GUIDELINES LET S TALK ABOUT THE ASTHMA ...MADE MORE PRACTICAL GUIDELINES FOR PRACTICE...

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1 LET S TALK ABOUT THE ASTHMA GUIDELINES GUIDELINES FOR PRACTICE......MADE MORE PRACTICAL NICE quality standard QOF asthma indicators BTS/SIGN guidelines Provided as a service to medicine by Teva UK Limited. For healthcare professionals.

2 Contents LET S TALK ABOUT the asthma guidelines CONTENTS NICE quality standard for asthma /17 GMS contract QOF 3 BTS/SIGN guidelines 4 Practical approach to diagnosis 4 Monitoring adults in primary care 8 Pharmacological management 11 Inhaler devices 18 Management of acute asthma 19 Management of acute asthma in pregnancy 25 Practical advice 28 Glossary 28 Annexes The aim of this guide is to make sure you have the key practical information you need, on hand when you need it. It s a condensed version of the guidelines for managing asthma in adults, made up of checklists, diagnostic procedures, treatment algorithms and evidence-based recommendations for drug therapies. As patient consultations are often time pressured, the structure and design have been developed with ease of use, quick reference and accessibility of information in mind. The sections of the guide are numbered in the same way as the BTS/SIGN guidelines, to make it easier for you to find more detailed information if you need it. KEY TO CONTENT Teva have other materials relating to this subject that you might find helpful, so ask your local rep for more information. Key takeouts that can jog your memory as you flip through the guide, or help you identify/ differentiate each section at a glance. Related content These show any related content within the guide, and the page number it can be found on. 1

3 2 NICE quality STANDARD for asthma? 1 Statement 1: People with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance. Statement 2: Adults with new onset asthma are assessed for occupational causes. Statement 3: People with asthma receive a personalised action plan. Statement 4: People with asthma are given specific training and assessment in inhaler technique before starting any new inhaler treatment. Statement 5: People with asthma receive a structured review at least annually. Statement 6: People with asthma who present with respiratory symptoms receive an assessment of their asthma control. Statement 7: People with asthma who present with an exacerbation of their symptoms receive an objective [QS25] Published February 2013 The definition of clinical best practice for the diagnosis and treatment of asthma in adults, young people and children aged 12 months and older. measurement of severity at the time of presentation. Statement 8: People aged five years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within one hour of presentation. Statement 9: People admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge. Statement 10: People who receive treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within two working days of treatment. Statement 11: People with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service. Indicator RECORDS 2016/17 GMS Contract Quality and Outcomes Framework 2 INITIAL DIAGNOSIS England QOF Guidance 9th Revision 2016/17 ASTHMA (AST) AST001. The contractor establishes and maintains a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months AST002. The percentage of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006), on the register, with measures of variability or reversibility recorded between 3 months before or any time after diagnosis ONGOING MANAGEMENT AST003. The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using the 3 RCP questions AST004. The percentage of patients with asthma aged 14 or over and who have not attained the age of 20, on the register, in whom there is a record of smoking status in the preceding 12 months Points Achievement thresholds NA 45 80% 45 70% 45 80% 3 NICE & QOF

4 British Thoracic Society Scottish Intercollegiate Guidelines Network 3 A national clinical guideline on the management of asthma, September 2016 SECTION 3.3 _ PRACTICAL APPROACH TO DIAGNOSIS 3 CHARACTERISTIC SYMPTOMS, SIGNS AND TEST RESULTS WHICH CAN LEAD TO A DIAGNOSIS OF ASTHMA IN ADULTS High probability of asthma 1+ of 1. Wheeze 2. Breathlessness 3. Chest tightness 4. Cough More likely if: Worse at night and early morning Worse with allergen exposure Occurs after taking aspirin or beta blockers SYMPTOMS Low probability of asthma Dizziness Light-headedness Peripheral tingling Chronic productive cough, with no wheeze or breathlessness Nasal symptoms without lung function abnormalities Food-related symptoms Airways obstruction on spirometry Reversibility tests and/or monitored initiation of treatment: Significant reversibility, or benefits from treatment trial treat as asthma Insignificant reversibility or no benefits from treatment trial consider alternative conditions Reversible airway obstruction treat as asthma Intermediate probability of asthma Patients with some, but not all, of the high probability features, or those who do not respond well to initial treatment have an intermediate probability of asthma INVESTIGATION No airways obstruction on spirometry Look for evidence of airway hyper-responsiveness and/ or airway inflammation Arrange further investigations before starting treatment BTS/SIGN Diagnosis History of atopy Family history of asthma and/or atopy HISTORY Smoking - over 30 pack years, age of onset >35 years Cardiac disease Without airflow obstruction Chronic cough syndromes DIFFERENTIAL DIAGNOSIS COPD With airflow obstruction Widespread wheeze Unexplained low FEV 1 or PEF during symptomatic episodes Unexplained blood eosinophilia EXAMINATION INVESTIGATION Repeatedly normal chest examination when symptomatic Normal PEF or spirometry when symptomatic Dysfunctional breathing Vocal cord dysfunction Rhinitis Gastro-oesophageal reflux Cardiac failure Pulmonary fibrosis Bronchiectasis* Inhaled foreign body* Obliterative bronchiolitis Large airway stenosis Lung cancer* Sarcoidosis* 4 * May also be associated with non-obstructive spirometry. 5

5 High probability of asthma Code as: suspected asthma 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 absence of symptoms of alternative diagnosis Intermediate probability of asthma Test for airway obstruction spirometry + bronchodilator reversibility recorded observation of wheeze personal history of atopy historical record of variable PEF or FEV 1 Low probability of asthma Diagnostic indications for specialist referral of adults Diagnosis unclear Referral for tests not available in primary care Suspected occupational asthma (symptoms that improve when patient is not at work, adult-onset asthma and workers in high-risk occupations) Poor response to asthma treatment Severe/life-threatening asthma attack Initiation of treatment Poor response Other diagnosis unlikely Assess response objectively (lung function/ validated symptom score) Good response Asthma Adjust maintenance dose. Provide selfmanagement Arrange on-going review Good response Options for investigations are: Test for variability: Test for eosinophilic reversibility inflammation or PEF charting atopy: challenge tests FeNO blood eosinophils skin-prick test, IgE Suspected asthma: Watchful waiting (if asymptomatic) or Commence treatment assess response objectively Poor response Investigate/treat for other more likely diagnosis Other diagnosis confirmed Red flags and indicators of other diagnoses Prominent systemic features (myalgia, fever, weight loss) Unexpected clinical findings (e.g. crackles, clubbing, cyanosis, cardiac disease, monophonic wheeze or stridor) Persistent non-variable breathlessness Chronic sputum production Unexplained restrictive spirometry Chest X-ray shadowing Marked blood eosinophilia In children under 5 years and others unable to undertake spirometry in whom there is a high or intermediate probability of asthma, the Patient anxiety or need for reassurance 6 7

6 SECTION 4.4 _ MONITORING ADULTS IN PRIMARY CARE 3 Routine clinical review in primary care on at least an annual basis Factors to monitor and record: ASK Symptom control Royal College of Physicians 3 questions, Asthma Control Questionnaire or Asthma Control Test Exacerbations, oral corticosteroid use and time off work Asthma assessment tools: ROYAL COLLEGE OF PHYSICIANS 3 QUESTIONS No to all questions means controlled asthma. In the last week (or month) 1. Sleeping Difficulty sleeping due to symptoms (including cough)? 2. Symptoms Usual symptoms during the day (cough, wheeze, chest tightness, or breathlessness)? 3. Restriction Interference with usual activities (e.g. work)? ASSESS Lung function PEF or spirometry to evaluate bronchoconstriction, or a long-term decline in lung function Inhaler technique CHECK Adherence prescription refill frequency Bronchodilator reliance prescription refill frequency Self-management/personal action plan possession of and use of PEAK EXPIRATORY FLOW (PEF) Widely available and simple. Variability can be determined from home readings in most patients. Scoring: >60 l/min increase in PEF suggested as best criteria for defining reversibility SPIROMETRY Enables clear demonstration of airflow obstruction. Highly repeatable. Scoring: >400 ml increase in FEV 1 postbronchodilator highly suggestive of asthma in adults BTS/SIGN - Monitoring 8 9

7 ASTHMA CONTROL QUESTIONNAIRE (ACQ) Full questionnaire has 7 questions 5 relating to symptoms, 1 to rescue treatment use, 1 to FEV 1 assessed over the previous week. Shortened questionnaire, with only the 5 symptom questions, is also valid. Scoring: 0.75 = well controlled 1.5 = inadequately controlled Further information available: Section 7 _ Pharmacological management 3 PHASED APPROACH TO MANAGEMENT IN ADULTS The aim is to achieve early control and to maintain it by increasing treatment as necessary and decreasing treatment when control is good. Before initiating a new therapy, recheck adherence and inhaler technique and eliminate trigger factors. Intermittent reliever therapy Regular preventer therapy SABA prn +ICS Inhaled short-acting ß 2 agonist. Add inhaled corticosteroids at a low dose.* (400 mcg starting dose is appropriate for many patients). ASTHMA CONTROL TEST (ACT) 5 questions 3 relating to symptoms, 1 to medication use, and 1 to overall control. 5-point response score. Scoring: 25 = under control = reasonably well controlled MINI ASTHMA QUALITY OF LIFE QUESTIONNAIRE (AQLQ) 15 questions in 4 domains symptoms, activity limitations, emotional function and environmental stimuli. Assessed over the previous 2 weeks. Related to the larger 32-item asthma quality of life questionnaire. Scoring: Mean of responses across the 4 domains values lie between 1 and 7 Higher scores indicate better quality of life Further information available at: Initial add-on therapy Additional add-on therapies High dose therapies Continuous or frequent use of oral steroids +LABA ICS +4th drug ICS +4th drug +Oral steroids Add LABA and assess: Good response continue LABA Improvement but not controlled continue LABA and increase ICS dose to medium continue LABA and ICS and add on an LTRA, LAMA or theophylline No response stop LABA and try: increase ICS dose to medium an LTRA a LAMA Combined maintenance and reliever therapy can be considered for patients who have a history of asthma attacks on medium dose ICS or ICS/LABA. Consider trials of: Increasing ICS dose to medium. If ineffective, reduce to the original dose Adding a 4th drug e.g. LTRA, SR theophylline, ß 2 agonist tablet. If the 4th drug is ineffective, stop the drug. Refer patients with inadequately controlled asthma to specialist care If control remains inadequate on medium dose ICS plus LABA, trial: - Increasing ICS dose to high dose - Adding a 4th drug, as above Daily steroid tablet in lowest daily dose for adequate control. Maintain ICS dose at high dose. Consider other treatments to minimise the use of oral steroids. BTS/SIGN Pharmacological Management 10 *BDP or equivalent. 11

8 No daytime symptoms Aims of asthma management No night-time awakening due to asthma No need for rescue medication No asthma attacks No limitations on activity including exercise Normal lung function (in practical terms FEV 1 and/or PEF>80% predicted or best) Minimal side effects from medication 7.2 _ Regular Preventer THERAPY 3 Inhaled corticosteroids are the recommended preventer drug for achieving overall treatment goals. Consider for patients with any of the following asthma-related features: Asthma attack in the last 2 years Using inhaled ß 2 agonists 3 times a week or more Symptomatic 3 times a week or more Waking 1 night a week 7.1 _ Intermittent reliever THERAPY 3 Short-acting bronchodilators include: Inhaled short-acting ß 2 agonists ß 2 agonist tablets or syrup DOSING Beclometasone dipropionate (BDP) Low dose Medium dose High dose (should only be used after referring the patient to secondary care) Inhaled ipratropium bromide Theophyllines 100 mcg two puffs twice a day 200 mcg two puffs twice a day 200 mcg four puffs twice a day Prescribe an inhaled short-acting ß 2 agonist as short-term reliever therapy for all patients with symptomatic asthma. Good asthma control is associated with little or no need for short-acting β 2 agonist. Anyone prescribed more than one device a month should have their asthma assessed and measures taken to improve asthma control if this is poor. Starting dose appropriate to the severity of disease (usually 400 mcg BDP per day), and titrate to the lowest effective dose Frequency of dosing Give inhaled corticosteroids initially twice daily (except ciclesonide which is given once daily) Once a day inhaled corticosteroids at the same total daily dose can be considered if good control is established SMOKING Advise patients that smoking reduces the effectiveness of therapy Higher doses of inhaled steroids may be needed in patients who are smokers or ex-smokers OTHER PREVENTER THERAPIES Less effective preventer therapies for patients taking short-acting ß 2 agonists alone are: Leukotriene receptor antagonists some clinical benefit Nedocromil sodium (sodium cromoglicate is only of some benefit) Theophyllines some beneficial effect Antihistamines and ketotifen are ineffective 12 13

9 7.3 _ INITIAL ADD-ON THERAPY 3 Before initiating a new therapy, recheck adherence and inhaler technique and eliminate trigger factors. First choice add-on is an inhaled LABA improves lung function and symptoms, and decreases asthma attacks consider adding before increasing the dose of ICS Combination inhalers are recommended to: Guarantee that the long-acting β 2 agonist is not taken without inhaled corticosteroid Improve inhaler adherence Combined maintenance and reliever therapy (MART) can be considered for patients who have a history of asthma attacks on medium dose ICS or ICS/LABA. LABAs should only be started in patients who are already on ICS therapy, which should be continued. 7.4 _ ADDITIONAL ADD-ON THERAPIES 3 If there is an improvement when a LABA is added, but control remains inadequate: Continue the LABA and increase the dose of ICS Continue the LABA and the ICS and add a leukotriene receptor antagonist (LTRA) or a long acting muscarinic agent (LAMA) or a theophylline If there is no improvement when a LABA is added, stop the LABA and try: An increased dose of ICS An LTRA A LAMA (LAMA are not licensed for this indication) If a trial of add-on treatment is ineffective, stop the drug (or in the case of increased dose of ICS reduce to original dose). 7.5 _ HIGH-DOSE THERAPIES 3 In a small proportion of patients asthma is not adequately controlled on a combination of short-acting β 2 agonist as required, medium dose ICS, and an additional drug, usually a LABA. If control remains inadequate on medium dose of an ICS + LABA, the following interventions can be considered: Increase the inhaled corticosteroids to high dose or Add a leukotriene receptor antagonist or Add a theophylline or Add slow-release β 2 agonist tablets or Add tiotropium 7.6 _ CONTINUOUS OR FREQUENT USE OF ORAL STEROIDS 3 The aim of treatment is to control asthma using the lowest possible doses of medication. For the small number of patients not controlled on high-dose therapies, use daily steroid tablets in the lowest dose providing adequate control. Patients on long-term steroid tablets (>3 months) or requiring frequent courses, are at risk of systemic side effects; monitor: Blood pressure Urine/blood sugar and cholesterol diabetes mellitus or hyperlipidaemia Bone mineral density if steroid dose is significantly reduced, offer a long-acting bisphosphonate Immunosuppressants (methotrexate, ciclosporin and oral gold) decrease long-term steroid requirements, but have significant side effects. They may be given as a 3-month trial once other drug treatments have been unsuccessful. Recommended method of reducing or eliminating oral steroid dose is through high dose inhaled corticosteroids. 14 Before proceeding to high dose or oral steroid therapies, refer patients with inadequately controlled asthma to specialist care. LABAs, leukotriene receptor antagonists and theophyllines can be trialled for around 6 weeks, but should be stopped if no improvement in steroid dose, symptoms or lung function. 15

10 SECTION 7.11 _ SPECIFIC MANAGEMENT ISSUES Exercise induced asthma Regular treatment including ICSs should be reviewed. Protective against exercise - induced asthma Inhaled corticosteroids 7.10 _ DECREASING TREATMENT 3 PATIENTS SHOULD BE MAINTAINED AT THE LOWEST POSSIBLE DOSE OF INHALED CORTICOSTEROID Reduction in inhaled corticosteroid dose should be slow, as patients deteriorate at different rates. Reductions should be considered every 3 months, decreasing the dose by around 25 50% each time. Short-acting ß 2 agonists Exercise induced asthma is a sign of poor disease control Not protective Anticholinergics Ketotifen If exercise is a specific problem in patients on ICSs who are otherwise well controlled, consider one of the following: Leukotriene receptor antagonists Long-acting ß 2 agonists Sodium cromoglicate or nedocromil sodium Oral ß 2 agonists Theophyllines Immediately before exercise, inhaled short-acting ß 2 agonists are the drug of choice Comorbid rhinitis Asthma patients often have rhinitis; intranasal steroids are the most effective therapy. In allergic rhinitis, intranasal steroids don t improve asthma control Allergic bronchopulmonary aspergillosis A 4-month trial of itraconazole should be considered may decrease steroid tablet use and improve asthma control Aspirin-intolerant asthma Avoid non-steroidal anti-inflammatory medications. Long-acting ß 2 agonists Theophyllines Leukotriene receptor antagonists Sodium cromoglicate or nedocromil sodium ß 2 agonist tablets Antihistamines There are theoretical reasons for the use of leukotriene receptor antagonists, but little evidence to justify treating these patients differently to other asthma patients Gastro-oesophageal reflux (GORD) The treatment of GORD does not improve asthma symptoms or lung function in patients with both conditions ß-blockers ß-blockers, including eye drops, are contraindicated in patients with asthma

11 SECTION 8 _ INHALER DEVICES TECHNIQUE AND TRAINING Prescribe inhalers only after patients have received training on how to use them, and have demonstrated correct technique. 8.2 ß 2 AGONIST DELIVERY Acute asthma: Patients with mild and moderate asthma attacks should be treated with pmdi + spacer, and doses titrated according to clinical response. Stable asthma: pmdi ± spacer is as effective as any other hand-held inhaler, but some patients may prefer some types of DPI. 8.3 INHALED CORTICOSTEROIDS FOR STABLE ASTHMA A pmdi ± spacer is as effective as any DPI. 8.4 PRESCRIBING DEVICES In patients who can t use a pmdi, the most important considerations are patient preference and local cost. Other considerations: Choice of device may be determined by choice of drug If the patient is unable to use a device satisfactorily an alternative should be found Inhaler technique should be assessed by a competent healthcare professional Medication should be titrated against clinical response for optimal efficacy Reassess inhaler technique at all clinical reviews Generic prescribing of inhalers should be avoided SECTION 9 _ MANAGEMENT OF ACUTE ASTHMA In a review of asthma deaths, adverse psychosocial and behavioural factors were recorded in the majority of patients who died from asthma PATIENTS AT RISK OF DEVELOPING NEAR-FATAL OR FATAL ASTHMA: Severe asthma Recognised by 1 or more of: Previous near-fatal asthma Previous admission for asthma Needs 3+ classes of asthma medications Heavy use of ß 2 agonist Repeated A&E attendances for asthma care + Adverse behavioural or psychosocial features Recognised by 1 or more of: Non-adherence with treatment or monitoring Failure to attend appointments Fewer GP contacts Frequent home visits Self discharge from hospital Psychosis, depression, other psychiatric illness or deliberate self harm Current or recent major tranquiliser use Denial Alcohol or drug abuse Obesity Learning difficulties Employment problems Income problems Social isolation Childhood abuse Severe domestic, marital or legal stress BTS/SIGN Acute asthma 18 19

12 9.2 _ ACUTE ASTHMA IN ADULTS 3 See annex for treatment algorithm on pages LEVELS OF SEVERITY OF ACUTE ASTHMA EXACERBATIONS Criteria for referral See annex for treatment algorithm on pages INITIAL ASSESSMENT OF SYMPTOMS, SIGNS AND MEASUREMENTS Moderate acute asthma Acute severe asthma Increasing symptoms PEF >50 75% best or predicted No features of acute severe asthma Any one of: PEF 33 50% of best or predicted Respiratory rate 25/min Clinical features These features can identify severe asthma, but their absence does not exclude it: Severe breathlessness unable to complete sentences Tachypnoea Tachycardia Silent chest Cyanosis Accessory muscle use Altered consciousness Collapse Heart rate 110/min Inability to complete sentences in one breath PEF or FEV 1 These are valid measures of airway calibre can guide intensity of treatment or decisions about admission. PEF is more convenient in the acute situation. Lifethreatening asthma Any one of the following in a patient with severe asthma: Clinical signs Altered conscious level Exhaustion Arrhythmia Hypotension Measurements PEF <33% best or predicted Sp0 2 <92% Pa0 2 <8 kpa Pulse oximetry Blood gases (ABG) Aim of O 2 therapy is to maintain SpO %. Gauges the need for ABG. ABGs needed if: SpO 2 <92% (with or without O 2 ) Other features of life-threatening asthma SpO 2 <92% shows risk of hypercapnia not detected by pulse oximetry. Near-fatal asthma Cyanosis Silent chest Poor respiratory effort Normal PaCO 2 ( kpa) Raised PaCO 2 and/or requiring mechanical ventilation with raised inflation pressures Chest X-ray Systolic paradox CXR not recommended in absence of: Suspected pneumothorax or pneumomediastinum Suspected consolidation Life-threatening asthma Failure to respond to treatment In need of ventilation Inadequate indicator of severity of attack should not be used

13 9.2.6 Criteria for hospital admission See annex for treatment algorithm on pages SECTION 9.3 _ TREATMENT OF ACUTE ASTHMA 3 See annex for treatment algorithm on pages life-threatening or near-fatal attack Any feature of a severe attack persisting after initial treatment If PEF >75% best or predicted 1 hour after initial treatment, a patient can be discharged from A&E unless: Still has significant symptoms Adherence concerns Lives alone/socially isolated Psychological problems Physical disability or learning difficulties Previous near-fatal asthma attack Asthma attack despite adequate dose steroid tablets pre-presentation Presents to A&E at night Pregnant Criteria for admission Oxygen Give supplementary oxygen to all hypoxaemic patients with acute severe asthma to maintain an SpO 2 of 94 98% Hypercapnia indicates the development of near-fatal asthma and the need for emergency specialist/anaesthetic intervention ß 2 agonist bronchodilators Use high-dose inhaled ß 2 agonists as first-line agents, and administer as early as possible reserve IV ß 2 agonists for patients who cannot use inhaled therapy reliably In severe asthma that responds poorly to an initial bolus dose of ß 2 agonist, consider continuous nebulisation with an appropriate nebuliser Steroid therapy Give steroids in adequate doses in all cases of acute asthma tablets are as effective as injected steroids, if they can be swallowed and retained Continue prednisolone mg daily for at least 5 days or until recovery Ipratropium bromide Add nebulised ipratropium bromide (0.5 mg 4 6 hourly) to ß 2 agonist treatment for patients with acute severe or life-threatening asthma or with a poor initial response to ß 2 agonist therapy Magnesium sulphate Nebulised magnesium sulphate is not recommended for treatment in adults with acute asthma Consider giving a single dose of IV magnesium sulphate for patients with acute severe asthma, who have not had a good initial response to inhaled bronchodilator therapy 23

14 9.3.6 Intravenous aminophylline Use only after consultation with senior medical staff it is unlikely to give any additional bronchodilation compared with standard care with inhaled bronchodilators and steroids, and side effects such as vomiting and arrhythmias are increased with IV administration Leukotriene receptor antagonists Evidence does not support oral use in acute asthma Insufficient evidence for IV treatment SECTION 12.2 _ MANAGEMENT OF ACUTE ASTHMA IN PREGNANCY POOR CONTROL DURING PREGNANCY Late pregnancy can affect residual capacity Needs close liaison between respiratory physician and obstetrician Antibiotics Not indicated Heliox Not recommended for use outside a clinical trial setting IV fluids Some patients require rehydration and correction of electrolyte imbalance hypokalaemia can be caused or exacerbated by ß 2 agonist and/or steroid treatment and must be corrected Nebulised furosemide Although theoretically furosemide may produce bronchodilation, trials have failed to show benefit vs. ß 2 agonists Early referral to critical care impaired ventilator mechanics in late pregnancy can lower functional residual capacity and may result in earlier O 2 desaturation ACUTE ASTHMA DURING PREGNANCY Give drug therapy for acute asthma as for the non-pregnant patient including systemic steroids and magnesium sulphate Give high flow O 2 to maintain SpO % Referral to intensive care Indications include the need for ventilatory support and severe or life-threatening asthma that is not responding to therapy, as shown by: 24 Deteriorating PEF Exhaustion, feeble respiration Persisting or worsening hypoxia Drowsiness, confusion, Hypercapnia altered conscious state ABGs ph dropping or H + rising Respiratory arrest Non-invasive ventilation Should only be considered in an ICU or equivalent clinical setting ACUTE SEVERE ASTHMA IN PREGNANCY IS AN EMERGENCY Treat vigorously in hospital Continuous foetal heart monitoring is recommended 25 BTS/SIGN Pregnancy

15 SECTION 12.3 _ DRUG THERAPY IN PREGNANCY 3 The risk of harm to the foetus from severe or chronically undertreated asthma outweighs any small risk from the medicines used to control asthma In general, asthma medicines are safe in pregnancy Short-acting ß 2 agonists use as normal Long-acting ß 2 agonists use as normal Inhaled steroids use as normal Theophyllines use oral and IV theophyllines as normal Steroid tablets use as normal The risk to the foetus of undertreating asthma outweighs any small risk of treatment Steroid tablets should never be withheld because of pregnancy, and women should be advised that the benefits of treatment outweigh the potential risks Leukotriene receptor antagonists continue if required to achieve adequate control prior to pregnancy Sodium cromoglicate or nedocromil sodium use as normal Immunomodulation therapy no clinical data yet on use of omalizumab for moderate severe allergic asthma in pregnancy SECTION 12.4 _ MANAGEMENT DURING LABOUR 3 If anaesthesia is required, regional blockade is preferable to general anaesthesia. Women on steroid tablets at a dose exceeding prednisolone 7.5 mg per day for more than 2 weeks prior to delivery should be given parenteral hydrocortisone 100 mg 6 8 hourly during labour. Advise women that acute asthma is rare in labour Advise women to continue their usual asthma medications in labour In the absence of acute severe asthma, reserve Caesarean section for the usual obstetric indications Use prostaglandin F2α with extreme caution in women with asthma because of the risk of inducing bronchoconstriction SECTION 12.5 _ DRUG THERAPY IN BREASTFEEDING MOTHERS 3 Encourage all women to breastfeed Use asthma medications as normal during lactation, in line with manufacturers recommendations 26 27

16 Annex 2* Available resources: PRACTICAL ADVICE Asthma UK ( offer a range of information including fact sheets and booklets British Lung Foundation ( run the Breathe Easy support network Management of acute severe asthma in adults in general practice Many deaths from asthma are preventable. Delay can be fatal. Factors leading to poor outcome include: n Clinical staff failing to assess severity by objective measurement n Patients or relatives failing to appreciate severity n Under-use of corticosteroids Regard each emergency asthma consultation as for acute severe asthma until shown otherwise. Assess and record: n Peak expiratory flow (PEF) n Symptoms and response to self treatment n Heart and respiratory rates n Oxygen saturation (by pulse oximetry) Caution: Patients with severe or life-threatening attacks may not be distressed and may not have all the abnormalities listed below. The presence of any should alert the doctor. Moderate asthma Acute severe asthma Life-threatening asthma INITIAL ASSESSMENT PEF>50-75% best or predicted PEF 33-50% best or predicted PEF<33% best or predicted FURTHER ASSESSMENT GLOSSARY n SpO 2 92% n Speech normal n Respiration <25 breaths/min n Pulse <110 beats/min n SpO 2 92% n Can t complete sentences n Respiration 25 breaths/min n Pulse 110 beats/min n SpO 2 <92% n Silent chest, cyanosis or poor respiratory effort n Arrhythmia or hypotension n Exhaustion, altered consciousness BDP BTS CFC Beclometasone dipropionate British Thoracic Society Chlorofluorocarbon LABA LAMA LTRA Long-acting ß 2 agonist Long-acting muscarinic antagonist Leukotriene receptor antagonist Treat at home or in surgery and ASSESS RESPONSE TO TREATMENT MANAGEMENT Consider admission Arrange immediate ADMISSION COPD Chronic Obstructive Pulmonary Disease NICE National Institute for Health and Care Excellence TREATMENT CXR DPI FAQ Chest X-Ray Dry powder inhaler Frequently asked questions FEV 1 Forced Expiratory Volume in 1 second FVC Forced Vital Capacity GMS GORD HFA ICS IV kpa General Medical Services Gastro-oesophageal Reflux Disease Hydrofluoroalkane Inhaled corticosteroid Intravenous Kilopascal (a unit of pressure) O 2 Oxygen PaCO 2 Partial pressure of carbon dioxide in arterial blood PEF Peak Expiratory Flow pmdi QOF RCP SABA SIGN SpO 2 Pressurised metered dose inhaler Quality and Outcomes Framework Royal College of Physicians Short-acting ß 2 agonist Scottish Intercollegiate Guidelines Network Oxygen saturation of peripheral capillaries Sources: 1. NICE Asthma Quality Standard. Feb Available at: qs25/resources/asthma Last accessed: October /17 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF). Available at: org/~/media/employers/documents/primary%20care%20contracts/qof/ / %20qof%20 guidance%20documents.pdf. Last accessed: October BTS/SIGN British guideline on the management of asthma. Sept Available at: asthma/btssign-asthma-guideline-2016/. Last accessed: October n β 2 bronchodilator: - via spacer (give 4 puffs initially and give a further 2 puffs every 2 minutes according to response up to maximum of 10 puffs) If PEF >50-75% predicted/best: n Nebuliser (preferably oxygen driven) (salbutamol 5 mg) n Give prednisolone mg n Continue or usual treatment If good response to first treatment (symptoms improved, respiration and pulse settling and PEF >50%) continue or usual treatment and continue prednisolone Admit to hospital if any: n Life threatening features n Features of acute severe asthma present after initial treatment n Previous near-fatal asthma Lower threshold for admission if afternoon or evening attack, recent nocturnal symptoms or hospital admission, previous severe attacks, patient unable to assess own condition, or concern over social circumstances n Oxygen to maintain SpO % if available n β 2 bronchodilator: - nebuliser (preferably oxygen driven) (salbutamol 5 mg) - or via spacer (give 4 puffs initially and give a further 2 puffs every 2 minutes according to response up to maximum of 10 puffs) n Prednisolone mg or IV hydrocortisone 100 mg n If no response in acute severe asthma: ADMIT If admitting the patient to hospital: n Stay with patient until ambulance arrives n Send written asssessment and referral details to hospital n β 2 bronchodilator via oxygen-driven nebuliser in ambulance n Oxygen to maintain SpO % n β 2 bronchodilator and ipratropium: - nebuliser (preferably oxygen driven) (salbutamol 5 mg and ipratropium 0.5mg) - or via spacer (give 4 puffs initially and give a further 2 puffs every 2 minutes according to response up to maximum of 10 puffs) n Prednisolone mg or IV hydrocortisone 100 mg immediately Follow up after treatment or discharge from hospital: n GP review within 2 working days n Monitor symptoms and PEF n Check inhaler technique n Written asthma action plan n Modify treatment according to guidelines for chronic persistent asthma n Address potentially preventable contributors to admission 28 *Annexes are numbered as in the BTS/SIGN Guidelines. 29

17 Annex 3 Annex 4 Time 5 mins mins 60 mins 120 mins Management of acute severe asthma in adults in A&E PEF >50-75% best or predicted Moderate asthma SpO 2 92% PEF >50-75% best or predicted No features of acute severe asthma Give salbutamol (give 4 puffs initially and give a further 2 puffs, every 2 minutes according to response up to maximum of 10 puffs) preferably via spacer Clinically stable AND PEF >75% POTENTIAL DISCHARGE n In all patients who received nebulised β 2 agonists prior to presentation, consider an extended observation period prior to discharge n If PEF<50% on presentation, give prednisolone mg/day for 5 days n In all patients ensure treatment supply of inhaled steroid and β 2 agonist and check inhaler technique n Arrange GP follow up within 2 working days post-discharge n Fax or discharge letter to GP Clinically stable AND PEF <75% Patient recovering AND PEF >75% n Refer to asthma liaison nurse/chest clinic PEF 33-50% best or predicted Acute severe asthma Features of severe asthma n PEF<50% best or predicted n Respiration 25/min n SpO 2 92% n Pulse 110 beats/min n Cannot complete sentence in one breath No life threatening features AND PEF 50-75% Repeat salbutamol 5 mg nebuliser Give prednisolone mg orally Give salbutamol 5 mg by oxygen driven nebuliser No signs of severe asthma AND PEF 50-75% OBSERVE AND MONITOR n SpO 2 n heart rate n respiratory rate Patient stable AND PEF>50% Signs of severe asthma OR PEF <50% PEF (l/min) EU Scale Life threatening features OR PEF <50% Signs of severe asthma OR PEF <50% PEF <33% best or predicted Life-threatening asthma n SpO 2 <92% n Silent chest, cyanosis, poor respiratory effort n Arrhythmia, hypotension n Exhaustion, altered consciousness Obtain senior/icu help now if any life threatening features are present IMMEDIATE MANAGEMENT n Oxygen to maintain SpO % n Salbutamol 5 mg plus ipratropium 0.5 mg via oxygen-driven nebuliser n Prednisolone mg orally or IV hydrocortisone 100 mg Measure arterial blood gases Markers of severity: Normal or raised PaCO 2 (Pa CO 2>4.6 kpa; 35 mmhg) Severe hypoxia (PaO 2 <8 kpa; 60 mmhg) Low ph (or high H + ) n Give/repeat salbutamol 5 mg with ipratropium 0.5 mg by oxygen-driven nebuliser after 15 minutes n Consider continuous salbutamol nebuliser 5-10 mg/hr n Consider IV magnesium sulphate g over 20 minutes n Correct fluid/electrolytes, especially K + disturbances n Chest X-ray n Repeat ABG ADMIT Patient accompanied by a nurse or doctor at all times Peak Expiratory Flow Rate - Normal Values Height Men 190 cm (75 in) 183 cm (72 in) 175 cm (69 in) 167 cm (66 in) 160 cm (63 in) Features of acute severe asthma n Peak expiratory flow (PEF) 33-50% of best (use % predicted if recent best unknown) n Can t complete sentences in one breath n Respiration 25 breaths/min n Pulse 110 beats/min Life-threatening features n PEF <33% of best or predicted n SpO2 <92% n Silent chest, cyanosis, or feeble respiratory effort n Arrhythmia or hypotension n Exhaustion, altered consciousness If a patient has any life-threatening feature, measure arterial blood gases. No other investigations are needed for immediate management. Blood gas markers of a life-threatening attack: n Normal (4.6-6 kpa, mmhg) PaCO2 n Severe hypoxia: PaO2 <8 kpa (60mmHg) irrespective of treatment with oxygen n A low ph (or high H + ) Caution: Patients with severe or lifethreatening attacks may not be distressed and may not have all these abnormalities. The presence of any should alert the doctor. Near fatal asthma n Raised PaCO2 n Requiring mechanical ventilation with raised inflation pressures PEF (l/min) EU Scale Peak Expiratory Flow Rate - Normal Values Height Women 183 cm (72 in) 175 cm (69 in) 167 cm (66 in) 160 cm (63 in) cm (60 in) Age (years) Adapted by Clement Clarke for use with EN13826 / EU scale peak flow meters from Nunn AJ Gregg I, Br Med J 1989:298; Management of acute severe asthma in adults in hospital Height Men 190 cm (75 in) 183 cm (72 in) 175 cm (69 in) 167 cm (66 in) 160 cm (63 in) IMMEDIATE TREATMENT n Oxygen to maintain SpO % n Salbutamol 5 mg or terbutaline 10 mg via an oxygen-driven nebuliser n Ipratropium bromide 0.5 mg via an oxygen-driven nebuliser n Prednisolone tablets mg or IV hydrocortisone 100 mg n No sedatives of any kind n Chest X-ray if pneumothorax or consolidation are suspected or patient requires mechanical ventilation IF LIFE-THREATENING FEATURES ARE PRESENT: n Discuss with senior clinician and ICU team n Consider IV magnesium sulphate g infusion over 20 minutes (unless already given) n Give nebulised β 2 agonist more frequently eg salbutamol 5 mg up to every minutes or 10 mg per hour via continuous nebulisation (requires special nebuliser) SUBSEQUENT MANAGEMENT IF PATIENT IS IMPROVING continue: n Oxygen to maintain SpO % n Prednisolone 40-50mg daily or IV hydrocortisone 100 mg 6 hourly n Nebulised β 2 agonist and ipratropium 4-6 hourly IF PATIENT NOT IMPROVING AFTER MINUTES: n Continue oxygen and steroids n Use continuous nebulisation of salbutamol at 5-10 mg/hour if an appropriate nebuliser is available. Otherwise give nebulised salbutamol 5 mg every minutes n Continue ipratropium 0.5 mg 4-6 hourly until patient is improving IF PATIENT IS STILL NOT IMPROVING: n Discuss patient with senior clinician and ICU team n Consider IV magnesium sulphate g over 20 minutes (unless already given) n Senior clinician may consider use of IV β 2 agonist or IV aminophylline or progression to mechanical ventilation MONITORING n Repeat measurement of PEF minutes after starting treatment n Oximetry: maintain SpO2 >94-98% n Repeat blood gas measurements within 1 hour of starting treatment if: - initial PaO2 <8 kpa (60 mmhg) unless subsequent SpO2 >92% - PaCO2 normal or raised - patient deteriorates n Chart PEF before and after giving β 2 agonists and at least 4 times daily throughout hospital stay Transfer to ICU accompanied by a doctor prepared to intubate if: n Deteriorating PEF, worsening or persisting hypoxia, or hypercapnia n Exhaustion, altered consciousness n Poor respiratory effort or respiratory arrest DISCHARGE When discharged from hospital, patients should have: n Been on discharge medication for hours and have had inhaler technique checked and recorded n PEF >75% of best or predicted and PEF diurnal variability<25% unless discharge is agreed with respiratory physician n Treatment with oral and inhaled steroids in addition to bronchodilators n Own PEF meter and written asthma action plan n GP follow up arranged within 2 working days n Follow-up appointment in respiratory clinic within 4 weeks Patients with severe asthma (indicated by need for admission) and adverse behavioural or psychosocial features are at risk of further severe or fatal attacks. n Determine reason(s) for exacerbation and admission n Send details of admission, discharge and potential best PEF to GP Height 340 Women 183 cm (72 in) cm (69 in) 167 cm (66 in) cm (63 in) cm (60 in) Age (years) Adapted by Clement Clarke for use with EN13826 / EU scale peak flow meters from Nunn AJ Gregg I, Br Med J 1989:298;

18 notes notes 32 33

19 Reporting of side effects If your patient experiences any side effects, including any possible side effects not listed in the package leaflet, they should speak to you or their nurse. They can also report side effects directly via the Yellow Card Scheme at By reporting side effects they can help provide more information on the safety of the medicine. Teva UK Limited, Ridings Point, Whistler Drive, Castleford, West Yorkshire, WF10 5HX. Approval code: UK/RESP/14/0015(1) Date of preparation: March 2017