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Asthma – BTS guideline adults

Presentation with respiratory symptoms : wheeze , cough , breathlessness , chest tightness.Structured clinical assessment 
( from history and examination of previous medical records )

Look for
 recurrent episodes of symptoms symptom variability abscence of symptoms of alternative diagnosis recorded observation of wheeze personal history of atopy historical record of variable PEF or FEV1.

high probability asthma – code as suspected asthma-initiation of treatment -assess response objectively-good response -Asthma-Adjust maintenance dose 
Provide self-management adv
Arrange on-going review

Intermediate probablity of asthma-Test for airway obstruction
spirometry + bronchodilator reversibility-Options for investigations are :Test for variability
 reversibility PEF charting challenge tests.Test for eosinophilic inflammation or atopy
 FeNO blood eosinophils skin- prick test IgE-Suspected asthma
Watchful waiting ( if asymptomatic )
Commence treatment and assess
response objectively

Low probability of asthma-Investigate / treat for other more likely diagnosis-Other diagnosis confirmed.Evaluation ○ assess symptoms ,measure lung function , check inhaler technique and adherence
○ adjust dose ○ update self management plan ○ move up or down as appropriate

Diagnosis and assessment-Consider monitored initiation of treatment with low-dose ICS

Regular preventer Low dose ICS.
Initial add-on therapy-Add inhaled LABA to low-dose ICS
( normally as a combination therapy ) 
Additional add-on therapies

No reponse to LABA → stop LABA and consider ↑ ed dose of ICS

If benefit from LABA but control still inadequate – cont LABA and ↑ ICS to medium dose

If benefit from LABA but control still inadequate – continue LABA and ICS and consider trial of other therapy – LTRA , SR Theophylline , LAMA

High dose therapiesConsider trials of :Increasing ICS up to high dose

Add a fourth drug , eg LTRA , SR Theophylline , beta agonist tablet , LAMA Refer patient for specialist care

Continous or frequent use of oral steroidsUse daily steroid tablet in lowest dose providing adequate control

Maintain high-dose ICS

Consider other treatments to minimize use of steroid tablets Refer patient for specialist care

References ; Further reading
 QRG 141 British guideline on the management of asthma accessed via
guideline-quick-reference-guide-2014/ Asthma overview NICE pathways via British guideline on the management of asthma QRG 153 September 20116


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