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QRG 141 • British gideline on the anageent of astha

Quick Reference Guide October 2014

Evidence





British Thoracic Society

Scottish Intercollegiate Guidelines Network

British gideline on the anageent of astha

Quick Reference Guide

Revised October 2014



ISBN 978 1 909103 29 0

First pblished 2003

Revised edition pblished 2014

SIGN and the BTS consent to the photocopying of this QRG for the purpose ofimplementation in the NHS in England, Wales, Northern Ireland and Scotland.

British Thoracic Societ

17 Doght Street, London WC1N 2PL

www.brit-thoracic.org.k

Scottish Intercollegiate Gidelines Network

Gle Sqare, 1 Soth Gle Crescent, Edinbrgh EH12 9EB

This Quick Reference Guide provides a summary of the main recommendations in

SIGN 141 British guideline on the management of asthma.

Recommendations are graded A B C D to indicate the strength of the supporting evidence.

Good practice points are provided where the guideline development group wishes to

highlight specific aspects of accepted clinical practice.

Details of the evidence supporting these recommendations can be found in the full guideline,

available on the SIGN website: www.sign.ac.uk . This Quick Reference Guide is also available as

part of the SIGN Guidelines app.

Available from

Android Market


http://slidepdf.com/reader/full/document1pdf-56975d0f6a249 5/281 Applies to all children Applies to children 5-12 Applies to children under 5 General Applies only to adults

DIAGNOSIS IN CHILDREN

INITIAL CLINICAL ASSESSmENT

CLINICAL FEATuRES THAT INCREASE THE PROBABILITy OF ASTHmA

CLINICAL FEATuRES THAT LOWER THE PROBABILITy OF ASTHmA

With a thorogh histor and exaination, a child can sall be classed into one of three grops:

y high probabilit – diagnosis of asthma likely

y low probabilit – diagnosis other than asthma likely y interediate probabilit – diagnosis uncertain.

y More than one of the following symptoms - wheeze, cough, difficultybreathing, chest tightness - particularly if these are frequent andrecurrent; are worse at night and in the early morning; occur inresponse to, or are worse after, exercise or other triggers,such as exposure to pets; cold or damp air, or with emotions orlaughter; or occur apart from colds

y Personal history of atopic disorder

y Family history of atopic disorder and/or asthma

y Widespread wheeze heard on auscultation y History of improvement in symptoms or lung function in response

to adequate therapy.

y Symptoms with colds only, with no interval symptoms

y Isolated cough in the absence of wheeze or difficulty breathing

y History of moist cough

y Prominent dizziness, light-headedness, peripheral tingling

y Repeatedly normal physical examination of chest whensymptomatic

y Normal peak expiratory flow (PEF) or spirometry whensymptomatic

y No response to a trial of asthma therapy

y Clinical features pointing to alternative diagnosis

Record the basis on which a diagnosis of asthma is suspected.

B Focs the initial assessent in children sspected of having astha on:

y presence of ke featres in histor and exaination

y carefl consideration of alternative diagnoses.



In some children, particularly the under 5s, there is insufficient evidence at the first consultation to makea firm diagnosis of asthma but no features to suggest an alternative diagnosis.

Possible approaches (dependent on frequency and severity of symptoms) include: y watchful waiting with review

y trial of treatment with review

y spirometry and reversibility testing.

DIAGNOSIS IN CHILDREN

HIGH PROBABILITy OF ASTHmA

LOW PROBABILITy OF ASTHmA

INTERmEDIATE PROBABILITy OF ASTHmA

C In children with an interediate probabilit of astha who can perfor spiroetr and have no

evidence of airwas obstrction:

y consider testing for atopic stats, bronchodilator reversibilit and if possible, bronchial

hper-responsiveness sing ethacholine, exercise or annitol

y consider specialist referral.

Reeber The diagnosis of asthma in children is a clinical one. It is based on recognising a characteristic pattern ofepisodic symptoms in the absence of an alternative explanation.

In children with a high probabilit of asthma:

y start a trial of treatment

y review and assess response

y reserve further testing for those with a poor response.

In children with a low probabilit of asthma, consider more detailed investigation and specialistreferral.

In children with an interediate probabilit of asthma who can perform spirometry and have evidence of airwas obstrction, assess the change in FEV1 or PEF in response to an inhaledbronchodilator (reversibility) and/or the response to a trial of treatment for a specified period:

y if there is significant reversibility, or if a treatment trial is beneficial, a diagnosis of asthmais probable. Continue to treat as asthma, but aim to find the minimum effective dose oftherapy. At a later point, consider a trial of reduction, or withdrawal, of treatment.

y if there is no significant reversibility, and treatment trial is not beneficial, consider tests foralternative conditions.

In children with an interediate probabilit of asthma who cannot perform spirometry, offer a trialof treatment for a specified period:

y if treatment is beneficial, treat as asthma and arrange a review

y if treatment is not beneficial, stop asthma treatment, and consider tests for alternative conditionsand specialist referral.



Clinical assessment

Consider

referral

Continue

treatment and

find minimum

effective dose

Assess compliance and

inhaler technique.

Consider further

investigation and/or referral

Continue

treatment

Further investigation.

Consider referral

+VE -VE

HIGH PROBABILITY:

diagnosis of asthma

likely

INTERMEDIATE

PROBABILITY:

diagnosis uncertain

or poor response to

asthma treatment

LOW PROBABILITY:

other diagnosis likely

Consider tests of

lung function*

and atopy

Response? Response?

Investigate/

treat other

condition

Trial of asthma

treatment

Yes No No Yes

* Lung function tests include spirometry before and after bronchodilator (test of airway reversibility) and

possible exercise or methacholine challenge (tests of airway responsiveness).Most children over the age of 5 years can perform lung function tests.

Presentation with suspected asthma in children

3 Applies to all children Applies to children 5-12 Applies to children under 5 General Applies only to adults



DIAGNOSIS IN ADuLTS

INITIAL ASSESSmENT

The diagnosis of asthma is based on the recognition of a characteristic pattern of symptoms and signsand the absence of an alternative explanation for them. The key is to take a careful clinical history.

CLINICAL FEATuRES THAT INCREASE THE PROBABILITy OF ASTHmA

CLINICAL FEATuRES THAT LOWER THE PROBABILITy OF ASTHmA

* A normal spirogram/spirometry when not symptomatic does not exclude the diagnosis of asthma.

Repeated measurements of lung function are often more informative than a single assessment.

y More than one of the following symptoms: wheeze, breathlessness,chest tightness and cough, particularly if:

– symptoms worse at night and in the early morning

– symptoms in response to exercise, allergen exposure and cold air

– symptoms after taking aspirin or beta blockers

y History of atopic disorder

y Family history of asthma and/or atopic disorder

y Widespread wheeze heard on auscultation of the chest

y Otherwise unexplained low FEV1 or PEF (historical or serial readings)

y Otherwise unexplained peripheral blood eosinophilia

y Prominent dizziness, light-headedness, peripheral tingling

y Chronic productive cough in the absence of wheeze or breathlessness

y Repeatedly normal physical examination of chest when symptomatic

y Voice disturbance y Symptoms with colds only

y Significant smoking history (ie > 20 pack-years)

y Cardiac disease

y Normal PEF or spirometry when symptomatic*

Base initial diagnosis on a careful assessment of symptoms and a measure of airflow obstruction: y in patients with a high probabilit of asthma move straight to a trial of treatment. Reserve

further testing for those whose response to a trial of treatment is poor.

y in patients with a low probabilit of asthma, whose symptoms are thought to be due to analternative diagnosis, investigate and manage accordingly. Reconsider the diagnosis ofasthma in those who do not respond.

y in patients with an interediate probabilit of asthma the preferred approach is to carryout further investigations, including an explicit trial of treatments for a specified period,before confirming a diagnosis and establishing maintenance treatment.

D Spiroetr is the preferred initial test to assess the presence and severit of airflow obstrction.



Clinical assessment including spirometry

(or PEF if spirometry not available)

Continue

treatment

Assess adherence and

inhaler technique.

Consider further

investigation and/or referral

Continue

treatment

Further investigation.

Consider referral

HIGH PROBABILITY:

diagnosis of asthma

likely

LOW PROBABILITY:

other diagnosis likely

Response? Response?

Investigate/

treat other

condition

Trial of

treatment*

Yes No No Yes

Presentation with suspected asthma

FEV1 / FVC

<0.7

FEV1 / FVC

>0.7

INTERMEDIATE

PROBABILITY:

diagnosis uncertain

Presentation with suspected asthma in adults




AIn adlts, written personalised astha action plans a be based on sptos and/or peak

flows: spto-based plans are generall preferable for children.

SuPPORTED SELFmANAGEmENT

Astha action plans Self-anageent in practice

Self-management education incorporating writtenpersonalised asthma action plans (PAAPs) improveshealth outcomes for people with asthma.

Asthma UK action plans and resources can bedownloaded from the their website:www.asthma.org.uk/control.

ADHERENCE AND CONCORDANCE

SELFmANAGEmENT IN SPECIFIC PATIENT GROuPS

ImPLEmENTATION IN PRACTICE

AAll people with astha (and/or their parents or carers) shold be offered self-anageentedcation which shold inclde a written personalised astha action plan and be spported b

reglar professional review.

y A hospital admission represents a window of opportunity to review self management skills. Nopatient should leave hospital without a written personalised asthma action plan.

y An acute consultation offers the opportunity to determine what action the patient has alreadytaken to deal with the asthma attack. Their self management strategy may be reinforced or

refined and the need for consolidation at a routine follow up considered.

y A consultation for an upper respiratory tract infection or other known trigger is an opportunityto rehearse with the patient their self management in the event of their asthma deteriorating.

y Education should include personalised discussion of issues such as trigger avoidance andachieving a smoke-free environment to support people and their families living with asthma.

y Brief simple education linked to patient goals is most likely to be acceptable to patients.

A

Self-anageent edcation, spported b a written personalised astha action plan, shold be

offered to all patients on general practice ‘active astha’ registers.

APrior to discharge, inpatients shold receive written personalised astha action plans, given b

healthcare professionals with expertise in providing astha edcation.

BCltrall appropriate spported self-anageent edcation shold be provided for people with

astha in ethnic inorit grops. Addressing langage barriers is insfficient.

A

Adherence to long-ter astha treatent shold be rotinel and reglarl addressed b

all healthcare professionals within the context of a coprehensive prograe of accessible

proactive astha care.

Computer repeat-prescribing systems provide a practical index of adherence and should be used inconjunction with a non-judgemental discussion about adherence.

B

Coissioners and providers of services for people with astha shold consider how thecan develop an organisation which prioritises and activel spports self anageent. This

shold inclde strategies to proactivel engage and epower patients and train and otivate

professionals as well as providing an environent that prootes self-anageent and onitors

ipleentation.

APriar care practices shold ensre that the have trained professionals and an environent

condcive to providing spported self anageent.

http://www.asthma.org.uk/control

http://www.asthma.org.uk/control



NONPHARmACOLOGICAL mANAGEmENT

There is a common perception amongst patients and carers that there are numerous environmental,dietary and other triggers of asthma and that avoiding these triggers will improve asthma and reducethe requirement for pharmacotherapy. Evidence that non-pharmacological management is effective canbe difficult to obtain and more well controlled intervention studies are required.

PRImARy PREVENTION

Ameasres to redce in tero or earl life exposre to single aeroallergens, sch as hose dst

ites or pets, or single food allergens, are not recoended for the priar prevention of

astha.

BFor children at risk of developing astha, coplex, lti-faceted interventions targeting ltiple

allergens a be considered in failies able to eet the costs, deands and inconvenience of

sch a deanding prograe.

Primary prevention relates to interventions introduced before the onset of disease and designed toreduce its incidence.

BIn the absence of an evidence of benefit and given the potential for adverse effects, aternal

food allergen avoidance dring pregnanc and lactation is not recoended as a strateg for

preventing childhood astha.

There is insufficient evidence to make a recommendation relating to the following as a strategy forpreventing childhood asthma:

y maternal dietary supplementation during pregnancy

y the use of dietary probiotics in pregnancy.

C Breast feeding shold be encoraged for its an benefits, inclding a potential protective effectin relation to earl astha.

BParents and parents-to-be shold be advised of the an adverse effects which soking has on

their children inclding increased wheezing in infanc and increased risk of persistent astha.

SECONDARy PREVENTION

Secondary prevention relates to interventions introduced after the onset of disease to reduce its impact.

APhsical and cheical ethods of redcing hose dst ite levels in the hoe ( includingacaricides, mattress covers, vacuum-cleaning, heating, ventilation, freezing, washing, air-filtration and

ionisers) are ineffective and shold not be recoended b healthcare professionals.

BParents with astha shold be advised abot the dangers to theselves and to their children

with astha, of soking, and be offered appropriate spport to stop soking.

CWeight loss in overweight patients has an health benefits, and shold be spported in people

with astha; if sccessfl, it a lead to iproveents in astha sptos.

A Air ionisers are not recoended for the treatent of astha.

A

Breathing exercise prograes (including physiotherapist-taught methods) can be offered to

people with astha as an adjvant to pharacological treatent to iprove qalit of life and

redce sptos.



PHARmACOLOGICAL mANAGEmENT

Until May 2009 all doses of inhaled corticosteroids were referenced against beclometasone dipropionate(BDP) given via CFC-MDIs. As BDP-CFC is now unavailable, the reference inhaled corticosteriod will be the

BDP-HFA product, which is available at the same dosage as BDP-CFC. Adjustments to doses will have to bemade for other inhaler devices and other corticosteroid molecules.

STEPPING DOWN

EXERCISE INDuCED ASTHmA

A

A

CA

C

C

A

CA

C

If exercise is a specific proble in patients taking inhaled corticosteroids who are otherwise

well controlled, consider adding one of the following therapies:

y lekotriene receptor antagonists

y long-acting β2 agonists

y sodi crooglicate or nedocroil sodi y oral β2 agonists

y theophllines.

COmBINATION INHALERS

In efficacy studies, where there is generally good adherence, there is no difference in efficacy in givinginhaled corticosteriod and a long-acting β2 agonist in combination or in separate inhalers. In clinicalpractice, however, it is generally considered that combination inhalers aid adherence and also have theadvantage of guaranteeing that the long-acting β2 agonist is not taken without the inhaled corticosteroid.

The ai of astha anageent is control of

the disease. Coplete control is defined as:

y no datie sptos

y no night tie awakening de to astha

y no need for resce edication

y no astha attacks

y no exacerbations

y no liitations on activit inclding exercise

y noral lng fnction (in practical ters

FEV1 and/or PEF >80% predicted or best)

y inial side effects fro edication.

THE STEPWISE APPROACH

1. Start treatment at the step most appropriateto initial severity.

2. Achieve early control

3. Maintain control by: stepping up treatment as necessary stepping down when control is good.

For most patients, exercise-induced asthma is an expression of poorly controlled asthma andregular treatment including inhaled corticosteroids should be reviewed.

A A Iediatel prior to exercise, inhaled short-acting β2 agonists are the drg of choice.

y Regular review of patients as treatment is stepped down is important. When deciding whichdrug to step down first and at what rate, the severity of asthma, the side effects of thetreatment, time on current dose, the beneficial effect achieved, and the patient’s preferenceshould all be taken into account.

y Patients should be maintained at the lowest possible dose of inhaled corticosteroid. Reduction ininhaled corticosteroid dose should be slow as patients deteriorate at different rates. Reductionsshould be considered every three months, decreasing the dose by approximately 25-50%

each time.

y Regular review of patients as treatment is stepped down is important. When deciding whichdrug to step down first and at what rate, the severity of asthma, the side effects of thetreatment, time on current dose, the beneficial effect achieved, and the patient’s preferenceshould all be taken into account.

y Patients should be maintained at the lowest possible dose of inhaled corticosteroid. Reduction ininhaled corticosteroid dose should be slow as patients deteriorate at different rates. Reductionsshould be considered every three months, decreasing the dose by approximately 25-50%

each time.

Combination inhalers are recommended to:

y guarantee that the long-acting β2 agonist is not taken without inhaled corticosteroid y improve inhaler adherence.

Before initiating a new drug therapypractitioners should check adherence withexisting therapies, inhaler technique andeliminate trigger factors.



I n h

a l e d s h o r t - a c t i n g β

2

a g o n i s t a s r e q u i r e d

S T E P

1

M i l d i n t e r m i t t e n t a s t h m a

A d d i n h a l e d c o r t i c o s t e r o i d

2 0 0 - 8

0 0 m i c r o g r a m s / d a y *

4 0 0 m

i c r o g r a m s i s a n

a p p r o

p r i a t e s t a r t i n g d o s e f o r

m a n y

p a t i e n t s

S t a r t a t d o s e o f i n h a l e d

c o r t i c o s t e r o i d a p p r o p r i a t e t o

s e v e r i t y o f d i s e a s e .

S T E P

2

R e g u l a r p r e v e n t e r t h e r a p y

1 .

A d d i n

h a l e d l o n g - a c t i n g

β

1 .

A d d i n h a l e d l o n g - a c t i n g

β 2 a g o n i s t ( L A B A )

2 .

A s s e s s

c o n t r o l o f a s t h m a :

• g o o d

r e s p o n s e t o

L A B A

- c o n t i n u e L A B A

• b e n e fi t f r o m L

A B A b u t

c o n t r

o l s t i l l i n a d e q u a t e

- c o n t i n u e L A B A a n d

i n c r e a s e i n h a l e d

c o r t i c o s t e r o i d d o s e t o 8 0 0

m i c r o g r a m s / d a y * ( i f n o t

a l r e a d y o n t h i s d o s e )

• n o r e s p o n s e t o L A B A

- s t o p

L A B A a n d i n c r e a s e

i n h a l e

d c o r t i c o s t e r o i d t o

8 0 0 m

i c r o g r a m s / d a y . * I f

c o n t r o l s t i l l i n a d e q u a t e ,

i n s t i t u

t e t r i a l o f o t h e r

t h e r a p i e s , l e u k o t r i e n e

r e c e p

t o r a n t a g o n i s t o r S R

t h e o p

h y l l i n e

1 .

A d d i n


β

S T E P

3

I n i t i a l a d d - o n t h e r a p y

C o n s i d e r t r i a l s o f :

• i n c r e a s i n g

i n h a l e d

c o r t i c o s t e r o i d u p t o

2 , 0 0 0 m i c r o g r a m s / d a y *

• a d d i t i o n o

f a

f o u r t h d

r u g

e g l e u k o t r

i e n e r e c e p t o r

a n t a g o n i s

t , S R t h e o p h y l l i n e ,

β 2 a g o n i s t

t a b l e t

S T

E P

4

P e r s i s t e n

t p o o r c o n t r o l

U s e d a i l y s t e r o i d t a b l e t

i n l o w e s t d o s e p

r o v i d i n g

a d e q u a t e c o n t r o l

M a i n t a i n h i g h d

o s e i n h a l e d

c o r t i c o s t e r o i d a

t 2 , 0 0 0

m i c r o g r a m s / d a y *

C o n s i d e r o t h e r t r e a t m e n t s t o

m i n i m i s e t h e u s

e o f s t e r o i d

t a b l e t s

R e f e r p a t i e n t f o

r s p e c i a l i s t

c a r e

S T E

P 5

C o n t i n u o u s

o r f r e q u e n t

u s e o f o r a

l s t e r o i d s

M O V E D O W N T O F I N D A N

D M A I N T A I N L O W E S T C O N T

R O L L I N G S T E P

* B D P o r e q u i v a l e n t

P a t i e n t s s h o u l d s t a r t t r e a t m e n t a t t h e s

t e p m o s t a p p r o p r i a t e t o t h e

i n i t i a l s e v e r i t y o f t h e i r a s t h m a .

C h e c k

a d h e r e n c e a n d r e c o n s i d e r

d i a g n o s i s i f r e s p o n s e t o t r e a t m e n

t i s u n e x p e c t e d l y p o o r .

M O V E U P T O

I M P R O V E C O N T R O L A S N E E D

E D

S Y M P T O M S

v s

T R E A T M E N T

Summary of stepwise management in adults




I n h a

l e d s h o r t - a c t i n g β

2


S T E P

1


A d d i n

h a l e d c o r t i c o s t e r o i d

2 0 0 - 4 0

0 m i c r o g r a m s / d a y *

( o t h e r p r e v e n t e r d r u g i f i n h a l e d

c o r t i c o

s t e r o i d c a n n o t b e

u s e d ) 2

0 0 m i c r o g r a m s i s a n

a p p r o p

r i a t e s t a r t i n g d o s e f o r

m a n y p

a t i e n t s

S t a r t a

t d o s e o f i n h a l e d

c o r t i c o

s t e r o i d a p p r o p r i a t e t o

s e v e r i t

y o f d i s e a s e .

S T E P

2

R e g u l a r p r e v e n t e r t h e r a p y

1 .

A d d i n


β

1 .

A d d i n h a l e d l o n g - a c t i n g β

2

a g o n i s

t ( L A B A )

2 .

A s s e s s

c o n t r o l o f a s t h m a :

• g

o o d r e s p o n s e t o L A B A

- c o n t i n u e L A B A

• b

e n e fi t f r o m L

A B A b u t

c o n t r o l s t i l l i n a d e q u a t e

- c o n t i n u e L A B A a n d

i n c r e a s e i n h a l e d

c o r t

i c o s t e r o i d d o s e t o 4 0 0

m i c r o g r a m s / d a y * ( i f n o t

a l r e a d y o n t h i s d o s e )

• n

o r e s p o n s e t o L A B A

- s t o p

L A B A a n d i n c r e a s e

i n h a

l e d c o r t i c o s t e r o i d

t o 4 0 0 m i c r o g r a m s / d a y . *

I f c o

n t r o l s t i l l i n a d e q u a t e ,

i n s t i t u t e t r i a l o f o t h e r

t h e r

a p i e s , l e u k o t r i e n e

r e c e

p t o r a n t a g o n i s t o r S R

t h e o

p h y l l i n e

1 .

A d d i n


β

S T E P

3


I n c r e a s e i n h

a l e d

c o r t i c o s t e r o

i d u p t o 8 0 0


S T

E P

4

P e r s i s t e n

t p o o r c o n t r o l

U s e d a i l y s t e r o i d t a b l e t

i n l o w e s t d o s e

p r o v i d i n g

a d e q u a t e c o n t r o l

M a i n t a i n h i g h

d o s e i n h a l e d

c o r t i c o s t e r o i d

a t 8 0 0


R e f e r t o r e s p i r a t o r y

p a e d i a t r i c i a n

S T E

P 5

C o n t i n u o u s o r f r e q u e n t

u s e o f o r

a l s t e r o i d s




* B D

P o r e q u i v a l e n t

M O V E U P T O

I M P R O V E C O N T R O L A S N E E

D E D

S Y M P T O M S

v s

T R E A T M E N T

P a t i e n t s s h o u l d s t a r t t r e a t m e n t a t t h e s t e p m o s t a p p r o p r i a t e t o t h e


C h e c k a d h e r e n c e a n d r e c o n s i d e r

d i a g n o s i s i f r e s p o n s e t o t r e a t m e n t

i s u n e x p e c t e d l y p o o r .

Summary of stepwise management in children aged 5-12 years




I n h a l e d s h o r t - a c t i n g β

2


S T E P

1


A d d i n h a l e d c o r t i c o s t e r o i d

2 0 0 - 4

0 0 m i c r o g r a m s / d a y * †

o r l e u k o t r i e n e

r e c e p t o r

a n t a g o n i s t i f i n h a l e d

c o r t i c o s t e r o i d

c a n n o t b e

u s e d .

S t a r t a t d o s e o f i n h a l e d

c o r t i c o s t e r o i d a p p r o p r i a t e

t o

s e v e r i t y o f d i s e a s e .

S T E P

2

R e g u l a r p r e v e n t e r t h e r a

p y

1 .


β

I n t h o s e c h i l d r e n t a k i n g

i n h a l e d c o r t i c o s t e r o i d 2 0 0 -

4 0 0 m i c r o g r a m s / d a y c o n s i d e r

a d d i t i o n o f l e u k o t r i e n e

r e c e p t o r a n t a g o n i s t .

I n t h o s e c h i l d r e n t a k i n g

a l e u k o t r i e n e r e c e p t o r

a n t a g o n i s t a l o n e r e c o n s i d e r

a d d i t i o n o f a n i n h a l e d

c o r t i c o s t e r o i d 2 0 0 - 4

0 0

m i c r o g r a m s / d a y .

I n c h i l d r e n u n d e r 2 y e a r s

c o n s i d e r p r o c e e d i n g t o s t e p 4

.

1 .


β

S T E P

3


R e f e r t o r e s p i r a t o r y

p a e d i a t r i c i a n .

S T E P

4

P e r s i s t e n t p o o r c o n t r o l

S Y M P T O M S

v s

T R E A T M E N T




* B D P o r e q u i v a

l e n t

† H i g h e r n o m i n

a l d o s e s m a y b e r e q u i r e d i f d r u g d e l i v e

r y i s d i ffi c u l t

M O V E U P T O

I M P R O V E C O N T R O L A S N E E D E D

P a t i e n t s s h o u l d s t a r t t r e a t m e n t a t t h e s

t e p m o s t a p p r o p r i a t e t o t h e


C h e c k

a d h e r e n c e a n d r e c o n s i d e r

d i a g n o s i s i f r e s p o n s e t o t r e a t m e n t i s u n e x p e c t e d l y p o o r .

Summary of stepwise management in children less than 5 years




INHALER DEVICES

TECHNIQuE AND TRAINING

PRESCRIBING DEVICES

β2 AGONIST DELIVERy

ACuTE ASTHmA

STABLE ASTHmA

INHALED CORTICOSTEROIDS FOR STABLE ASTHmA

INHALER DEVICES IN CHILDREN

In young children, little or no evidence is available on which to base recommendations.

A A B Children and adlts with ild and oderate astha attacks shold be treated b pmDI +

spacer with doses titrated according to clinical response.

A In children aged 5-12, pmDI + spacer is as effective as an other hand held inhaler.

In adlts pmDI ± spacer is as effective as an other hand held inhaler, bt patients a

prefer soe tpes of DPI.

A

A In children aged 5-12 ears, pmDI + spacer is as effective as an DPI.

In adlts, a pmDI ± spacer is as effective as an DPI.A

B Prescribe inhalers onl after patients have received training in the se of the device and

have deonstrated satisfactor techniqe.

y The choice of device may be determined by the choice of drug

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

y The patient should have their ability to use the prescribed inhaler device assessed by acompetent healthcare professional

y The medication needs to be titrated against clinical response to ensure optimum efficacy

y Reassess inhaler technique as part of structured clinical review.

In children, pMDI and spacer are the preferred method of delivery of β2 agonists or inhaledcorticosteroids. A face mask is required until the child can breathe reproducibly using the spacermouthpiece. Where this is ineffective a nebuliser may be required.

Prescribing mixed inhaler types may cause confusion and lead to increased errors in use. Using thesame type of device to deliver preventer and reliever treatments may improve outcomes.



mANAGEmENT OF ACuTE ASTHmA IN ADuLTS

ACuTE SEVERE ASTHmA

Any one of: y PEF 33-50% best or predicted y respiratory rate ≥25/min y heart rate ≥110/min y inability to complete sentences in one breath

NEARFATAL ASTHmA

Raised PaCO2 and/or requiring mechanicalventilation with raised inflation pressures

increasing symptoms PEF >50-75% best or predicted no features of acute severe asthma

mODERATE ASTHmA LIFETHREATENING ASTHmA

In a patient with severe asthma any one of: y PEF <33% best or predicted

y SpO2 <92%

y PaO2 <8 kPa

y normal PaCO2 (4.6-6.0 kPa)

y silent chest

y cyanosis

y poor respiratory effort

y arrhythmia

y exhaustion, altered conscious level

y hypotension

INITIAL ASSESSmENT

ASSESSmENT OF SEVERE ASTHmA

Clinical

featres

Severe breathlessness (including too breathless to complete sentences in onebreath), tachypnoea, tachycardia, silent chest, cyanosis or collapse

None of these singly or together is specific and their absence does not exclude a severeattack

PEF or FEV1 PEF or FEV1 are useful and valid measures of airway calibre. PEF expressed as a % ofthe patient’s previous best value is most useful clinically. In the absence of this, PEFas a % of predicted is a rough guide

Plse

oxietr

Oxygen saturation (SpO2) measured by pulse oximetry determines the adequacy ofoxygen therapy and the need for arterial blood gas measurement (ABG). The aim ofoxygen therapy is to maintain SpO2 94-98%

Blood gases

(ABG)

Patients with SpO2 <92% or other features of life-threatening asthma require ABG

measurement

Chest X-ra Chest X-ray is not routinely recommended in patients in the absence of:- suspected pneumomediastinum or pneumothorax- suspected consolidation- life-threatening asthma- failure to respond to treatment satisfactorily- requirement for ventilation

B Healthcare professionals st be aware that patients with severe astha and one or ore

adverse pschosocial factors are at risk of death.



CRITERIA FOR ADmISSION

mANAGEmENT OF ACuTE ASTHmA IN ADuLTS

B Adit patients with an featre of a life-threatening or near-fatal astha attack.

Adit patients with an featre of a severe astha attack persisting after initial treatent.B

Patients whose peak flow is greater than 75% best or predicted one hor after initial treatent

a be discharged fro ED, nless there are other reasons wh adission a be appropriate.C

STEROID THERAPy

IPRATROPIum BROmIDE

Give steroids in adeqate doses in all cases

of acte astha attack.A

BOTHER THERAPIES

REFERRAL TO INTENSIVE CARE

Refer any patient: y requiring ventilatory support y with acute severe or life-threatening asthma, who

is failing to respond to therapy, as evidenced by: - deteriorating PEF - persisting or worsening hypoxia - hypercapnia

- ABG analysis showing pH or H+

- exhaustion, feeble respiration - drowsiness, confusion, altered conscious state - respiratory arrest

Rotine prescription of antibiotics is not

indicated for patients with acte astha.B

Continue prednisolone 40-50 mg daily for atleast five days or until recovery.

Magnesium sulphate (1.2-2 g IV infusion over20 minutes) should only be used followingconsultation with senior medical staff.

TREATmENT OF ACuTE ASTHmA

OXyGEN β2 AGONIST BRONCHODILATORS

A In severe astha that is poorl responsive

to an initial bols dose of β2 agonist,

consider continos neblisation with an

appropriate nebliser.

In patients with acute asthma with life-threatening features the nebulised route(oxygen-driven) is recommended.

A Neblised agnesi is not recoended

for treatent in adlts with acte astha.

A use high-dose inhaled β2 agonists as first

line agents in patients with acte astha

and adinister as earl as possible. Reserve

intravenos β2 agonists for those patients

in who inhaled therap cannot be sed

reliabl.

y Give sppleentar oxgen to all

hpoxaeic patients with acte severe

astha to aintain an SpO2 level of

94-98%. Lack of plse oxietr shold

not prevent the se of oxgen.

y In hospital, ablance and priarcare, neblisers for giving neblised

β2 agonist bronchodilators shold

preferabl be driven b oxgen.

C

A

B Consider giving a single dose of IV

agnesi slphate to patients with:

y acte severe astha (PEF <50% bestor predicted) who have not had a

good initial response to inhaled

bronchodilator therap.

y It is essential that the patient’s primary care practice is informed within 24 hours of dischargefrom the emergency department or hospital following an asthma attack. y Keep patients who have had a near-fatal asthma attack under specialist supervision indefinitely y A respiratory specialist should follow up patients admitted with a severe asthma attack for at

least one year after the admission.

FOLLOW uP

Add neblised ipratropi broide (0.5mg 4-6 hourly) to β2 agonist treatent

for patients with acte severe or life-

threatening astha or those with a poor

initial response to β2 agonist therap.



OXyGEN

INITIAL TREATmENT OF ACuTE ASTHmA

mANAGEmENT OF ACuTE ASTHmA IN CHILDREN AGED 2 yEARS AND OVER

The following clinical signs shold be recorded:

y Pulse rate – increasing tachycardia generally denotes worsening asthma; a fall in heart rate in life-threatening asthma is a pre-terminal event

y Respiratory rate and degree of breathlessness – ie too breathless to complete sentences in one breathor to feed

y Use of accessory muscles of respiration – best noted by palpation of neck muscles

y Amount of wheezing – which might become biphasic or less apparent with increasing airwaysobstruction

y Degree of agitation and conscious level – always give calm reassurance

NB Clinical signs correlate poorly with the severity of airways obstruction. Some children with acute severeasthma do not appear distressed.

BConsider intensive inpatient treatent of children with SpO2 <92% in air after initial

bronchodilator treatent.

Increase β2 agonist dose by giving one puff every 30-60 seconds, according to response, up to amaximum of ten puffs

LIFETHREATENINGACuTE SEVERE

SpO2 <92% PEF 33-50% best or predicted

y Can’t complete sentences in one breath or

too breathless to talk or feed y Heart rate >125 (>5 years) or >140 (2-5years)

y Respiratory rate >30 breaths/min (>5 years)or >40 (2-5 years)

CRITERIA FOR ADmISSION

SpO2 <92% PEF <33% best or predicted

y Silent chest

y Cyanosis y Poor respiratory effort

y Hypotension

y Exhaustion

y Confusion

Parents/carers of children with an acute asthma attack at home and symptoms not controlled by upto 10 puffs of salbutamol via pMDI and spacer, should seek urgent medical attention.

If symptoms are severe additional doses of bronchodilator should be given as needed whilst awaitingmedical attention.

Paramedics attending to children with an acute asthma attack should administer nebulisedsalbutamol, using a nebuliser driven by oxygen if symptoms are severe, whilst transferring the child tothe emergency department.

Children with severe or life-threatening asthma should be transferred to hospital urgently

Children with life-threatening asthma or SpO2 <94% should receive high flow oxygen via a tight

fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations of 94–98%.



BRONCHODILATORS

mANAGEmENT OF ACuTE ASTHmA IN CHILDREN AGED 2 yEARS AND OVER

IV magnesium sulphate is a safe treatment for acute asthma although its place in management is not yetestablished.

A Inhaled β2 agonists are the first line treatent for acte astha.

Repeated doses of ipratropium bromide should be given early to treat children who are poorlyresponsive to β2 agonists.

Discontinue long-acting β2 agonists when short-acting β2 agonists are required more often than fourhourly.

y Use a dose of 20 mg prednisolone for children aged 2–5 years and a dose of 30–40 mg forchildren >5 years. Those already receiving maintenance steroid tablets should receive 2 mg/kgprednisolone up to a maximum dose of 60 mg.

y Repeat the dose of prednisolone in children who vomit and consider intravenous steroids inthose who are unable to retain orally ingested medication.

y Treatment for up to three days is usually sufficient, but the length of course should be tailoredto the number of days necessary to bring about recovery. Tapering is unnecessary unless thecourse of steroids exceeds 14 days.

A A pmDI + spacer is the preferred option in children with ild to oderate astha.

B Individalise drg dosing according to severit and adjst according to the patient’s response.

AIf sptos are refractor to initial β2 agonist treatent, add ipratropi broide (250micrograms/dose mixed with the nebulised β2 agonist solution).

CConsider adding 150 g agnesi slphate to each neblised salbtaol and ipratropi in

the first hor in children with a short dration of acte severe astha sptos presenting with

an oxgen satration less than 92%.

STEROID THERAPy

A Give oral steroids earl in the treatent of acte astha attacks.

SECOND LINE TREATmENT OF ACuTE ASTHmA

BConsider earl addition of a single bols dose of intravenos salbtaol (15 micrograms/kg over10 minutes) in a severe astha attack where the patient has not responded to initial inhaled

therap.

A Ainophlline is not recoended in children with ild to oderate acte astha.

BConsider ainophlline for children with severe or life-threatening astha nresponsive to

axial doses of bronchodilators and steroids.



mANAGEmENT OF ACuTE ASTHmA IN CHILDREN AGED uNDER 2 yEARS

TREATmENT OF ACuTE ASTHmA

y The assessment of acute asthma in early childhood can be difficult

y Intermittent wheezing attacks are usually due to viral infection and the response to asthmamedication is inconsistent

y Prematurity and low birth weight are risk factors for recurrent wheezing

y The differential diagnosis of symptoms includes: – Aspiration pneumonitis

– Pneumonia

– Bronchiolitis

– Tracheomalacia

– Complications of underlying conditions such as congenital anomalies and cystic fibrosis

BRONCHODILATORS

Steroid tablet therapy (10 mg of soluble prednisolone for up to three days) is the preferred steroidpreparation for use in this age group.

B Oral β2 agonists are not recoended for acte astha in infants.

AFor ild to oderate acte astha attacks, a pmDI + spacer and ask is the optial drg deliver

device.

BConsider inhaled ipratropi broide in cobination with an inhaled β2 agonist for ore severe

sptos.

STEROID THERAPy

B In infants, consider steroid tablets earl in the anageent of severe astha attacks in thehospital setting.

For children with frequent episodes of wheeze associated with viruses caution should be taken inprescribing multiple courses of oral steroids.



DIFFICuLT ASTHmA

Difficult asthma is defined as persistent symptoms and/or frequent exacerbations despite treatment atstep 4 or 5

ASSESSING DIFFICuLT ASTHmA

FACTORS CONTRIBuTING TO DIFFICuLT ASTHmA

POOR ADHERENCE

PSyCHOSOCIAL FACTORS

mONITORING AIRWAy RESPONSE

DPatients with difficlt astha shold be ssteaticall evalated, inclding:

y confiration of the diagnosis of astha, and

y identification of the echanis of persisting sptos and assessent of adherence to

therap.

D This assessent shold be facilitated throgh a dedicated ltidisciplinar difficlt astha

service, b a tea experienced in the assessent and anageent of difficlt astha.

C Healthcare professionals shold alwas consider poor adherence to aintenance therap before

escalating treatent in patients with difficlt astha.

C Healthcare professionals shold be aware that difficlt astha is coonl associated with

coexistent pschological orbidit.

D Assessent of coexistent pschological orbidit shold be perfored as part of a difficlt

astha assessent. In children this a inclde a pschosocial assessent of the fail.

B In patients with difficlt astha, consider onitoring indced spt eosinophil conts to gide

steroid treatent.



ASTHmA IN ADOLESCENTS

Adolescents are defined by the World Health Organisation (WHO) as young people between the ages 10and 19 years of age.

Key elements of working effectively with adolescents in the transition to adulthood include:

y seeing them on their own, separate from their parents/carers, for part of the consultation, and

y discussing confidentiality and its limitations.

DIAGNOSIS AND ASSESSmENT

Symptoms and signs of asthma in adolescents are no different from those of other age groups.

Exercise-related wheezing and breathlessness are common asthma symptoms in adolescents butonly a minority show objective evidence of exercise-induced bronchospasm. Other causes such ashyperventilation or poor fitness can usually be diagnosed and managed by careful clinical assessment.

Qestionnaires y The asthma control questionnaire (ACQ) and the asthmacontrol test (ACT) have been validated in adolescents withasthma.

Qalit of life easres y QoL scales (such as AQLQ12+) can be used.

Lng Fnction y Tests of airflow obstruction and airway responsivenessmay provide support for a diagnosis of asthma but mostadolescents with asthma will have normal lung function.

Bronchial hper-reactivit y A negative response to an exercise test is helpful in excludingasthma in children with exercise related breathlessness.

Anxiet and depressive disorders y Major depression, panic attacks and anxiety disorder arecommoner in adolescents with asthma and make asthmasymptoms more prominent.

y Brief screening questionnaires for anxiety and depression mayhelp identify those with significant anxiety and depression.

NONPHARmACOLOGICAL mANAGEmENT

PREVALENCE OF ASTHmA IN ADOLESCENCE

Asthma is common in adolescents but is frequently undiagnosed because of under-reporting ofsymptoms.

Clinicians seeing adolescents with any cardiorespiratory symptoms should consider asking aboutsymptoms of asthma.

Adolescents with asthma (and their parents and carers) should be encouraged to avoid exposure toETS and should be informed about the risks and urged not to start smoking.

Adolescents with asthma should be asked if they smoke personally. If they do and wish to stop,they should be offered advice on how to stop and encouraged to use local NHS smoking cessationservices.

Healthcare professionals should be aware that CAM use is common in adolescents and should askabout its use.



PHARmACOLOGICAL mANAGEmENT

ORGANISATION AND DELIVERy OF CARE

LONG TERm OuTLOOK AND ENTRy INTO THE WORK PLACE

Young adults with asthma have a low awareness of occupations that might worsen asthma (eg, exposureto dusts, fumes, spray, exertion and temperature changes, see page 22).

Transition to adlt based health care

Transition to adult services is important for all adolescents with asthma, irrespective of the asthmaseverity. Transition should be seen as a process and not just the event of transfer to adult services.It should begin early, be planned, involve the young person, and be both age and developmentallyappropriate. In the UK, general guidance on transition is available from the RCPCH and DOH websites.

Clinicians should discuss future career choices with adolescents with asthma and highlightoccupations that might increase susceptibility to work related asthma symptoms.

B School based clinics a be considered for adolescents with astha to iprove attendance.

BPeer-led interventions for adolescents in the school setting shold be considered.

Integration of school based clinics with primary care services is essential.

Specific evidence about the pharmacological management of adolescents with asthma is limited andis usually extrapolated from paediatric and adult studies. Pharmacological management of asthma iscovered on pages 8-11.

Specific evidence about inhaler device use and choice in adolescents is also limited. Inhaler devices arecovered on page 12.

INHALER DEVICES

Adolescent preference for inhaler device should be taken into consideration as a factor in improvingadherence to treatment.

As well as checking inhaler technique it is important to enquire about factors that may affect inhalerdevice use in real life settings, such as school.

Consider prescribing a more portable device (as an alternative to a pMDI with spacer) for deliveringbronchodilators when away from home.

PATIENT EDuCATION AND SELF mANAGEmENT

Effective transition care involves preparing adolescents with asthma to take independent responsibilityfor their own asthma management. Clinicians need to educate and empower adolescents to manage asmuch of their asthma care as they are capable of doing while supporting parents gradually to hand overresponsibility for management to their child.

Adherence y When asked, adolescents with asthma admit their adherence with asthma treatment and with asthma

trigger avoidance is often poor. y Strategies to improve adherence emphasise the importance of focusing on the individual and their

lifestyle and using individualised asthma planning and personal goal setting



C If anaesthesia is reqired, regional blockade is preferable to general anaesthesia.

ASTHmA IN PREGNANCy

ACuTE ASTHmA IN PREGNANCy

DRuG THERAPy IN PREGNANCy

DRuG THERAPy IN BREASTFEEDING mOTHERS

mANAGEmENT DuRING LABOuR

Several physiological changes occur during pregnancy which could worsen or improve asthma.Pregnancy can affect the course of asthma, and asthma and its treatment can affect pregnancy outcomes.

C use steroid tablets as noral when indicated dring pregnanc for severe astha. Steroid tablets

shold never be withheld becase of pregnanc.

C Give drg therap for acte astha as for non-pregnant patients, inclding ssteic steroids and

agnesi slphate.

D Acte severe astha in pregnanc is an eergenc and shold be treated vigorosl in hospital

C Encorage woen with astha to breastfeed

Cmonitor pregnant woen with oderate/severe astha closel to keep their astha well

controlled.

Advise women who smoke about the dangers for themselves and their babies and give appropriatesupport to stop smoking.

Continuous fetal monitoring is recommended for acute severe asthma For women with poorly controlled asthma there should be close liaison between the

respiratory physician and obstetrician, with early referral to critical care physicians for womenwith acute severe asthma

Advise women: - that an acute asthma attack is rare in labour - to continue their usual asthma medications in labour Women receiving steroid tablets at a dose exceeding prednisolone 7.5 mg per day for >2

weeks prior to delivery should receive parenteral hydrocortisone 100 mg 6-8 hourly duringlabour

In the absence of an acute severe asthma attack, reserve Caesarean section for the usual obstetricindications.

B Woen shold be advised of the iportance of aintaining good control of their astha dring

pregnanc to avoid probles for both other and bab.

C If lekotriene receptor antagonists are reqired to achieve adeqate control of astha then the

shold not be withheld dring pregnanc.

D Deliver high flow oxgen iediatel to aintain satration 94-98%.

use prostaglandin F2α with extree cation in woen with astha becase of the risk ofindcing bronchoconstriction.

D

C use astha edications as noral dring lactation.

C

C

B

C

The following drgs shold be sed as noral dring pregnanc:

y short acting B2 agonists

y long acting B2 agonsits

y inhaled corticosteroids

y oral and intravenos theophllines



OCCuPATIONAL ASTHmA

1 . A t

l e a s t 1 i n 1 0 c a s e s o f n e w

o r r e a p p e a r a n c e o f c h i l d h o o d a s t h m a i n a d u l t l i f e a r e a t t r i b u t a b l e t o o c c u p a t i o n .

2 . E n

q u i r e o f a d u l t p a t i e n t s w i t h r h i n i t i s o r a s t h m a a b o u t t h e i r j o b a n d t h e m a t e r i a l s

w i t h w h i c h t h e y w o r k .

3 . R h i n o - c o n j u n c t i v i t i s m a y p r e c e d e I g E - a s s

o c i a t e d o c c u p a t i o n a l a s t h m a ; t h e r i s k o

f d e v e l o p i n g a s t h m a b e i n g h i g h e s t i n t h

e y e a r a f t e r t h e o n s e t o f r h i n i t i s .

4 . T h

e p r o g n o s i s o f o c c u p a t i o n a l a s t h m a i s i m p r o v e d b y e a r l y i d e n t i f i c a t i o n a n d e a r

l y a v o i d a n c e o f f u r t h e r e x p o s u r e t o i t s c

a u s e

5 . C o n f i r m a

d i a g n o s i s s u p p o r t e d b y o b j e c t i v e c r i t e r i a a n d n o t o n t h e b a s i s o f a c o m

p a t i b l e h i s t o r y a l o n e b e c a u s e o f t h e p o

t e n t i a l i m p l i c a t i o n s f o r e m p l o y m e n t .

6 . A r

r a n g e f o r w o r k e r s w h o m y o u s u s p e c t o f h a v i n g w o r k - r e l a t e d a s t h m a t o p e r f o r m

s e r i a l p e a k f l o w

m e a s u r e m e n t s a t l e a s

t f o u r t i m e s a d a y .

W O R K - R E L A T E D A S T H M A A N D R H I N I T I S : C A S E F I N D I N G A N D M A N A G E M E

N T I N P R I M A R Y C A R E

D o s y m p t o m s i m p r o v e

w h e n a w a y f r o m w o r k

o r d e t e r i o r a t e w

h e n a t w o r k ?

G u i d e l i n e s f o r t h e I d e n t i f i c a t i o n ,

M a n a g e m e n t a n d P r e v e n t i o n

o f O c c u p a t i o n a l A s t h m a • w w

w . b o h r f . o r g . u

k / c o n t e n t / a s t h m

a . h

t m

H a s a n o c c u p a t i o n a l c a u s e o f s y m p t o m s b e e n

e x c l u d

e d ? 1 , 2

N o

Y e s

N o

Y e s

Y e s

A S T H M A

R H I N I T I S

H a s t h e

p a t i e n t

d e v e l o p e d

a s t h m a ?

• b

a k i n g

• p

a s t r y m a k i n g

• s

p r a y p a i n t i n g

• l a b o r a t o r y a n i m a l w o r k

• h

e a l t h c a r e

• d

e n t a l c a r e

• f o o d p r o c e s s i n g

• w

e l d i n g

• s

o l d e r i n g

• m

e t a l w o r k

• w

o o d w o r k

• c

h e m i c a l p r o c e s s i n g

• t e x t i l e , p l a s t i c s a n d r u b b e r m a n u f a c t u r e

• f a r m i n g a n d o t h e r j o b s w i t h e x p o s u r e t o d u s t s a n d f u m e s

H i g h r i s k w o r k 2 i n c l u d e s :

N o n - o c c u p a t i o n a l d i s e a s e

C o n t i n u e t r e a t m e n t

P o s s i b l e w o r k - r e l a t e d a s t h m a

R e f e r q u i c k l y t o a c h e s t p h y s i c i a n

o r o c c u p a t i o n a l p h y s i c i a n 4 , 5

A r r a n g e s e r i a l P E F m e a s u r e m e n t s 6

P o s s i b l e w o r k - r e l a t e d r h i n i t i s

R e f e r t o a

n a l l e r g y s p e c i a l i s t o r o c c u p a t i o n a l p h y s i c i a n

M o n i t o r

f o r t h e d e v e l o p m e n t o f a s t h m a s y m p t o m s 3



ORGANISATION AND DELIVERy OF CARE

STRuCTuRED REVIEW

B Training for priar care clinicians shold inclde edcational otreach visits sing ltifaceted

prograes that inclde consltation training inclding goal setting.

EDuCATING CLINICIANS

There is strong evidence that educating clinicians can improve health outcomes for patients. Interventionsneed to be of sufficient intensity to engage with, and change, the way practices are organised.

Proactive clinical review of people with asthma improves clinical outcomes. Evidence for benefit isstrongest when reviews include discussion and use of a written personalised asthma action plan (PAAP).

A In priar care, people with astha shold be reviewed reglarl b a nrse or doctor with

appropriate training in astha anageent. Review shold incorporate a written action plan.

It is good practice to audit the percentage of patients reviewed annually. Consider focusing onparticular groups such as those overusing bronchodilators, patients on higher treatment steps, thosewith asthma attacks or from groups with more complex needs.

ASTHmA CLINICS

There is insufficient evidence to make a recommendation about the provision of care through primarycare asthma clinics or specialist asthma clinics. Within primary care, structured reviews may be delivered asappointments in routine surgeries, or within a dedicated asthma clinic.

INTERVENTIONS INVOLVING SPECIFIC GROuPS

SCHOOLBASED INTERVENTIONS

B Consider a ltifaceted approach to school-based astha edcation prograes targeting

children’s health professionals as well as the children theselves.

ETHNICITy/CuLTuREBASED INTERVENTIONS

C Establish intensive clinic-based prograes for people fro ethnic inorit grops who have

attended eergenc care.

LAyLED INTERVENTIONS

A La-led self-anageent prograes for people with astha are not recoended.

PHARmACISTLED INTERVENTIONS

Evidence for pharmacist-led interventions is lacking and further high quality randomised trials testingpharmacist-led interventions to improve asthma outcomes are needed.



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