Asthma
Questionnaire/history:
Wheeze? Noisy breathing?
Cough?
Breathlessness?
Chest tightness?
Variation of above symptoms?
- Diurnal (worse during the night or early morning)? - Seasonal?
Triggered or exacerbated by: - Exercise?
- Viral infection? - Cold air? - Allergens?
Past medical history? - Atopic disorders?
Family history? - Atopic disorders?
Current medication?
Drug allergies?
Examination: Chest auscultation? - Expiratory, polyphonic wheeze?
Investigations > 16 years:
BEC or FeNO BDR with spirometry BDR delayed or not available: PEF variability Bronchial challenge test
5-16 years:
FeNO
BDR with spirometry
BDR delayed or not available: PEF variability
Skin prick test or total IgE and BEC
Bronchial challenge test
< 5 years:
Objective tests difficult + lack of good reference standards
Diagnosis:
Suspected asthma
Confirmed asthma (basis):
History suggestive of asthma
+ > 16 years: BEC > ULN or FeNO ≥ 50 ppb? Reversible airflow obstruction ≥ 12% from baseline + ≥ 200 ml (or ≥ 10% of predicted normal)?
Amplitude percentage mean ≥ 20%?
Bronchial hyperresponsiveness
5-16 years:
FeNO level ≥ 35 ppb?
Reversible airflow obstruction ≥ 12% from baseline (or ≥ 10% of predicted normal)?
Amplitude percentage mean ≥ 20%?
Skin prick with evidence of house dust mite sensitisation or total IgE raised?
If total IgE raised, BEC > 0.5 10*9 per litre?
Bronchial hyperresponsiveness
Management:
≥ 12 years:
Step 1: low-dose ICS/formoterol combination inhaler to be taken as needed (AIR therapy) Step 2: low-dose MART Step 3: check FeNo level, if available, and blood eosinophil count If either is raised, referral to a specialist in asthma care
If neither is raised: LTRA or LAMA in addition to moderate-dose MART for 8-12 weeks
If asthma controlled, continue treatment
If control has improved but is still inadequate, continue the treatment and start a trial of the other medicine (LTRA or LAMA)
If control had not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA)
5-11 years:
Step 1: paediatric low-dose ICS
Step 2: paediatric low-dose MART
Step 3: paediatric moderate-dose MART Step 4: referral to a specialist in asthma care Unable to manage MART regimen: Step 2: paediatric low-dose ICS + LTRA bd + SABA prn Step 3: paediatric low-dose ICS/LABA combination bd (with or without an LTRA) + SABA prn
Step 4: paediatric moderate-dose ICS/LABA combination bd (with or without an LTRA) + SABA prn
Step 5: referral to a specialist in asthma care
< 5 years: Step 1: paediatric low-dose ICS bd + SABA prn for 8-12 weeks
If symptoms resolve during trial consider stopping treatment after 8-12 weeks and review symptoms after a further 3 months
If symptoms recur after review or acute episode requires systemic corticosteroids or hospitalization Step 2: restart paediatic low-dose ICS bd and titrate up to a paediatric moderate dose prn + SABA prn
Consider a further trial without treatment after reviewing the child within 12 months
Step 3: paediatric ICS bd + LTRA + SABA prn for 8-12 weeks
Step 4: stop the LTRA and referral to a specialist in asthma care
Abbrevations:
AIR therapy = anti-inflammatory reliever therapy (AIR)
BEC = Blood eosinophil count
BDR = Bronchodilator reversibility
DPI = Dry powder inhaler
ICS = inhaled corticosteroid
LABA = long-acting beta-2 agonist
LAMA = long-acting muscarinic receptor antagonist (e.g. tiotropium bromide)
LTRA = leukotriene receptor antagonist (e.g. montelukast (Singulair))
MART = maintenance and reliever therapy (using ICS/formoterol combination inhalers)
PEF = Peak expiratory flow variability
pMDI = pressured metered-dose inhaler
ppb = parts per billion
SABA = short-acting -2 agonistFeNO = Fractional Exhaled Nitric Oxide (FeNO)
ULN = upper limit of normal, as defined by laboratory reference range
Uncontrolled asthma: any exacerbation requiring oral corticosteroids or frequent regular symptoms (such as using reliever inhaler 3 or more days a week or night-time 1 or more times a week)
Inhalers:
≥ 12 years:
AIR therapy:
Symbicort Turbohaler 200/6mcg 1 dose when required (max 8-12 doses daily)
Low dose MART:
Symbicort Turbohaler 200/6mcg 1 dose bd + 1 dose when required (max 8-12 doses daily)
Fostair NEXThaler 100/6mcg 1 dose bd + 1 dose when required (max 8 doses daily) Moderate dose MART:
Symbicort Turbohaler 200/6mcg 2 doses bd + 1 dose when required (max 8-12 doses daily)
Fostair NEXThaler 100/6mcg 2 doses bd + 1 dose when required (max 8-12 doses daily) (off-label)
5-11 years:
Paediatric low-dose MART:
Symbicort 100/6mcg 1 dose bd + 1 dose when required (max 8 doses daily, max 4 doses at any one time) Paediatric moderate-dose MART:
Symbicort Turbohaler 100/6mcg 1-2 doses bd + 1 dose when required (max 8 doses daily, max 4 doses at any one time)
Paediatric low-dose ICS: Clenil Modulite inhaler 100mcg 1 dose bd (pMDI, Co2 high) Pulmicort Turbohaler 100mcg 1 dose bd (DPI, Co2 low) Paediatric low-dose ICS/LABA: Symbicort Turbohaler 100/6mcg 1 dose bd
< 5 years:
Paediatric low-dose ICS:
Clenil Modulite inhaler 100mcg 1 dose bd (pMDI, Co2 high)Pulmicort Turbohaler 100mcg 1 dose bd (DPI, Co2 low)
Resource(s):
Information for patients/carer(s):
Asthma + Lung UK: How to use your inhaler
Ashtma + Lung UK: Your AIR asthma action plan
Ashtma + Lung UK: MART asthma action plan
Ashtma + Lung UK: Child asthma action plan