British Guideline on the Management of Asthma

Aims Review of current SIGN/BTS guidelines –Diagnosing Asthma –Stepwise management of Asthma –Managing Acute Asthma –When to admit

Age Groups Children Adults

Diagnostic Algorithms Clinical features –Increase/decrease the probability of Asthma Diagnostic probability –Low, intermediate and high.

Clinical features & Probability Increase –Wheeze, cough, shortness of breath, tight chest. –Worse at night/morning –Triggers Exercise,allergen,cold air, drugs –Atopy –FH asthma/atopy –Widespread wheeze –Response to treatment –Unexplained low FEV1 or eosinophilia Decrease –No interval symptoms –Cough only –Moist cough –Hyperventilation symptom –Normal examination –Normal PF/spirometry –No response to Rx –Cardiac disease –Voice disturbance –Significant smoking history

Management Non-pharmacological –Breast feeding –Avoidance of tobacco smoke –Weight reduction Pharmacological

Pharmacological Management Aim for complete control –No daytime symptoms, no night time awakening, no need for rescue meds, no exacerbations, normal activity, normal lung function. Stepwise approach –Start at most appropriate step –Early control –Maintain by stepping up or down

Stepwise Management in Adults

Management in Children 5-12 yrs

Management in Children <5 yrs

Management of Acute Asthma

Assessment –Clinical features –PEF –Pulse oximetry –Blood gases (ABG) –Chest X-ray Not routine –Suspected pneumothorax, consolidation, life threatening, failure to respond, requiring ventilation

Management of Acute Asthma Moderate –PEFR >50-75% –No severe features Severe –PEFR 33-50% –RR ≥ 25 (adult), >30 (>5yrs), >40 (2-5yrs) –HR ≥ 110 (adult), >125 (>5yrs), >140 (2-5yrs) –Unable to complete sentences or feed Life threatening –PEFR <33% –SpO2 <92% –Silent chest, cyanosis, exhaustion, altered consciousness

Management of Acute Asthma Oxygen –Hypoxic patients – aim 94-98% –Drive nebulisers with oxygen  2 agonist bronchodilators –As early as possible –Consider continuous nebulisers if poor initial response Oral steroids Ipratropium bromide IV magnesium sulphate –Poor response to  2 agonist or life threatening IV salbutamol/aminophylline - Paediatrics

Admission criteria - Adults Life threatening –Immediately Severe –If any features of severe attack after initial treatment

Admission criteria - Children Severe of life threatening –Immediately Moderate –No improvement after 10 puffs of  2 agonist

Difficult Asthma Persistent symptoms or frequent exacerbations despite step 4 or 5 –Confirm diagnosis –Consider poor compliance –Consider psychosocial assessment

Conclusion Asthma is frequently under treated Use current guidelines to aid diagnosis and help in acute and chronic management If patients are not responding as you would expect –Is the diagnosis right? –Are they taking the appropriate medication? –Are psychological or social factors hindering management?