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British Guideline on the MAnAGeMent of AsthMA 12 Figure 1: Presentation with suspected asthma in children HIGH PROBABILITY: diagnosis of asthma likely Continue treatment and find minimum effective dose Trial of asthma treatment Assess compliance and inhaler technique. Consider further investigation and/or referral Clinical assessment INTERMEDIATE PROBABILITY: diagnosis uncertain or poor response to asthma treatment +VE Consider tests of lung function* and atopy -VE Further investigation. Consider referral LOW PROBABILITY: other diagnosis likely Consider referral Investigate/ treat other condition Response? Response? Yes No No Yes Continue treatment * 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.
2.4 diAGnosis in Adults The diagnosis of asthma is based on the recognition of a characteristic pattern of symptoms and signs and the absence of an alternative explanation for them (see Table 5). The key is to take a careful clinical history. In many cases this will allow a reasonably certain diagnosis of asthma, or an alternative diagnosis, to be made. If asthma does appear likely, the history should also explore possible causes, particularly occupational. In view of the potential requirement for treatment over many years, it is important even in relatively clear cut cases, to try to obtain objective support for the diagnosis. Whether or not this should happen before starting treatment depends on the certainty of the initial diagnosis and the severity of presenting symptoms. Repeated assessment and measurement may be necessary before confirmatory evidence is acquired. Confirmation hinges on demonstration of airflow obstruction varying over short periods of time. Spirometry, which is now becoming more widely available, is preferable to measurement of peak expiratory flow because it allows clearer identification of airflow obstruction, and the results are less dependent on effort. It should be the preferred test where available (although some training is required to obtain reliable recordings and to interpret the results). Of note, a normal spirogram (or PEF) obtained when the patient is not symptomatic does not exclude the diagnosis of asthma. Results from spirometry are also useful where the initial history and examination leave genuine uncertainty about the diagnosis. In such cases, the differential diagnosis and approach to investigation is different in patients with and without airflow obstruction (see Figure 2 and Table 6). In patients with a normal or near-normal spirogram when symptomatic, potential differential diagnoses are mainly non-pulmonary; 71,72 these conditions do not respond to inhaled corticosteroids and bronchodilators. In contrast, in patients with an obstructive spirogram the question is less whether they will need inhaled treatment but rather exactly what form and how intensive this should be. Other tests of airflow obstruction, airway responsiveness and airway inflammation can also provide support for the diagnosis of asthma, but to what extent the results of the tests alter the probability of a diagnosis of asthma has not been clearly established, nor is it clear when these tests are best performed. 2 diAGnosis 13
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 and 16: 2.1.6 CHILDREN WITH AN INTERMEDIATE
Page 17: 2.3 suMMAry focus the initial asses
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
Page 67 and 68: 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
Page 151:
ISBN 978 1 905813 28 5 British Thor
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