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Sample Topic: Asthma

Asthma : Last revised in December 2013


Managing adults with suspected asthma

How should I manage adults with a low probability of asthma?

Consider an alternative diagnosis, or refer to secondary care for further investigations.

Basis for recommendation
This recommendation is based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011].

How should I manage adults with a high probability of asthma?

  • Start a trial of asthma treatment for 2–3 months. The choice of treatment depends on the severity and frequency of symptoms. For more information, see the section titled ‘How should I start treatment for asthma?‘ below. If response is good, continue treatment.
  • If response is poor:
    • Assess compliance and inhaler technique.
    • Consider checking airway reversibility (in addition to spirometry at the initial diagnosis), or refer to secondary care for additional tests.

Basis for recommendation
This recommendation is based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011].

How should I manage adults with an intermediate probability of asthma?

If the person has an intermediate probability of asthma, consider performing a reversibility test (in addition to spirometry at the initial diagnosis) and/or a trial of treatment for 2–3 months:

  • If a trial of treatment is offered, the choice of treatment depends on the severity and frequency of symptoms. For more information, see the section titled ‘How should I start treatment for asthma?‘ below.
  • If a reversibility test shows significant reversibility (a greater than 400 mL improvement in forced expiratory volume in 1 second [FEV1]), start a trial of asthma treatment.
  • If a reversibility test shows no reversibility (less than 400 mL improvement in FEV1), consider referring to secondary care for additional tests.
  • If a trial of asthma treatment has been started and:
    • Response is good, continue treatment.
    • Response is poor, check for reversibility. If there is insignificant reversibility, consider referring to secondary care for additional tests. If there is significant reversibility, assess compliance and inhaler technique.

Basis for recommendation
This recommendation is based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011].

How should I start treatment for asthma?

  • Explain that lifestyle changes and medication are meant to control asthma symptoms and prevent an exacerbation.
  • Explain the difference between reliever and preventive therapy, and demonstrate how to use inhalers and spacer devices.
  • Prescribe an effective delivery device on the basis of convenience, cost, and suitability.
  • Prescribe a short-acting beta2-agonist for use as required to treat daytime symptoms (twice weekly or less often) of short duration (lasting only a few hours).
  • Prescribe a regular inhaled corticosteroid with the short-acting beta2-agonist if symptoms are at least three times weekly, or waking the person one night weekly.
  • Prescribe a peak flow meter, record the person’s best peak expiratory flow rate reading, and advise monitoring during an exacerbation, worsening symptoms, or a medication change. Regular monitoring of peak expiratory flow is no longer advised as it does not provide additional benefit when added to a symptom based management strategy. However, adults with severe disease or who have a poor perception of bronchoconstriction may benefit from regular peak expiratory flow rate monitoring.
  • Provide self-management information about asthma, such as how to monitor symptoms and recognize an exacerbation.

Additional information

  • Demonstrate how to use inhalers and spacer devices. Ask the person to repeat the technique back to you. For more information on how to use inhalers (with demonstrations), see www.asthma.org.uk or www.ginasthma.org.
  • Encourage monitoring of asthma control on the basis of symptoms [SIGN and BTS, 2011]:
    • Symptoms that worsen at night, or exercise-induced asthma, may suggest poor asthma control. The frequency of short-acting beta2-agonist use is a useful guide to asthma control. Ideally, people should not be using reliever medication in controlled asthma.
    • Do not recommend routine monitoring of peak expiratory flow rate (PEFR) unless the person has severe asthma or a poor perception of bronchoconstriction [SIGN and BTS, 2011]. However, encourage measuring PEFR as part of a self management programme: loss of asthma control may be assessed by symptoms or by measuring PEFR or both [SIGN and BTS, 2011].
  • A short-acting beta2-agonist should be started on an as required basis for mild, intermittent symptoms. People should have normal lung function and no nocturnal awakening. When symptoms are more frequent or are worsening, people require treatment at a level based on the severity of symptoms.

Basis for recommendation
This recommendation is based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011]:

  • Measuring peak expiratory flow rate (PEFR): The guideline development group for the British Guideline on the Management of Asthma: a national clinical guideline commented that in most adults with asthma, symptom-based monitoring is adequate [SIGN and BTS, 2011].
  • Short-acting bronchodilators: inhaled short-acting beta2-agonists are the preferred treatment for rapid symptom relief. The evidence suggests that short-acting beta2-agonists have a quicker onset of action and fewer adverse effects than other reliever drugs (inhaled anticholinergics, short-acting oral beta2-agonists, and short-acting theophylline). An as required regimen is at least as effective as regular use in people with asthma [GINA, 2006].