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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 ) OR 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
Asthma-diagnosed 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 https://www.brit-thoracic.org.uk/document-library/ clinical-information/asthma/btssign-asthma- guideline-quick-reference-guide-2014/ Asthma overview NICE pathways via http://pathways.nice.org.uk/pathways/asthma British guideline on the management of asthma QRG 153 September 20116