British Guideline on the Management of Asthma

Aims

• Review of current SIGN/BTS guidelines

– Diagnosing Asthma

– Stepwise management of Asthma

– Managing Acute Asthma

– When to admit

Age Groups

• Children

• Adults

Diagnostic Algorithms

• Clinical features– Increase/decrease the probability of Asthma

• Diagnostic probability– Low, intermediate and high.

Clinical features & Probability

• Increase– Wheeze, cough, shortness of

breath, tight chest.– Worse at night/morning– Triggers

• Exercise,allergen,cold air, drugs

– Atopy– FH asthma/atopy– Widespread wheeze– Response to treatment– Unexplained low FEV1 or

eosinophilia

• Decrease– No interval symptoms– Cough only– Moist cough– Hyperventilation symptom– Normal examination– Normal PF/spirometry– No response to Rx– Cardiac disease– Voice disturbance– Significant smoking history

Management

• Non-pharmacological– Breast feeding– Avoidance of tobacco smoke– Weight reduction

• Pharmacological

Pharmacological Management

• Aim for complete control– No daytime symptoms, no night time awakening, no

need for rescue meds, no exacerbations, normal activity, normal lung function.

• Stepwise approach– Start at most appropriate step– Early control– Maintain by stepping up or down

Stepwise Management in Adults

Management in Children 5-12 yrs

Management in Children <5 yrs

Management of Acute Asthma

Management of Acute Asthma

• Assessment– Clinical features– PEF– Pulse oximetry– Blood gases (ABG)– Chest X-ray

• Not routine– Suspected pneumothorax, consolidation, life threatening,

failure to respond, requiring ventilation

Management of Acute Asthma• Moderate

– PEFR >50-75%– No severe features

• Severe– PEFR 33-50%– RR ≥ 25 (adult), >30 (>5yrs), >40 (2-5yrs)– HR ≥ 110 (adult), >125 (>5yrs), >140 (2-5yrs)– Unable to complete sentences or feed

• Life threatening– PEFR <33%– SpO2 <92%– Silent chest, cyanosis, exhaustion, altered consciousness

Management of Acute Asthma• Oxygen

– Hypoxic patients – aim 94-98%– Drive nebulisers with oxygen

2 agonist bronchodilators– As early as possible– Consider continuous nebulisers if poor initial response

• Oral steroids

• Ipratropium bromide

• IV magnesium sulphate– Poor response to 2 agonist or life threatening

• IV salbutamol/aminophylline - Paediatrics

Admission criteria - Adults

• Life threatening– Immediately

• Severe– If any features of severe attack after initial

treatment

Admission criteria - Children

• Severe of life threatening– Immediately

• Moderate– No improvement after 10 puffs of 2 agonist

Difficult Asthma

• Persistent symptoms or frequent exacerbations despite step 4 or 5– Confirm diagnosis– Consider poor compliance– Consider psychosocial assessment

Conclusion

• Asthma is frequently under treated

• Use current guidelines to aid diagnosis and help in acute and chronic management

• If patients are not responding as you would expect– Is the diagnosis right?– Are they taking the appropriate medication?– Are psychological or social factors hindering

management?