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British Guideline on the MAnAGeMent of AsthMA Annex 5 n Recent hospital admission or previous severe attack n Concern over social circumstances or ability to cope at home 118 LOWER THRESHOLD FOR ADMISSION IF: n Attack in late afternoon or at night NB: If a patient has signs and symptoms across categories, always treat according to their most severe features n Recent hospital admission or previous severe attack n Concern over social circumstances or ability to cope at home LOWER THRESHOLD FOR ADMISSION IF: n Attack in late afternoon or at night NB: If a patient has signs and symptoms across categories, always treat according to their most severe features n Continue prednisolone for up to 3 days n Arrange follow-up clinic visit n Continue prednisolone for up to 3 days n Arrange follow-up clinic visit n Continue β agonist via spacer or nebuliser, 2 as needed but not exceeding 4-hourly n If symptoms are not controlled repeat β agonist and refer to hospital 2 n Repeat β agonist via oxygen-driven nebuliser 2 in ambulance n Stay with patient until ambulance arrives n Send written assessment and referral details n Continue β agonist via spacer or nebuliser, 2 as needed but not exceeding 4-hourly n If symptoms are not controlled repeat β agonist and refer to hospital 2 n Repeat β agonist via oxygen-driven nebuliser 2 in ambulance n Stay with patient until ambulance arrives n Send written assessment and referral details GOOD RESPONSE POOR RESPONSE GOOD RESPONSE POOR RESPONSE IF POOR RESPONSE ARRANGE ADMISSION IF POOR RESPONSE REPEAT β AGONIST AND ARRANGE 2 ADMISSION REPEAT β AGONIST 2 VIA OXYGEN-DRIVEN NEBULISER WHILST ARRANGING IMMEDIATE HOSPITAL ADMISSION IF POOR RESPONSE ARRANGE ADMISSION IF POOR RESPONSE REPEAT β AGONIST AND ARRANGE 2 ADMISSION REPEAT β AGONIST 2 VIA OXYGEN-DRIVEN NEBULISER WHILST ARRANGING IMMEDIATE HOSPITAL ADMISSION Increase β agonist dose 2 by 2 puffs every 2 minutes according to response up to 10 puffs Assess response to treatment 15 mins after β agonist 2 Assess response to treatment 15 mins after β agonist 2 Increase β agonist dose 2 by 2 puffs every 2 minutes according to response up to 10 puffs n β agonist 2-10 puffs via 2 spacer ± facemask n Consider soluble prednisolone 20 mg n Oxygen via face mask n 2-10 puffs of β agonist [give 2 2 puffs, every 2 minutes according to response up to maximum of 10 puffs] or nebulised salbutamol 2.5 mg or terbutaline 5 mg n Soluble prednisolone 20 mg n Soluble prednisolone 20 mg or IV hydrocortisone 50 mg n Oxygen via face mask n Nebulise: - salbutamol 2.5 mg or terbutaline 5 mg + - ipratropium 0.25 mg n β agonist 2-10 puffs via 2 spacer n Consider soluble prednisolone 30-40 mg n Oxygen via face mask n 2-10 puffs of β agonist 2 [give 2 puffs, every 2 minutes according to response up to maximum of 10 puffs] or nebulised salbutamol 2.5-5 mg or terbutaline 5-10 mg n Soluble prednisolone 30-40 mg n Soluble prednisolone 30-40 mg or IV hydrocortisone 100 mg n Oxygen via face mask n Nebulise: - salbutamol 5 mg or terbutaline 10 mg + - ipratropium 0.25 mg n Respiratory rate >40/min n Use of accessory neck muscles n Altered consciousness n Cyanosis n Respiratory rate ≤30/min n Respiratory rate >30/min n Use of accessory neck muscles n Altered consciousness n Cyanosis n Poor respiratory effort n Agitation n Heart rate ≤140/min n Respiratory rate ≤40/min n Poor respiratory effort n Agitation n Able to talk n Too breathless to talk n Heart rate >140/min n PEF ≥50% best or predicted n Able to talk n Heart rate ≤125/min n PEF 33-50% best or predicted n Too breathless to talk n Heart rate >125/min n PEF
Annex 6 Consider prednisolone 20 mg daily for up to 3 days Advise to contact GP if not controlled on above treatment Provide a written asthma action plan Review regular treatment Check inhaler technique Arrange GP follow up Admit all cases if features of severe exacerbation persist after initial treatment Consider prednisolone 30-40 mg daily for up to 3 days Advise to contact GP if not controlled on above treatment Provide a written asthma action plan Review regular treatment Check inhaler technique Arrange GP follow up Admit all cases if features of severe exacerbation persist after initial treatment DISCHARGE PLAN Continue β 2 agonist 4 hourly prn Arrange immediate transfer to PICU/HDU if poor response to treatment DISCHARGE PLAN Continue β 2 agonist 4 hourly as necessary Arrange immediate transfer to PICU/HDU if poor response to treatment Reassess within 1 hour Increase β agonist dose 2 by 2 puffs every 2 minutes up to 10 puffs according to response Consider soluble oral prednisolone 20 mg β agonist 2-10 puffs via 2 spacer ± facemask [given one at a time single puffs, tidal breathing and inhaled separately] β agonist 10 puffs via 2 spacer ± facemask or nebulised salbutamol 2.5 mg or terbutaline 5 mg Soluble prednisolone 20 mg or IV hydrocortisone 4 mg/kg Repeat β agonist up to 2 every 20-30 minutes according to response If poor response add 0.25 mg nebulised ipratropium bromide Repeat bronchodilators every 20-30 minutes Reassess within 1 hour Nebulised β agonist: 2 salbutamol 2.5 mg or terbutaline 5 mg plus ipratropium bromide 0.25 mg nebulised Oral prednisolone 20mg or IV Hydrocortisone 4mg/ kg if vomiting Discuss with senior clinician, PICU team or paediatrician Increase β agonist dose 2 by 2 puffs every 2 minutes up to 10 puffs according to response Oral prednisolone 30-40 mg β agonist 2-10 puffs via 2 spacer β agonist 10 puffs via 2 spacer or nebulised salbutamol 2.5-5 mg or terbutaline 5-10 mg Oral prednisolone 30-40 mg or IV hydrocortisone 4 mg/kg if vomiting If poor response nebulised ipratropium bromide 0.25 mg Repeat β2 agonist and ipratropium up to every 20-30 minutes according to response Repeat bronchodilators every 20-30 minutes Nebulised β agonist: 2 salbutamol 5 mg or terbutaline 10 mg plus ipratropium bromide 0.25 mg nebulised Oral prednisolone 30- 40mg or IV Hydrocortisone 4mg/kg if vomiting Discuss with senior clinician, PICU team or paediatrician Oxygen via face mask/nasal prongs to achieve SpO2 94-98% Oxygen via face mask/nasal prongs to achieve SpO2 94-98% Moderate asthma SpO2 ≥92% No clinical features of severe asthma NB: If a patient has signs and symptoms across categories, always treat according to their most severe features Too breathless to talk or eat Heart rate >140/min Respiratory rate >40/min Use of accessory neck muscles Poor respiratory effort Agitation Altered consciousness Cyanosis PEF ≥50% best or predicted No clinical features of severe asthma NB: If a patient has signs and symptoms across categories, always treat according to their most severe features Heart rate >125/min Respiratory rate >30/min Use of accessory neck muscles Severe asthma SpO2
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101 British Guideline on the Manage
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British Thoracic Society Scottish I
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Revised 2011 Revised 2011 Revised 2
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1 introduction 1.1 the need for A G
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1.3.1 PATIENT vERSION Patient versi
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Table 1: Clinical features that inc
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Case detection studies have used sy
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2.1.6 CHILDREN WITH AN INTERMEDIATE
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2.3 suMMAry focus the initial asses
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2.4 diAGnosis in Adults The diagnos
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2.4.1 FURTHER INvESTIGATION OF PATI
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Table 6: Differential diagnosis of
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2.5.1 TREATMENT TRIALS AND REvERSIB
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A small prospective observational s
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Table 8: Summary of tools that can
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Measurement Methodology Asthma Cont
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Measurement Methodology Eosinophil
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3.1.2 FOOD ALLERGEN AvOIDANCE Sensi
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The limited data on antenatal or ea
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3.3.2 AIR POLLUTION Challenge studi
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3.5 CoMPleMentAry And AlternAtive M
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Revised 2011 4 Pharmacological mana
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Table 8b: Equivalent doses of inhal
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4.2.3 SAFETy OF INHALED STEROIDS Th
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4.3.2 ADD-ON THERAPy Options for ad
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4.4 steP 4: Poor Control on ModerAt
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4 PhArMAColoGiCAl MAnAGeMent Colchi
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MOVE UP TO IMPROVE CONTROL AS NEEDE
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4.6 stePPinG doWn Stepping down the
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4.7.5 ASPIRIN-INTOLERANT ASTHMA The
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5.3 inhAled steroids for stABle Ast
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Revised 2009 6 Management of acute
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Patients with brittle or difficult
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Table 11: Initial assessment - the
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In acute asthma without life threat
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6.3.8 ANTIBIOTICS 6.3.9 HELIOx When
Page 73 and 74: 6.6.2 PATIENT EDUCATION Following d
Page 75 and 76: 6.7.2 PULSE OxIMETRy 6.7.3 PEF Accu
Page 77 and 78: Frequent doses up to every 20-30 mi
Page 79 and 80: 6.9.3 Iv MAGNESIUM SULPHATE Intrave
Page 81 and 82: New 2011 7 special situations 7.1 A
Page 83 and 84: Gender During adolescence there is
Page 85 and 86: Complementary and alternative medic
Page 87 and 88: Table 13: Recommendations for organ
Page 89 and 90: 7.2 diffiCult AsthMA 7.2.1 DEFINING
Page 91 and 92: Revised 2009 Controlled studies usi
Page 93 and 94: Continuous fetal monitoring should
Page 95 and 96: C use steroid tablets as normal whe
Page 97 and 98: 7.9.2 AT-RISK POPULATIONS Several h
Page 99 and 100: 7.9.6 SPECIFIC BRONCHIAL PROvOCATIO
Page 101 and 102: Asthma clinics in primary care may
Page 103 and 104: A 8.3 Audit discharge from hospital
Page 105 and 106: 9 Patient education and self manage
Page 107 and 108: 9.2.1 COMPLIANCE WITH MONITORING AN
Page 109 and 110: Table 15. Summary of the key compon
Page 111 and 112: 8. What role does patient preferenc
Page 113 and 114: Dr James Paton* Reader and Honorary
Page 115 and 116: INHALER DEvICES Dr John White (Chai
Page 117 and 118: 11.4 disseMinAtion GrouP Mrs Sheila
Page 119 and 120: Abbreviations ABG arterial blood ga
Page 121 and 122: Annex 2 Management of acute severe
Page 123: Annex 4 Features of acute severe as
Page 127 and 128: Annex 8 Management of acute asthma
Page 129 and 130: Annex 10 PEF (l/min) EU Scale 680 6
Page 131 and 132: Annex 11 (contd) Annexes 125
Page 133 and 134: 56. Abu-Hasan M, Tannous B, Weinber
Page 135 and 136: 156. Lodrup Carlsen KC, Carlsen KH,
Page 137 and 138: 256. Malmstrom M, Ahlner J, Carlsso
Page 139 and 140: 352. Brocklebank D, Ram F, Wright J
Page 141 and 142: 456. McDowell KM, Chatburn RL, Myer
Page 143 and 144: 562. McDonald JC, Keynes HL, Meredi
Page 145 and 146: 668. Enright PL, McClelland RL, New
Page 147 and 148: 767. Berger W. Budesonide inhalatio
Page 149 and 150: 862. Pedroletti C, Lundahl J, Alvin
Page 151: ISBN 978 1 905813 28 5 British Thor
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