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British Guideline on the MAnAGeMent of AsthMA isBn 978 1 905813 28 5 first published 2003 revised edition published 2008 revised edition published 2009 revised edition published 2011 revised edition published 2012 SIGN and the BTS consent to the photocopying of this guideline for the purpose of implementation in the NHS in England, Wales, Northern Ireland and Scotland. scottish intercollegiate Guidelines network elliott house, 8 -10 hillside Crescent edinburgh eh7 5eA www.sign.ac.uk British thoracic society 17 doughty street, london, WC1n 2Pl www.brit-thoracic.org.uk
Revised 2011 Revised 2011 Revised 2011 Contents 1 introduction 1 1.1 The need for a guideline 1 1.2 Remit of the guideline 1 1.3 Statement of intent 2 2 diagnosis 4 2.1 Diagnosis in children 4 2.2 Other investigations 10 2.3 Summary 11 2.4 Diagnosis in adults 13 2.5 Further investigations that may be useful in patients with an intermediate probability of asthma 18 2.6 Monitoring asthma 20 3 non-pharmacological management 28 3.1 Primary prophylaxis 28 3.2 Secondary non-pharmacological prophylaxis 31 3.3 Other environmental factors 32 3.4 Dietary manipulation 33 3.5 Complementary and alternative medicine 35 3.6 Other complementary or alternative approaches 36 4 Pharmacological management 37 4.1 Step 1: mild intermittent asthma 38 4.2 Step 2: introduction of regular preventer therapy 38 4.3 Step 3: initial add-on therapy 42 4.4 Step 4: poor control on moderate dose of inhaled steroid + add-on therapy: addition of fourth drug 45 4.5 Step 5: continuous or frequent use of oral steroids 45 4.6 Stepping down 51 4.7 Specific management issues 51 5 inhaler devices 54 5.1 Technique and training 54 5.2 β 2 agonist delivery 54 5.3 Inhaled steroids for stable asthma 55 5.4 CFC propellant PMDi vs HFA propellant PMDI 55 5.5 Prescribing devices 56 5.6 Use and care of spacers 56 6 Management of acute asthma 57 6.1 Lessons from studies of asthma deaths and near-fatal asthma 57 6.2 Acute asthma in adults 59 6.3 Treatment of acute asthma in adults 62 6.4 Further investigation and monitoring 66 6.5 Asthma management protocols and proformas 66 Contents
Page 1 and 2: 101 British Guideline on the Manage
Page 3: British Thoracic Society Scottish I
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 and 18: 2.3 suMMAry focus the initial asses
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
Page 67 and 68:
Table 11: Initial assessment - the
Page 69 and 70:
In acute asthma without life threat
Page 71 and 72:
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
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
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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
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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
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Abbreviations ABG arterial blood ga
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Annex 2 Management of acute severe
Page 123 and 124:
Annex 4 Features of acute severe as
Page 125 and 126:
Annex 6 Consider prednisolone 20 mg
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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