICU and FV critical care anaesthetist

28 5.3 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in Emergency Department Age > 5 Years Assess Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features Moderate Exacerbation SpO 2 92% PEF 50% best or predicted No clinical features of severe asthma Able to talk in sentences Severe Exacerbation SpO 2 <92% in air PEF <50% best or predicted Heart rate >120/min Respiratory rate >30/min Too breathless to talk Use of accessory neck muscles Life Threatening Asthma SpO 2 <92% plus any of: PEF <33% best or predicted Silent chest Poor respiratory effort Altered consciousness or exhaustion Cyanosis Salbutamol 100mcgx10 puffs via spacer ± facemask Add 30-40mg soluble oral prednisolone Reassess after 15 minutes Give nebulised salbutamol 5mg with oxygen as driving gas Continue O 2 via face mask/nasal prongs Give soluble prednisolone 30-40mg if not already given or IV hydrocortisone 100mg if vomiting or not tolerating oral Send U&E and venous gas if siting IV cannula Responding Continue inhaled ß 2 agonist 1-4 hourly Not Responding Repeat inhaled ß 2 agonist Arrange Admission (lower threshold if concern over social circumstances) Discharge Plan Continue ß 2 agonist 4 hourly as necessary Prednisolone 30-40mg daily for up to 3 days Advise to contact GP (or NHS 24 if out of hours) if not controlled on above treatment Provide written asthma action plan Review regular treatment Check inhaler technique Arrange GP follow-up If Life Threatening Features Present Discuss with senior clinician and consultant paediatrician Repeat nebulised Salbutamol 5mg + Ipratropium bromide 0.25mg 4 hourly Consider Bolus IV salbutamol 15 mcg/kg to maximum dose 250 mcg of over 10 minutes (see PICU folder for IV salbutamol monograph) Repeat nebulised Salbutamol or commence infusion at 2 mcg/kg/min Portable chest x-ray and capillary blood gases Plus Consider IV Magnesium if poor response and normovolaemic Arrange immediate transfer to Children s Ward if poor response to treatment Admit all cases if features of severe exacerbation persist September 2013

29 5.4 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in hospital Children age 2 5 years Assess Asthma Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features Moderate Exacerbation SpO 2 92% No clinical features of severe asthma Severe Exacerbation SpO 2 <92% in air Too breathless to talk or eat Heart rate >130/min Respiratory rate >50/min If vomiting cannulate and give steroid IV as hydrocortisone 4mg/Kg slowly then maintenance IV fluids as Sodium Chloride 0.45%:Glucose 5% with KCl Use of accessory neck muscles or abdominal muscles in expiration Life Threatening Asthma SpO 2 <92% as for severe plus any of: Silent chest Poor respiratory effort Agitation Altered consciousness or exhaustion Cyanosis Oxygen via face mask/nasal prongs to achieve saturations >94% refer for admission to hospital ß 2 agonist via spacer ± facemask (given one puff at a time, tidal breathing 5-10 breaths then shake MDI reload spacer and repeat) 1 puff every minute up to 10 puffs Soluble oral prednisolone 20mg Review and record precipitating cause for exacerbation Reassess within 1 hour ß 2 agonist 10 puffs via spacer ± facemask or nebulised salbutamol 2.5mg with oxygen Soluble prednisolone 20mg Repeat ß 2 agonist up to every minutes according to response If poor response add 250 micrograms nebulised ipratropium bromide If vomiting cannulate and give steroid IV as hydrocortisone 4mg/Kg slowly then maintenance IV fluids as 5%:0.45 with KCl Nebulised ß 2 agonist: salbutamol 2.5mg plus nebulised ipratropium bromide 250 micrograms Weigh child or estimate weight from length, cannulate and take U&E and venous gas Keep nil by mouth IV hydrocortisone 4mg/kg give slowly as risk for vomiting Discuss with paediatric and ED consultant Repeat bronchodilators every minutes Bolus IV salbutamol 15microg/kg over 5 minutes to maximum 250 mcg total dose see PICU folder for drug preparation. Start IV fluids as 5% dextrose and 0.45% saline with KCl at 75% maintenance rate Contact Children s Ward for admission as HDU patient ASSESS RESPONSE TO TREATMENT: record respiratory rate, heart rate and oxygen saturation every 1-4 hours Responding Repeat multi-dose salbutamol after 1 hour Review inhaler technique with MDI and spacer Reinforce use of multi-dose for severe wheeze Review preceding asthma control with parents Advise any change in management Update Personal Asthma Action Plan for home and nursery/school Observe for 4 hours to confirm response Advise viewing of Attacking Asthma programme while in hospital Offer parents Understanding Asthma booklet Advise 2013 against exposure to tobacco smoke Discharge with 3 day course of prednisolone and acute asthma action plan GP review within 3 days Consider referral to paediatric respiratory clinic if additional concerns Not Responding Arrange HDU/admission to Children s Ward FVRH Tel: Consider: Portable chest x-ray and capillary blood gases IV salbutamol 15mcg/kg bolus over 10 minutes (if not already given) followed by continuous infusion 1-2mcg/kg/min (dilute to 200mcg/ml) see Purple retrieval folder for drug preparation IV Salbutamol infusion requires HDU care (cubicle and one to one care) and 12 hourly electrolyte check as K+ can be low Consider IV Magnesium 40mg/Kg max 2g over 20mins (see PICU folder for drug preparation) IV aminophylline 5mg/kg loading dose over 20 minutes (omit loading in those receiving oral theophyllines) followed by continuous infusion 1mg/kg/hour FV consultant to discuss with FV ITU and PICU if deteriorating or becoming exhausted Tel (Yorkhill direct line) or (RHSC)

30 5.4 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in hospital Age > 5 years Assess Asthma Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features If not responding treat as next level of severity Moderate Exacerbation SpO 2 92% PEF 50% predicted No clinical features of severe asthma Severe Exacerbation SpO 2 <92% PEF <50% best or predicted Heart rate >120/min Respiratory rate >30/min Use of accessory neck muscles Life Threatening Asthma signs as for severe SpO 2 <92% plus any of: PEF <33% best or predicted Silent chest Poor respiratory effort, exhausted Altered consciousness Cyanosis Oxygen via face mask/nasal prongs to achieve oxygen saturations >94% refer for admission to hospital ß 2 agonist up to 10 puffs via spacer (given one minute at a time single puffs, 5-10 breaths tidal breathing and inhaled separately) Oral prednisolone 30-40mg If SpO2 < 94% give oxygen via facemask to achieve normal saturations. Reassess within 1 hour See below for management when responding ß 2 agonist 10 puffs via spacer one puff per minute or nebulised salbutamol 5mg Oral prednisolone 30-40mg or IV hydrocortisone 4mg/kg if vomiting. Inject slowly If poor response add nebulised ipratropium bromide 250 micrograms Repeat ß 2 agonist and ipratropium up to every minutes according to response Nebulised salbutamol 5mg plus nebulised ipratropium bromide 250 micrograms Weigh child or estimate weight from length Cannulate and take U&E and venous gas Keep nil by mouth Monitor ECG IV hydrocortisone 4mg/kg give slowly as risk for vomiting Discuss with paediatric and ED consultants Repeat bronchodilators every minutes Bolus IV salbutamol 15microg/kg over 5 minutes to maximum 250 mcg total dose see PICU folder for drug preparation. Start IV fluids as 5% dextrose and 0.45% saline with KCl at 75% maintenance rate Contact Children s Ward for admission as HDU ASSESS RESPONSE TO TREATMENT Record respiratory rate, respiratory effort, heart rate, oxygen saturation and PEF/FEV every 1-4 hours Not Responding Continue minute ipratropium nebulisers while further treatment below is administered Arrange HDU care (i.e. one to one nursing in HDU cubicle) Discuss with PICU if deteriorating or no response to further steps below Consider: Portable chest x-ray and capillary blood gases Ensure serum potassium is normal before giving IV salbutamol Consider risks and benefits of: Bolus IV salbutamol 15mcg/kg to maximum 250mcg over 5 minutes. Bolus IV infusion of magnesium sulphate 40mg/kg max 2g over 20 minutes (unlicensed but evidence based use) (beware risk for hypotension if hypovolaemic) Continuous IV salbutamol infusion 1-5mcg/kg/min (see PICU folder for drug preparation) IV Salbutamol infusion requires 12 hourly electrolyte check as K+ can be low especially with steroids and aminophylline Stop long acting beta agonist while on IV salbutamol IV aminophylline 5mg/kg loading dose over 20 minutes (omit in those receiving oral theophyllines) followed by continuous infusion 1mg/kg/hour. Monitor BP and side effects 6 hourly IV Hydrocortisone 4mg/Kg given slowly to avoid vomiting until tolerating oral steroid IV 2013 fluids to maintain blood pressure and consider referral to ITU/PICU for inotrope support if hypotensive Reduce nebuliser frequency to 4 hourly when on IV salbutamol Consider omeprazole 20mg o.d during acute severe exacerbation and may benefit from continuing long term if difficult to control asthma persists Check capillary blood gas if clinical deterioration or no improvement after treatment Contact FVRH consultant for critical care and confirm referral to PICU if PCO2 rising or clinically exhausted

31 5.4 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in hospital Age > 5 years (cont) After the crisis is over Child with Acute Asthma Attending Hospital Following immediate management in OOH, ED or PAU Responding Repeat multi-dose Salbutamol after 1 hour Review inhaler technique with MDI and spacer Reinforce use of multi-dose for severe wheeze Review preceding asthma control with parents Record trigger for exacerbation if known and advise avoidance if possible Advise any change in management Update Personal Asthma Action Plan for home and nursery/school Observe for at least 4 hours to confirm response Advise viewing of Attacking Asthma programme while in hospital Advise against exposure to tobacco smoke Discharge to complete a 3 day course of prednisolone Consider need for a home supply of oral steroid as part of acute asthma action plan Ensure discharge note for GP is given to parent or sent electronically GP review within 3 days Refer to children s respiratory clinic if ongoing concerns about asthma management Confirm GP asthma clinic review continues and informs school health Child with Acute Asthma Attending Hospital following admission to Children s Ward Responding Maintain oxygen saturation at > 94% Reduce IV aminophylline to half then stop when observations satisfactory When off aminophylline, reduce IV salbutamol infusion rate 4 hourly as tolerated Start PEFR record when child can co-operate Reduce nebulised ipratropium to prn when wheeze free after 4 hours When off IV salbutamol prescribe prn multi-dose or nebulised salbutamol up to 2 hourly Continue regular 4 hourly nebulised salbutamol till out of oxygen Observe with SaO2 monitoring for at least 4 hours post bronchodilator and during sleep to confirm recovery Review inhaler technique with MDI and spacer Reinforce use of multi-dose for severe wheeze Review preceding asthma control with parents Identify any suspected new triggers especially rhinitis/hay fever or exposure to animals Advise any change in management Update Personal Asthma Action Plan for home and nursery/school Arrange viewing of Attacking Asthma programme while in hospital Offer Understanding Asthma booklet to parents with Asthma UK leaflets Advise against exposure to tobacco smoke Discharge with 3 day course of prednisolone and acute asthma action plan and Advise primary care review within 3 days Ensure GP and practice nurse have an eward IDL and asthma care plan at discharge Respiratory Clinic follow up for all life threatening asthma admissions with alert as high risk on e ward Ensure GP Asthma Clinic review continues and informs School Health GP review within 3 days Community 2013 Children s Nurse for Complex Respiratory Disease to review etc If this was a life threatening attack or there are additional concerns after a severe attack: Request Children s Complex Respiratory Nurse to review Asthma Action Plan Request respiratory clinic new patient appointment within a month

32 5.4.1 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in Hospital Life-Threatening Asthma Infusion Guidelines for Salbutamol and Magnesium Refer to BNFfC and PICU website for additional information Approved Name: Salbutamol Application: Bronchodilator Contra-indications: Nil relevant Precautions: Tachycardia, hypokalaemia, QT interval prolongation, hyperglycaemia, diabetes (risk of ketoacidosis) hyperthyroidism Drug Interactions: Corticosteroids: increased risk of hypokalaemia Theophylline/Aminophylline: increased risk of hypokalaemia Dose: Loading Dose: 15 microgram/kg over 15mins to maximum dose of 250 micrograms as a single dose Maintenanc e Dose: 2-5microgram/kg/ min Maximum rate 10microgram/kg/min in consultation with PICU Stability in IV Solutions: Sodium Chloride 0.9% Glucose 5% Water for Injections Sodium Chloride 0.45%:Glucose 5% Reconstitution: This requires 20 (twenty) ampoules of Salbutamol Remove 100ml from a 500ml bag Use 5mg/5ml salbutamol ampoules Replace with 20 (twenty) x5ml ampoules =100mg Salbutamol Concentration = 200microgram/ml Administration: Loading dose 0.075ml/Kg over 15mins gives 15mcg/Kg Maintenance infusion: 0.3ml/kg/hr = 1microgram/kg/min Stability: Stable for 24hours Physical Compatibility with other Drugs: Incompatible with Aminophylline Side Effects: Tachycardia, tremor, hypokalaemia Comments: Venous irritant, central access preferable Monitor blood glucose and serum potassium Monitor ECG Approved Name: Magnesium Sulphate (use in asthma) Application: Adjunct to bronchodilators in severe status asthmaticus Contra-indications: Nil relevant Precautions: Monitor blood pressure, avoid hypovolaemia Drug Interact ions: Nil relevant Dose: 40mg/kg (=0.08 ml/kg of 50% Magnesium Sulphate), Max 2g Reconstitution: Further dilution is required Stability in IV Solutions: Sodium Chloride 0.9% Glucose 5% Flushes compatible: Sodium Chloride 0.9%, Glucose 5% Administration: Dilute dose 5 times before administration (e.g. dose = 1ml, dilute to 5ml) Administer over 20 minutes Stability: Use dilute solution immediately Physical Compatibility with other Drugs: Do not mix with other drugs Side Effects: High magnesium levels can cause dystonia, nausea, vomiting, flushing Comments: 1g magnesium sulphate = 4mmol magnesium

33 5.5 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in Hospital Infants Aged < 2 years Asthma is rare in children under 2 years of age. Consider other causes of wheeze if first presentation. See section Indications for Referral and Clues to Alternative Diagnoses in Wheezy Children. Assess Asthma Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features Moderate Exacerbation SpO 2 92% Audible wheezing Using accessory neck muscles Still feeding Severe Exacerbation SpO 2 <92% Cyanosis Marked respiratory distress Too breathless to feed Showing signs of fatigue Most infants are audibly wheezy with intercostal recession but may not be distressed Life-threatening features include apnoea, bradycardia and poor respiratory effort IMMEDIATE MANAGEMENT Oxygen via close fitting mask or nasal prongs to achieve normal saturations Admit if poor or transient response to initial treatment Give trial of ß 2 agonist: salbutamol up to 10 x 100mcg puffs via spacer and face mask or nebulised salbutamol 2.5mg Repeat ß 2 agonist every 1-4 hours if responding Consider: soluble prednisolone mg o.d. for up to 3 days Ensure adequate but not excessive hydration Document evidence for asthma diagnosis Offer parent education Advise avoiding exposure to tobacco smoke Record identified trigger for exacerbation Consider secondary care follow up in view of age If poor response: Add nebulised ipratropium bromide 0.25mg Establish continuous close monitoring Heart rate Pulse rate Pulse oximetry Supportive nursing care with adequate hydration nurse in HDU Consider the need for chest x-ray and CBG Consider IV aminophylline Record alertness/signs of exhaustion If not responding or any life threatening features discuss with senior paediatrician who may refer to PICU September 2013

34 5.6 NHS Forth Valley Guideline for the Management of Asthma Adverse Effects of Treatment in Children Guidance on Issuing Steroid Cards Professional discretion should be considered when supplying and discussing content of Steroid Cards with patients and appropriate others Steroid Cards should be issued to the following patients 1,2,3 and are available from: Banner Business Supplies 20 South Gyle Crescent Edinburgh EH12 9EB Inhaled Steroids Children Inhaled Steroid Threshold Dose (per day) Beclometasone Dose > 400mcg 1 (age not stated) Budesonide Dose > 800mcg 1 (12 years and under) Fluticasone Dose > 400mcg 1 (4-16 years) Mometasone (Non Formulary) Dose > 800mcg 1 (12-16 years) Ciclesonide (Non Formulary) Dose > 320mcg 4 (12-16 years) Unlicensed dose Adrenal Suppression When to consider synacthen tests in patients Group A- adrenal function not known- consider synacthen test (standard) 1. On inhaled corticosteroids over licensed dose (see table 1) 2. Regular rescue doses - 2 courses/month for 3 consecutive months (Note: need to be off prednisolone for at least 2 weeks prior to synacthen test) 3.On licensed dose of steroids, but symptoms suggestive of adrenal insufficiency Group B- assume adrenal suppression- (synacthen test difficult to interpret)- Patients with other possible causes of adrenal suppression 1. IM triamcinolone 2. Regular daily oral steroids Repeat synacthen in 12 months unless clinically indicated. Change in steroid dose or symptomatic Patients with other possible causes of adrenal suppression References: 1. CSM. Current problem in pharmacovigilance. May 2006; 31:5 2. Scottish Executive. Steroid treatment cards. SEHD/CMO (2006) th July BNF 52. BMJ/RPS. September GINA Guideline 2006 September 2013

35 5.6 NHS Forth Valley Guideline for the Management of Asthma Adverse Effects of Treatment in Children All dry powder inhaled steroids have the potential to be cariogenic Inhaled steroids increase the risk of oral candidiasis Adverse Effects of Non-Steroid Treatments Sympathomimetics: Tachycardia, tremor and agitation/hyperactivity may be worse with salbutamol so if troublesome try change to terbutaline at equivalent dose. Review need for frequent high dose sympathomimetic Anti-cholinergic: May cause drying of secretions that make them difficult to clear in very young infants Montelukast: Some children become agitated and sleep may be disrupted try giving dose in morning. Appetite may increase or decrease review need for medication and advise to avoid giving dose at main mealtime Theophyllines: Children often suffer headaches and may have difficulty concentrating at school, have sleep disturbance and tremor as do adults but they are less likely to complain about these adverse effects. Any child receiving long term theophyllines should be asked specifically about adverse effects and advised how to minimise them. References: 1. CSM. Current problem in pharmacovigilance. May 2006; 31:5 2. Scottish Executive. Steroid treatment cards. SEHD/CMO (2006) th July BNF 52. BMJ/RPS. September GINA Guideline 2006 September 2013

36 6.1 Stepwise Management of Adult Asthma Treatment Cost Comparison Underline denotes preferred choice/device Step 1 Step 2 Step 3 Step 4 MDI Consider spacer device particularly with ICS DPI As required use of SABA Salbutamol inhaler 100mcg ( 1.50) 2 puffs prn Easyhaler Salbutamol 100mcg, ( 3.31) 2 puffs prn Asmasal Clickhaler 95mcg, ( 5.65) 2 puffs prn Pulvinal Salbutamol 200mcg, ( 4.85) 1 puff prn Ventolin Accuhaler 200mcg, ( 4.92) 1 puff prn Terbutaline Turbohaler 500mcg, ( 6.72) 1 puff prn Add Regular Preventer Therapy up to 400mcg/day BDP equiv Clenil Modulite 100mcg, 2 puffs bd ( 4.52) (400mcg BDP equiv) QVAR Inhaler 50mcg, 2 puffs bd ( 4.82) (400mcg BDP equiv) Fluticasone 50 Evohaler, 2 puffs bd ( 5.09) (400mcg BDP equiv) Easyhaler Beclometasone 200mcg, 1 puff bd ( 4.18) (400mcg BDP equiv) Easyhaler Budesonide 200mcg, 1 puff bd ( 4.96) (400mcg BDP equiv) Beclometasone Clickhaler 100mcg, 2 puffs bd ( 5.28) (400mcg BDP equiv) Pulvinal Beclometasone200mcg, 1 puff bd ( 5.53) (400mcg BDP equiv) Budesonide Turbohaler 200mcg, 1 puff bd ( 6.63) (400mcg BDP equiv) Fluticasone 100 Accuhaler 1puff bd ( 8.33) (400mcg BDP equiv) 1. Add LABA 2. Increase ICS to 800mcg/day BDP equiv 1. Add LABA Fostair 100/6 1puff bd ( 13.68) (500mcg BDP equiv) Seretide 50 Evohaler 2 puffs bd ( 16.80) (400mcg BDP equiv) Flutiform 50/5 2 puffs bd ( 16.80) (400mcg BDP equiv) 2. Increase ICS to 800mcg day No MDI equivalent in combined form 1. Add LABA Seretide 100 Accuhaler 1 puff bd ( 16.80) (400mcg BDP equiv) Symbicort 100/6 Turbohaler 2 puff bd ( 30.80) (400mcg BDP equiv) 2. Increase ICS to 800mcg/day Symbicort 200/6 2 puffs bd ( 35.50) (800mcg BDP equiv) Symbicort 400/12 1 puff bd ( 35.50) (800mcg BDP equiv) Increase ICS to max 2000mcg day BDP equiv (Step 5 continue 2000mcg day ICS) Fostair 100/6 2 puffs bd ( 27.37) (1000mcg BDP equiv) Seretide 125 Evohaler 2 puffs bd ( 32.66) (1000mcg BDP equiv) Flutiform 125/5 2 puffs bd ( 27.30) (1000mcg BDP equiv) Seretide 250 Evohaler 2 puffs bd ( 55.51) (2000mcg BDP equiv) Flutiform 250/10 2 puffs bd ( 42.52) (2000mcg BDP equiv) Seretide 250 Accuhaler 1 puff bd ( 32.66) (1000mcg BDP equiv) Symbicort 400/12 Turbohaler 2 puffs bd ( 70.90) (1600mcg BDP equiv) Seretide 500 Accuhaler 1 puff bd ( 38.19) (2000mcg BDP equiv) Breathe Actuated Treatment trials Salbutamol Autohaler (Airomir ) 100mcg ( 6.02) 2 puffs prn Salbutamol Easi-Breathe 100mcg, ( 6.30) 2 puffs prn BDP Equivalents: 2mcg Beclometasone/Budesonide = 1mcg Fluticasone = 1mcg CFC - Free Beclometasone(QVAR) = 0.8mcg BDP in Fostair QVAR Autohaler 100mcg, 1 puff bd ( 4.82) (400mcg BDP equiv) QVAR Easi-Breathe 100mcg, 1 puff bd ( 4.82) (400mcg BDP equiv) Consider treatment trials - 3 months discontinue if ineffective LTRA Montelukast ( 26.97) Theophylline Uniphyllin Consider treatment trials 3 months discontinue if ineffective LTRA Montelukast ( 26.97) Theophylline Uniphylllin Always check inhaler technique and concordance before changing, and remember to Review and Step Down. Costs for 28 days usage BNF March 2013 < > 50 (NB. cost for SABA is equivalent to 1x inhaler) Underline denotes preferred choice / device

37 Bronchodilators - Cost per Average Adult Daily Dose Analysis (equivalent to 400mcg salbutamol daily (cost for 28 days)) Bricanyl Turbohaler Salbutamol Easi-Breathe Airomir Autohaler Asmasal Clickhaler Ventolin Accuhaler Pulvinal Salbutamol Salbutamol Easyhaler Salbulin Novolizer Salbutamol CFC free MDI Cost ( ) September 2013 Page 1 of 5

38 Corticosteroid Cost per Adult Dose Analysis (equivalent to 400mcg BDP equivalents per day (cost per 28 days therapy)) Flixotide Accuhaler Pulmicort Turbohaler Pulvinal Beclometasone Budesonide Novolizer Asmabec Clickhaler Flixotide MDI Budesonide Easyhaler QVAR Autohaler QVAR MDI QVAR Easi-Breathe Clenil Modulite Beclometasone Easyhaler Cost ( ) September 2013 Page 2 of 5

39 Corticosteroid Cost per Adult Dose Analysis (equivalent to 2000mcg BDP equivalents per day (cost per 28 days therapy)) Pulmicort Turbohaler Flixotide Accuhaler Flixotide MDI Asmabec Clickhaler Budesonide Novolizer Budesonide Easyhaler QVAR Autohaler QVAR MDI QVAR Easi-Breathe Clenil Modulite Pulvinal Beclometasone Beclometasone Easyhaler Cost ( ) September 2013 Page 3 of 5

40 Combination Therapy Costs per 28 days therapy at doses indicated Doses do not imply therapeutic equivalence Symbicort 400/12 Turbohaler (2p bd) Seretide 250 MDI (2p bd) Flutiform 250/10 MDI (2p bd) Seretide 500 Accuhaler (1p bd) Symbicort 400/12 Turbohaler (1p bd) Symbicort 200/6 Turbohaler (2p bd) Seretide 250 Accuhaler (1p bd) Seretide 125 MDI (2p bd) Symbicort 100/6 Turbohaler (2p bd) Fostair 100/6 MDI (2p bd) Flutiform 125/5 MDI (2p bd) Symbicort 200/6 Turbohaler (1p bd) Flutiform 50/5 MDI (2p bd) Seretide 100 Accuhaler (1p bd) Seretide 50 MDI (2p bd) Symbicort 100/6 Turbohaler (1p bd) Cost ( ) September 2013 Page 4 of 5

41 Equivalent Inhaled Corticosteroid Doses BECLOMETASONE (CFC Free Clenil Modulite ) / dose FLUTICASONE (CFC Free)/ dose 50mcg - 100mcg 200mcg 250mcg QVAR (CFC Free BDP)/dose 50mcg 100mcg BUDESONIDE (CFC Free)/ dose 100mcg 200mcg 400mcg 50mcg 100mcg 125mcg FLUTICASONE / dose 50mcg 100mcg FLUTICASONE / dose 50mcg 100mcg 200mcg Titrate the dose of inhaled steroid to the lowest dose at which effective control is maintained September 2013 Page 5 of 5

42 6.1.1 NHS Forth Valley Guideline for the Management of Asthma Stepping Down Treatment in Adults Regular review of patients as treatment is stepped down is important. When deciding which drug to step down first and at what rate, the severity of asthma, the side effects of the treatment, time on current dose, the beneficial effect achieved, and the patient s preference should be taken into account. Patients should be maintained at the lowest possible dose of inhaled steroid. Reduction in inhaled steroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every 3 months, decreasing the dose by approximately 25-50% each time. If the patient becomes more symptomatic with reduction, put back up to the previous dose when they were more stable. September 2013

43 Asthma Step Down Guide for Seretide, Flutiform and Fostair BTS / SIGN Step 4/5 BTS/SIGN Step 3 BTS/SIGN Step 2 MDI Seretide Evohaler Or Seretide puffs bd ( 55.51) (2000mcg BDP equiv +100mcg salmeterol) Seretide puffs bd ( 32.66) (1000mcg BDP equiv +100mcg salmeterol) Seretide 50 2 puffs bd ( 16.80) (400mcg BDP equiv +100mcg salmeterol) Prescribe and ICS device equivalent to mcg BDP per day Flutiform MDI Flutiform 250/10 2 puffs bd ( 42.52) (2000mcg BDP equiv + 40mcg formoterol) or Flutiform 125/5 2 puffs bd ( 27.30) (1000mcg BDP equiv + 20mcg formoterol) or Flutiform 50/5 2 puffs bd ( 16.80) (400mcg BDP equiv+ 20mcg eformoterol) Clenil Modulite 100mcg 2 puffs bd ( 4.52) Fostair MDI Fostair not appropriate at BDP equiv. does of 2000 mcg/day Fostair 100/6 2 puffs bd ( 27.37) (1000mcg BDP equiv + 24 mcg formoterol) Fostair 100/6 1 puffs bd ( 13.68) (500mcg BDP equiv + 12 mcg formoterol) DPI Seretide Accuhaler Please note: With 1 puff twice daily of Seretide or Flutiform MDI only half the optimum β 2 agonist dose is being administered Seretide puff bd ( 38.19) (2000mcg BDP equiv +100mcg salmeterol) Seretide puff bd ( 32.66) (1000mcg BDP equiv +100mcg salmeterol) Seretide puff bd (16.80) (400mcg BDP equiv +100mcg salmeterol) Prescribe an ICS device equivalent to mcg BDP per day Easyhaler Beclometasone 200mccg 1 puff bd ( 4.18) Note - When stepping down from some combinations above, the dose of LABA is also reduced. Notes: Costs based on 28 days treatment BNF March 2013 Total daily dose of BDP equivalents and LABA doses are shown in brackets If patient is taking add-on therapies e.g montelukast,or theophylline, then consider reducing / stopping these prior to reducing ICS dose. Always reduce maintenance dose steroid first Developed by Clare Colligan. Approved by Respiratory MCN. Issued June Review June 2015

44 Asthma Step Down Guide for Symbicort BTS / SIGN Step 4/5 BTS/SIGN Step 3 BTS/SIGN Step 2 Symbicort Turbohaler 400/12 Symbicort 400/12 2 puffs bd ( 70.90) (1600mcg BDP equiv+ 48mcg formoterol) Symbicort 400/12 1 puff bd ( 35.50) Or Symbicort 200/6 2 puffs bd ( 35.50) (800mcg BDP equiv+ 24mcg formoterol) Symbicort 200/6 2 puffs bd ( 35.50) Symbicort 200/6 1 puff bd ( 17.73) (400mcg BDP equiv + 12mcg formoterol) Or Symbicort 100/6 2 puffs bd ( 30.80) (400mcg BDP equiv + 24mcg formoterol) Prescribe and ICS device equivalent to mcg BDP per day Easyhaler Beclometasone 200mccg 1 puff bd ( 4.18) Symbicort Turbohaler 200/6 (800mcg BDP equiv+ 24mcg formoterol) Symbicort 200/6 1 puffs bd ( 17.73) (400mcg BDP equiv+ 12mcg formoterol) Symbicort Turbohaler 100/6 Note - When stepping down from some combinations above, the dose of LABA is also reduced. Symbicort 100/6 2 puffs bd ( 30.80) (400mcg BDP equiv+ 24mcg formoterol) Notes: Costs based on 28 days treatment BNF March 2013 Total daily dose of BDP equivalents and LABA doses are shown in brackets If patient is taking add-on therapies e.g montelukast,or theophylline, then consider reducing / stopping these prior to reducing ICS dose. Always reduce maintenance dose steroid first Developed by Clare Colligan. Approved by Respiratory MCN. Issued June Review June 2015

45 6.1.2 NHS Forth Valley Management of Asthma Prescribing of Symbicort SMART / Fostair MART Step 3 Do not reduce equivalent dose of inhaled corticosteroid when making switch to this strategy Good education required to ensure patient knows how to use strategy and when to seek further advice. Patients taking rescue doses once a day or more on a regular basis should have their treatment reviewed. Symbicort 100/6 1 puff twice daily (can use 2 puffs once daily) as maintenance plus 1-2 puffs to relieve symptoms as required. Maximum of 8 puffs in 24 hours (12 puffs per day can be used for a limited period) Symbicort 200/6 1 puff twice daily (can use 2 puffs once daily) up to 2 puffs twice daily as maintenance plus 1-2 puffs to relieve symptoms as required. Maximum of 8 puffs in 24 hours (12 puffs per day can be used for a limited period) Fostair 100/6 1 puff twice daily as maintenance plus 1 puff to relieve symptoms as required. Maximum of 8 puffs in 24 hours. September 2013

46 6.1.3 NHS Forth Valley Guideline for Management of Asthma Treatment of Exacerbations of Asthma in Adults At present there is no definite consensus on treating exacerbations of asthma, however, doubling the dose of steroids is no longer recommended (SIGN 101, May 2008) As of March 2009, the Airways MCN recommend the following: Restart an Inhaled Corticosteroid (ICS) if this has been stopped. If the patient is on low dose (e.g. 200mcg/day BDP equivalents) of inhaled steroids, then their dose should be increased substantially (e.g to 1200mcg/day) at the time of an exacerbation until the patients symptoms settle. Patients on moderate or high dose ( 400mcg/day BDP equivalents) of inhaled steroids should go directly onto an oral steroid course as increasing the inhaled steroid dose is ineffective. If however, doubling the ICS dose has previously been effective, then continue with this method of treatment. Continue to monitor asthma closely e.g. by symptoms or peak flows. Ensure the patient has adequate reliever medication and is aware of how to use it appropriately and when to seek further advice. Previous advice holds regarding starting oral steroids i.e. that if symptoms and/or peak flow is worsening, despite an increased dose of inhaled steroids and reliever, then patients should commence oral steroids if they have a self management plan which includes this or seek advice from their GP or Asthma Nurse Written management plan should be altered accordingly to advise on new inhaled steroid dose The Airways MCN will provide updates with regard to alternative strategies in due course, when further information becomes available. September 2013

47 6.3 NHS Forth Valley Guideline for the Management of Asthma Source: SIGN101 Annex 3. Reproduced with the permission of and thanks to SIGN, and accurate at the time of review in NHS Forth Valley September 2013

48 6.4 NHS Forth Valley Guideline for the Management of Asthma Inpatient Management of Acute Asthma in Adults

49 Acute severe asthma Sign/Symptom PEF 33-50% of best (most useful) or predicted PEFR (if best PEFR not known) Inability to speak in sentences Respiratory rate 25/min Pulse 110/min Life threatening features include: Sign/Symptom PEF <33% of best or predicted SaO 2 <92% PaO2 <8 kpa Silent Chest Feeble respiratory effort Bradycardia Dysrhythmia Hypotension Exhaustion Confusion Near Fatal Asthma Sign/Symptom Raised PaCO2 Respiratory arrest Requiring ventilation with raised inflation pressures Admission Admit patients with: any feature of a life threatening or near fatal attack any features of a severe attack persisting after initial treatment patients whose PEF is < 75% best or predicted one hour after initial treatment September

50 Psychosocial Factors Patients with severe asthma and one or more psychosocial factor are at risk of death: Non-compliance with treatment or monitoring Failure to attend appointments Self discharge from hospital Psychosis, depression, other psychiatric illness or deliberate self-harm Current or recent major tranquilliser use Denial Alcohol or drug abuse Obesity Learning difficulties Employment problems Income problems Social isolation Childhood abuse Severe domestic, marital or legal stress Observations PEF after minutes and pre and post nebulisers at least 4 times daily on PEF chart Respiratory Rate Heart Rate SpO 2 at least 4 times daily on oxygen chart aiming for 94-98% Daily BM Frequency of observations may increase depending upon trigger score - ensure if 1 X RED, 2 X YELLOW or nurse is concerned- trigger protocol must be initiated September

51 Immediate Investigations (All patients) Arterial blood gases Repeat within 2 hours if initial PO2 < 8kPa (unless subsequent SaO2 >92%), PCO2 normal or raised or patient deteriorates CXR FBC Daily U and E Glucose Sputum MC and S September

52 Immediate Treatment 1. Give 40%-60% oxygen via high flow mask 2. (a) Salbutamol 5mg at least 4-6 hourly and as required via oxygen driven nebuliser. Up to every minutes or back to back nebulisers in poorly responsive severe asthma 2. (b) Ipratropium 0.5mg 4-6 hourly in acute severe or life threatening asthma or poor response to treatment via oxygen driven nebuliser 3. Prednisolone 40mg once daily for at least 5 days or until recovery Or Hydrocortisone 100mg intravenously 6 hourly Both if very ill (for first 24 hours) If life threatening or near fatal asthma or not improving after minutes: Discuss with senior clinician Refer to intensive care (accompanied by a doctor prepared to intubate) Add IV Magnesium 2g infusion over 20 minutes Consider IV Aminophylline - 5mg/kg loading dose over 20 minutes unless on maintenance oral therapy, then infusion of mg/kg/hr with daily theophylline level (aim for mg/l) IV beta 2 agonist Mechanical ventilation Magnesium, aminophylline and salbutamol infusions see appendices 1-2 for further guidance. Other Treatments Antibiotic not routinely indicated No sedatives of any kind September

53 Full discharge planning Yes No Reason for exacerbation and admission determined On discharge medication for 24 hours PEFR > 75% of best or predicted and PEFR variability < 25% Record value of PEFR on day of discharge Recommended to check and record peak flow twice daily and advised to bring to clinic Follow up arranged with patient s GP or Practice Asthma Nurse within 2 working days of discharge Inhaler technique checked On inhaled steroid On oral steroid and instructed on how to reduce Advised on recognising worsening symptoms Advised on precipitating factors Written Asthma Action Plan given Sent copy of Eward letter to Respiratory Consultant who will arrange: Review appointment for Asthma clinic in 4 weeks if seen or under active follow up by Respiratory Consultant New patient appointment for Asthma Clinic in 4 weeks if not seen or not under active follow up by Respiratory Consultant September

54 Appendix 1 Magnesium for IV Infusion Mg(SO 4 ) 2 50% w/v injection 4mls (2.0g) Dilute to 50mls with NaCl 0.9% Infuse over 20 minutes Salbutamol for IV infusion (5mg/5ml) Must be diluted before administration in 500mls with Sodium Chloride 0.9% or Dextrose 5% to give a 10mcg/ml solution Infusion rate mls/min. September

55 Administration of Intravenous Aminophylline Infusion Aminophylline 25mg/ml BOLUS DOSE: ONLY give to patients who are not currently taking oral aminophylline / theophylline. Dose: 5mg/kg (max.500mg) Dilute in 250mls Sodium Chloride 0.9% or Dextrose 5% and give over 20 minutes Weight (kg) Vol of 25mg/ml solution to be diluted (mls) MAINTENANCE INFUSION: Start infusion at 0.5mg/kg/hr Dilute 20mls (500mg) in 500mls Sodium Chloride 0.9% or Dextrose 5% Dose Weight (kg) mg/kg/hr Infusion Rate (mls/hr) INTERACTIONS: Common drug interactions: Ciprofloxacin Clarithromycin Fluconazole CAUTIONS: Cardiovascular disease Hypertension Hyperthyroidism Cardiac arrhythmias MONITORING: Telemetry Daily U + E s particularly K+ Daly theophylline levels whilst on IV therapy, 8 hours after each dose change (Ref range: mgl/l) September

56 September

57 6.5 NHS Forth Valley Guideline for the Management of Asthma Severe or Difficult to Manage Asthma in Adults Introduction There are no validated algorithms in the management of severe or difficult to manage asthma and the following is what is considered as best practice at present. Definition of Severe Asthma Patients with a Physician diagnosis of asthma and treatment is at Step 5 of BTS guidelines (continuous or frequent use of oral steroids) (section 4.5) Or Continued symptoms or lung function impairment despite prescribed treatment at Step 4 of BTS guidelines (persistent poor control) (section 4.4) Note: Severe asthma is not poorly controlled asthma, which is more a transient state of condition, in which, the level of symptoms can be improved when standard approaches to therapy are appropriately used. September

58 6.5 NHS Forth Valley Guideline for the Management of Asthma Management Management can be divided into 3 stages: a. Confirmation of diagnosis of asthma b. Assessment of confounding/exacerbating factors c. Treatment Confirmation of Diagnosis of Asthma 1. History: including occupational asthma and drug history (e.g. Betablockers, Aspirin, non-steroidal anti-inflammatories) 2. Full blood count, eosinophil count, ESR, U&Es, urinalysis, thyroid function tests, IgE with specific IgE and IgG to aspergillus and ANCA 3. ECG, echocardiogram 4. Chest x-ray, high resolution CT scan (excludes other diagnoses e.g. emphysema, alveolitis, sarcoidosis) 5. Pulmonary function testing: peak flow monitoring, reversibility studies flow volume and transfer factor, lung volumes, bronchial challenge testing, respiratory exercise testing, and in selected cases exhaled nitric oxide and cardiopulmonary exercise testing. 6. Bronchoscopy in selected cases Investigations in red may be carried out by secondary care following referral to Respiratory Department Guidelines for Referral Consider specialist referral for any patient who meets the criteria for a diagnosis of severe asthma Appropriate investigations as above September

59 6.5 NHS Forth Valley Guideline for the Management of Asthma Compliance Assessment of Confounding/Exacerbating Factors Subjective assessment of compliance with medication check with patient Objective assessment of compliance with medication pharmacy records, theophylline level if appropriate, morning cortisol if appropriate (should be suppressed if on Prednisolone) Social Housing Psychiatric Mental illness Psychological Teenagers Denial of condition Concerns about side effects Compliance Physical Rare but possible e.g. oropharyngeal abnormalities Educational Inhaler technique Management plan use Level of education Literacy Learning disability Cognitive Alzhiemers Dementia Assessment of Factors Affecting Compliance Enquire regarding barriers to adherence without being confrontational Enquire regarding beliefs around asthma diagnosis and pharmacological treatments and possible side effects Psycho-social review by Respiratory Nurses with possible psychiatric or psychological referral Completion of Quality of Life Questionnaire and Hospital Anxiety and Depression Scale (HADS) September

60 6.5 NHS Forth Valley Guideline for the Management of Asthma Assessment of Confounding/Exacerbating Factors Other Possible Diagnoses Exclude other diagnoses whose control may help asthma symptoms: a. Assess for oesophageal reflux history, consider trial of PPI, consider referral for PH monitoring b. Assess upper airways treat any sinusitis, post nasal drip, rhinitis etc. Consider ENT referral for polyps or non-resolving symptoms c. Assessment of allergies e.g. type 1 skin testing, specific IgE to relevant allergies d. Obesity e. Others e.g. bronchiectasis, obstructive sleep apnoea, COPD, vocal cord dysfunction, dysfunctional breathing September

61 6.5 Assess NHS Forth Valley Guideline for the Management of Asthma Treatment Treat any other modifiable aggravating factors e.g. sinus disease with anti-histamines, nasal steroids etc, reflux oesophagitis with a PPI, nasal CPAP for obstructive sleep apnoea Implement identifiable allergy avoidance including occupational factors and possible dietary factors (possible referral to Dietician) Non-Pharmacological Treatment of Asthma: 1. Follow asthma treatment plan as per guidelines. 2. Introduce, if necessary, a written management plan with peak flow monitoring and diary/review and modify existing management plan. 3. Smoking cessation if relevant (refer to local smoking cessation clinic). 4. Weight loss if relevant establish BMI. 5. Ongoing education and develop the relationship with the patient. 6. If poor compliance identified, try to modify: Emphasise the value of the regime and the effect of adherence Provide information around safety of long term steroid treatment or any other patient concerns Elicit patient s feelings about their ability to follow the regime, and if necessary, design supports to promote adherence Focus on benefits of good asthma control in other areas of life Provide simple, clear instructions and simplify the regime as much as possible Encourage the use of a medication taking system Customise the regime in accordance with the patient s wishes Obtain the help of family members and/or friends Reinforce desirable behaviour and results when appropriate 7. Regular review until stable with a combination of a Doctor and Respiratory Nurse (including telephone follow-up) to allow monitoring of clinical condition, pulmonary function and medication. 8. Advise to obtain medic alert bracelet (can be obtained via Pharmacy) for those with sudden severe episodes. 9. Referral to Pulmonary Rehabilitation. September

62 6.5 NHS Forth Valley Guideline for the Management of Asthma Treatment Pharmacological Treatment of Asthma: Trial of regular nebulised bronchodilators. If compliance is an issue, consider medication with long half-lives and depot medications e.g. Depot Triamcinolone (useful at start to help non-adherence issues). For asthma that is exacerbated pre-menstrually, consider increasing inhaled steroids pre-menstrually or Progesterone (either Depot IM or orally one week before menstruation). In severe cases oral steroids can be given 5-7 days pre-menstrually. Consider use of LHRH analogues. If possible use theopylline. Consider continuous sub-cutaneous infusion of Terbutaline. Consider education on self-administration of Adrenaline. Consider use of Methotrexate/Cyclosporin/Gold Salts some evidence to show have steroid sparing effect but potentially toxic and little indication for use. Omalizumab (Humanised Monoclonal Antibody) in selected cases with raised IgE - Consultant prescribing only. Bronchial thermoplasty (using thermal energy via a bronchoscope to decrease smooth muscle mass in the bronchi) Consultant referral only. If medication not of any benefit after an adequate trial, decrease and consider stopping. Any patient on oral steroids should have a steroid card. (See section 6.6 Adverse Effects of Treatment in Adults for guidance on issuing steroid cards.) September

63 6.6 NHS Forth Valley Guideline for the Management of Asthma Adverse Effects of Treatment in Adults Guidance on Issuing Steroid Cards Professional discretion should be considered when supplying and discussing the content of Steroid Cards with patients and appropriate others Steroid Cards should be issued to the following patients 1,2,3 and are available from: Banner Business Supplies 20 South Gyle Crescent Edinburgh EH12 9EB Inhaled Steroids Inhaled Steroid Threshold Dose (per day) Adults Beclometasone Dose 1000mcg 4 Budesonide Dose > 800mcg 4 Fluticasone Dose 500mcg 4 Mometasone (Non Formulary) Dose > 800mcg 4 Ciclesonide (Non Formulary) Dose > 320mcg 4 Unlicensed dose Systemic Steroids Adults Receiving repeated courses, 2-3 courses per year (particularly if taken for longer than 3 weeks) Taking a short course within 1 year of stopping long-term therapy Receiving more than 40mg prednisolone daily (or equivalent) Receiving repeated doses in the evening Receiving more than 3 weeks treatment including maintenance therapy at any dose Patients with other possible causes of adrenal suppression These patients are at risk of disease relapse and/or hypoadrenalism if treatment is withdrawn rapidly 2 Oral Candidiasis Oral thrush is a common side effect with inhaled steroids. Several measures can be taken to try and minimise this. Patients receiving high dose inhaled steroids via a metered dose inhaler, should use a spacer device to reduce local drug deposition. Advising the patient to rinse their mouth after taking their steroid inhaler can also reduce the incidence. For patients who still have problems, a change in inhaler device can be beneficial. Ciclesonide (Alvesco ), a non formulary inhaled corticosteroid in Forth Valley, is reported to have a reduced incidence of oral thrush, this can be tried if all other approaches fail. Osteoporosis Prophylaxis Individual patients should have their fracture risk assessed and patients at high risk from long term steroid use (> 5mg prednisolone for > 3 months) should be considered for DEXA and bone protection therapy. Patients on maintenance oral steroids Ensure blood pressure and blood glucose levels are controlled. Patients may be at risk of hyperlipidaemia. May 2013

64 6.6 NHS Forth Valley Guideline for the Management of Asthma Adverse Effects of Non-Steroid Treatments Sympathomimetics: Tachycardia, tremor, muscle cramp and headache. Changing the β 2 agonist can sometimes alleviate troublesome side-effects. High dose therapy can result in hypokalaemia particularly in combination with theophyllines, corticosteroids and diuretics. Theophyllines: Tachycardia, palpitations and GI upset. Headache and CNS stimulation particularly on commencing treatment. Patients should be started on low dose (e.g. 200mg twice daily of Uniphyllin increasing to 300mg twice daily after a week if tolerated) and titrated up being guided by serum levels and patient's tolerance. Uniphyllin is the formulation of choice as it appears to be best tolerated. Serum levels should be measured 6-8 hours post dose, at least 3 days after a dose adjustment. Theophylline toxicity can develop in patients who stop smoking and remain on the same dose. Dose reduction (50%), should be considered in patients commenced on macrolide or quinolone (except moxifloxacin) antibiotics and azole antifungals for the duration of the course. Uniphyllin tablets should not be halved which may mean that patients require to be prescribed a lower strength for the duration of antibiotic / antifungal therapy. References:1. CSM. Current problem in pharmacovigilance. May 2006; 31:5 2. Scottish Executive. Steroid treatment cards. SEHD/CMO (2006) th July BNF 65. BMJ/RPS. September GINA Guideline 2006 May 2013

65 6.7 NHS Forth Valley Guideline for the Management of Asthma Occupational Asthma Source: SIGN101 Annex 9. Reproduced with the permission of and thanks to SIGN, and accurate at the time of review in NHS Forth Valley, September 2013

66 6.8 NHS Forth Valley Guideline for the Management of Asthma Source: SIGN101 Quick Reference Guide. Reproduced with the permission of and thanks to SIGN, and accurate at the time of review in NHS Forth Valley, September 2013 For information with regard to keys to evidence statements and grades of recommendation please refer to the full text of the SIGN guideline, available at

67 7 NHS Forth Valley Guideline for the Management of Asthma Exercise Induced Asthma When given chronically the following medications give protection against exercise induced asthma in adults >12 years and children 5-12 years: Inhaled steroid Short-acting β 2 agonists Long-acting β 2 agonists Theophyllines Leukotriene receptor agonists Chromones β 2 agonist tablets In adults, long-acting β 2 agonists and leukotriene agonists provide more prolonged protection than short-acting β 2 agonists, but a degree of tolerance develops with long-acting β 2 agonists particularly with respect to duration of action. No tolerance has been demonstrated with leukotriene receptor agonists. September 2013

68 8.1 NHS Forth Valley Guideline for the Management of Asthma Inhaler Assessment Information

69 Contents Flow Chart to Assist in Choosing an Appropriate Inhaler Device...2 Brand Prescribing... 3 What Should Influence Our Assessment when Selecting an Inhaler Device?... 4 General Points to Consider... 5 General Advice for All Inhaled Medication... 6 Advice for Using Inhaled Steroids... 7 Supply of Inhalers... 8 How to Use a Metered Dose Inhaler (MDI)... 9 Potential Difficulties in Using a MDI Optimally How to Use a Metered Dose Inhaler with a Spacer Paediatric Advice Tips for Administering Inhalers to Young Children Examples of Common Spacers Care of Spacers How to Use the Haleraid with the Metered Dose Inhaler Breath Actuated Devices How to Use the Easibreathe Device How to use the Autohaler device Dry Powder Inhalers (DPI) How to Use the Accuhaler Device How to Use the Clickhaler Device How to Use the Turbohaler Device How to Use the Handihaler Device How to Use the Twisthaler Device How to Use the Pulvinal Device How to Use the Novolizer Device How to Use the Easyhaler Device When to Measure Peak Flow...28 When Should Patients Monitor their Peak Flows?...29 Peak Expiratory Flow Rate Normal Values...30 Peak Flow Measurements in Children...31 Paediatric Normal Values...32 September

70 Factors for consideration Check device availability for intended drug. Other inhaler devices used in the past and why they were changed. The patients lifestyle, their likes and dislikes. Any disability e.g. arthritis, blind. Patient s age especially if a child. Concordance and financial issues: - Use of combination devices will reduce the amount of prescriptions the individual needs to get. Keep the number of different devices to a minimum to aid technique. Flow Chart to Assist in Choosing an Appropriate Inhaler Device Is the patient able to use a Metered Dose Inhaler (MDI) in less than 3 attempts? Breath Actuated Devices Autohaler Easibreathe No Consider: MDI plus spacer (This is generally not appropriate for reliever use due to portability problems) Is the patient competent using the MDI plus spacer? No Consider addition of Haleraid if the individual has arthritic or dexterity problems. Is the patient now competent? No Consider Dry Powder Devices Accuhaler Clickhaler Turbohaler Yes Yes Yes If no conflicting factors for consideration, ensure patient s prescription is updated. NB Brand prescribing may be required (see page 3) If no conflicting factors for consideration, ensure patient s prescription is updated. NB Brand prescribing may be required (see page 3) If no conflicting factors for consideration, ensure patient s prescription is updated. NB Brand prescribing may be required (see page 3) September

71 Brand Prescribing Special Note Prescribe combination inhalers by brand name e.g. Symbicort ; Seretide, Fostair or Flutiform Prescribe any inhaler that is not a metered dose inhaler by brand to ensure the patient gets the correct device type Preferred options/ devices are shown in bold. Non formulary options are shown in italics Prescribed name EMIS name should read SHORT ACTING β 2 AGONIST Salamol CFC free inhaler Salbutamol 200 dose CFC free Inhaler 100mcg/dose Easyhaler Salbutamol Easyhaler salbutamol dry powder inhaler Airomir Autohaler Airomir Autohaler breath- actuated inhaler (cfc free) 100mcgs/dose Airomir Airomir CFC free inhaler 100mcg/dose Asmasal clickhaler Asmasal clickhaler breath- actuated inhaler 95mcg Bricanyl Turbohaler Bricanyl Turbohaler 500mcgs per dose Novolizer Salbutamol Salbulin novolizer inhalation powder with device- Pulvinal Salbutamol Pulvinal salbutamol dry powder inhaler Salamol Easi-Breathe Salamol cfc free breathe-actuated inhaler Ventolin accuhaler Ventolin accuhaler 200mcg/dose Ventolin evohaler Salbutamol CFC free Inhaler 100mcg/dose LONG ACTING β 2 AGONIST Formoterol Easyhaler Formoterol easyhaler dry powder inhaler Atimos Modulite Atimos modulite cfc free inhaler Foradil inhaler Foradil dry powder for inhalation with inhaler device Oxis turbohaler Oxis turbohaler breathe-actuated Onbrez Breezhaler Onbrez Breezhaler inhalation powder capsules Serevent evohaler Salmeterol xinafoate CFC free 25mcg/dose inhaler Serevent accuhaler Serevent accuhaler 50mcg/dose ANTIMUSCARINIC AGENTS Spiriva inhaler Spiriva combopack Spiriva capsules refill Spiriva refill dry powder capsules for inhalation Atrovent 20mcg/dose mdi Ipratropium bromide CFC free Inhal 20mcg/dose Eklira Genuair - Aclidinium Eklira Genuair dry powder Seebri breezhaler - Glycopyrronium Seebri breezhaler inhalation powder capsules INHALED CORTICOSTEROIDS Clenil modulite CFC free Clenil modulite cfc free Easyhaler Beclometasone Easyhaler beclometasone Asmabec clickhaler Asmabec clickhaler 100mcg/dose or 250mcg/dase Pulvinal Beclometasone diproprionate Pulvinal beclometasone diproprionate Qvar CFC free inhaler Qvar (50mcg,or 100mcg strength )cfc free inhaler Qvar Autohaler Qvar ( strength )Autohaler Qvar Easi-breathe Qvar Easibreathe breathe-actuated inhaler Easyhaler Budesonide Easyhaler budesonide - Novolizer Budesonide Novolizer Budesonide - Pulmicort Turbohaler Pulmicort turbohaler - Flixotide evohaler Fluticasone propionate CFC free INHAL Flixotide Accuhaler Flixotide Accuhaler Asmanex twisthaler Asmanex twisthaler dry powder Alvesco Alvesco cfc free inhaler COMBINATION INHALER ICS/LABA Fostair Fostair cfc free inhaler Flutiform metered dose inhaler Flutiform cfc free inhaler Seretide evohaler Seretide evohaler cfc free Seretide accuhaler Seretide accuhaler dry powder for inhalation September

72 What Should Influence Our Assessment when Selecting an Inhaler Device? The choice of device may be determined by the limitations of the drugs available. The ability to use a device correctly. The individuals preference for a device - if they don t like it they won t use it. The individual s inspiratory effort (an In-Check kit is available from Clement Clarke to assess this). The ability to use the device when experiencing an acute attack of breathlessness or coughing. The portability of the reliever device - will the individual actually carry the spacer? The individuals age, either very young or elderly. Children 0-5 years of ages should use a metered dose inhaler with a spacer and facemask and then move onto a spacer with a mouthpiece when they are able to. Conditions that can affect manual dexterity,e.g. CVA, Rheumatid Arthritis, Parkinson s Disease etc. Impaired vision. Learning disability Impaired mental state. The individual s lifestyle, do they play sports? Will they bow to peer pressure (especially teenagers and young adults)? Is the individual affected by the Freon affect (coughing when trying to use an aerosol inhaler) - if so they will need to use a dry powder device. September

73 General Points to Consider Individuals with asthma should have a portable device to use when they are short of breath. In general individuals should have as few different devices as possible. Some individuals may need a different device to distinguish between their reliever and their preventer e.g. if they are blind, or have learning difficulties. Think about cost if the individual needs to pay for their prescriptions. Combination inhalers may be more economic for them. Also give advice about pre-payment schemes. The individual should be aware of how to use their devices differently when unwell, or to go and seek medical help if unable to use their device. Adolescents are a particular challenge, as 70% of them are thought to have concordance issues. Consider negotiating a compromise e.g. if preventer can be used once daily when control is good Concordance in general is a huge issue. Any issues, including psychosocial or financial issues need to be investigated and discussed to achieve any improvement in this area. Special Note If an individual is unable to use an MDI after 3 attempts consider: Using MDI with a spacer, also consider a Haleraid if there are any dexterity problems. Consider a breath actuated or dry powder device for reliever use. Remember a patient s ability to use an inhaler may change over time; therefore inhaler technique should be assessed annually. Patient choice!!! September

74 General Advice for All Inhaled Medication The individual must be sitting or standing in an upright position, prior to using their inhaler. Following inhalation the individual should hold their breath for 10 seconds or as long as possible prior to exhalation. If concordance or memory is thought to be an issue, then an inhaler with a dose counter may assist. Ensure that the individual replaces the dust caps on the devices when they are not in use. If a metered dose inhaler has not been used for 1 week or more, then it must be activated prior to using. Remember that CFC inhalers may clog, so give advice to wash the canister every week. If certain dry powdered devices are going to be exposed to high humidity conditions e.g. left beside a swimming pool, particularly in holiday destinations, or kept in bathrooms, it may need to be changed to an aerosol device. Special Note Every person is an individual. They need to be personally matched to their device and assessed with it. It is important that THEY feel comfortable and confident when using it. September

75 Advice for Using Inhaled Steroids To reduce the incidence of local side effects to the throat, advise the additional use of a spacer with all metered dose inhaler devices. The individual should rinse their mouth and spit not swallow immediately after taking their inhaler to reduce the chances of getting local side effects such as Oral Candida. If they have dentures these should be removed and cleaned to ensure any particles under the plate are removed. Consider the size of the spacer (does the individual find it too bulky). Consider the inhaled steroid, including the molecular size of the particle and lung deposition data. If the individual s condition is stable, can the dose of inhaled steroid be reduced? Special Note If the individual complains of a sore throat or hoarseness, consider all of the above. If they have a spacer are they actually using it and when was it last renewed? September

76 Supply of Inhalers Advice to stop individuals running out Advise the individual to always have at least 1 spare inhaler (depending on amount used) for all the inhaled medication they use regularly, in a secure cupboard. When they have to use an inhaler from the cupboard, advise them to order a replacement right away. Multidose use during an acute attack will greatly reduce contents of a metered dose inhaler. Remind patients to restock their MDI reliever after using it in acute attacks. Reassure the user that questioning about apparent overuse of their reliever by a health professional or pharmacist should not dter them from multidosing when appropriate. The individual may require several reliever inhalers, for example; to keep 1 in a drawer at work, at Nursery or school, in a jacket pocket or in the car. The individual should make their General Practitioner aware of the reason for requesting multiple reliever inhalers. Give advice regarding the effects of very high or very low temperatures on aerosol devices, as they may need to replace them. Also advise regarding the effect of humidity on some dry powdered devices, if they are left in a damp area as they may need to be replaced. Ensure the individual is aware of the need to activate their metered dose inhaler, if it has not been used for more than a week. Ensure the individual is aware of how many inhalers they require to take when going on holiday, and what to do if they require more when on holiday. September

77 How to Use a Metered Dose Inhaler (MDI) Remove the dust cap. Shake the inhaler gently. Breathe out slowly. Place the mouthpiece between your lips and start to breathe in slowly. Whilst breathing in, depress the canister, continuing to breathe in as deeply and evenly as possible. Hold your breath for as long as is comfortable, and breathe out through your nose. If another inhalation is required, repeat the above steps seconds later. Wipe the mouthpiece after use and replace the dust cap. Remove the canister and wash weekly to prevent blocking. If it is not used regularly depress the canister once before using. September

78 Potential Difficulties in Using a MDI Optimally The Inability to depress the inhaler - e.g. due to Arthritis, CVA or Parkinson s Disease. Manual dexterity or strength can be a problem with both children and adults. The inability to control and co-ordinate breathing, especially when the individual s condition is unstable. Observe for the Freon affect the individual will cough quite dramatically, when the aerosol mist hits the back of the throat. The Freon affect may even occur when using a spacer device. Children in particular may find this distressing. Special Note Correct technique requires co-ordination of depressing the inhaler and also breathing. Some individuals just cannot do it no matter how hard they try! September

79 How to Use a Metered Dose Inhaler with a Spacer Advantages or Benefits Assists with co-ordination and breathing control. Can sometimes reduce the Freon affect. Can help reduce the incidence of local side effects or Oral Candida if used with a mouthpiece. Can be used for high dose delivery (multi-dose) in acute severe attacks as effective as a nebuliser. Disadvantages The size - it can be bulky. Not always compatible with the type (make) of metered dose inhaler. Not very portable - will the individual use it all the time? How to Use a Spacer Remove the dust cap. Shake the inhaler gently, and place the mouthpiece in the end of the spacer. Breathe out slowly. Place the mouthpiece of the spacer between your lips, depress the canister, and breathe in slowly, deeply and as evenly as possible. Hold your breath for as long as is comfortable. If another inhalation is required, repeat the above steps seconds later. Wipe the mouthpiece after use and replace the dust cap. If the individual is unable to carry out the above steps then: Following depression of the canister, breathe in and out 5 times for each single inhalation (tidal breathing). Wait seconds in between inhalations. How to Use a Spacer with a Facemask This can be useful for patients who have comprehension difficulties or have difficulty keeping the mouthpiece between their lips eg following a CVA, or in the case of a young child. Usually a carer/parent is required to assist with the administration if this method of inhaler delivery is chosen. As far as possible ensure the individual breathes through their mouth while using the facemask to avoid drug deposition in the nose. The instructions for use are as above Special Note Each technique is as effective as the other is. Technique depends on the individual s ability and preference. Tidal breathing should be used when multiple dosing in an emergency. There is a one-way valve on spacers that permits breathing out without removing the mouthpiece from the mouth or mask from the face. The dose of drug delivered is not affected by doing this. September

80 Paediatric Advice Young children should use a spacer with a facemask, along with the tidal breathing technique until they are competent to take consistent, deep inspiratory breaths and are happy to use other inhaler devices. A spacer should still be provided for emergency use with their metered dose inhaler. They should have instructions for use as part of their self-management plan. Children vary in their acceptance of different spacers and their competence. This should be confirmed by observed use when delivered by patient or carer/parent. Most children over the age of 4 can use a spacer with a mouthpiece along with tidal breathing. September

81 Tips for Administering Inhalers to Young Children Parents often need advice about holding young children while administering inhalers: Giving the child time to be comfortable handling and trying the spacer alone before administering medication often helps. Teaching a parent or carer and letting the child see their trusted adult using the spacer with the MDI often helps give the child confidence and ensures the carer is competent in administering the medication. Holding the child with minimum restraint to avoid them struggling and repeating the process until familiar can help. If there is significant difficulty then help can be sought from the children s nurses based at the Children s Ward, Forth Valley Royal Hospital Tel: or the Community Children s Nurses Tel: September

82 Examples of Common Spacers Volumatic Aerochamber (Fits all makes of metered dose inhaler) Care of Spacers The spacer should be washed monthly in household detergent, and allowed to air dry, not dried with a cloth as this increases static. The white coating often seen is only drug residue, and individuals should be advised that the spacer is not dirty. The coating allows more drug delivery to the lungs. Priming is not currently recommended, as the amount of puffs advised varied from 2 puffs to 50 or more. The mouthpiece or facemask should be wiped following use. Ensure any facemask is the appropriate size for the patient to use comfortably. Spacers should be changed routinely as per manufacturer s advice, usually 6 monthly or yearly. September

83 How to Use the Haleraid with the Metered Dose Inhaler This is a metered dose inhaler accessory to assist patients who have difficulty depressing the canister e.g. those who are frail, have poor dexterity, arthritic hands previous CVA etc. Remove the dust cap from the metered dose inhaler. Open the Haleraid Fit the inhaler mouthpiece into the opening in the Haleraid. Close the Haleraid to fit snugly over the inhaler like a jacket. Squeeze the Haleraid lever to activate the inhaler. The Haleraid with metered dose inhaler can be used in conjunction with a spacer. The Haleraid can be washed in soapy water, and dried. Special Note There are 2 sizes of Haleraid. The White Haleraid is for 120 dose inhalers and is smaller in size. The Blue Haleraid is for 200 dose inhalers and is larger. The Haleraid does not fit all metered dose inhalers. The individual should have a separate Haleraid for each device to avoid difficulties removing the Haleraid from one device to another. The Haleraid is not a prescribable item and the individual may be required to pay for it. The cost is approximately 1. September

84 Breath Actuated Devices A vacuum operated trigger mechanism activates the drug. This is released when the patient breathes in. This removes the need for co-ordination of breathing. Potential Difficulties or Issues Individuals may have difficulties with the lever, or cap due to dexterity issues, secondary to a variety of conditions. Multiple Sclerosis Parkinson s CVA Arthritis September

85 How to Use the Easibreathe Device Optimum Inspiratory Effort Required l/min = low/medium Shake the inhaler gently. Open the cap (foot). Breathe out slowly. Place the mouthpiece between your lips. Do not cover the air vents with your fingers. Breathe in slowly and deeply. Do NOT stop breathing when the inhaler puffs the dose into your mouth. Continue breathing in as evenly as possible. Hold your breathe for as long as is comfortable, breathe out through your nose. Close the cap (foot). If another dose is required, wait 1 minute and repeat the above steps. Wipe the mouthpiece after use. Potential Difficulties with Using the Easibreathe Device Optimally If the individual has arthritis, or dexterity problems they may have difficulty with opening and closing the mouthpiece (foot) of the device. The device makes a very soft noise- some individuals do not think they have taken it. Some patients find the force of the metered dose causes them to catch their breath and makes the inhalation ineffective. Advantages The top can be unscrewed and used as a metered dose inhaler via a spacer in an emergency. The individual will require instruction to do this. September

86 How to use the Autohaler device Optimum Inspiratory Effort Required l/ min = low/medium Remove the dust cap. Shake the inhaler gently and push the lever on the top of the device up. Breathe out; place the mouthpiece between your lips. Do not cover the air vents at the bottom of the inhaler with your fingers. Breathe in as deeply and as evenly as possible. Continue breathing after the device has fired, a loud click will be heard. Do NOT stop breathing when the inhaler puffs the dose into your mouth. Hold your breathe for as long as is comfortable, breathe out through your nose. If another dose is required wait 1 minute and then repeat above. Clean the mouthpiece after use. Potential difficulties with using the Autohaler device optimally If the individual has arthritis, or dexterity problems they may have difficulty with lifting the lever on the top of the device, and removing the dust cap. The device makes quite a sharp, loud noise- some individuals stop breathing when the drug is released. Some cannot stop doing this despite practice. Advantages The noise can confirm to some individuals they have received their dose. Some individuals find that reassuring especially if their inspiratory effort is low. September

87 Dry Powder Inhalers (DPI) The individual breathing in activates the device. There is no associated Freon affect. There is no need for co-ordination of breathing with activating the drug in any way. If concordance or memory problems are an issue, most devices have a dose counter or sign to alert the inhaler is almost finished. Some devices may require a higher inspiratory effort to achieve optimum disposition of the drug in the lungs. September

88 How to Use the Accuhaler Device Optimum Inspiratory Effort Required l/ min = low/ medium To open, hold the outer case in one hand, place the thumb of the other hand on the thumb grip and push away until you hear a click. Hold the device level, with the mouthpiece towards you. Slide the lever on the side of the device away from you until it clicks. Each time the lever is pushed back a new blister is primed for inhalation. The dose counter will count down each time a blister is primed. Breathe out gently. Close lips firmly around the mouthpiece and suck in steadily and deeply. Hold your breathe for as long as is comfortable. Breathe out slowly through your nose. Close the Accuhaler by placing your thumb in the thumb grip and sliding it towards you until it clicks shut. If a second blister is required repeat the above steps. The dose counter counts down from 60 0 the last 5 doses are in red. This device is guaranteed humidity proof as the drug is contained in an individual foil blister. September

89 How to Use the Clickhaler Device Optimum Inspiratory Effort Required l/min = low Remove the mouthpiece cover. Shake the inhaler gently. Hold the inhaler upright with your thumb on the base and a finger on the push button on the top of the inhaler. Breathe out slowly (but not into the device). Place the mouthpiece in your mouth with your lips firmly closed around it. Activate the dose by pressing down on the button on the top of the inhaler. Breathe in through your mouth steadily and deeply. Hold your breathe for as long as possible, breathe out through your nose. If a second dose is required wait seconds and repeat the above. Replace the mouthpiece cover. The dose counter counts up from Once inhaler is removed from the foil pouch it must be used within 6 months. Wipe the mouthpiece after use. May be susceptible to humidity which could cause the inhaler to clog. September

90 How to Use the Turbohaler Device Optimum Inspiratory Effort Required l/min = moderate / high Remove the lid by unscrewing from device. Hold the Turbohaler upright and turn the bottom grip in either a clockwise or anticlockwise fashion until a click is heard, usually it turns twice once in each direction. Breathe out slowly and deeply, place the mouthpiece between your teeth and close lips around the mouthpiece. Holding the Turbohaler horizontally breathe in as quickly and deeply as possible. Ensure your lips do not cover air vents. Remove the device from mouth. Close your lips and hold your breath for as long as is comfortable, breathe out through your nose. If a second dose is required repeat the above steps. Replace the cap. Advise the individual that there will be no taste. There is a window with a red dose counter to advise when the inhaler is getting near to empty. Advise the individual that the inhaler will always make a noise when shaken even when empty due to the desiccant. Wipe the mouthpiece after use. May be susceptible to humidity which could cause the inhaler to clog. September

91 How to Use the Handihaler Device Optimum Inspiratory Effort Required l/min = low Open the dust cap and then the mouthpiece. Remove the capsule from the blister strip and place in the centre chamber, it does not matter which way up it is placed. Close the mouthpiece until a click is heard. Push in the green button at the side of the device once and release. Breathe out (do not breathe into mouthpiece) put the mouthpiece in your mouth and close your lips firmly around the mouthpiece. Breathe in slowly and deeply and listen for the capsule to gently rattle. Hold your breath for as long as possible; breathe out through your nose. Breathe in again as above, to ensure all the drugs is released from the capsule. Open the mouthpiece, tip out the used capsule and dispose of it. Close the mouthpiece. May be susceptible to humidity which could cause the inhaler to clog. Special Note Caution storage of capsules. The drug may be affected if the capsule is left exposed to the air for more than 10 days. Advise the individual to pull foil strip down to reveal one capsule at a time. Particularly important if the individual has been admitted to hospital for a number of days, and capsules left exposed. Advise to destroy them. September

92 How to Use the Twisthaler Device Optimal Inspiratory Effort Required 28 l / min = medium Before removing the white cap ensure the counter and the arrow on the base are in line with each other. Hold the inhaler upright, grip the base and turn the cap anticlockwise. As you remove the cap the dose counter will count down. Bring the inhaler to your mouth. Insert the mouthpiece in your mouth, close your lips around the mouth piece, breathe in rapidly and deeply. Remove the inhaler and hold your breath for as long as is comfortable, breathe out through your nose. Do NOT breathe out through the inhaler. Replace the cap immediately after each inhalation. For another dose, replace the cap and turn clockwise, gently pressing the cap until a click is heard, the arrow must be fully lined up. Wipe the mouthpiece after use. Avoid contact with water. 01 on counter means 1 dose left, at 00 the inhaler will lock, preventing use of an empty inhaler. May be susceptible to humidity which could cause the inhaler to clog. September

93 How to Use the Pulvinal Device Optimum Inspiratory Effort Required 28 l/min = medium Unscrew the cap, hold the inhaler upright and tap gently to level the powder. Press the blue button, on the side of the inhaler with one hand, and with the other rotate the inhaler anticlockwise through 180 until red mark shows through the hole in the mouthpiece (this is the dose loading position). Then rotate the inhaler back again until a click is heard. A green mark shows through the hole in mouthpiece (this is the dose delivery position). Breathe out deeply. Put the inhaler between your lips, while holding the inhaler upright. Breathe in through your mouth as quickly and deeply as possible. Hold your breath for as long as you are able; breathe out through your nose. Remove the inhaler and replace protective cap. For a second dose repeat the above steps. When the red knobs become visible on the bottom of the inhaler, this means it needs replacing, as the correct dose delivery cannot be guaranteed. The Presence of powder in your mouth and slight sweet taste confirms the dose has been taken. If you load an extra dose in error, turn the inhaler upside down and tap the powder from the inhaler on a hard surface, to empty the chamber. Following use, wipe the mouthpiece with a dry tissue. May be susceptible to humidity which could cause the inhaler to clog. Do not rinse the device September

94 How to Use the Novolizer Device Optimum Inspiratory Effort Required: l/min = moderate/high Inserting a cartridge into the device (only do this immediately before first use) On the top of the Novolizer device there is a lid. Remove this by squeezing both sides of the ribbed surface. Move the lid forward and lift off. With the dosage counter facing the mouthpiece insert the cartridge into the device. Replace the lid using the lid guides, push the lid down to be level with the button opposite the mouthpiece. It will click into place. Using the Novolizer device 1. Keep the device level and remove the mouthpiece cap by squeezing the sides gently and sliding it forward. 2. Press the button at the back of the device down until you hear a click. The window below the dosage counter will turn from red to green. 3. Before putting the inhaler in your mouth breathe out. 4. Put your lips round the mouthpiece and inhale with a strong deep breath. You should hear a loud click. Continue inhaling as strong and deep as possible. Hold your breath for a few seconds and then breathe out slowly. The dosage counter will turn from green back to red. 5. Repeat steps 2 to 4 if a further dose is required. 6. Replace the mouthpiece cap. Special Note The cartridge should be replaced when empty or every 3 months. Potential Difficulties with Using the Novolizer Device Difficulty inserting cartridge Not replacing cartridge every 3 months. Advantages Dosage indicator Colour indicator changes when inspiration effort is correct Replaceable drug cartridge September

95 How to Use the Easyhaler Device Optimum Inspiratory Effort Required: 28 l/min = low 1. Shake the device and then hold in an upright position. 2. Remove the mouthpiece cap. 3. Press the top of the device down once. You will hear a click. 4. Breathe out and then place the mouthpiece between your teeth and close your lips round it. 5. Breathe strong and deep through the device and hold your breath for 5-10 seconds. Remove the device from your mouth and breathe out. 6. If another dose is required repeat steps 3 to Replace the mouthpiece cap. Special Note The device should be replaced within 6 months of opening the foil pack. Potential difficulties with use of the Easyhaler Device not loaded or primed correctly Inhalation rate too slow or too fast. Advantages Easy to use Dose counter Window to view the powder September

96 Peak Flow Monitoring How to Measure Peak Flow Rate When should patients monitor their peak flows? Set the marker to zero. The individual should be standing, if they are unable to stand this should be recorded alongside the measurement, so it is meaningful for the future. The individual should hold the meter horizontally in front of their mouth. They should breathe in as deeply and fully as possible. Place the mouthpiece firmly between the teeth and close lips around the mouthpiece. Advise to breathe out as hard and as fast as possible. The reading should be noted as shown by the marker. This should be repeated twice more. The highest reading should be recorded, in their peak flow diary. Special Note All asthmatics should be aware of their usual peak flow rate. This should be recorded in their self-management plan. Peak flow meters should be changed every 3 years. Use the individual s own peak flow meter whenever possible to ensure valid comparison with home recording. If not available ensure the meter used is recorded in the notes as the low range meter may give a higher reading due to the narrower mouthpiece used September

97 When Should Patients Monitor their Peak Flows? Peak flow monitoring is used to aid in the diagnosis of asthma. Newly diagnosed asthmatics should monitor and record their peak flows to assess response to medication, and help them to learn about self - management and control of their asthma symptoms. Individuals may be requested to carry out serial peak flow monitoring for a number of weeks to aid in the diagnosis of occupational asthma. This should normally only be carried out if requested by a respiratory physician. If the individual has attended A&E, their GP surgery, or been admitted to hospital for an exacerbation of their asthma, they might be required to monitor and record their peak flows for a number of weeks following this. The frequency will be determined by the individual's condition, in discussion with their doctor or nurse. If the individual has used a nebuliser or multi dosed via a spacer, for emergency use their peak flow should be monitored closely. If the individual has poor perception of their asthma symptoms, or has been previously ventilated, they should be encouraged to monitor and record their peak flow more regularly even when well. This will require negotiation between the health care professional and the individual, depending on the severity of their asthma and what the individual wishes to do. This should be recorded on the self-management plan. If the individual gets a cold or virus, or people they live with (in particular young children) get a cold or virus, they should monitor their peak flow and symptoms to ensure they remain in control of their asthma. Special note Peak flow monitoring should include recording of typical asthma symptoms, e.g. night-time wakening etc and the amount of reliever medication used per day or per week. Any triggers identified should be recorded, especially if allergic e.g. if exposed to a dog. If women are possibly affected by their menstrual cycle this should also be recorded. September

98 Peak Expiratory Flow Rate Normal Values September

99 Peak Flow Measurements in Children Peak flow recording can be used in the same way for children as for adults provided the child can understand and perform the maximal expiratory effort reliably. Most children over the age of 5 can do this and for them the peak flow diary and PEFR based self-management plan is useful. As in adults expected PEFR ranges change with age and height (see page 30). Height adjusted standard should be revised at least annually when the child s growth velocity is reviewed. A low range Peak Flow Meter is appropriate for younger children. Many young children are unable to perform peak flow reliably when they feel breathless and so the use of PEFR measurements for deciding on additional treatment or action may be unhelpful. It can be very distressing for the child to be asked to perform forced expiration when this induces a coughing bout or respiratory distress. - In these circumstances treatment plans based on symptoms or signs of respiratory distress are more appropriate. The Peak Flow can be reintroduced when the child is recovering to confirm return to usual airway function. Peak flow is useful as a tool to confirm exercise induced bronchospasm or significance of uncertain symptoms when the child is not acutely unwell. As in adults, children with asthma and their parents/carers should be made aware of their usual peak flow rate. This should be recorded in their self-management plan if this is appropriate. Special Note Many children over the age of 4 can perform a peak flow manoeuvre when they are well, with simple instruction and encouragement. However they can easily be confused about the different requirements for inhaling their medication and exhaling for PEFR. They are very keen to please and may end up blowing hard into their spacer. It is more important that the use of inhaled medication is reliable and the child is confident in its effect and so attempts to achieve PEFR recordings should be cautious and only encouraged under supervision if the child and parents are competent and find the information useful. September

100 Paediatric Normal Values September

101 8.2 NHS Forth Valley Guideline for the Management of Asthma September 2013

102 9 NHS Forth Valley Guideline for the Management of Asthma Patient Recall Process in Primary Care Asthma Screening Protocol Once per month run search and send recall letters for review Reset review period in screening protocol Enter result: - Screening Invite - not attended Offer next appointment in one years time Enter review data in clinical patient information system* or paper-based tool Patient responded to 1st recall Yes No Direct contact discounted by clinician or follow-up still declined by patient Patient responded to 2nd recall Yes No Pass case notes to responsible clinician to review need for direct contact No Patient responded to 3rd recall Yes Patient responds to follow-up September 2013

103 10 NHS Forth Valley Guideline for the Management of Asthma Self Management Over 5 years of age: Self Management and Patient Information Local self management plans are available to download and adapt in electronic format: Long Term Plan Short Term Plan (following exacerbation) SMART Under 5 years of age: The NHS Forth Valley Airways MCN recommends the use of the Asthma UK Asthma Management Plan for under 5 s. It is free to download and print from the Asthma UK website Direct link: Peak Flow Diaries Peak Flow Diaries are available free of charge from: Elaine Haston, Health Promotion Department [email protected] Tel: Patient Information NHS Forth Valley has developed a series of patient information leaflets which are available to download and print. Leaflet 1 What is Asthma? Leaflet 2 Symptoms of Asthma Leaflet 3 Asthma Triggers Leaflet 4 Tests for Asthma Leaflet 5 Medication for Asthma (Part 1) Leaflet 6 Medication for Asthma (Part 2) Leaflet 7 Holiday Advice Leaflet 8 Asthma and Pregnancy September 2013

104 10 Under Fives NHS Forth Valley Guideline for the Management of Asthma NHS Forth Valley Airways MCN recommend the use of Asthma UK s publication Asthma in the Under Fives. It contains basic information for parents/carers of children less than five years of age. The information leaflets are available free for parents/carers to order from the Asthma UK website: Direct link: September 2013

105 NHS Education for Scotland Portal 11.1 NHS Forth Valley Guideline for the Management of Asthma Education and Continuing Professional Development Nurse Education: Nurses using this guideline would be registered Level 1 and either hold or be working towards a recognised diploma module in Asthma Care. The modules are available through either Education for Health and Respiratory Education UK, listed below. Education for Health The Athenaeum 10 Church Street Warwick CV34 4AB Tel: for general enquiries or submit an enquiry via contact us section of the website: Respiratory Education UK Unit 45 Sixth Avenue University Hospital Aintree Lower Lane Liverpool L9 7AL Tel: for general enquiries or Website: Pharmacist Education: Pharmacists can access elearning through NES. There are currently two asthma modules available in this format. Link below for elearning portal. NHS Education for Scotland Portal Further information can be obtained from NHS Education for Scotland (Pharmacy) Westport 102 West Port Edinburgh EH3 9DN Tel: Fax: NHS Education for Scotland September 2013

106 11.2 NHS Forth Valley Guideline for the Management of Asthma Organisation and Delivery of Care and Audit For information on the organisation and delivery of asthma care and audit, please refer to section 8 of the SIGN/BTS British Guideline on the Management of Asthma: Information and Support If you would like advice or support in relation to quality improvement activities, please contact the Quality Improvement Service: (Euro House) [email protected] The NHS Forth Valley Quality Improvement intranet/internet site also provides information resources in relation to quality improvement and hints and tips for undertaking clinical audit. September 2013

107 Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact For other formats contact , text , fax or - [email protected]