ASTHMA GUIDELINES

NICE quality standard QOF asthma indicators BTS/SIGN guidelines

...MADE MORE PRACTICAL

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GUIDELINES FOR PRACTICE...

LET’S TALK ABOUT THE

Key takeouts …

1

The aim of this guide is to make sure you have the key practical information you need, on hand when you need it. It’s a condensed version of the guidelines for managing asthma in adults, made up of checklists, diagnostic procedures, treatment algorithms and evidence-based recommendations for drug therapies.

As patient consultations are often time pressured, the structure and design have been developed with ease of use, quick reference and accessibility of information in mind.

The sections of the guide are numbered in the same way as the BTS/SIGN guidelines, to make it easier for you to find more detailed information if you need it.

Teva have other materials relating to this subject that you might find helpful, so ask your local rep for more information.

…that can jog your memory as you flip through the guide, or help you identify/differentiate each section at a glance.

These show any related content within the guide, and the page number it can be found on.

KEY TO CONTENT

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CONTENTSLET’S TALK ABOUT the asthma guidelines

NICE quality standard for asthma 2

2016/17 GMS contract QOF 3

BTS/SIGN guidelines 4

Practical approach to diagnosis 4

Monitoring adults in primary care 8

Pharmacological management 11

Inhaler devices 18

Management of acute asthma 19

Management of acute asthma in pregnancy 25

Practical advice 28

Glossary 28

Annexes 29-31

Contents

2016/17 GMS Contract Quality and Outcomes Framework2

3

ASTHMA (AST)

Indicator

England QOF Guidance 9th Revision 2016/17

INITIAL DIAGNOSIS

AST002. The percentage of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006), on the register, with measures of variability or reversibility recorded between 3 months before or any time after diagnosis

RECORDS

AST001. The contractor establishes and maintains a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months

ONGOING MANAGEMENT

AST003. The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using the 3 RCP questions

AST004. The percentage of patients with asthma aged 14 or over and who have not attained the age of 20, on the register, in whom there is a record of smoking status in the preceding 12 months

AchievementthresholdsPoints

4

15

20

6

NA

45–80%

45–70%

45–80%

NICE & QO

F

2

Statement 1: People with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance.

Statement 2:Adults with new onset asthma are assessed for occupational causes.

Statement 3:People with asthma receive a personalised action plan.

Statement 4:People with asthma are given specific training and assessment in inhaler technique before starting any new inhaler treatment.

Statement 5:People with asthma receive a structured review at least annually.

Statement 6: People with asthma who present with respiratory symptoms receive an assessment of their asthma control.

Statement 7: People with asthma who present with an exacerbation of their symptoms receive an objective

measurement of severity at the time of presentation.

Statement 8:People aged five years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within one hour of presentation.

Statement 9: People admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge.

Statement 10:People who receive treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within two working days of treatment.

Statement 11: People with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service.

The definition of clinical best practice for the diagnosis and treatment of asthma in adults, young people and children aged 12 months and older.

[QS25] Published February 2013

NICE quality STANDARD for asthma?1

5

Reversible airway obstruction – treat as asthma

Airways obstruction on spirometry

Reversibility tests and/or monitored initiation of treatment:• Significant reversibility,

or benefits from treatment trial – treat as asthma

• Insignificant reversibility or no benefits from treatment trial – consider alternative conditions

No airways obstruction on spirometry

• Look for evidence of airway hyper-responsiveness and/or airway inflammation

• Arrange further investigations before starting treatment

INVESTIGATION

BTS/SIGN • Diagnosis

Patients with some, but not all, of the ‘high probability’ features, or those who do not respond well to initial treatment have an intermediate probability of asthma

Intermediate probability of asthma

Without airflow obstruction

With airflow obstruction

Chronic cough syndromes

Dysfunctional breathing

Vocal cord dysfunction

Rhinitis

Gastro-oesophageal reflux

Cardiac failure

Pulmonary fibrosis

COPD

Bronchiectasis*

Inhaled foreign body*

Obliterative bronchiolitis

Large airway stenosis

Lung cancer*

Sarcoidosis*

DIFFERENTIAL DIAGNOSIS

* May also be associated with non-obstructive spirometry.4

High probability of asthma Low probability of asthma

1+ of 1. Wheeze 2. Breathlessness 3. Chest tightness 4. Cough

More likely if:• Worse at night and early morning• Worse with allergen exposure• Occurs after taking aspirin

or beta blockers

• History of atopy• Family history of asthma

and/or atopy

• Unexplained low FEV1 or PEF during symptomatic episodes

• Unexplained blood eosinophilia

• Widespread wheeze

• Dizziness• Light-headedness• Peripheral tingling• Chronic productive cough,

with no wheeze or breathlessness

• Nasal symptoms without lung function abnormalities

• Food-related symptoms

• Smoking - over 30 pack years, age of onset >35 years

• Cardiac disease

• Normal PEF or spirometry when symptomatic

• Repeatedly normal chest examination when symptomatic

SYMPTOMS

HISTORY

EXAMINATION

INVESTIGATION

British Thoracic Society Scottish Intercollegiate Guidelines Network3

A national clinical guideline on the management of asthma, September 2016

SECTION 3.3 _ PRACTICAL APPROACH TO DIAGNOSIS3 CHARACTERISTIC SYMPTOMS, SIGNS AND TEST RESULTS WHICH CAN

LEAD TO A DIAGNOSIS OF ASTHMA IN ADULTS

Patient anxiety or need for reassurance

Referral for tests not available in primary care

• Diagnosis unclear • Suspected occupational asthma (symptoms that improve when

patient is not at work, adult-onset asthma and workers in high-risk occupations)

• Poor response to asthma treatment • Severe/life-threatening asthma attack

‘Red flags’ and indicators of other diagnoses

• Prominent systemic features (myalgia, fever, weight loss)• Unexpected clinical findings (e.g. crackles, clubbing, cyanosis,

cardiac disease, monophonic wheeze or stridor)• Persistent non-variable breathlessness • Chronic sputum production• Unexplained restrictive spirometry • Chest X-ray shadowing • Marked blood eosinophilia

7

3.3.5 Diagnostic indications for specialist referral of adults

6

Figure 1: Diagnostic algorithm

Presentation with respiratory symptoms: wheeze, cough, breathlessness, chest tightness1

High probabilityof asthma

Code as:suspected asthma

Initiation oftreatment

Assess responseobjectively

(lung function/validated symptom

score)

Good response

Asthma

Adjust maintenancedose. Provide self-

managementArrange on-going

review

Intermediate probability of asthma

Test for airway obstructionspirometry + bronchodilator reversibility

Suspected asthma:Watchful waiting (if

asymptomatic)or

Commence treatmentassess response objectively

Goodresponse

Other diagnosiscon�rmed

Investigate/treat forother more likely

diagnosis

Other diagnosisunlikely

Low probability ofasthma

Poorresponse

Poorresponse

1In children under 5 years and others unable to undertake spirometry in whom there is a high or intermediate probability of asthma, theoptions are monitored initiation of treatment or watchful waiting according to the assessed probabilityof asthma.

Structured clinical assessment (from history and examination of previous medical records) Look for:

� recurrent episodes of symptoms� symptom variability� absence of symptoms of alternative diagnosis

� recorded observation of wheeze� personal history of atopy� historical record of variable PEF or FEV1

Options for investigations are:

Test for variability:• reversibility• PEF charting• challenge tests

•••

Test for eosinophilicin�ammation oratopy:• FeNO• blood eosinophils• skin-prick test, IgE

Presentation with respiratory symptoms: wheeze, cough, breathlessness, chest tightness

9

Asthma assessment tools:

In the last week (or month)

1. Sleeping – Difficulty sleeping due to symptoms (including cough)?

2. Symptoms – Usual symptoms during the day (cough, wheeze, chest tightness, or breathlessness)?

3. Restriction – Interference with usual activities (e.g. work)?

ROYAL COLLEGE OF PHYSICIANS’ ‘3 QUESTIONS’ ‘No’ to all questions means controlled asthma.

Scoring:

>60 l/min increase in PEF suggested as best criteria for defining reversibility

PEAK EXPIRATORY FLOW (PEF) Widely available and simple. Variability can be determined from home readings in most patients.

Scoring:

>400 ml increase in FEV1 postbronchodilator highly suggestive of asthma in adults

SPIROMETRY Enables clear demonstration of airflow obstruction. Highly repeatable.

8

• Symptom control – Royal College of Physicians’ ‘3 questions’, Asthma Control Questionnaire or Asthma Control Test

• Exacerbations, oral corticosteroid use and time off work

• Lung function – PEF or spirometry to evaluate bronchoconstriction, or a long-term decline in lung function

• Inhaler technique

• Adherence – prescription refill frequency

• Bronchodilator reliance – prescription refill frequency

• Self-management/personal action plan – possession of and use of

ASK

ASSESS

CHECK

Factors to monitor and record:

Routine clinical review in primary care on at least an annual basisSECTION 4.4 _ MONITORING ADULTS IN PRIMARY CARE3

BTS/SIGN - M

onitoring

11

BTS/SIGN • Pharm

acological Managem

ent

PHASED APPROACH TO MANAGEMENT IN ADULTS

*BDP or equivalent.

Intermittent reliever therapy

SABA prn

Regular preventertherapy

+ICS

Initial add-ontherapy

+LABA

Additional add-on therapies

Continuous or frequent use of oral steroids

+Oral steroids

ICS+4th drug

➔

Add LABA and assess:Good response – continue LABAImprovement but not controlled – continue LABA and increase ICS dose to medium– continue LABA and ICS and add on an LTRA, LAMA or theophyllineNo response – stop LABA and try:– increase ICS dose to medium– an LTRA– a LAMA

Consider trials of: • Increasing ICS dose to medium. If ineffective, reduce to the original dose

• Adding a 4th drug e.g. LTRA, SR theophylline, ß2 agonist tablet. If the 4th drug is ineffective, stop the drug.

Daily steroid tablet in lowest daily dose for adequate control. Maintain ICS dose at high dose. Consider other treatments to minimise the use of oral steroids.

Add inhaled corticosteroids at a low dose.*(400 mcg starting dose is appropriate for many patients).

Combined maintenance and reliever therapy can be considered for patients who have a history of asthma attacks on medium dose ICS or ICS/LABA.

Inhaled short-acting ß2 agonist.

ICS+4th drug

➔ ➔High dose therapies

If control remains inadequate on medium dose ICS plus LABA, trial: - Increasing ICS dose to high dose - Adding a 4th drug, as above

Section 7 _ Pharmacological management3

The aim is to achieve early control and to maintain it by increasing treatment as necessary and decreasing treatment when control is good. Before initiating a new therapy, recheck adherence and inhaler technique and eliminate trigger factors.

Refer patients with inadequately controlled asthma to specialist care

10

Scoring:

25 = under control

20–24 = reasonably well controlled

Scoring:

Mean of responses across the 4 domains – values lie between 1 and 7

Higher scores indicate better quality of life

Further information available at: www.qoltech.co.uk/miniaqlq.html

Scoring:

≤0.75 = well controlled

≥1.5 = inadequately controlled

Further information available: www.qoltech.co.uk/acq.html

ASTHMA CONTROL TEST (ACT) 5 questions – 3 relating to symptoms, 1 to medication use, and 1 to overall control. 5-point response score.

MINI ASTHMA QUALITY OF LIFE QUESTIONNAIRE (AQLQ) 15 questions in 4 domains – symptoms, activity limitations, emotional function and environmental stimuli. Assessed over the previous 2 weeks. Related to the larger 32-item asthma quality of life questionnaire.

ASTHMA CONTROL QUESTIONNAIRE (ACQ) Full questionnaire has 7 questions – 5 relating to symptoms, 1 to rescue treatment use, 1 to FEV1 – assessed over the previous week. Shortened questionnaire, with only the 5 symptom questions, is also valid.

13

Consider for patients with any of the following asthma-related features:

• Asthma attack in the last 2 years

• Using inhaled ß2 agonists 3 times a week or more

• Symptomatic 3 times a week or more

• Waking 1 night a week

Aims of asthma management

• No daytime symptoms

• No night-time awakening due to asthma

• No need for rescue medication

• No asthma attacks

• No limitations on activity including exercise

• Normal lung function (in practical terms FEV1 and/or PEF>80% predicted or best)

• Minimal side effects from medication

12

Starting dose – appropriate to the severity of disease (usually 400 mcg BDP per day), and titrate to the lowest effective dose

Frequency of dosing – Give inhaled corticosteroids initially twice daily (except ciclesonide which is given once daily)• Once a day inhaled corticosteroids at the same total daily dose can be

considered if good control is established

SMOKING• Advise patients that smoking reduces the effectiveness of therapy• Higher doses of inhaled steroids may be needed in patients

who are smokers or ex-smokers

OTHER PREVENTER THERAPIESLess effective preventer therapies for patients taking short-acting ß2 agonists alone are:• Leukotriene receptor antagonists – some clinical benefit• Nedocromil sodium (sodium cromoglicate is only of some benefit) • Theophyllines – some beneficial effect• Antihistamines and ketotifen are ineffective

7.2 _ Regular Preventer THERAPY3

Inhaled corticosteroids are the recommended preventer drug for achieving overall treatment goals.

200 mcg fourpuffs twice a day

High dose (should only be used after referring the patient to secondary care)

200 mcg twopuffs twice a day

Medium dose

100 mcg twopuffs twice a day

Low doseBeclometasone dipropionate (BDP)

DOSING

Short-acting bronchodilators include:

• Inhaled short-acting ß2 agonists • ß2 agonist tablets or syrup

• Inhaled ipratropium bromide • Theophyllines

Prescribe an inhaled short-acting ß2 agonist as short-term reliever therapy for all patients with symptomatic asthma.

7.1 _ Intermittent reliever THERAPY3

Good asthma control is associated with little or no need for short-acting β2 agonist. Anyone prescribed more than one device a month should have their asthma assessed and measures taken

to improve asthma control if this is poor.

Combination inhalers are recommended to:

• Guarantee that the long-acting β2 agonist is not taken without inhaled corticosteroid

• Improve inhaler adherence

15

For the small number of patients not controlled on high-dose therapies, use daily steroid tablets in the lowest dose providing adequate control. Patients on long-term steroid tablets (>3 months) or requiring frequent courses, are at risk of systemic side effects; monitor:• Blood pressure• Urine/blood sugar and cholesterol – diabetes mellitus or hyperlipidaemia • Bone mineral density – if steroid dose is significantly reduced,

offer a long-acting bisphosphonate Immunosuppressants (methotrexate, ciclosporin and oral gold) decrease long-term steroid requirements, but have significant side effects. They may be given as a 3-month trial once other drug treatments have been unsuccessful.

In a small proportion of patients asthma is not adequately controlled on a combination of short-acting β2 agonist as required, medium dose ICS, and an additional drug, usually a LABA.If control remains inadequate on medium dose of an ICS + LABA, the following interventions can be considered:• Increase the inhaled corticosteroids to high dose • Add a leukotriene receptor antagonist • Add a theophylline • Add slow-release β2 agonist tablets • Add tiotropium

The aim of treatment is to control asthma using the lowest possible doses of medication.

7.6 _ CONTINUOUS OR FREQUENT USE OF ORAL STEROIDS3

7.5 _ HIGH-DOSE THERAPIES3

Recommended method of reducing or eliminating oral steroid dose is through high dose inhaled corticosteroids.

or

oror

or

14

• First choice add-on is an inhaled LABA – improves lung function and symptoms, and decreases asthma attacks – consider adding before increasing the dose of ICS

If there is an improvement when a LABA is added, but control remains inadequate:• Continue the LABA and increase the dose of ICS • Continue the LABA and the ICS and add a leukotriene receptor antagonist (LTRA) or a long acting muscarinic agent (LAMA) or a theophyllineIf there is no improvement when a LABA is added, stop the LABA and try: • An increased dose of ICS • An LTRA • A LAMA (LAMA are not licensed for this indication)

LABAs should only be started in patients who are already on ICS therapy, which should be continued.

Combined maintenance and reliever therapy (MART) can be considered for patients who have a history of asthma attacks on

medium dose ICS or ICS/LABA.

Before initiating a new therapy, recheck adherence and inhaler technique and eliminate trigger factors.

Before proceeding to high dose or oral steroid therapies, refer patients with inadequately controlled asthma to specialist care.

If a trial of add-on treatment is ineffective, stop the drug (or in the case of increased dose of ICS reduce to original dose).

7.3 _ INITIAL ADD-ON THERAPY3

7.4 _ ADDITIONAL ADD-ON THERAPIES3

LABAs, leukotriene receptor antagonists and theophyllines can be trialled for around 6 weeks, but should be stopped if no improvement in steroid dose, symptoms or lung function.

17

7.11.3 Comorbid rhinitis

Asthma patients often have rhinitis; intranasal steroids are the most effective therapy.

In allergic rhinitis, intranasal steroids don’t improve asthma control.

7.11.4 Allergic bronchopulmonary aspergillosis

A 4-month trial of itraconazole should be considered – may decrease steroid tablet use and improve asthma control.

7.11.6 Gastro-oesophageal reflux (GORD)

The treatment of GORD does not improve asthma symptoms or lung function in patients with both conditions.

7.11.7 ß-blockers

Immediately before exercise, inhaled short-acting ß2 agonists are the drug of choice.

7.11.5 Aspirin-intolerant asthma

There are theoretical reasons for the use of leukotriene receptor antagonists, but little evidence to justify treating these patients differently to other asthma patients.

Avoid non-steroidal anti-inflammatory medications.

ß-blockers, including eye drops, are contraindicated in patients with asthma.

If exercise is a specific problem in patients on ICSs who are otherwise well controlled, consider one of the following:• Leukotriene receptor antagonists• Long-acting ß2 agonists• Sodium cromoglicate or nedocromil sodium• Oral ß2 agonists• Theophyllines

SECTION 7.11 _ SPECIFIC MANAGEMENT ISSUES3

16

7.11.2 Exercise induced asthmaRegular treatment including ICSs should be reviewed.

Exercise induced asthma is a sign of poor

disease control

Protective against exercise - induced asthma Not protective

Inhaled corticosteroids

Short-acting ß2 agonists

Long-acting ß2 agonists

Theophyllines

Leukotriene receptor antagonists

Sodium cromoglicate or nedocromil sodium

ß2 agonist tablets

Anticholinergics

Ketotifen

Antihistamines

PATIENTS SHOULD BE MAINTAINED AT THE LOWEST POSSIBLE DOSE OF INHALED CORTICOSTEROID

Reduction in inhaled corticosteroid dose should be slow, as patients deteriorate at different rates. Reductions should be considered every 3 months, decreasing the dose by around 25–50% each time.

7.10 _ DECREASING TREATMENT3

19

SECTION 9 _ MANAGEMENT OF ACUTE ASTHMA3

Severe asthma Adverse behavioural or psychosocial features

Recognised by 1 or more of:

• Previous near-fatal asthma

• Previous admission for asthma

• Needs 3+ classes of asthma medications

• Heavy use of ß2 agonist

• Repeated A&E attendances for asthma care

Recognised by 1 or more of:

• Non-adherence with treatment or monitoring

• Failure to attend appointments

• Fewer GP contacts

• Frequent home visits

• Self discharge from hospital

• Psychosis, depression, other psychiatric illness or deliberate self harm

• Current or recent major tranquiliser use

• Denial

• Alcohol or drug abuse

• Obesity

• Learning difficulties

• Employment problems

• Income problems

• Social isolation

• Childhood abuse

• Severe domestic, marital or legal stress

9.1.3 In a review of asthma deaths, adverse psychosocial and behavioural factors were recorded in the majority of patients who died from asthma

PATIENTS AT RISK OF DEVELOPING NEAR-FATAL OR FATAL ASTHMA:

+

BTS/SIGN • Acute asthm

a

18

SECTION 8 _ INHALER DEVICES3

8.1 TECHNIQUE AND TRAININGPrescribe inhalers only after patients have received training on how to use them, and have demonstrated correct technique.

8.2 ß2 AGONIST DELIVERYAcute asthma: Patients with mild and moderate asthma attacks should be treated with pMDI + spacer, and doses titrated according to clinical response.Stable asthma: pMDI ± spacer is as effective as any other hand-held inhaler, but some patients may prefer some types of DPI.

8.3 INHALED CORTICOSTEROIDS FOR STABLE ASTHMAA pMDI ± spacer is as effective as any DPI.

8.4 PRESCRIBING DEVICESIn patients who can’t use a pMDI, the most important considerations are patient preference and local cost.

Other considerations:

• Choice of device may be determined by choice of drug

• If the patient is unable to use a device satisfactorily an alternative should be found

• Inhaler technique should be assessed by a competent healthcare professional

• Medication should be titrated against clinical response for optimal efficacy

• Reassess inhaler technique at all clinical reviews

• Generic prescribing of inhalers should be avoided

21

Clinical features

PEF or FEV1

Pulse oximetry

Blood gases (ABG)

Chest X-ray

Systolic paradox

Aim of O2 therapy is to maintain SpO2 94–98%.

Gauges the need for ABG.

ABGs needed if:

• SpO2 <92% (with or without O2)• Other features of life-threatening asthma

SpO2 <92% shows risk of hypercapnia – not detected by pulse oximetry.

CXR not recommended in absence of:

• Suspected pneumothorax or pneumomediastinum• Suspected consolidation• Life-threatening asthma• Failure to respond to treatment• In need of ventilation

Inadequate indicator of severity of attack – should not be used.

These are valid measures of airway calibre – can guide intensity of treatment or decisions about admission.

PEF is more convenient in the acute situation.

These features can identify severe asthma, but their absence does not exclude it:

• Severe breathlessness – unable to complete sentences• Tachypnoea• Tachycardia• Silent chest• Cyanosis• Accessory muscle use• Altered consciousness• Collapse

See annex for treatment algorithm on pages 29–31

INITIAL ASSESSMENT OF SYMPTOMS, SIGNS AND MEASUREMENTS

9.2.5 Criteria for referral

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Moderate acute asthma

Acute severe asthma

Life- threatening asthma

Near-fatal asthma

Any one of:

• PEF 33–50% of best or predicted

• Respiratory rate ≥25/min

• Heart rate ≥110/min

• Inability to complete sentences in one breath

Any one of the following in a patient with severe asthma:

Clinical signs

• Altered conscious level

• Exhaustion

• Arrhythmia

• Hypotension

• Cyanosis

• Silent chest

• Poor respiratory effort

Measurements

• PEF <33% best or predicted

• Sp02 <92%

• Pa02 <8 kPa

• ‘Normal’ PaCO2 (4.6–6.0 kPa)

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

• Increasing symptoms

• PEF >50–75% best or predicted

• No features of acute severe asthma

See annex for treatment algorithm on pages 29–31

LEVELS OF SEVERITY OF ACUTE ASTHMA EXACERBATIONS

9.2 _ ACUTE ASTHMA IN ADULTS3

23

See annex for treatment algorithm on pages 29–31

9.3.1 Oxygen

• Give supplementary oxygen to all hypoxaemic patients with acute severe asthma to maintain an SpO2 of 94–98%

• Hypercapnia indicates the development of near-fatal asthma and the need for emergency specialist/anaesthetic intervention

9.3.2 ß2 agonist bronchodilators

• Use high-dose inhaled ß2 agonists as first-line agents, and administer as early as possible – reserve IV ß2 agonists for patients who cannot use inhaled therapy reliably

• In severe asthma that responds poorly to an initial bolus dose of ß2 agonist, consider continuous nebulisation with an appropriate nebuliser

9.3.3 Steroid therapy

• Give steroids in adequate doses in all cases of acute asthma – tablets are as effective as injected steroids, if they can be swallowed and retained

• Continue prednisolone 40–50 mg daily for at least 5 days or until recovery

9.3.4 Ipratropium bromide

• Add nebulised ipratropium bromide (0.5 mg 4–6 hourly) to ß2 agonist treatment for patients with acute severe or life-threatening asthma or with a poor initial response to ß2 agonist therapy

9.3.5 Magnesium sulphate

• Nebulised magnesium sulphate is not recommended for treatment in adults with acute asthma

• Consider giving a single dose of IV magnesium sulphate for patients with acute severe asthma, who have not had a good initial response to inhaled bronchodilator therapy

SECTION 9.3 _ TREATMENT OF ACUTE ASTHMA3

22

life-threatening or near-fatal attack

Any feature of a severe attack persisting after initial treatment

If PEF >75% best or predicted 1 hour after initial treatment, a patient can be discharged from A&E unless:

• Still has significant symptoms

• Adherence concerns

• Lives alone/socially isolated

• Psychological problems

• Physical disability or learning difficulties

• Previous near-fatal asthma attack

• Asthma attack despite adequate dose steroid tablets pre-presentation

• Presents to A&E at night

• Pregnant

See annex for treatment algorithm on pages 29–31

Criteria for admission

9.2.6 Criteria for hospital admission

25

SECTION 12.2 _ MANAGEMENT OF ACUTE ASTHMA IN PREGNANCY Late pregnancy

can affect residual capacity

POOR CONTROL DURING PREGNANCY

• Needs close liaison between respiratory physician and obstetrician

• Early referral to critical care – impaired ventilator mechanics in late pregnancy can lower functional residual capacity and may result in earlier O2 desaturation

ACUTE ASTHMA DURING PREGNANCY

• Give drug therapy for acute asthma as for the non-pregnant patient including systemic steroids and magnesium sulphate

• Give high flow O2 to maintain SpO2 94–98%

ACUTE SEVERE ASTHMA IN PREGNANCY IS AN EMERGENCY

• Treat vigorously in hospital

• Continuous foetal heart monitoring is recommended

BTS/SIGN • Pregnancy24

9.3.6 Intravenous aminophylline• Use only after consultation with senior medical staff – it is unlikely to give

any additional bronchodilation compared with standard care with inhaled bronchodilators and steroids, and side effects such as vomiting and arrhythmias are increased with IV administration

9.3.7 Leukotriene receptor antagonists• Evidence does not support oral use in acute asthma• Insufficient evidence for IV treatment

9.3.8 Antibiotics• Not indicated

9.3.9 Heliox• Not recommended for use outside a clinical trial setting

9.3.10 IV fluids• Some patients require rehydration and correction of electrolyte

imbalance – hypokalaemia can be caused or exacerbated by ß2 agonist and/or steroid treatment and must be corrected

9.3.11 Nebulised furosemide• Although theoretically furosemide may produce bronchodilation,

trials have failed to show benefit vs. ß2 agonists

9.3.12 Referral to intensive care• Indications include the need for ventilatory support and severe or

life-threatening asthma that is not responding to therapy, as shown by:

– Deteriorating PEF – Exhaustion, feeble respiration

– Persisting or worsening hypoxia – Drowsiness, confusion,

– Hypercapnia altered conscious state

– ABGs – pH dropping or H+ rising – Respiratory arrest

9.3.13 Non-invasive ventilation• Should only be considered in an ICU or equivalent clinical setting

27

If anaesthesia is required, regional blockade is preferable to general anaesthesia.

Women on steroid tablets at a dose exceeding prednisolone 7.5 mg per day for more than 2 weeks prior to delivery should be given parenteral hydrocortisone 100 mg 6–8 hourly during labour.

• Advise women that acute asthma is rare in labour

• Advise women to continue their usual asthma medications in labour

• In the absence of acute severe asthma, reserve Caesarean section for the usual obstetric indications

• Use prostaglandin F2α with extreme caution in women with asthma because of the risk of inducing bronchoconstriction

• Encourage all women to breastfeed

• Use asthma medications as normal during lactation, in line with manufacturers’ recommendations

SECTION 12.5 _ DRUG THERAPY IN BREASTFEEDING MOTHERS3

SECTION 12.4 _ MANAGEMENT DURING LABOUR3SECTION 12.3 _ DRUG THERAPY IN PREGNANCY3

26

The risk of harm to the foetus from severe or chronically undertreated asthma outweighs any small risk from the medicines used to control asthma.

12.3.1– 12.3.7 In general, asthma medicines are safe in pregnancy

• Short-acting ß2 agonists – use as normal

• Long-acting ß2 agonists – use as normal

• Inhaled steroids – use as normal

• Theophyllines – use oral and IV theophyllines as normal

• Steroid tablets – use as normal

– Steroid tablets should never be withheld because of pregnancy, and women should be advised that the benefits of treatment outweigh the potential risks

• Leukotriene receptor antagonists – continue if required to achieve adequate control prior to pregnancy

• Sodium cromoglicate or nedocromil sodium – use as normal

• Immunomodulation therapy – no clinical data yet on use of omalizumab for moderate–severe allergic asthma in pregnancy

The risk to the foetus of undertreating asthma outweighs any small risk

of treatment

148 |

British guideline on the management of asthma

Management of acute severe asthma in adults in general practice

INITIAL ASSESSMENT

FURTHER ASSESSMENT

MANAGEMENT

TREATMENT

Moderate asthma Acute severe asthma Life-threatening asthma

PEF>50-75% best or predicted PEF 33-50% best or predicted PEF<33% best or predicted

n SpO2 ≥92%

n Speech normal

n Respiration <25 breaths/min

n Pulse <110 beats/min

n SpO2 ≥92%

n Can’t complete sentences

n Respiration ≥25 breaths/min

n Pulse ≥110 beats/min

n SpO2 <92%

n Silent chest, cyanosis or poor respiratory e�ort

n Arrhythmia or hypotension

n Exhaustion, altered consciousness

Treat at home or in surgery andASSESS RESPONSE TO TREATMENT Consider admission Arrange immediate ADMISSION

n β2 bronchodilator:

- via spacer (give 4 pu�s initially and give a further 2 pu�s every 2 minutes according to response up to maximum of 10 pu�s)

If PEF >50-75% predicted/best:

n Nebuliser (preferably oxygen driven) (salbutamol 5 mg)

n Give prednisolone 40-50 mg

n Continue or usual treatment

If good response to �rst treatment (symptoms improved, respiration and pulse settling and PEF >50%) continue or usual treatment and continue prednisolone

n Oxygen to maintain SpO2 94-98% if available

n β2 bronchodilator:

- nebuliser (preferably oxygen driven) (salbutamol 5 mg)

- or via spacer (give 4 pu�s initially and give a further 2 pu�s every 2 minutes according to response up to maximum of 10 pu�s)

n Prednisolone 40-50 mg or IV hydrocortisone 100 mg

n If no response in acute severe asthma: ADMIT

n Oxygen to maintain SpO2 94-98%

n β2 bronchodilator and

ipratropium:

- nebuliser (preferably oxygen driven) (salbutamol 5 mg and ipratropium 0.5mg)

- or via spacer (give 4 pu�s initially and give a further 2 pu�s every 2 minutes according to response up to maximum of 10 pu�s)

n Prednisolone 40-50 mg or IV hydrocortisone 100 mg immediately

Many deaths from asthma are preventable. Delay can be fatal. Factors leading to poor outcome include:

n Clinical sta� failing to assess severity by objective measurement

n Patients or relatives failing to appreciate severity

n Under-use of corticosteroids

Regard each emergency asthma consultation as for acute severe asthma until shown otherwise.

Assess and record:

n Peak expiratory �ow (PEF)

n Symptoms and response to self treatment

n Heart and respiratory rates

n Oxygen saturation (by pulse oximetry)

Caution: Patients with severe or life-threatening attacks may not be distressed and may not have all the abnormalities listed below. The presence of any should alert the doctor.

Admit to hospital if any:

n Life threatening features

n Features of acute severe asthma present after initial treatment

n Previous near-fatal asthma

Lower threshold for admission if afternoon or evening attack, recent nocturnal symptoms or hospital admission, previous severe attacks, patient unable to assess own condition, or concern over social circumstances

If admitting the patient to hospital:

n Stay with patient until ambulance arrives

n Send written asssessment and referral details to hospital

n β2 bronchodilator via oxygen-driven nebuliser in ambulance

Follow up after treatment or discharge from hospital:

n GP review within 2 working days

n Monitor symptoms and PEF

n Check inhaler technique

n Written asthma action plan

n Modify treatment according to guidelines for chronic persistent asthma

n Address potentially preventable contributors to admission

Annex 2

29

Annex 2*

*Annexes are numbered as in the BTS/SIGN Guidelines.28

Available resources:

• Asthma UK (www.asthma.org.uk) offer a range of information including fact sheets and booklets

• British Lung Foundation (www.blf.org.uk) run the Breathe Easy support network

BDP Beclometasone dipropionateBTS British Thoracic SocietyCFC ChlorofluorocarbonCOPD Chronic Obstructive Pulmonary

DiseaseCXR Chest X-RayDPI Dry powder inhalerFAQ Frequently asked questionsFEV1 Forced Expiratory Volume in 1

secondFVC Forced Vital CapacityGMS General Medical ServicesGORD Gastro-oesophageal Reflux DiseaseHFA HydrofluoroalkaneICS Inhaled corticosteroidIV IntravenouskPa Kilopascal (a unit of pressure)

LABA Long-acting ß2 agonistLAMA Long-acting muscarinic antagonistLTRA Leukotriene receptor antagonistNICE National Institute for Health and

Care ExcellenceO2 OxygenPaCO2 Partial pressure of carbon dioxide

in arterial bloodPEF Peak Expiratory FlowpMDI Pressurised metered dose inhalerQOF Quality and Outcomes FrameworkRCP Royal College of PhysiciansSABA Short-acting ß2 agonistSIGN Scottish Intercollegiate Guidelines

NetworkSpO2 Oxygen saturation of peripheral

capillaries

PRACTICAL ADVICE

GLOSSARY

Sources: 1. NICE Asthma Quality Standard. Feb 2013. Available at: https://www.nice.org.uk/guidance/qs25/resources/asthma-2098547456965. Last accessed: October 2016. 2. 2016/17 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF). Available at: http://www.nhsemployers.org/~/media/Employers/Documents/Primary%20care%20contracts/QOF/2016-17/2016-17%20QOF%20guidance%20documents.pdf. Last accessed: October 2016. 3. BTS/SIGN British guideline on the management of asthma. Sept 2016. Available at: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/. Last accessed: October 2016.

150 |

British guideline on the management of asthma

Management of acute severe asthma in adults in hospital

IMMEDIATE TREATMENT

n Oxygen to maintain SpO2 94-98% n Salbutamol 5 mg or terbutaline 10 mg via an oxygen-driven nebuliser n Ipratropium bromide 0.5 mg via an oxygen-driven nebuliser n Prednisolone tablets 40-50 mg or IV hydrocortisone 100 mg n No sedatives of any kind n Chest X-ray if pneumothorax or consolidation are suspected or patient

requires mechanical ventilation

IF LIFE-THREATENING FEATURES ARE PRESENT: n Discuss with senior clinician and ICU team n Consider IV magnesium sulphate 1.2-2 g infusion over 20 minutes (unless already

given) n Give nebulised β2 agonist more frequently eg salbutamol 5 mg up to every 15-30

minutes or 10 mg per hour via continuous nebulisation (requires special nebuliser)

Features of acute severe asthma

n Peak expiratory �ow (PEF) 33-50% of best (use % predicted if recent best unknown)

n Can’t complete sentences in one breath n Respiration ≥25 breaths/min n Pulse ≥110 beats/min

Life-threatening features

n PEF <33% of best or predicted n SpO2 <92% n Silent chest, cyanosis, or feeble

respiratory e�ort n Arrhythmia or hypotension n Exhaustion, altered consciousness

If a patient has any life-threatening feature,measure arterial blood gases. No otherinvestigations are needed for immediate management.

Blood gas markers of a life-threatening attack:

n ‘Normal’ (4.6-6 kPa, 35-45 mmHg) PaCO2

n Severe hypoxia: PaO2 <8 kPa (60mmHg) irrespective of treatment with oxygen

n A low pH (or high H+)

Caution: Patients with severe or life-threatening attacks may not be distressed and may not have all these abnormalities. The presence of any should alert the doctor.

Near fatal asthma n Raised PaCO2

n Requiring mechanical ventilation with raised in�ation pressures

SUBSEQUENT MANAGEMENT

IF PATIENT IS IMPROVING continue: n Oxygen to maintain SpO2 94-98% n Prednisolone 40-50mg daily or IV hydrocortisone 100 mg 6 hourly n Nebulised β2 agonist and ipratropium 4-6 hourly

IF PATIENT NOT IMPROVING AFTER 15-30 MINUTES: n Continue oxygen and steroids n Use continuous nebulisation of salbutamol at 5-10 mg/hour if an appropriate

nebuliser is available. Otherwise give nebulised salbutamol 5 mg every 15-30 minutes

n Continue ipratropium 0.5 mg 4-6 hourly until patient is improving

IF PATIENT IS STILL NOT IMPROVING: n Discuss patient with senior clinician and ICU team n Consider IV magnesium sulphate 1.2-2 g over 20 minutes (unless already given) n Senior clinician may consider use of IV β2 agonist or IV aminophylline or

progression to mechanical ventilation

MONITORING

n Repeat measurement of PEF 15-30 minutes after starting treatment n Oximetry: maintain SpO2 >94-98% n Repeat blood gas measurements within 1 hour of starting treatment if:

- initial PaO2 <8 kPa (60 mmHg) unless subsequent SpO2 >92% - PaCO2 normal or raised - patient deteriorates

n Chart PEF before and after giving β2 agonists and at least 4 times daily throughout hospital stay

Transfer to ICU accompanied by a doctor prepared to intubate if: n Deteriorating PEF, worsening or persisting hypoxia, or hypercapnia n Exhaustion, altered consciousness n Poor respiratory e�ort or respiratory arrest

DISCHARGE

When discharged from hospital, patients should have: n Been on discharge medication for 12-24 hours and have had inhaler technique

checked and recorded n PEF >75% of best or predicted and PEF diurnal variability<25% unless discharge is

agreed with respiratory physician n Treatment with oral and inhaled steroids in addition to bronchodilators n Own PEF meter and written asthma action plan n GP follow up arranged within 2 working days n Follow-up appointment in respiratory clinic within 4 weeks

Patients with severe asthma (indicated by need for admission) and adverse behavioural or psychosocial features are at risk of further severe or fatal attacks.

n Determine reason(s) for exacerbation and admission n Send details of admission, discharge and potential best PEF to GP

Adapted by Clement Clarke for use with EN13826 / EU scale peak flow metersfrom Nunn AJ Gregg I, Br Med J 1989:298;1068-70

300

320

340

360

380

400

420

440

460

480

500

520

540

560

580

600

620

640

660

680

15 20 25 30 35 40 45 50 55 60 65 70 75 80 85

Age (years)

PE

F (

l/min

) E

U S

cale

HeightMen190 cm (75 in)183 cm (72 in)175 cm (69 in)167 cm (66 in)160 cm (63 in)

HeightWomen183 cm (72 in)175 cm (69 in)167 cm (66 in)160 cm (63 in)152 cm (60 in)

Peak Expiratory Flow Rate - Normal Values

Annex 4

| 149

Management of acute severe asthma in adults in A&E

PEF >50-75% best or predictedModerate asthma

SpO2 ≥92% PEF >50-75% best or predicted

No features of acute severe asthma

PEF 33-50% best or predictedAcute severe asthma

Features of severe asthma n PEF<50% best or predicted

n Respiration ≥25/min

n SpO2 ≥92%

n Pulse ≥110 beats/min

n Cannot complete sentence in one breath

PEF <33% best or predicted Life-threatening asthma

n SpO2<92%

n Silent chest, cyanosis, poor respiratory e�ort

n Arrhythmia, hypotension

n Exhaustion, altered consciousness

Obtain senior/ICU help now if any life threatening features are present

IMMEDIATE MANAGEMENT n Oxygen to maintain SpO2

94-98%

n Salbutamol 5 mg plus ipratropium 0.5 mg via oxygen-driven nebuliser

n Prednisolone 40-50 mg orally or IV hydrocortisone 100 mg

Measure arterial blood gases Markers of severity: ‘Normal’ or raised PaCO2 (Pa CO2>4.6 kPa; 35 mmHg) Severe hypoxia (PaO2 <8 kPa; 60 mmHg) Low pH (or high H+)

n Give/repeat salbutamol 5 mg with ipratropium 0.5 mg by oxygen-driven nebuliser after 15 minutes

n Consider continuous salbutamol nebuliser 5-10 mg/hr

n Consider IV magnesium sulphate 1.2-2 g over 20 minutes

n Correct �uid/electrolytes, especially K+ disturbances

n Chest X-ray

n Repeat ABG

ADMIT Patient accompanied by a nurse or

doctor at all times

POTENTIAL DISCHARGE n In all patients who received nebulised β2 agonists

prior to presentation, consider an extended observation period prior to discharge

n If PEF<50% on presentation, give prednisolone 40-50 mg/day for 5 days

n In all patients ensure treatment supply of inhaled steroid and β2 agonist and check inhaler technique

n Arrange GP follow up within 2 working days post-discharge

n Fax or email discharge letter to GP

n Refer to asthma liaison nurse/chest clinic

Time

5 mins

15-20 mins

60 mins

120mins Signs of severe

asthmaOR PEF <50%

Signs of severeasthma

OR PEF <50%

No signs of severe asthma

AND PEF 50-75%

Life threateningfeatures

OR PEF <50%

No life threatening

features AND PEF 50-75%

Clinicallystable

AND PEF<75%

Give salbutamol 5 mg by oxygen driven nebuliser

Give salbutamol (give 4 pu�s initially and give a further 2 pu�s, every 2 minutes according to response up to maximum of 10 pu�s) preferably via spacer

Patient recoveringAND PEF >75%

Patient stableAND PEF>50%

Repeat salbutamol 5 mg nebuliser

Give prednisolone40-50 mg orally

OBSERVE AND MONITOR n SpO2

n heart rate

n respiratory rate

Clinicallystable

AND PEF>75%

Adapted by Clement Clarke for use with EN13826 / EU scale peak flow metersfrom Nunn AJ Gregg I, Br Med J 1989:298;1068-70

300

320

340

360

380

400

420

440

460

480

500

520

540

560

580

600

620

640

660

680

15 20 25 30 35 40 45 50 55 60 65 70 75 80 85

Age (years)

PEF

(l/m

in) E

U S

cale

HeightMen190 cm (75 in)183 cm (72 in)175 cm (69 in)167 cm (66 in)160 cm (63 in)

HeightWomen183 cm (72 in)175 cm (69 in)167 cm (66 in)160 cm (63 in)152 cm (60 in)

Peak Expiratory Flow Rate - Normal Values

Annex 3

Annexes

31

Annex 4

30

Annex 3

notesnotes

3332

Approval code: UK/RESP/14/0015(1) Date of preparation: March 2017

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