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Implementing the revised BTS/SIGN British guideline on the management of asthma Diagnosis Clinical features in children

Symptoms that increase the probability of asthma: More than one of the following—wheeze, cough, difficulty breathing, chest tightness—especially if symptoms are: frequent and recurrent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c worse at night and early in the morning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c in response to, or worse after exercise/other triggers (e.g. exposure to pets, cold air) . . . . . . . . . . . . . c not associated with colds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c History of atopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Family history of atopy and/or asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Wheeze audible on chest auscultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Improvement of symptoms or lung function in response to adequate therapy . . . . . . . . . . . . . . . . . . . . . . c Lung function tests can be performed by most children over the age of 5 years . . . . . . . . . . . . . . . . . c

Clinical features in adults

Symptoms that increase the probability of asthma: More than one of the following—wheeze, breathlessness, chest tightness, cough—especially if symptoms are: worse at night and early in the morning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c in response to exercise, allergies, and cold air . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c after taking aspirin or beta blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c History of atopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Family history of atopy and/or asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Wheeze audible on chest auscultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Unexplained low FEV1 or PEF (historical or serial readings) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Unexplained peripheral blood eosinophilia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c

Management Non-pharmacological Offer smoking cessation advice and advise parents/parents-to-be to stop . . . . . . . . . . . . . . . . . . . . . . . c Recommend weight reduction to obese patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Consider immunotherapy where clinically significant allergen cannot be avoided . . . . . . . . . . . . . . . c

Pharmacological*

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Stepped approach—start at level appropriate to severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Aim to achieve early control and maintain control by stepping up/down as necessary . . . . . . . . . . c Prescribe all beclometasone hydrofluoroalkane inhalers by brand name . . . . . . . . . . . . . . . . . . . . . . . . . c For adults and children aged 5–12 years: Step 1—Inhaled short-acting β2 agonist as required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Step 2—Add inhaled steroid appropriate to severity of disease: 200–800 µg/day† for adults (200–400 µg/day† for children aged 5–12 years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Step 3—Add inhaled long-acting β2 agonist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c If response seen but control inadequate, increase inhaled steroid to 800 µg/day† for adults (400 µg/day† if aged 5–12 years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c If no response, stop long-acting β2 agonist, increase inhaled steroid to 800 µg/day† for adults (400 µg/day† if aged 5–12 years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Guidelines in Practice approached Chiesi Limited to fund the printing costs for this checklist. Chiesi Limited was not involved in its development, although it was allowed to review it just prior to printing. At all times editorial control has remained with Guidelines in Practice. BTS/SIGN was not involved in the development of this checklist. Sponsorship of the checklist does not imply BTS/SIGN endorsement of the sponsoring company’s products.


Implementingthe Implementing theBritish revisedguideline BTS/SIGN on the management British guideline of asthma on the management of asthma If control still inadequate, consider trial of other therapies (e.g. leukotriene receptor antagonist or SR theophylline) for adults and children aged 5–12 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Consider budesonide/formoterol as a single inhaler as a rescue medication instead of a short-acting β2 agonist in certain adults whose asthma is poorly controlled . . . . . . . . . . . . . . . . . . . . c Step 4—Increase inhaled steroid to 2000 µg/day† (800 µg/day† if aged 5–12 years) . . . . . . . . . . . . . . . . . . . . . c In adults add fourth drug, e.g. leukotriene receptor antagonist, SR theophylline, β2 agonist tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Step 5—Daily steroid tablets at lowest dose for adequate control plus high-dose inhaled steroid (up to 2000 µg/day† for adults) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Refer for specialist care (respiratory paediatrician for children) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c

Use combination inhalers to improve adherence and ensure long-acting β2 agonist is taken with inhaled steroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Ensure prevention and treatment of steroid tablet systemic side-effects as appropriate . . . . . . . . . c Monoclonal antibody therapy should only be initiated in specialist centres . . . . . . . . . . . . . . . . . . . . . . c

Monitoring in primary care Provide routine clinical review at least once a year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Children Monitor and record:

symptom score (e.g. Children’s Asthma Control Test, Asthma Control Questionnaire) . . . . . . . . . . . . . . . . c exacerbations, oral corticosteroid use, and time off school or nursery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c inhaler technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c adherence using prescription refill frequency . . c height and weight on growth chart . . . . . . . . . . . . c exposure to tobacco smoke . . . . . . . . . . . . . . . . . . . c use of self management or personal action plan . c

Adults Monitor and record:

symptom control using specific questions (e.g. RCP three questions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c lung function using spirometry or PEF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c exacerbations, oral corticosteroid use, and time off work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c inhaler technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c adherence using prescription refill frequency . . c use of self management or personal action plan . c

Consider closer monitoring of people with poor lung function and a history of exacerbations in the previous year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c

Asthma in adolescents (between ages 10 and 19 years)

*Refer to the full guideline for further information and recommendations on the use of pharmacological therapies; †beclometasone dipropionate or equivalent FEV1=forced expiratory volume in one second; PEF=peak expiratory flow; SR=sustained release; RCP=Royal College of Physicians Date of preparation: June 2011

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Be aware of under diagnosis (most have normal lung function despite having symptoms) . . . . . . c Identify patients with anxiety and depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Take into account inhaler preference to improve adherence to treatment . . . . . . . . . . . . . . . . . . . . . . . c Use school-based clinics, integrated with primary care, to improve attendance . . . . . . . . . . . . . . . . . . c Ensure that education delivered by healthcare professionals addresses individual needs . . . . . . . c Consider the use of peer-led education in schools for overall improvement . . . . . . . . . . . . . . . . . . . . . c Ensure that the transition to adult services is part of a process to allow the adolescent to take independent responsibility for their own asthma management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Give guidance on career choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c

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