QRG 141 British guideline on the mngement of sthm Quik Referene Guide Otoer 2014 Evidene
British Thori Soiety Sottish Interollegite Guidelines Network British guideline on the mngement of sthm Quik Referene Guide Revised Otoer 2014
This Quik Referene Guide provides summry of the min reommendtions in SIGN 141 British guideline on the mngement of sthm. Reommendtions re grded A B C D to indite the strength of the supporting evidene. Good prtie points re provided where the guideline development group wishes to highlight speifi spets of epted linil prtie. Detils of the evidene supporting these reommendtions n e found in the full guideline, ville on the SIGN wesite: www.sign..uk. This Quik Referene Guide is lso ville s prt of the SIGN Guidelines pp. Aville from Android Mrket ISBN 978 1 909103 29 0 First pulished 2003 Revised edition pulished 2014 SIGN nd the BTS onsent to the photoopying of this QRG for the purpose of implementtion in the NHS in Englnd, Wles, Northern Irelnd nd Sotlnd. British Thori Soiety 17 Doughty Street, London WC1N 2PL www.rit-thori.org.uk Sottish Interollegite Guidelines Network Gyle Squre, 1 South Gyle Cresent, Edinurgh EH12 9EB
DIAGNOSIS IN hildren Initil linil ssessment B Fous the initil ssessment in hildren suspeted of hving sthm on: y presene of key fetures in history nd exmintion y reful onsidertion of lterntive dignoses. Clinil fetures tht inrese the proility of sthm y More thn one of the following symptoms - wheeze, ough, diffiulty rething, hest tightness - prtiulrly if these re frequent nd reurrent; re worse t night nd in the erly morning; our in response to, or re worse fter, exerise or other triggers, suh s exposure to pets; old or dmp ir, or with emotions or lughter; or our prt from olds y Personl history of topi disorder y Fmily history of topi disorder nd/or sthm y Widespred wheeze herd on usulttion y History of improvement in symptoms or lung funtion in response to dequte therpy. Clinil fetures tht lower the proility of sthm y Symptoms with olds only, with no intervl symptoms y Isolted ough in the sene of wheeze or diffiulty rething y History of moist ough y Prominent dizziness, light-hededness, peripherl tingling y Repetedly norml physil exmintion of hest when symptomti y Norml pek expirtory flow (PEF) or spirometry when symptomti y No response to tril of sthm therpy y Clinil fetures pointing to lterntive dignosis With thorough history nd exmintion, hild n usully e lssed into one of three groups: y high proility dignosis of sthm likely y low proility dignosis other thn sthm likely y intermedite proility dignosis unertin. Reord the sis on whih dignosis of sthm is suspeted. Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 1
DIAGNOSIS IN hildren high proility of sthm In hildren with high proility of sthm: y strt tril of tretment y review nd ssess response y reserve further testing for those with poor response. low proility of sthm In hildren with low proility of sthm, onsider more detiled investigtion nd speilist referrl. intermedite proility of sthm In hildren with n intermedite proility of sthm who n perform spirometry nd hve evidene of irwys ostrution, ssess the hnge in FEV 1 or PEF in response to n inhled ronhodiltor (reversiility) nd/or the response to tril of tretment for speified period: y if there is signifint reversiility, or if tretment tril is enefiil, dignosis of sthm is prole. Continue to tret s sthm, ut im to find the minimum effetive dose of therpy. At lter point, onsider tril of redution, or withdrwl, of tretment. y if there is no signifint reversiility, nd tretment tril is not enefiil, onsider tests for lterntive onditions. In hildren with n intermedite proility of sthm who n perform spirometry nd hve no evidene of irwys ostrution: y onsider testing for topi sttus, ronhodiltor reversiility nd if possile, ronhil hyper-responsiveness using methholine, exerise or mnnitol y onsider speilist referrl. In hildren with n intermedite proility of sthm who nnot perform spirometry, offer tril of tretment for speified period: y if tretment is enefiil, tret s sthm nd rrnge review y if tretment is not enefiil, stop sthm tretment, nd onsider tests for lterntive onditions nd speilist referrl. In some hildren, prtiulrly the under 5s, there is insuffiient evidene t the first onsulttion to mke firm dignosis of sthm ut no fetures to suggest n lterntive dignosis. Possile pprohes (dependent on frequeny nd severity of symptoms) inlude: y wthful witing with review y tril of tretment with review y spirometry nd reversiility testing. Rememer The dignosis of sthm in hildren is linil one. It is sed on reognising hrteristi pttern of episodi symptoms in the sene of n lterntive explntion. 2 Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl
Presenttion with suspeted sthm in hildren Clinil ssessment HIGH PROBABILITY: dignosis of sthm likely INTERMEDIATE PROBABILITY: dignosis unertin or poor response to sthm tretment LOW PROBABILITY: other dignosis likely Consider referrl Tril of sthm tretment +VE Consider tests of lung funtion* nd topy -VE Investigte/ tret other ondition Response? Response? Yes No No Yes Continue tretment nd find minimum effetive dose Assess ompline nd inhler tehnique. Consider further investigtion nd/or referrl Further investigtion. Consider referrl Continue tretment * Lung funtion tests inlude spirometry efore nd fter ronhodiltor (test of irwy reversiility) nd possile exerise or methholine hllenge (tests of irwy responsiveness). Most hildren over the ge of 5 yers n perform lung funtion tests. Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 3
DIAGNOSIS IN ADULTS Initil ssessment The dignosis of sthm is sed on the reognition of hrteristi pttern of symptoms nd signs nd the sene of n lterntive explntion for them. The key is to tke reful linil history. Bse initil dignosis on reful ssessment of symptoms nd mesure of irflow ostrution: y in ptients with high proility of sthm move stright to tril of tretment. Reserve further testing for those whose response to tril of tretment is poor. y in ptients with low proility of sthm, whose symptoms re thought to e due to n lterntive dignosis, investigte nd mnge ordingly. Reonsider the dignosis of sthm in those who do not respond. y in ptients with n intermedite proility of sthm the preferred pproh is to rry out further investigtions, inluding n expliit tril of tretments for speified period, efore onfirming dignosis nd estlishing mintenne tretment. d Spirometry is the preferred initil test to ssess the presene nd severity of irflow ostrution. Clinil fetures tht inrese the proility of sthm y More thn one of the following symptoms: wheeze, rethlessness, hest tightness nd ough, prtiulrly if: symptoms worse t night nd in the erly morning symptoms in response to exerise, llergen exposure nd old ir symptoms fter tking spirin or et lokers y History of topi disorder y Fmily history of sthm nd/or topi disorder y Widespred wheeze herd on usulttion of the hest y Otherwise unexplined low FEV 1 or PEF (historil or seril redings) y Otherwise unexplined peripherl lood eosinophili Clinil fetures tht lower the proility of sthm y Prominent dizziness, light-hededness, peripherl tingling y Chroni produtive ough in the sene of wheeze or rethlessness y Repetedly norml physil exmintion of hest when symptomti y Voie disturne y Symptoms with olds only y Signifint smoking history (ie > 20 pk-yers) y Crdi disese y Norml PEF or spirometry when symptomti* * A norml spirogrm/spirometry when not symptomti does not exlude the dignosis of sthm. Repeted mesurements of lung funtion re often more informtive thn single ssessment. 4 Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl
Presenttion with suspeted sthm in dults Presenttion with suspeted sthm Clinil ssessment inluding spirometry (or PEF if spirometry not ville) HIGH PROBABILITY: dignosis of sthm likely INTERMEDIATE PROBABILITY: dignosis unertin LOW PROBABILITY: other dignosis likely FEV 1 / FVC <0.7 FEV 1 / FVC >0.7 Tril of tretment* Investigte/ tret other ondition Response? Response? Yes No No Yes Continue tretment Assess dherene nd inhler tehnique. Consider further investigtion nd/or referrl Further investigtion. Consider referrl Continue tretment Applies only to dults * See setion 2.5.1 See Tle 6 Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 5
Supported self-mngement Asthm tion plns Self-mngement edution inorporting written personlised sthm tion plns (PAAPs) improves helth outomes for people with sthm. Self-mngement in prtie Asthm UK tion plns nd resoures n e downloded from the their wesite: www.sthm.org.uk/ontrol. A A All people with sthm (nd/or their prents or rers) should e offered self-mngement edution whih should inlude written personlised sthm tion pln nd e supported y regulr professionl review. In dults, written personlised sthm tion plns my e sed on symptoms nd/or pek flows: symptom-sed plns re generlly preferle for hildren. y A hospitl dmission represents window of opportunity to review self mngement skills. No ptient should leve hospitl without written personlised sthm tion pln. y An ute onsulttion offers the opportunity to determine wht tion the ptient hs lredy tken to del with the sthm ttk. Their self mngement strtegy my e reinfored or refined nd the need for onsolidtion t routine follow up onsidered. y A onsulttion for n upper respirtory trt infetion or other known trigger is n opportunity to reherse with the ptient their self mngement in the event of their sthm deteriorting. y Edution should inlude personlised disussion of issues suh s trigger voidne nd hieving smoke-free environment to support people nd their fmilies living with sthm. y Brief simple edution linked to ptient gols is most likely to e eptle to ptients. SELF-MANAGEMENT IN SPECIFIC PATIENT GROUPS A A A B Self-mngement edution, supported y written personlised sthm tion pln, should e offered to ll ptients on generl prtie tive sthm registers. Primry re prties should ensure tht they hve trined professionls nd n environment onduive to providing supported self mngement. Prior to dishrge, inptients should reeive written personlised sthm tion plns, given y helthre professionls with expertise in providing sthm edution. Culturlly pproprite supported self-mngement edution should e provided for people with sthm in ethni minority groups. Addressing lnguge rriers is insuffiient. ADHERENCE AND CONCORDANCE A Adherene to long-term sthm tretment should e routinely nd regulrly ddressed y ll helthre professionls within the ontext of omprehensive progrmme of essile protive sthm re. Computer repet-presriing systems provide prtil index of dherene nd should e used in onjuntion with non-judgementl disussion out dherene. IMPLEMENTATION IN PRACTICE B Commissioners nd providers of servies for people with sthm should onsider how they n develop n orgnistion whih prioritises nd tively supports self mngement. This should inlude strtegies to protively engge nd empower ptients nd trin nd motivte professionls s well s providing n environment tht promotes self-mngement nd monitors implementtion. 6 Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl
NON-PHARMACOLOGICAL MANAGEMENT There is ommon pereption mongst ptients nd rers tht there re numerous environmentl, dietry nd other triggers of sthm nd tht voiding these triggers will improve sthm nd redue the requirement for phrmotherpy. Evidene tht non-phrmologil mngement is effetive n e diffiult to otin nd more well ontrolled intervention studies re required. PRIMARY PREVENTION Primry prevention reltes to interventions introdued efore the onset of disese nd designed to redue its inidene. Mesures to redue in utero or erly life exposure to single erollergens, suh s house dust mites or pets, or single food llergens, re not reommended for the primry prevention of sthm. For hildren t risk of developing sthm, omplex, multi-feted interventions trgeting multiple llergens my e onsidered in fmilies le to meet the osts, demnds nd inonveniene of suh demnding progrmme. In the sene of ny evidene of enefit nd given the potentil for dverse effets, mternl food llergen voidne during pregnny nd lttion is not reommended s strtegy for preventing hildhood sthm. There is insuffiient evidene to mke reommendtion relting to the following s strtegy for preventing hildhood sthm: y mternl dietry supplementtion during pregnny y the use of dietry proiotis in pregnny. Brest feeding should e enourged for its mny enefits, inluding potentil protetive effet in reltion to erly sthm. Prents nd prents-to-e should e dvised of the mny dverse effets whih smoking hs on their hildren inluding inresed wheezing in infny nd inresed risk of persistent sthm. SECONDARY PREVENTION Seondry prevention reltes to interventions introdued fter the onset of disese to redue its impt. Physil nd hemil methods of reduing house dust mite levels in the home (inluding riides, mttress overs, vuum-lening, heting, ventiltion, freezing, wshing, ir-filtrtion nd ionisers) re ineffetive nd should not e reommended y helthre professionls. Prents with sthm should e dvised out the dngers to themselves nd to their hildren with sthm, of smoking, nd e offered pproprite support to stop smoking. Weight loss in overweight ptients hs mny helth enefits, nd should e supported in people with sthm; if suessful, it my led to improvements in sthm symptoms. Air ionisers re not reommended for the tretment of sthm. Brething exerise progrmmes (inluding physiotherpist-tught methods) n e offered to people with sthm s n djuvnt to phrmologil tretment to improve qulity of life nd redue symptoms. Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 7
PHARMACOLOGICAL MANAGEMENT The im of sthm mngement is ontrol of the disese. Complete ontrol is defined s: y no dytime symptoms y no night time wkening due to sthm y no need for resue medition y no sthm ttks y no exertions y no limittions on tivity inluding exerise y norml lung funtion (in prtil terms FEV 1 nd/or PEF >80% predited or est) y miniml side effets from medition. THE STEPWISE APPROACH 1. Strt tretment t the step most pproprite to initil severity. 2. Ahieve erly ontrol 3. Mintin ontrol y: stepping up tretment s neessry stepping down when ontrol is good. Before inititing new drug therpy prtitioners should hek dherene with existing therpies, inhler tehnique nd eliminte trigger ftors. Until My 2009 ll doses of inhled ortiosteroids were referened ginst elometsone dipropionte (BDP) given vi CFC-MDIs. As BDP-CFC is now unville, the referene inhled ortiosteriod will e the BDP-HFA produt, whih is ville t the sme dosge s BDP-CFC. Adjustments to doses will hve to e mde for other inhler devies nd other ortiosteroid moleules. COMBINATION INHALERS In effiy studies, where there is generlly good dherene, there is no differene in effiy in giving inhled ortiosteriod nd long-ting β 2 gonist in omintion or in seprte inhlers. In linil prtie, however, it is generlly onsidered tht omintion inhlers id dherene nd lso hve the dvntge of gurnteeing tht the long-ting β 2 gonist is not tken without the inhled ortiosteroid. Comintion inhlers re reommended to: y gurntee tht the long-ting β 2 gonist is not tken without inhled ortiosteroid y improve inhler dherene. STEPPING DOWN y Regulr review of ptients s tretment is stepped down is importnt. When deiding whih drug to step down first nd t wht rte, the severity of sthm, the side effets of the tretment, time on urrent dose, the enefiil effet hieved, nd the ptient s preferene should ll e tken into ount. y Ptients should e mintined t the lowest possile dose of inhled ortiosteroid. Redution in inhled ortiosteroid dose should e slow s ptients deteriorte t different rtes. Redutions should e onsidered every three months, deresing the dose y pproximtely 25-50% eh time. EXERCISE INDUCED ASTHMA For most ptients, exerise-indued sthm is n expression of poorly ontrolled sthm nd regulr tretment inluding inhled ortiosteroids should e reviewed. If exerise is speifi prolem in ptients tking inhled ortiosteroids who re otherwise well ontrolled, onsider dding one of the following therpies: y leukotriene reeptor ntgonists y long-ting β 2 gonists y sodium romoglite or nedoromil sodium y orl β 2 gonists y theophyllines. Immeditely prior to exerise, inhled short-ting β 2 gonists re the drug of hoie. 8 Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl
Summry of stepwise mngement in dults Ptients should strt tretment t the step most pproprite to the initil severity of their sthm. Chek dherene nd reonsider dignosis if response to tretment is unexpetedly poor. Inhled short-ting β 2 gonist s required STEP 1 Mild intermittent sthm Add inhled ortiosteroid 200-800 mirogrms/dy* 400 mirogrms is n pproprite strting dose for mny ptients Strt t dose of inhled ortiosteroid pproprite to severity of disese. STEP 2 Regulr preventer therpy 1. Add inhled long-ting β 2 gonist (LABA) 2. Assess ontrol of sthm: good response to LABA - ontinue LABA enefit from LABA ut ontrol still indequte - ontinue LABA nd inrese inhled ortiosteroid dose to 800 mirogrms/dy* (if not lredy on this dose) no response to LABA - stop LABA nd inrese inhled ortiosteroid to 800 mirogrms/dy.* If ontrol still indequte, institute tril of other therpies, leukotriene reeptor ntgonist or SR theophylline 1. Add inhled long-ting STEP 3 β Initil dd-on therpy Consider trils of: inresing inhled ortiosteroid up to 2,000 mirogrms/dy* ddition of fourth drug eg leukotriene reeptor ntgonist, SR theophylline, β 2 gonist tlet STEP 4 Persistent poor ontrol Use dily steroid tlet in lowest dose providing dequte ontrol Mintin high dose inhled ortiosteroid t 2,000 mirogrms/dy* Consider other tretments to minimise the use of steroid tlets Refer ptient for speilist re STEP 5 Continuous or frequent use of orl steroids * BDP or equivlent MOVE UP TO IMPROVE CONTROL AS NEEDED MOVE DOWN TO FIND AND MAINTAIN LOWEST CONTROLLING STEP SYMPTOMS vs TREATMENT Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 9
Summry of stepwise mngement in hildren ged 5-12 yers Inhled short-ting β 2 gonist s required STEP 1 Mild intermittent sthm Add inhled ortiosteroid 200-400 mirogrms/dy* (other preventer drug if inhled ortiosteroid nnot e used) 200 mirogrms is n pproprite strting dose for mny ptients Strt t dose of inhled ortiosteroid pproprite to severity of disese. STEP 2 Regulr preventer therpy 1. Add inhled long-ting β 2 gonist β (LABA) 2. Assess ontrol of sthm: good response to LABA - ontinue LABA enefit from LABA ut ontrol still indequte - ontinue LABA nd inrese inhled ortiosteroid dose to 400 mirogrms/dy* (if not lredy on this dose) no response to LABA - stop LABA nd inrese inhled ortiosteroid to 400 mirogrms/dy.* If ontrol still indequte, institute tril of other therpies, leukotriene reeptor ntgonist or SR theophylline 1. Add inhled long-ting STEP 3 β Initil dd-on therpy Inrese inhled ortiosteroid up to 800 mirogrms/dy* STEP 4 Persistent poor ontrol Use dily steroid tlet in lowest dose providing dequte ontrol Mintin high dose inhled ortiosteroid t 800 mirogrms/dy* Refer to respirtory peditriin STEP 5 Continuous or frequent use of orl steroids * BDP or equivlent MOVE UP TO IMPROVE CONTROL AS NEEDED Ptients should strt tretment t the step most pproprite to the initil severity of their sthm. Chek dherene nd reonsider dignosis if response to tretment is unexpetedly poor. MOVE DOWN TO FIND AND MAINTAIN LOWEST CONTROLLING STEP SYMPTOMS vs TREATMENT 10 Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl
Summry of stepwise mngement in hildren less thn 5 yers MOVE UP TO IMPROVE CONTROL AS NEEDED Ptients should strt tretment t the step most pproprite to the initil severity of their sthm. Chek dherene nd reonsider dignosis if response to tretment is unexpetedly poor. Inhled short-ting β 2 gonist s required Add inhled ortiosteroid 200-400 mirogrms/dy* or leukotriene reeptor ntgonist if inhled ortiosteroid nnot e used. Strt t dose of inhled ortiosteroid pproprite to severity of disese. 1. In those Add inhled hildren long-ting tking inhled β ortiosteroid 200-400 mirogrms/dy onsider ddition of leukotriene reeptor ntgonist. In those hildren tking leukotriene reeptor ntgonist lone reonsider ddition of n inhled ortiosteroid 200-400 mirogrms/dy. Refer to respirtory peditriin. MOVE DOWN TO FIND AND MAINTAIN LOWEST CONTROLLING STEP In hildren under 2 yers onsider proeeding to step 4. STEP 1 Mild intermittent sthm STEP 2 Regulr preventer therpy 1. Add inhled long-ting STEP 3 β Initil dd-on therpy SYMPTOMS vs TREATMENT STEP 4 Persistent poor ontrol * BDP or equivlent Higher nominl doses my e required if drug delivery is diffiult Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 11
INHALER DEVICES TECHNIQUE AND TRAINING Presrie inhlers only fter ptients hve reeived trining in the use of the devie nd hve demonstrted stisftory tehnique. β 2 AGONIST DELIVERY ACUTE ASTHMA A A B Children nd dults with mild nd moderte sthm ttks should e treted y pmdi + sper with doses titrted ording to linil response. STABLE ASTHMA A In hildren ged 5-12, pmdi + sper is s effetive s ny other hnd held inhler. A In dults pmdi ± sper is s effetive s ny other hnd held inhler, ut ptients my prefer some types of DPI. INHALED CORTICOSTEROIDS FOR STABLE ASTHMA A In hildren ged 5-12 yers, pmdi + sper is s effetive s ny DPI. A In dults, pmdi ± sper is s effetive s ny DPI. PRESCRIBING DEVICES y The hoie of devie my e determined y the hoie of drug y If the ptient is unle to use devie stisftorily, n lterntive should e found y The ptient should hve their ility to use the presried inhler devie ssessed y ompetent helthre professionl y The medition needs to e titrted ginst linil response to ensure optimum effiy y Ressess inhler tehnique s prt of strutured linil review. Presriing mixed inhler types my use onfusion nd led to inresed errors in use. Using the sme type of devie to deliver preventer nd reliever tretments my improve outomes. INHALER DEVICES in hildren In young hildren, little or no evidene is ville on whih to se reommendtions. In hildren, pmdi nd sper re the preferred method of delivery of β 2 gonists or inhled ortiosteroids. A fe msk is required until the hild n rethe reproduily using the sper mouthpiee. Where this is ineffetive neuliser my e required. 12 Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl
ASSESSMENT of severe sthm MANAGEMENT OF ACUTE ASTHMA IN ADULTS B Helthre professionls must e wre tht ptients with severe sthm nd one or more dverse psyhosoil ftors re t risk of deth. INITIAL ASSESSMENT MODERATE ASTHMA inresing symptoms PEF >50-75% est or predited no fetures of ute severe sthm ACUTE SEVERE ASTHMA Any one of: y PEF 33-50% est or predited y respirtory rte 25/min y hert rte 110/min y inility to omplete sentenes in one reth LIFE-THREATENING ASTHMA In ptient with severe sthm ny one of: y PEF <33% est or predited y SpO 2 <92% y PO 2 <8 kp y norml PCO 2 (4.6-6.0 kp) y silent hest y ynosis y poor respirtory effort y rrhythmi y exhustion, ltered onsious level y hypotension NEAR-FATAL ASTHMA Rised PCO 2 nd/or requiring mehnil ventiltion with rised infltion pressures Clinil fetures PEF or FEV 1 Pulse oximetry Blood gses (ABG) Chest X-ry severe rethlessness (inluding too rethless to omplete sentenes in one reth), thypnoe, thyrdi, silent hest, ynosis or ollpse None of these singly or together is speifi nd their sene does not exlude severe ttk PEF or FEV 1 re useful nd vlid mesures of irwy lire. PEF expressed s % of the ptient s previous est vlue is most useful linilly. In the sene of this, PEF s % of predited is rough guide Oxygen sturtion (SpO 2 ) mesured y pulse oximetry determines the dequy of oxygen therpy nd the need for rteril lood gs mesurement (ABG). The im of oxygen therpy is to mintin SpO 2 94-98% Ptients with SpO 2 <92% or other fetures of life-thretening sthm require ABG mesurement Chest X-ry is not routinely reommended in ptients in the sene of: - suspeted pneumomedistinum or pneumothorx - suspeted onsolidtion - life-thretening sthm - filure to respond to tretment stisftorily - requirement for ventiltion Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 13
CRITERIA FOR ADMISSION MANAGEMENT OF ACUTE ASTHMA IN ADULTS Admit ptients with ny feture of life-thretening or ner-ftl sthm ttk. Admit ptients with ny feture of severe sthm ttk persisting fter initil tretment. Ptients whose pek flow is greter thn 75% est or predited one hour fter initil tretment my e dishrged from ED, unless there re other resons why dmission my e pproprite. TREATMENT of ute sthm OXYGEN STEROID THERAPY B Give steroids in dequte doses in ll ses of ute sthm ttk. Continue prednisolone 40-50 mg dily for t lest five dys or until reovery. OTHER THERAPIES ygive supplementry oxygen to ll hypoxemi ptients with ute severe sthm to mintin n SpO 2 level of 94-98%. Lk of pulse oximetry should not prevent the use of oxygen. y In hospitl, mulne nd primry re, neulisers for giving neulised β 2 gonist ronhodiltors should preferly e driven y oxygen. Neulised mgnesium is not reommended for tretment in dults with ute sthm. Consider giving single dose of IV mgnesium sulphte to ptients with: y ute severe sthm (PEF <50% est or predited) who hve not hd good initil response to inhled ronhodiltor therpy. Mgnesium sulphte (1.2-2 g IV infusion over 20 minutes) should only e used following onsulttion with senior medil stff. Routine presription of ntiiotis is not indited for ptients with ute sthm. β 2 AGONIST BRONCHODILATORS IPRATROPIUM BROMIDE Use high-dose inhled β 2 gonists s first line gents in ptients with ute sthm nd dminister s erly s possile. Reserve intrvenous β 2 gonists for those ptients in whom inhled therpy nnot e used relily. In ptients with ute sthm with lifethretening fetures the neulised route (oxygen-driven) is reommended. In severe sthm tht is poorly responsive to n initil olus dose of β 2 gonist, onsider ontinuous neulistion with n pproprite neuliser. Add neulised iprtropium romide (0.5 mg 4-6 hourly) to β 2 gonist tretment for ptients with ute severe or lifethretening sthm or those with poor initil response to β 2 gonist therpy. REFERRAL TO INTENSIVE CARE Refer ny ptient: y requiring ventiltory support y with ute severe or life-thretening sthm, who is filing to respond to therpy, s evidened y: - deteriorting PEF - persisting or worsening hypoxi - hyperpni - ABG nlysis showing ph or H + - exhustion, feele respirtion - drowsiness, onfusion, ltered onsious stte - respirtory rrest follow up y It is essentil tht the ptient s primry re prtie is informed within 24 hours of dishrge from the emergeny deprtment or hospitl following n sthm ttk. y Keep ptients who hve hd ner-ftl sthm ttk under speilist supervision indefinitely y A respirtory speilist should follow up ptients dmitted with severe sthm ttk for t lest one yer fter the dmission. 14 Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl
MANAGEMENT OF ACUTE ASTHMA IN hildren ged 2 yers nd over ACUTE SEVERE SpO 2 <92% PEF 33-50% est or predited y Cn t omplete sentenes in one reth or too rethless to tlk or feed y Hert rte >125 (>5 yers) or >140 (2-5 yers) y Respirtory rte >30 reths/min (>5 yers) or >40 (2-5 yers) LIFE-THREATENING SpO 2 <92% PEF <33% est or predited y Silent hest y Cynosis y Poor respirtory effort y Hypotension y Exhustion y Confusion CRITERIA FOR ADMISSION Inrese β 2 gonist dose y giving one puff every 30-60 seonds, ording to response, up to mximum of ten puffs Prents/rers of hildren with n ute sthm ttk t home nd symptoms not ontrolled y up to 10 puffs of slutmol vi pmdi nd sper, should seek urgent medil ttention. If symptoms re severe dditionl doses of ronhodiltor should e given s needed whilst witing medil ttention. Prmedis ttending to hildren with n ute sthm ttk should dminister neulised slutmol, using neuliser driven y oxygen if symptoms re severe, whilst trnsferring the hild to the emergeny deprtment. Children with severe or life-thretening sthm should e trnsferred to hospitl urgently Consider intensive inptient tretment of hildren with SpO 2 <92% in ir fter initil ronhodiltor tretment. The following linil signs should e reorded: y Pulse rte inresing thyrdi generlly denotes worsening sthm; fll in hert rte in lifethretening sthm is pre-terminl event y Respirtory rte nd degree of rethlessness ie too rethless to omplete sentenes in one reth or to feed y Use of essory musles of respirtion est noted y plption of nek musles y Amount of wheezing whih might eome iphsi or less pprent with inresing irwys ostrution y Degree of gittion nd onsious level lwys give lm ressurne NB Clinil signs orrelte poorly with the severity of irwys ostrution. Some hildren with ute severe sthm do not pper distressed. Initil tretment of ute sthm OXYGEN Children with life-thretening sthm or SpO 2 <94% should reeive high flow oxygen vi tight fitting fe msk or nsl nnul t suffiient flow rtes to hieve norml sturtions of 94 98%. Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 15
MANAGEMENT OF ACUTE ASTHMA IN hildren ged 2 yers nd over BRONCHODILATORS Inhled β 2 gonists re the first line tretment for ute sthm. A pmdi + sper is the preferred option in hildren with mild to moderte sthm. Individulise drug dosing ording to severity nd djust ording to the ptient s response. If symptoms re refrtory to initil β 2 gonist tretment, dd iprtropium romide (250 mirogrms/dose mixed with the neulised β 2 gonist solution). Repeted doses of iprtropium romide should e given erly to tret hildren who re poorly responsive to β 2 gonists. Consider dding 150 mg mgnesium sulphte to eh neulised slutmol nd iprtropium in the first hour in hildren with short durtion of ute severe sthm symptoms presenting with n oxygen sturtion less thn 92%. Disontinue long-ting β 2 gonists when short-ting β 2 gonists re required more often thn four hourly. STEROID THERAPY Give orl steroids erly in the tretment of ute sthm ttks. y Use dose of 20 mg prednisolone for hildren ged 2 5 yers nd dose of 30 40 mg for hildren >5 yers. Those lredy reeiving mintenne steroid tlets should reeive 2 mg/kg prednisolone up to mximum dose of 60 mg. y Repet the dose of prednisolone in hildren who vomit nd onsider intrvenous steroids in those who re unle to retin orlly ingested medition. y Tretment for up to three dys is usully suffiient, ut the length of ourse should e tilored to the numer of dys neessry to ring out reovery. Tpering is unneessry unless the ourse of steroids exeeds 14 dys. Seond line tretment of ute sthm Consider erly ddition of single olus dose of intrvenous slutmol (15 mirogrms/kg over 10 minutes) in severe sthm ttk where the ptient hs not responded to initil inhled therpy. Aminophylline is not reommended in hildren with mild to moderte ute sthm. Consider minophylline for hildren with severe or life-thretening sthm unresponsive to mximl doses of ronhodiltors nd steroids. IV mgnesium sulphte is sfe tretment for ute sthm lthough its ple in mngement is not yet estlished. 16 Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl
MANAGEMENT OF ACUTE ASTHMA IN CHILDREN AGED UNDER 2 YEARS y The ssessment of ute sthm in erly hildhood n e diffiult y Intermittent wheezing ttks re usully due to virl infetion nd the response to sthm medition is inonsistent y Premturity nd low irth weight re risk ftors for reurrent wheezing y The differentil dignosis of symptoms inludes: Aspirtion pneumonitis Pneumoni Bronhiolitis Trheomli Complitions of underlying onditions suh s ongenitl nomlies nd ysti firosis TREATMENT of ute sthm BRONCHODILATORS Orl β 2 gonists re not reommended for ute sthm in infnts. For mild to moderte ute sthm ttks, pmdi + sper nd msk is the optiml drug delivery devie. Consider inhled iprtropium romide in omintion with n inhled β 2 gonist for more severe symptoms. STEROID THERAPY In infnts, onsider steroid tlets erly in the mngement of severe sthm ttks in the hospitl setting. Steroid tlet therpy (10 mg of solule prednisolone for up to three dys) is the preferred steroid preprtion for use in this ge group. For hildren with frequent episodes of wheeze ssoited with viruses ution should e tken in presriing multiple ourses of orl steroids. Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 17
diffiult sthm Diffiult sthm is defined s persistent symptoms nd/or frequent exertions despite tretment t step 4 or 5 ASSESSING DIFFICULT ASTHMA d d Ptients with diffiult sthm should e systemtilly evluted, inluding: y onfirmtion of the dignosis of sthm, nd y identifition of the mehnism of persisting symptoms nd ssessment of dherene to therpy. This ssessment should e filitted through dedited multidisiplinry diffiult sthm servie, y tem experiened in the ssessment nd mngement of diffiult sthm. FACTORS CONTRIBUTING TO DIFFICULT ASTHMA poor dherene Helthre professionls should lwys onsider poor dherene to mintenne therpy efore eslting tretment in ptients with diffiult sthm. psyhosoil ftors d Helthre professionls should e wre tht diffiult sthm is ommonly ssoited with oexistent psyhologil moridity. Assessment of oexistent psyhologil moridity should e performed s prt of diffiult sthm ssessment. In hildren this my inlude psyhosoil ssessment of the fmily. monitoring irwy response In ptients with diffiult sthm, onsider monitoring indued sputum eosinophil ounts to guide steroid tretment. 18 Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl
ASTHMA IN ADOLESCENTS Adolesents re defined y the World Helth Orgnistion (WHO) s young people etween the ges 10 nd 19 yers of ge. Key elements of working effetively with dolesents in the trnsition to dulthood inlude: y seeing them on their own, seprte from their prents/rers, for prt of the onsulttion, nd y disussing onfidentility nd its limittions. PREVALENCE OF ASTHMA IN ADOLESCENCE Asthm is ommon in dolesents ut is frequently undignosed euse of under-reporting of symptoms. Cliniins seeing dolesents with ny rdiorespirtory symptoms should onsider sking out symptoms of sthm. DIAGNOSIS AND ASSESSMENT Symptoms nd signs of sthm in dolesents re no different from those of other ge groups. Exerise-relted wheezing nd rethlessness re ommon sthm symptoms in dolesents ut only minority show ojetive evidene of exerise-indued ronhospsm. Other uses suh s hyperventiltion or poor fitness n usully e dignosed nd mnged y reful linil ssessment. Questionnires Qulity of life mesures Lung Funtion Bronhil hyper-retivity Anxiety nd depressive disorders y The sthm ontrol questionnire (ACQ) nd the sthm ontrol test (ACT) hve een vlidted in dolesents with sthm. y QoL sles (suh s AQLQ12+) n e used. y Tests of irflow ostrution nd irwy responsiveness my provide support for dignosis of sthm ut most dolesents with sthm will hve norml lung funtion. y A negtive response to n exerise test is helpful in exluding sthm in hildren with exerise relted rethlessness. y Mjor depression, pni ttks nd nxiety disorder re ommoner in dolesents with sthm nd mke sthm symptoms more prominent. y Brief sreening questionnires for nxiety nd depression my help identify those with signifint nxiety nd depression. NON-PHARMACOLOGICAL MANAGEMENT Adolesents with sthm (nd their prents nd rers) should e enourged to void exposure to ETS nd should e informed out the risks nd urged not to strt smoking. Adolesents with sthm should e sked if they smoke personlly. If they do nd wish to stop, they should e offered dvie on how to stop nd enourged to use lol NHS smoking esstion servies. Helthre professionls should e wre tht CAM use is ommon in dolesents nd should sk out its use. Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 19
PHARMACOLOGICAL MANAGeMENT Speifi evidene out the phrmologil mngement of dolesents with sthm is limited nd is usully extrpolted from peditri nd dult studies. Phrmologil mngement of sthm is overed on pges 8-11. Speifi evidene out inhler devie use nd hoie in dolesents is lso limited. Inhler devies re overed on pge 12. Inhler devies Adolesent preferene for inhler devie should e tken into onsidertion s ftor in improving dherene to tretment. As well s heking inhler tehnique it is importnt to enquire out ftors tht my ffet inhler devie use in rel life settings, suh s shool. Consider presriing more portle devie (s n lterntive to pmdi with sper) for delivering ronhodiltors when wy from home. LONG TERM OUTLOOK AND ENTRY INTO THE WORK PLACE Young dults with sthm hve low wreness of ouptions tht might worsen sthm (eg, exposure to dusts, fumes, spry, exertion nd temperture hnges, see pge 22). Cliniins should disuss future reer hoies with dolesents with sthm nd highlight ouptions tht might inrese suseptiility to work relted sthm symptoms. ORGANISATION AND DELIVERY OF CARE Shool sed linis my e onsidered for dolesents with sthm to improve ttendne. Peer-led interventions for dolesents in the shool setting should e onsidered. Integrtion of shool sed linis with primry re servies is essentil. Trnsition to dult sed helth re Trnsition to dult servies is importnt for ll dolesents with sthm, irrespetive of the sthm severity. Trnsition should e seen s proess nd not just the event of trnsfer to dult servies. It should egin erly, e plnned, involve the young person, nd e oth ge nd developmentlly pproprite. In the UK, generl guidne on trnsition is ville from the RCPCH nd DOH wesites. Ptient edution nd self mngement Effetive trnsition re involves prepring dolesents with sthm to tke independent responsiility for their own sthm mngement. Cliniins need to edute nd empower dolesents to mnge s muh of their sthm re s they re ple of doing while supporting prents grdully to hnd over responsiility for mngement to their hild. Adherene y When sked, dolesents with sthm dmit their dherene with sthm tretment nd with sthm trigger voidne is often poor. y Strtegies to improve dherene emphsise the importne of fousing on the individul nd their lifestyle nd using individulised sthm plnning nd personl gol setting 20 Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl
DRUG THERAPY IN PREGNANCY ACUTE ASTHMA IN PREGNANCY MANAGEMENT DURING LABOUR ASTHMA IN PREGNANCY Severl physiologil hnges our during pregnny whih ould worsen or improve sthm. Pregnny n ffet the ourse of sthm, nd sthm nd its tretment n ffet pregnny outomes. Use steroid tlets s norml when indited during pregnny for severe sthm. Steroid tlets should never e withheld euse of pregnny. If leukotriene reeptor ntgonists re required to hieve dequte ontrol of sthm then they should not e withheld during pregnny. Give drug therpy for ute sthm s for non-pregnnt ptients, inluding systemi steroids nd mgnesium sulphte. d Aute severe sthm in pregnny is n emergeny nd should e treted vigorously in hospitl d Deliver high flow oxygen immeditely to mintin sturtion 94-98%. If nesthesi is required, regionl lokde is preferle to generl nesthesi. DRUG THERAPY IN BREASTFEEDING MOTHERS Women should e dvised of the importne of mintining good ontrol of their sthm during pregnny to void prolems for oth mother nd y. Monitor pregnnt women with moderte/severe sthm losely to keep their sthm well ontrolled. Advise women who smoke out the dngers for themselves nd their ies nd give pproprite support to stop smoking. Continuous fetl monitoring is reommended for ute severe sthm For women with poorly ontrolled sthm there should e lose liison etween the respirtory physiin nd ostetriin, with erly referrl to ritil re physiins for women with ute severe sthm d The following drugs should e used s norml during pregnny: y short ting B 2 gonists y long ting B 2 gonsits y inhled ortiosteroids y orl nd intrvenous theophyllines Use prostglndin F2α with extreme ution in women with sthm euse of the risk of induing ronhoonstrition. Advise women: - tht n ute sthm ttk is rre in lour - to ontinue their usul sthm meditions in lour Women reeiving steroid tlets t dose exeeding prednisolone 7.5 mg per dy for >2 weeks prior to delivery should reeive prenterl hydroortisone 100 mg 6-8 hourly during lour In the sene of n ute severe sthm ttk, reserve Cesren setion for the usul ostetri inditions. Enourge women with sthm to restfeed Use sthm meditions s norml during lttion. Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 21
ouptionl sthm WORK-RELATED ASTHMA AND RHINITIS: CASE FINDING AND MANAGEMENT IN PRIMARY CARE Non-ouptionl disese Continue tretment Yes No Hs n ouptionl use of symptoms een exluded? 1,2 No Do symptoms improve when wy from work or deteriorte when t work? Yes High risk work 2 inludes: king pstry mking spry pinting lortory niml work helthre dentlre food proessing welding soldering metlwork woodwork hemil proessing textile, plstis nd ruer mnufture frming nd other jos with exposure to dusts nd fumes ASTHMA RHINITIS Possile work-relted sthm Refer quikly to hest physiin or ouptionl physiin 4,5 Arrnge seril PEF mesurements 6 Yes Hs the ptient developed sthm? Possile work-relted rhinitis Refer to n llergy speilist or ouptionl physiin Monitor for the development of sthm symptoms 3 1. At lest 1 in 10 ses of new or repperne of hildhood sthm in dult life re ttriutle to ouption. 2. Enquire of dult ptients with rhinitis or sthm out their jo nd the mterils with whih they work. 3. Rhino-onjuntivitis my preede IgE-ssoited ouptionl sthm; the risk of developing sthm eing highest in the yer fter the onset of rhinitis. 4. The prognosis of ouptionl sthm is improved y erly identifition nd erly voidne of further exposure to its use 5. Confirm dignosis supported y ojetive riteri nd not on the sis of omptile history lone euse of the potentil implitions for employment. 6. Arrnge for workers whom you suspet of hving work-relted sthm to perform seril pek flow mesurements t lest four times dy. Guidelines for the Identifition, Mngement nd Prevention of Ouptionl Asthm www.ohrf.org.uk/ontent/sthm.htm 22 Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl
ORGANISATION nd DELIVERY OF CARE EDUCATING CLINICIANS There is strong evidene tht eduting liniins n improve helth outomes for ptients. Interventions need to e of suffiient intensity to engge with, nd hnge, the wy prties re orgnised. Trining for primry re liniins should inlude edutionl outreh visits using multifeted progrmmes tht inlude onsulttion trining inluding gol setting. StrUCTURED REVIEW Protive linil review of people with sthm improves linil outomes. Evidene for enefit is strongest when reviews inlude disussion nd use of written personlised sthm tion pln (PAAP). In primry re, people with sthm should e reviewed regulrly y nurse or dotor with pproprite trining in sthm mngement. Review should inorporte written tion pln. It is good prtie to udit the perentge of ptients reviewed nnully. Consider fousing on prtiulr groups suh s those overusing ronhodiltors, ptients on higher tretment steps, those with sthm ttks or from groups with more omplex needs. ASTHMA CLINICS There is insuffiient evidene to mke reommendtion out the provision of re through primry re sthm linis or speilist sthm linis. Within primry re, strutured reviews my e delivered s ppointments in routine surgeries, or within dedited sthm lini. INTERVENTIONS INVOLVING SPECIFIC GROUPS SCHOOL-BASED INTERVENTIONS Consider multifeted pproh to shool-sed sthm edution progrmmes trgeting hildren s helth professionls s well s the hildren themselves. ETHNICITY/CULTURE-BASED INTERVENTIONS Estlish intensive lini-sed progrmmes for people from ethni minority groups who hve ttended emergeny re. LAY-LED INTERVENTIONS Ly-led self-mngement progrmmes for people with sthm re not reommended. PHARMACIST-LED INTERVENTIONS Evidene for phrmist-led interventions is lking nd further high qulity rndomised trils testing phrmist-led interventions to improve sthm outomes re needed. Applies only to dults Applies to ll hildren Applies to hildren 5-12 Applies to hildren under 5 Generl 23
ISBN 978 1 909103 29 0 www.sign..uk www.helthreimprovementsotlnd.org Edinurgh Offie Gyle Squre 1 South Gyle Cresent Edinurgh EH12 9EB Telephone 0131 623 4300 Fx 0131 623 4299 Glsgow Offie Delt House 50 West Nile Street Glsgow G1 2NP Telephone 0141 225 6999 Fx 0141 248 3776 The Helthre Environment Inspetorte, the Sottish Helth Counil, the Sottish Helth Tehnologies Group, the Sottish Interollegite Guidelines Network (SIGN) nd the Sottish Mediines Consortium re key omponents of our orgnistion.