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1 Summary of management in adults sthma - suspected dult asthma - diagnosed Diagnosis and ssessment Evaluation: assess symptoms, measure lung function, check inhaler technique and adherence adjust dose update self-management plan move up and down as appropriate Move up to improve control as needed Move down to find and maintain lowest controlling therapy dditional add-on therapies High dose therapies Regular preventer Initial add-on therapy No response to L stop L and consider increased dose of IS If benefit from L but control still inadequate continue L and increase IS to medium dose onsider trials of: Increasing IS up to high dose ddition of a fourth drug, eg LTR, SR theophylline, beta agonist tablet, LM onsider monitored initiation of treatment with low dose IS. Low dose IS. dd inhaled L to low-dose IS (normally as a combination inhaler) IIf benefit from L but control still inadequate - continue L and IS and consider trial of other therapy - LTR, S-R theophylline, LM Infrequent, short-lived wheeze Refer patient for specialist care Short acting β 2 agonists as required consider moving up if using three doses a week or more ontinuous or frequent use of oral steroids Use daily steroid tablet in the lowest dose providing adequate control Maintain high dose IS onsider other treatments to minimize use of steroid tablets Refer patient for specialist care 12 pplies only to adults pplies to children 1 pplies to children 5-12 pplies to children under 5 General pplies to adolescents

2 Summary of management in children sthma - suspected Paediatric asthma - diagnosed Diagnosis and ssessment Evaluation: assess symptoms, measure lung function, check inhaler technique and adherence adjust dose update self-management plan move up and down as appropriate Move up to improve control as needed Move down to find and maintain lowest controlling therapy dditional add-on therapies High dose therapies Regular preventer Initial add-on preventer No response to L - stop L and increase dose of IS to low dose If benefit from L but control still inadequate continue L and increase IS to low dose onsider trials of: Increasing IS up to medium dose IS ddition of a fourth drug SR theophylline. onsider monitored initiation of treatment with very low- to low-dose IS Very low (paediatric) dose IS (or LTR < 5 years) Very low (paediatric) dose IS Plus If benefit from L but control still inadequate - continue L and IS and consider trial of other therapy - LTR Infrequent, short-lived wheeze hildren 5 - add inhaled L hildren < 5 - add LTR Refer patient for specialist care Short acting β 2 agonists as required consider moving up if using three doses a week or more ontinuous or frequent use of oral steroids Use daily steroid tablet in the lowest dose providing adequate control Maintain medium-dose IS onsider other treatments to minimize use of steroid tablets Refer patient for specialist care pplies only to adults pplies to children 1 pplies to children 5-12 pplies to children under 5 General pplies to adolescents 13

3 DULT DOSES OF INHLED ORTIOSTEROIDS PHRMOLOGIL MNGEMENT IS Dose Low dose Medium dose High dose* Pressurised metered dose inhalers (pmdi) eclometasone dipropionate Non-proprietary 200 micrograms four lenil Modulite 250 micrograms two Qvar (extrafine) Qvar autohaler 50 micrograms two puffs twice 100 micrograms four Qvar Easi-breathe iclesonide lvesco erosol inhaler 80 micrograms two puffs once 160 micrograms two puffs once Fluticasone propionate Flixotide Evohaler 50 micrograms two puffs twice 125 micrograms two 250 micrograms two Dry powder inhalers eclometasone Non-proprietary Easyhaler smabec Pulvinal udesonide Non-proprietary Easyhaler udelin Novolizer Pulmicort Turbohaler Fluticasone propionate Flixotide ccuhaler Mometasone smanex Twisthaler 200 micrograms one puff twice 100 micrograms one puff twice 100 micrograms one puff twice 200 micrograms one puff twice 100 micrograms one puff twice 200 micrograms one puff twice 200 micrograms one puff twice 400 micrograms one puff twice 250 micrograms one puff twice 400 micrograms one puff twice * High doses should only be used after referring the patient to secondary care. 400 micrograms one puff twice 400 micrograms two 200 micrograms four 400 micrograms two 500 micrograms one puff twice pplies only to adults pplies to children 1 pplies to children 5-12 pplies to children under 5 General pplies to adolescents 9

4 Dose IS Low dose Medium dose High dose* ombination inhalers eclometasone dipropionate (extrafine) with formoterol Fostair (pmdi) 100/6 one puff twice 100/6 two puffs twice 200/6 two puffs twice Fostair (NEXThaler) 100/6 one puff twice udesonide with formoterol DuoResp Spiromax 200/6 one puff twice PHRMOLOGIL MNGEMENT DULT DOSES OF INHLED ORTIOSTEROIDS (ONTINUED) 100/6 two puffs twice 200/6 two puffs twice 400/12 one puff twice 400/12 two puffs twice Symbicort Turbohale 100/6 two puffs twice 200/6 one puff twice Fluticasone propionate with formoterol Flutiform 50/5 two puffs twice Fluticasone propionate with salmeterol Seretide ccuhaler 100/50 one puff twice Seretide Evohaler Fluticasone furoate with vilanterol Relvar 50/25 two puffs twice 200/6 two puffs twice 400/12 one puff twice 125/5 two puffs twice 250/50 one puff twice 125/25 two puffs twice 92/22 one puff once 400/12 two puffs twice 250/10 two puffs twice 500/50 one puff twice 250/25 two puffs twice 184/22 one puff once * High doses should only be used after referring the patient to secondary care. 10 pplies only to adults pplies to children 1 pplies to children 5-12 pplies to children under 5 General pplies to adolescents

5 PEDITRI DOSES OF INHLED ORTIOSTEROIDS Dose IS Very low dose Low dose Medium dose # Pressurised metered dose inhalers (pmdi) with spacer eclometasone dipropionate Non-proprietary lenil Modulite Qvar (extrafine)* Qvar autohaler Qvar Easi-breathe iclesonide lvesco erosol inhaler Fluticasone propionate Flixotide Evohaler Dry powder inhalers eclometasone smabec** udesonide Non-proprietary Easyhaler Pulmicort Turbohaler Fluticasone propionate Flixotide ccuhaler Mometasone smanex Twisthaler 50 micrograms two 50 micrograms two 50 micrograms one puff twice 100 micrograms one puff twice 50 micrograms one puff twice ombination Inhalers udesonide with formoterol Symbicort turbohaler 100/6 one puff twice a day ** Fluticasone propionate with salmeterol Seretide ccuhaler Seretide Evohaler 50 micrograms two 80 micrograms two puffs once 50 micrograms two 100 micrograms one puff twice 200 micrograms one puff twice 100 micrograms one puff twice 200 micrograms one puff twice 100/6 two puffs twice ** 200/6 one puff twice * 100/50 one puff twice 50/25 two puffs twice * Not licensed for children under 12 years ** Not licensed for children under 6 years # Medium doses should only be used after referral of patient to secondary care 160 micrograms two puffs once 125 micrograms two 400 micrograms one puff twice 250 micrograms one puff twice pplies only to adults pplies to children 1 pplies to children 5-12 pplies to children under 5 General pplies to adolescents 11

6 SSESSMENT OF SEVERE STHM MNGEMENT OF UTE STHM IN DULTS Healthcare professionals must be aware that patients with severe asthma and one or more adverse psychosocial factors are at risk of death. INITIL SSESSMENT MODERTE UTE STHM LIFE-THRETENING STHM y increasing symptoms y PEF >50 75% best or predicted y no features of acute severe asthma UTE SEVERE STHM ny one of: y PEF 33 50% best or predicted y respiratory rate 25/min y heart rate 110/min y inability to complete sentences in one breath In a patient with severe asthma any one of: y PEF <33% best or predicted y SpO 2 <92% y PaO 2 <8 kpa y normal PaO 2 ( kpa) y silent chest y cyanosis y poor respiratory effort y arrhythmia y exhaustion y altered conscious level y hypotension NER-FTL STHM INITIL SSESSMENT OF SYMPTOMS, SIGNS ND MESUREMENTS linical features PEF or FEV 1 Pulse oximetry Raised PaO 2 and/or requiring mechanical ventilation with raised inflation pressures Severe breathlessness (including too breathless to complete sentences in one breath), tachypnoea, tachycardia, silent chest, cyanosis or collapse None of these singly or together is specific and their absence does not exclude a severe attack PEF or FEV 1 are useful and valid measures of airway calibre. PEF expressed as a % of the patient s previous best value is most useful clinically. In the absence of this, PEF as a % of predicted is a rough guide Oxygen saturation (SpO 2 ) measured by pulse oximetry determines the adequacy of oxygen therapy and the need for arterial blood gas measurement (G). The aim of oxygen therapy is to maintain SpO % lood gases (G) hest X-ray Patients with SpO 2 <92% or other features of life-threatening asthma require G measurement hest X-ray is not routinely recommended in patients in the absence of: - suspected pneumomediastinum or pneumothorax - suspected consolidation - life-threatening asthma - failure to respond to treatment satisfactorily - requirement for ventilation pplies only to adults pplies to children 1 pplies to children 5-12 pplies to children under 5 General pplies to adolescents 15

7 PHRMOLOGIL MNGEMENT PPROH TO MNGEMENT The aim of asthma management is control of the disease. omplete control is defined as: y no daytime symptoms y no night time awakening due to asthma y no need for rescue medication y no asthma attacks y no limitations on activity including exercise y normal lung function (in practical terms FEV 1 and/or PEF >80% predicted or best) y minimal side effects from medication. 1. Start treatment at the level most appropriate to initial severity. 2. chieve early control. 3. Maintain control by: increasing treatment as necessary decreasing treatment when control is good. efore initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique and eliminate trigger factors. Until May 2009 all doses of inhaled corticosteroids were referenced against beclometasone dipropionate (DP) given via F-MDIs. DP-F is now unavailable. Doses of IS are expressed as very low (generally paediatric dose), low (generally starting dose for adults), medium and high. djustments to doses will have to be made for other inhaler devices and other corticosteroid molecules. OMINTION INHLERS In efficacy studies, where there is generally good adherence, there is no difference in efficacy in giving inhaled corticosteriod and a long-acting β 2 agonist in combination or in separate inhalers. In clinical practice, however, it is generally considered that combination inhalers aid adherence and also have the advantage of guaranteeing that the long-acting β 2 agonist is not taken without the inhaled corticosteroid. ombination inhalers are recommended to: y guarantee that the long-acting β 2 agonist is not taken without inhaled corticosteroid y improve inhaler adherence. DERESING TRETMENT y Regular review of patients as treatment is decreased is important. When deciding which drug to decrease first and at what rate, the severity of asthma, the side effects of the treatment, time on current dose, the beneficial effect achieved, and the patient s preference should all be taken into account. y 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 three months, decreasing the dose by approximately 25-50% each time. EXERISE INDUED STHM For most patients, exercise-induced asthma is an expression of poorly controlled asthma and regular treatment including inhaled corticosteroids should be reviewed. If exercise is a specific problem in patients taking inhaled corticosteroids who are otherwise well controlled, consider adding one of the following therapies: y leukotriene receptor antagonists y long-acting β 2 agonists y sodium cromoglicate or nedocromil sodium y oral β 2 agonists y theophyllines. Immediately prior to exercise, inhaled short-acting β 2 agonists are the drug of choice. 8 pplies only to adults pplies to children 1 pplies to children 5-12 pplies to children under 5 General pplies to adolescents

8 MNGEMENT OF UTE STHM IN HILDREN GED 1 YER ND OVER 1 UTE SEVERE SpO 2 <92% PEF 33 50% best or predicted y an t complete sentences in one breath or too breathless to talk or feed y Heart rate >125 (>5 years) or >140 (1-5 years) y Respiratory rate >30 breaths/min (>5 years or >40 (1 5 years) LIFE-THRETENING SpO 2 <92% PEF <33% best or predicted y Silent chest y yanosis y Poor respiratory effort y Hypotension y Exhaustion y onfusion RITERI FOR DMISSION Increase β 2 agonist dose by giving one puff every seconds, according to response, up to a maximum of ten puffs Parents/carers of children with an acute asthma attack at home and symptoms not controlled by up to 10 puffs of salbutamol via a pmdi and spacer, should seek urgent medical attention. If symptoms are severe additional doses of bronchodilator should be given as needed whilst awaiting medical attention. Paramedics attending to children with an acute asthma attack should administer nebulised salbutamol, using a nebuliser driven by oxygen if symptoms are severe, whilst transferring the child to the emergency department. hildren with severe or life-threatening asthma should be transferred to hospital urgently onsider intensive inpatient treatment of children with SpO 2 <92% in air after initial bronchodilator treatment. The following clinical signs should be recorded: y Pulse rate increasing tachycardia generally denotes worsening asthma; a fall in heart rate in lifethreatening asthma is a pre-terminal event y Respiratory rate and degree of breathlessness ie too breathless to complete sentences in one breath or to feed y Use of accessory muscles of respiration best noted by palpation of neck muscles y mount of wheezing which might become biphasic or less apparent with increasing airways obstruction y Degree of agitation and conscious level always give calm reassurance N linical signs correlate poorly with the severity of airways obstruction. Some children with acute severe asthma do not appear distressed. INITIL TRETMENT OF UTE STHM OXYGEN hildren with life-threatening asthma or SpO 2 <94% should receive high-flow oxygen via a tight-fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations of 94 98%. 1 Management of acute asthma in children under 1 year should be under the direction of a respiratory paediatrician. pplies only to adults pplies to children 1 pplies to children 5-12 pplies to children under 5 General pplies to adolescents 17

9 MNGEMENT OF UTE STHM IN HILDREN GED 1 YER ND OVER 1 RONHODILTORS Inhaled β 2 agonists are the first-line treatment for acute asthma in children. pmdi + spacer is the preferred option in children with mild to moderate asthma. Individualise drug dosing according to severity and adjust according to the patient s response. If symptoms are refractory to initial β 2 agonist treatment, add ipratropium bromide (250 micrograms/ dose mixed with the nebulised β 2 agonist solution). Repeated doses of ipratropium bromide should be given early to treat children who are poorly responsive to β 2 agonists. onsider adding 150 mg magnesium sulphate to each nebulised salbutamol and ipratropium in the first hour in children with a short duration of acute severe asthma symptoms presenting with an SpO2 <92%. Discontinue long-acting β 2 agonists when short-acting β 2 agonists are required more often than four hourly. STEROID THERPY Give oral steroids early in the treatment of acute asthma attacks in children. yuse a dose of 10 mg prednisolone for children under 2 years of age, 20 mg for children aged 2 5 years and mg for children >5 years. Those already receiving maintenance steroid tablets should receive 2 mg/kg prednisolone up to a maximum dose of 60 mg. yrepeat the dose of prednisolone in children who vomit and consider intravenous steroids in those who are unable to retain orally ingested medication. ytreatment for up to three days is usually sufficient, but the length of course should be tailored to the number of days necessary to bring about recovery. Tapering is unnecessary unless the course of steroids exceeds 14 days. SEOND LINE TRETMENT OF UTE STHM onsider early addition of a single bolus dose of intravenous salbutamol (15 micrograms/kg over 10 minutes) in a severe asthma attack where the patient has not responded to initial inhaled therapy. minophylline is not recommended in children with mild to moderate acute asthma. onsider aminophylline for children with severe or life-threatening asthma unresponsive to maximal doses of bronchodilators and steroids. In children who respond poorly to first-line treatments, consider the addition of intravenous magnesium sulphate as first-line intravenous treatment (40 mg/kg/day). DISHRGE PLNNING ND FOLLOW UP hildren can be discharged when stable on 3-4 hourly inhaled bronchodilators that can by continued at home. PEF and/or FEV 1 should be >75% of best or predicted and SpO 2 >94%. y rrange follow up by primary care services within two working days y rrange follow up in a paediatric asthma clinic within one to two months y rrange referral to a paediatric respiratory specialist if there have been life-threatening features. 1 Management of acute asthma in children under 1 year should be under the direction of a respiratory paediatrician. 18 pplies only to adults pplies to children 1 pplies to children 5-12 pplies to children under 5 General pplies to adolescents

Adult Summary flowchart for Asthma Switch and Step Down to preferred inhaler choices

HVCCG Adult Asthma Switch and Step Down Algorithms - Approved by Hertfordshire Medicines Management Committee June 2016 Page 1 of 6 Adult Summary flowchart for Asthma Switch and Step Down to preferred