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British Guideline on the MAnAGeMent of AsthMA 2.2 other investiGAtions 2.2.1 TESTS OF AIRWAy HyPER-RESPONSIvENESS 10 The role of tests of airway responsiveness (airway hyper-reactivity) in the diagnosis of childhood asthma is unclear. 45,55 For example, a methacholine challenge test has a much lower sensitivity than symptoms in diagnosing asthma in children and only marginally increases the diagnostic accuracy after the symptom history is taken into account. 45 However, a negative methacholine test in children, which has a high negative predictive value, makes a diagnosis of asthma improbable. 55 Similarly, a negative response to an exercise challenge test is helpful in excluding asthma in children with exercise related breathlessness. 56 2.2.2 TEST OF EOSINOPHILIC AIRWAy INFLAMMATION Eosinophilic inflammation in children can be assessed non-invasively using induced sputum differential eosinophil count or exhaled nitric oxide concentrations (FENO). Sputum induction is feasible in school age children. 57,58 Higher sputum eosinophil counts are associated with more marked airways obstruction and reversibility, greater asthma severity and atopy. 59 In children with newly diagnosed mild asthma, sputum eosinophilia is present and declines with inhaled steroid treatment. 58 Sputum induction is possible in approximately 75% of children tested, but it is technically demanding and time consuming and at present remains a research tool. It is feasible to measure FENO in unsedated children from the age of 3-4 years. 60 A raised FENO is neither a sensitive nor a specific marker of asthma with overlap with children who do not have asthma. 61 FENO is closely linked with atopic status, age and height. 62,63 In some studies, FENO correlated better with atopic dermatitis and allergic rhinitis than with asthma. It is not closely linked with underlying lung function. FENO could not differentiate between groups once atopy was taken into account. 64 Home measurements of FENO have a highly variable relationship with other measures of disease activity and vary widely from day to day. 65 At present, there is insufficient evidence to support a role for markers of eosinophilic inflammation in the diagnosis of asthma in children. They may have a role in assessing severity of disease or response to treatment. 2.2.3 TESTS OF ATOPy Positive skin tests, 66 blood eosinophilia ≥4% 10 , or a raised specific IgE to cat, dog or mite, 67,68 increase the probability of asthma in a child with wheeze, particularly in children over five years of age. 66 It is important to recognise that non-atopic wheezing is as frequent as atopic wheezing in school-age children. 69 2.2.4 CHEST x-RAy A study in primary care in children age 0-6 years concluded that a chest x-ray (CxR), in the absence of a clinical indication, need not be part of the initial diagnostic work up. 70 ; Reserve chest x-rays for children with severe disease or clinical clues suggesting other conditions. 3 2 ++ 2 + 2 ++
2.3 suMMAry focus the initial assessment of children suspected of having asthma on: presence of key features in the history and clinical examination careful consideration of alternative diagnoses. record the basis on which the diagnosis of asthma is suspected. Using a structured questionnaire may produce a more standardised approach to the recording of presenting clinical features and the basis for a diagnosis of asthma. 1. in children with a high probability of asthma: move straight to a trial of treatment reserve further testing for those with a poor response. 2. in children with a low probability of asthma: consider more detailed investigation and specialist referral. 3. in children with an intermediate probability of asthma who can perform spirometry and have evidence of airways obstruction, offer a reversibility test and/or a trial of treatment for a specified period: if there is reversibility, or if treatment is beneficial, treat as asthma if there is insignificant reversibility, and/or treatment trial is not beneficial, consider tests for alternative conditions. 4. in children with an intermediate probability of asthma who can perform spirometry, and have no evidence of airways obstruction, consider testing for atopic status, bronchodilator reversibility and, if possible, bronchial hyper-responsiveness using methacholine or exercise. 5. in children with an intermediate probability of asthma, who cannot perform spirometry, consider testing for atopic status and offering a trial of treatment for a specified period: if treatment is beneficial, treat as asthma if treatment is not beneficial, stop asthma treatment, and consider tests for alternative conditions and specialist referral. Table 4: Indications for specialist referral in children Diagnosis unclear or in doubt Symptoms present from birth or perinatal lung problem Excessive vomiting or posseting Severe upper respiratory tract infection Persistent wet or productive cough Family history of unusual chest disease Failure to thrive Nasal polyps Unexpected clinical findings eg focal signs, abnormal voice or cry, dysphagia, inspiratory stridor Failure to respond to conventional treatment (particularly inhaled corticosteroids above 400 mcg/day or frequent use of steroid tablets) Parental anxiety or need for reassurance 2 diAGnosis 11
Page 1 and 2: 101 British Guideline on the Manage
Page 3 and 4: British Thoracic Society Scottish I
Page 5 and 6: Revised 2011 Revised 2011 Revised 2
Page 7 and 8: 1 introduction 1.1 the need for A G
Page 9 and 10: 1.3.1 PATIENT vERSION Patient versi
Page 11 and 12: Table 1: Clinical features that inc
Page 13 and 14: Case detection studies have used sy
Page 15: 2.1.6 CHILDREN WITH AN INTERMEDIATE
Page 19 and 20: 2.4 diAGnosis in Adults The diagnos
Page 21 and 22: 2.4.1 FURTHER INvESTIGATION OF PATI
Page 23 and 24: Table 6: Differential diagnosis of
Page 25 and 26: 2.5.1 TREATMENT TRIALS AND REvERSIB
Page 27 and 28: A small prospective observational s
Page 29 and 30: Table 8: Summary of tools that can
Page 31 and 32: Measurement Methodology Asthma Cont
Page 33 and 34: Measurement Methodology Eosinophil
Page 35 and 36: 3.1.2 FOOD ALLERGEN AvOIDANCE Sensi
Page 37 and 38: The limited data on antenatal or ea
Page 39 and 40: 3.3.2 AIR POLLUTION Challenge studi
Page 41 and 42: 3.5 CoMPleMentAry And AlternAtive M
Page 43 and 44: Revised 2011 4 Pharmacological mana
Page 45 and 46: Table 8b: Equivalent doses of inhal
Page 47 and 48: 4.2.3 SAFETy OF INHALED STEROIDS Th
Page 49 and 50: 4.3.2 ADD-ON THERAPy Options for ad
Page 51 and 52: 4.4 steP 4: Poor Control on ModerAt
Page 53 and 54: 4 PhArMAColoGiCAl MAnAGeMent Colchi
Page 55 and 56: MOVE UP TO IMPROVE CONTROL AS NEEDE
Page 57 and 58: 4.6 stePPinG doWn Stepping down the
Page 59 and 60: 4.7.5 ASPIRIN-INTOLERANT ASTHMA The
Page 61 and 62: 5.3 inhAled steroids for stABle Ast
Page 63 and 64: Revised 2009 6 Management of acute
Page 65 and 66: 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
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6.6.2 PATIENT EDUCATION Following d
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6.7.2 PULSE OxIMETRy 6.7.3 PEF Accu
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Frequent doses up to every 20-30 mi
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6.9.3 Iv MAGNESIUM SULPHATE Intrave
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New 2011 7 special situations 7.1 A
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Gender During adolescence there is
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Complementary and alternative medic
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Table 13: Recommendations for organ
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7.2 diffiCult AsthMA 7.2.1 DEFINING
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Revised 2009 Controlled studies usi
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Continuous fetal monitoring should
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C use steroid tablets as normal whe
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7.9.2 AT-RISK POPULATIONS Several h
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7.9.6 SPECIFIC BRONCHIAL PROvOCATIO
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Asthma clinics in primary care may
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A 8.3 Audit discharge from hospital
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9 Patient education and self manage
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9.2.1 COMPLIANCE WITH MONITORING AN
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Table 15. Summary of the key compon
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8. What role does patient preferenc
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Dr James Paton* Reader and Honorary
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INHALER DEvICES Dr John White (Chai
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11.4 disseMinAtion GrouP Mrs Sheila
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Abbreviations ABG arterial blood ga
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Annex 2 Management of acute severe
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Annex 4 Features of acute severe as
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Annex 6 Consider prednisolone 20 mg
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Annex 8 Management of acute asthma
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Annex 10 PEF (l/min) EU Scale 680 6
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Annex 11 (contd) Annexes 125
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56. Abu-Hasan M, Tannous B, Weinber
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156. Lodrup Carlsen KC, Carlsen KH,
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256. Malmstrom M, Ahlner J, Carlsso
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352. Brocklebank D, Ram F, Wright J
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456. McDowell KM, Chatburn RL, Myer
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562. McDonald JC, Keynes HL, Meredi
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668. Enright PL, McClelland RL, New
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767. Berger W. Budesonide inhalatio
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862. Pedroletti C, Lundahl J, Alvin
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ISBN 978 1 905813 28 5 British Thor
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