New asthma guidelines from BTS and Sign

This is an update on the asthma guideline from BTS / SIGN.

There are lots of little changes, but probably the biggest change is that they seem to have moved away from using short-acting b2 agonists in the initial management. The first step in children is now very low dose inhaled steroids and in adults is low dose inhaled steroids.

Another change is that treatment should be stepped up if ventolin is needed more than 3 times a week, rather than just 2 times a week as was previously advised.

This really is a massive guideline, so I've tried to just add in the bigger changes, rather than all the tiny ones, which really aren't that relevant. I've also added in the useful tables / charts that summarise diagnosis or treatment. At the end are charts with all the different inhalers / strengths which I think are really helpful. Hopefully this makes it all a little quicker to go through. There is still a lot I'm afraid!

Initial assessment - symptoms and signs:

  • Base your initial assessment on the symptoms and signs you would expect to see in asthma.
  • Cough alone would not normally be enough to make a diagnosis.
  • Absence of wheeze on examination during a 'symptomatic' episode would go against a diagnosis of asthma (unless they are very unwell).
  • Failure to respond to treatment (both subjectively and objectively) would also go against a diagnosis of asthma.

Initial assessment - diagnosis:

Decide whether a patient has a 'high', 'intermediate' or 'low' probability of having asthma:

  • High probability: Typical history and examination with no features to suggest an alternative diagnosis.
  • Intermediate probability: Have some, but not all the features of typical asthma.
  • Low probability: None of the typical features of asthma, or have features of an alternative diagnosis.

The following chart then outlines the initial steps to diagnosis:

qrg153-dragged

Non-pharmacological management

There is nothing new in this guideline. They reiterate that you shouldn't advise patients to take measures to reduce house dust mites as studies suggest that this does not affect symptoms.

All patients should have an 'Action plan'. An excellent version can be downloaded from asthma.org.uk. This includes a section on how to manage an exacerbation etc.

General points about pharmacological management

Combination inhalers. There is no evidence from studies that the use of combination inhalers improves symptoms as there is generally good compliance. However, it is felt that in normal practice, they improve compliance and hence symptoms.

They reiterate that you shouldn't advise patients to take measures to reduce house dust mites as studies suggest that this does not affect symptoms.

Exercise induced asthma. Normally asthma symptoms during exercise suggest poorly controlled asthma and stepping-up treatment would be advised. However if the asthma is otherwise well controlled and  if a short acting b2 agonist is needed then advise its use immediately before exercise (previous advice was to use it 30 mins before exercise).

Pharmacological Management in adults

Step-up treatment if ventolin is needed more than 3 times a week (this used to be 2 times a week).

The biggest change here is that a low dose steroid inhaler is advised both in the initial diagnosis and assessment and from step 1 (rather than just using short acting b2 agonists. The following table outlines treatment:

qrg153-b-dragged

Pharmacological management in children

I couldn't find specific advice on what age limit this goes up to.

The main difference is that management starts with very low dose steroids or leukotriene receptor antagonists.

The following table outlines treatment:

qrg153-c-dragged

Occupational asthma.

1 in 10 recurrences of asthma in adults are due to occupational asthma, so take a good history. If a patient has rhinitis which is worsened by being at work, they have a higher risk of asthma starting in the 1st year of symptoms. Occupational asthma has a worse prognosis if there is continued exposure, so prompt diagnosis is important. Advise serial PEF readings (at least 4 a day) and prompt referral to a respiratory specialist. The following chart is helpful:

qrg153-rhinitis-dragged

Different inhalers

The following tables show all the different inhalers and their strengths for adults and children.

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