British Thoracic Society
Scottish Intercollegiate Guidelines Network
British guideline on the management of asthma
A national clinical guideline
Revised 2014
,British guideline on the management of asthma
ISBN 978 1 905813 28 3
First published 2003
Revised edition published 2014
SIGN and the BTS consent to the photocopying of this guideline for the purpose of
implementation in the NHS in England, Wales, Northern Ireland and Scotland.
Scottish Intercollegiate Guidelines Network
Gyle Square, 1 South Gyle Crescent
Edinburgh EH12 9EB
www.sign.ac.uk
British Thoracic Society
17 Doughty Street
London, WC1N 2PL
www.brit-thoracic.org.uk
, Contents
Contents 5 Non-pharmacological management............... 47
5.1 Primary prevention..................................................... 47
1 Introduction.........................................................1 5.2 Secondary non-pharmacological prevention... 52
1.1 The need for a guideline........................................... 1 6 Pharmacological management........................ 58
1.2 Remit of the guideline............................................... 1 6.1 Step 1: mild intermittent asthma.......................... 59
1.3 Statement of intent.................................................... 3 6.2 Step 2: introduction of regular
preventer therapy....................................................... 59
2 Key recommendations....................................... 6
6.3 Step 3: initial add-on therapy................................. 64
2.1 Diagnosis and monitoring....................................... 6
6.4 Step 4: poor control on moderate
2.2 Supported self management.................................. 7 dose of inhaled corticosteroid + add-on
therapy: addition of fourth drug.....................66
2.3 Non-pharmacological management................... 7
6.5 Step 5: continuous or frequent use of
2.4 Pharmacological management.............................. 8 oral steroids................................................................... 67
2.5 Inhaler devices............................................................. 8 6.6 Stepping down............................................................ 75
2.6 Acute asthma................................................................ 8 6.7 Specific management issues................................... 75
2.7 Difficult asthma............................................................ 9 7 Inhaler devices..................................................... 78
2.8 Asthma in pregnancy................................................ 9 7.1 Technique and training............................................. 78
2.9 Occupational asthma................................................ 10 7.2 Β agonist delivery....................................................... 78
2
3 Diagnosis and monitoring................................. 11 7.3 Inhaled corticosteroids for stable asthma.......... 79
3.1 Diagnosis in children................................................. 11 7.4 Prescribing devices..................................................... 80
3.2 Other investigations.................................................. 18 7.5 Use and care of spacers............................................ 80
3.3 Summary........................................................................ 19 8 Management of acute asthma.......................... 81
3.4 Diagnosis in adults..................................................... 22 8.1 Lessons from asthma deaths and
near-fatal asthma........................................................ 81
3.5 Further investigations that may be useful in
patients with an intermediate probability 8.2 Acute asthma in adults............................................. 83
of asthma....................................................................... 27
8.3 Treatment of acute asthma in adults................... 86
3.6 Monitoring asthma..................................................... 30
8.4 Further investigation and monitoring................. 91
4 Supported self management............................ 38
8.5 Asthma management protocols and
4.1 Effectiveness of supported self management.. 38 proformas...................................................................... 91
4.2 Components of a self-management 8.6 Hospital discharge and follow up......................... 91
programme................................................................... 38
8.7 Acute asthma in children aged 2 years
4.3 Self management in specific patient groups.... 41 and over.......................................................................... 92
4.4 Adherence and concordance.................................. 44 8.8 Initial treatment of acute asthma in children
aged 2 years and over............................................... 94
4.5 Implementation in practice..................................... 45
, British guideline on the management of asthma
8.9 Second line treatment of acute asthma 12.2 At-risk populations..................................................... 121
in children aged 2 years and over........................ 98
12.3 Diagnosis........................................................................ 121
8.10 Assessment of acute asthma in children
aged less than 2 years............................................... 100 12.4 Management of occupational asthma................ 124
8.11 Treatment of acute asthma in children 13 Organisation and delivery of care...................126
aged less than 2 years............................................... 100
13.1 Care pathways.............................................................. 126
9 Difficult asthma................................................... 102
13.2 Educating clinicians................................................... 126
9.1 Defining and assessing difficult asthma............. 102
13.3 Asthma clinics.............................................................. 127
9.2 Factors contributing to difficult asthma............. 102
13.4 Telehealthcare interventions.................................. 128
10 Asthma in adolescents....................................... 105
13.5 School-based interventions.................................... 129
10.1 Definitions..................................................................... 105
13.6 Ethnicity/culture-based interventions................ 129
10.2 Prevalence of asthma in adolescence.................. 105
13.7 Lay-led interventions................................................. 130
10.3 Diagnosis and assessment....................................... 105
13.8 Pharmacist-led interventions................................. 130
10.4 Risk factors..................................................................... 106
14 Provision of information.................................... 131
10.5 Comorbidities and modifiable behaviours........ 107
14.1 Sources of further information............................... 131
10.6 Asthma attacks and the risk of hospital
admission....................................................................... 108 15 The evidence base..............................................133
10.7 Long-term outlook and entry into the 15.1 Systematic literature review.................................... 133
work place..................................................................... 108
15.2 Recommendations for research............................. 133
10.8 Non-pharmacological management................... 108
15.3 Review and updating................................................ 133
10.9 Pharmacological management.............................. 109
16 Development of the guideline.........................134
10.10 Inhaler devices............................................................. 109
16.1 Introduction.................................................................. 134
10.11 Organisation and delivery of care......................... 110
16.2 Executive and steering groups............................... 134
10.12 Patient education and self management........... 112
16.3 Evidence review groups........................................... 135
11 Asthma in pregnancy......................................... 114
16.4 Acknowledgements................................................... 139
11.1 Natural history and management
of stable asthma.......................................................... 114 16.5 Consultation and peer review................................ 139
11.2 Management of acute asthma in pregnancy.... 115 Abbreviations......................................................141
11.3 Drug therapy in pregnancy..................................... 116 Annexes.................................................................145
11.4 Management during labour.................................... 119 References............................................................158
11.5 Drug therapy in breastfeeding mothers............. 120
12 Occupational asthma......................................... 121
12.1 Incidence........................................................................ 121
Scottish Intercollegiate Guidelines Network
British guideline on the management of asthma
A national clinical guideline
Revised 2014
,British guideline on the management of asthma
ISBN 978 1 905813 28 3
First published 2003
Revised edition published 2014
SIGN and the BTS consent to the photocopying of this guideline for the purpose of
implementation in the NHS in England, Wales, Northern Ireland and Scotland.
Scottish Intercollegiate Guidelines Network
Gyle Square, 1 South Gyle Crescent
Edinburgh EH12 9EB
www.sign.ac.uk
British Thoracic Society
17 Doughty Street
London, WC1N 2PL
www.brit-thoracic.org.uk
, Contents
Contents 5 Non-pharmacological management............... 47
5.1 Primary prevention..................................................... 47
1 Introduction.........................................................1 5.2 Secondary non-pharmacological prevention... 52
1.1 The need for a guideline........................................... 1 6 Pharmacological management........................ 58
1.2 Remit of the guideline............................................... 1 6.1 Step 1: mild intermittent asthma.......................... 59
1.3 Statement of intent.................................................... 3 6.2 Step 2: introduction of regular
preventer therapy....................................................... 59
2 Key recommendations....................................... 6
6.3 Step 3: initial add-on therapy................................. 64
2.1 Diagnosis and monitoring....................................... 6
6.4 Step 4: poor control on moderate
2.2 Supported self management.................................. 7 dose of inhaled corticosteroid + add-on
therapy: addition of fourth drug.....................66
2.3 Non-pharmacological management................... 7
6.5 Step 5: continuous or frequent use of
2.4 Pharmacological management.............................. 8 oral steroids................................................................... 67
2.5 Inhaler devices............................................................. 8 6.6 Stepping down............................................................ 75
2.6 Acute asthma................................................................ 8 6.7 Specific management issues................................... 75
2.7 Difficult asthma............................................................ 9 7 Inhaler devices..................................................... 78
2.8 Asthma in pregnancy................................................ 9 7.1 Technique and training............................................. 78
2.9 Occupational asthma................................................ 10 7.2 Β agonist delivery....................................................... 78
2
3 Diagnosis and monitoring................................. 11 7.3 Inhaled corticosteroids for stable asthma.......... 79
3.1 Diagnosis in children................................................. 11 7.4 Prescribing devices..................................................... 80
3.2 Other investigations.................................................. 18 7.5 Use and care of spacers............................................ 80
3.3 Summary........................................................................ 19 8 Management of acute asthma.......................... 81
3.4 Diagnosis in adults..................................................... 22 8.1 Lessons from asthma deaths and
near-fatal asthma........................................................ 81
3.5 Further investigations that may be useful in
patients with an intermediate probability 8.2 Acute asthma in adults............................................. 83
of asthma....................................................................... 27
8.3 Treatment of acute asthma in adults................... 86
3.6 Monitoring asthma..................................................... 30
8.4 Further investigation and monitoring................. 91
4 Supported self management............................ 38
8.5 Asthma management protocols and
4.1 Effectiveness of supported self management.. 38 proformas...................................................................... 91
4.2 Components of a self-management 8.6 Hospital discharge and follow up......................... 91
programme................................................................... 38
8.7 Acute asthma in children aged 2 years
4.3 Self management in specific patient groups.... 41 and over.......................................................................... 92
4.4 Adherence and concordance.................................. 44 8.8 Initial treatment of acute asthma in children
aged 2 years and over............................................... 94
4.5 Implementation in practice..................................... 45
, British guideline on the management of asthma
8.9 Second line treatment of acute asthma 12.2 At-risk populations..................................................... 121
in children aged 2 years and over........................ 98
12.3 Diagnosis........................................................................ 121
8.10 Assessment of acute asthma in children
aged less than 2 years............................................... 100 12.4 Management of occupational asthma................ 124
8.11 Treatment of acute asthma in children 13 Organisation and delivery of care...................126
aged less than 2 years............................................... 100
13.1 Care pathways.............................................................. 126
9 Difficult asthma................................................... 102
13.2 Educating clinicians................................................... 126
9.1 Defining and assessing difficult asthma............. 102
13.3 Asthma clinics.............................................................. 127
9.2 Factors contributing to difficult asthma............. 102
13.4 Telehealthcare interventions.................................. 128
10 Asthma in adolescents....................................... 105
13.5 School-based interventions.................................... 129
10.1 Definitions..................................................................... 105
13.6 Ethnicity/culture-based interventions................ 129
10.2 Prevalence of asthma in adolescence.................. 105
13.7 Lay-led interventions................................................. 130
10.3 Diagnosis and assessment....................................... 105
13.8 Pharmacist-led interventions................................. 130
10.4 Risk factors..................................................................... 106
14 Provision of information.................................... 131
10.5 Comorbidities and modifiable behaviours........ 107
14.1 Sources of further information............................... 131
10.6 Asthma attacks and the risk of hospital
admission....................................................................... 108 15 The evidence base..............................................133
10.7 Long-term outlook and entry into the 15.1 Systematic literature review.................................... 133
work place..................................................................... 108
15.2 Recommendations for research............................. 133
10.8 Non-pharmacological management................... 108
15.3 Review and updating................................................ 133
10.9 Pharmacological management.............................. 109
16 Development of the guideline.........................134
10.10 Inhaler devices............................................................. 109
16.1 Introduction.................................................................. 134
10.11 Organisation and delivery of care......................... 110
16.2 Executive and steering groups............................... 134
10.12 Patient education and self management........... 112
16.3 Evidence review groups........................................... 135
11 Asthma in pregnancy......................................... 114
16.4 Acknowledgements................................................... 139
11.1 Natural history and management
of stable asthma.......................................................... 114 16.5 Consultation and peer review................................ 139
11.2 Management of acute asthma in pregnancy.... 115 Abbreviations......................................................141
11.3 Drug therapy in pregnancy..................................... 116 Annexes.................................................................145
11.4 Management during labour.................................... 119 References............................................................158
11.5 Drug therapy in breastfeeding mothers............. 120
12 Occupational asthma......................................... 121
12.1 Incidence........................................................................ 121
