Abstract

Key recommendations

2.1 Diagnosis
C Compare the results of diagnostic tests undertaken whilst a patient is asymptomatic with those undertaken when a patient is symptomatic to detect variation over time.
D Carry out quality-assured spirometry using the lower limit of normal to demonstrate airway obstruction, provide a baseline for assessing response to initiation of treatment and exclude alternative diagnoses.
• Obstructive spirometry with positive bronchodilator reversibility increases the probability of asthma.
• Normal spirometry in an asymptomatic patient does not rule out the diagnosis of asthma.
D Undertake a structured clinical assessment to assess the initial probability of asthma. This should be based on:
• a history of recurrent episodes (attacks) of symptoms, ideally corroborated by variable peak flow when symptomatic and asymptomatic
• symptoms of wheeze, cough, breathlessness and chest tightness that vary over time
• recorded observation of wheeze heard by a healthcare professional
• personal/family history of other atopic conditions (in particular, atopic eczema/dermatitis, allergic rhinitis)
• no symptoms/signs to suggest alternative diagnoses.
? In patients with a high probability of asthma:
• record the patient as likely to have asthma and commence a carefully monitored initiation of treatment (typically six weeks of inhaled corticosteroids)
• assess the patient’s status with a validated symptom questionnaire, ideally corroborated by lung function tests (FEV1 at clinic visits or by domiciliary serial peak flows to capture times with/without symptoms)
• with a good symptomatic and objective response to treatment, confirm the diagnosis of asthma and record the basis on which the diagnosis was made
• if the response is poor or equivocal, check inhaler technique and adherence, arrange further tests and consider alternative diagnoses.

Key recommendations
2.2 Monitoring
>12 5-12 <5 yrs yrs yrs
D B D Assess risk of future asthma attacks at every asthma review by asking about history of previous attacks, objectively assessing current asthma control, and reviewing reliever use.
2.3 Supported self management
A All people with asthma (and/or their parents or carers) should be offered
self-management education, which should include a written personalised asthma action plan and be supported by regular professional review.
A Prior to discharge, inpatients should receive written personalised asthma action plans, given by healthcare professionals with expertise in providing asthma education.
D Adherence to long-term asthma treatment should be routinely and regularly addressed by all healthcare professionals within the context of a comprehensive programme of accessible proactive asthma care.
2.4 Non-pharmacological management
B People with asthma and parents of children with asthma should be advised about the dangers of smoking and second-hand tobacco smoke exposure, and be offered appropriate support to stop smoking.
B Weight loss interventions (including dietary and exercise-based programmes) should be considered for overweight and obese adults and children with asthma to improve asthma control.
A Breathing exercise programmes (including face-to-face physiotherapist taught methods and audiovisual programmes) can be offered to adults with asthma as an adjuvant to pharmacological treatment to improve quality of life and reduce symptoms.
2.5 Pharmacological management
? Before initiating a new drug therapy practitioners should check adherence
with existing therapies, check inhaler technique, and eliminate trigger factors.
A A A Inhaled corticosteroids are the recommended preventer drug for adults and children for achieving overall treatment goals.
A The first choice as add-on therapy to inhaled corticosteroids in adults is an inhaled long-acting ß2 agonist, which should be considered before increasing the dose of inhaled corticosteroids.
D D I f asthma control remains suboptimal after the addition of an inhaled long-acting ß2 agonist then:
• increase the dose of inhaled corticosteroids from low dose to medium dose in adults or from very low dose to low dose in children (5–12 years), if not already on these doses.
• consider adding a leukotriene receptor antagonist.

2.6 Inhaler devices
B ? ? Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique.
? Generic prescribing of inhalers should be avoided as this might lead to people with asthma being given an unfamiliar inhaler device which they are not able to use properly.
? In young children, a pMDI and spacer is the preferred method of delivery of ß2 agonists and inhaled corticosteroids. A face mask is required until the child can breathe reproducibly using the spacer mouthpiece. Where this is ineffective a nebuliser may be required.
2.7 Acute asthma
2.7.1 Adults
D Refer to hospital any patients with features of acute severe or life threatening
asthma.
C Give controlled supplementary oxygen to all hypoxaemic patients with acute severe asthma titrated to maintain an SpO2 level of 94–98%.
Do not delay oxygen administration in the absence of pulse oximetry but commence monitoring of SpO2 as soon as it becomes available.
A Use high-dose inhaled ß2 agonists as first-line agents in patients with acute asthma and administer as early as possible. Reserve intravenous ß2 agonists for those patients in whom inhaled therapy cannot be used reliably.
A Give steroids in adequate doses to all patients with an acute asthma attack.
2.7.2 Children
? Children with life-threatening asthma or SpO2 <94% should receive high-flow oxygen via a tight-fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations of 94–98%.
A Inhaled ß2 agonists are the first-line treatment for acute asthma in children.
A Give oral steroids early in the treatment of acute asthma attacks in children.
2.7.3 All patients
? It is essential that the patient’s primary care practice is informed within 24 hours of discharge from the emergency department or hospital following an asthma attack. Ideally this communication should be directly with a named
individual responsible for asthma care within the practice.
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2.8 Difficult asthma
D Patients with difficult asthma should be systematically evaluated, including:
• confirmation of the diagnosis of asthma, and
• identification of the mechanism of persisting symptoms and assessment
of adherence to therapy.
2.9 Asthma in pregnancy
B Women should be advised of the importance of maintaining good control
of their asthma during pregnancy to avoid problems for both mother and baby.
C Counsel women with asthma regarding the importance and safety of continuing their asthma medications during pregnancy to ensure good asthma control.
2.10 Occupational asthma
B In patients with adult onset, or reappearance of childhood asthma, healthcare professionals should consider that there may be an occupational cause.
? Adults with suspected asthma or unexplained airflow obstruction should be asked:
• Are you the same, better, or worse on days away from work?
• Are you the same, better, or worse on holiday?
Those with positive answers should be investigated for occupational asthma.

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