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STEP 5: CONTINUOUS OR FREQUENT USE OF ORAL STEROIDS Use daily steroid tablet in lowest dose providing adequate control Maintain high dose inhaled steroid at 2000 mcg/day* Consider other treatments to minimise the use of steroid tablets Refer patient for specialist care STEP 4: PERSISTENT POOR CONTROL Consider trials of: increasing inhaled steroid up to 2000 mcg/day* addition of a fourth drug e.g. leukotriene receptor antagonist, SR theophylline, β 2 agonist tablet STEP 3: ADD-ON THERAPY 1. Add inhaled long-acting β 2 agonist (LABA) 2. Assess control of asthma: good response to LABA - continue LABA benefit from LABA but control still inadequate - continue LABA and increase inhaled steroid dose to 800 mcg/day* (if not already on this dose) no response to LABA - stop LABA and increase inhaled steroid to 800 mcg/day.* If control still inadequate, institute trial of other therapies, e.g. leukotriene receptor antagonist or SR theophylline STEP 2: REGULAR PREVENTER THERAPY Add inhaled steroid 200-800 mcg/day* 400 mcg is an appropriate starting dose for many patients Start at dose of inhaled steroid appropriate to severity of disease. STEP 1: MILD INTERMITTENT ASTHMA Inhaled short-acting β 2 agonist as required * BDP or equivalent

STEP 5: CONTINUOUS OR FREQUENT USE OF ORAL STEROIDS Use daily steroid tablet in lowest dose providing adequate control Maintain high dose inhaled steroid at 800 mcg/day* Refer to respiratory paediatrician. STEP 4: PERSISTENT POOR CONTROL Increase inhaled steroid up to 800 mcg/day* STEP 3: ADD-ON THERAPY 1. Add inhaled long-acting β 2 agonist (LABA) 2. Assess control of asthma: good response to LABA - continue LABA benefit from LABA but control still inadequate - continue LABA and increase inhaled steroid dose to 400 mcg/day* (if not already on this dose) no response to LABA - stop LABA and increase inhaled steroid to 400 mcg/day.* If control still inadequate, institute trial of other therapies, e.g. leukotriene receptor antagonist or SR theophylline STEP 2: REGULAR PREVENTER THERAPY Add inhaled steroid 200-400 mcg/day* (other preventer drug if inhaled steroid cannot be used) 200 mcg is an appropriate starting dose for many patients Start at dose of inhaled steroid appropriate to severity of disease. STEP 1: MILD INTERMITTENT ASTHMA Inhaled short-acting β 2 agonist as required * BDP or equivalent

STEP 4: PERSISTENT POOR CONTROL Refer to respiratory paediatrician. STEP 3: ADD-ON THERAPY In children aged 2-5 years consider trial of leukotriene receptor antagonist. In children under 2 years consider proceeding to step 4. STEP 2: REGULAR PREVENTER THERAPY Add inhaled steroid 200-400 mcg/day* or leukotriene receptor antagonist if inhaled steroid cannot be used Start at dose of inhaled steroid appropriate to severity of disease. STEP 1: MILD INTERMITTENT ASTHMA Inhaled short-acting β 2 agonist as required * BDP or equivalent Higher nominal doses may be required if drug delivery is difficult

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IN THE LAST WEEK / MONTH "Have you had difficulty sleeping because of your asthma symptoms (including cough)?" "Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?" YES NO "Has your asthma interfered with your usual activities (eg,housework, work, school etc)?" Date / / Applies to all patients with asthma aged 16 and over. Only use after diagnosis has been established.

Management of acute severe asthma in adults in general practice Many deaths from asthma are preventable, but delay can be fatal. Factors leading to poor outcome include: Doctors failing to assess severity by objective measurement Patients or relatives failing to appreciate severity Under use of corticosteroids Regard each emergency asthma consultation as for acute severe asthma until it is shown to be otherwise. Assess and record: Peak expiratory flow (PEF) Symptoms and response to self treatment Heart and respiratory rates Oxygen saturation (by pulse oximetry, if available) 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% best or predicted PEF 33-50% best or predicted PEF <33% best or predicted INITIAL ASSESSMENT FURTHER ASSESSMENT Speech normal Respiration <25 breaths/min Pulse <110 beats/min Can t complete sentences Respiration 25 breaths/min Pulse 110 beats/min SpO2 <92% Silent chest, cyanosis, or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma MANAGEMENT Treat at home or in surgery and ASSESS RESPONSE TO TREATMENT Consider admission Arrange immediate ADMISSION TREATMENT High dose β 2 bronchodilator: - Ideally via oxygen-driven nebuliser (salbutamol 5 mg or terbutaline 10 mg) - Or via spacer or air-driven nebuliser (1 puff 10-20 times) If PEF >50-75% predicted/best: Give prednisolone 40-50 mg Continue or step up usual treatment If good response to first nebulised treatment (symptoms improved, respiration and pulse settling, and PEF >50%) continue or step up usual treatment and continue prednisolone Oxygen 40-60% if available High dose β 2 bronchodilator: - Ideally via oxygen-driven nebuliser (salbutamol 5 mg or terbutaline 10 mg) - Or via spacer (1 puff β 2 agonist via a large volume spacer and repeat 10-20 times) or air-driven nebuliser Prednisolone 40-50 mg or IV hydrocortisone 100 mg If no response in acute severe asthma: ADMIT Oxygen 40-60% Prednisolone 40-50 mg or IV hydrocortisone 100 mg immediately High dose β 2 bronchodilator and ipratropium: - Ideally via oxygen-driven nebuliser (salbutamol 5 mg or terbutaline 10 mg and ipratropium 0.5mg) Or via spacer (1 puff β 2 agonist via a large volume spacer, repeated 10-20 times) or air driven nebuliser Admit to hospital if any : life threatening features features of acute severe asthma present after initial treatment 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. If admitting the patient to hospital: Stay with patient until ambulance arrives Send written assessment and referral details to hospital Give high dose β 2 bronchodilator via oxygen-driven nebuliser in ambulance Follow up after treatment or discharge from hospital: GP review within 48 hours Monitor symptoms and PEF Check inhaler technique Written asthma action plan Modify treatment according to guidelines for chronic persistent asthma Address potentially preventable contributors to admission

STANDARD DEVIATION MEN STANDARD DEVIATION WOMEN 48 litres/min 42 litres/min IN MEN, VALUES OF PEF UP TO 100 LITRES/MIN, LESS THAN PREDICTED, AND IN WOMEN LESS THAN 85 LITRES/MIN, LESS THAN PREDICTED, ARE WITHIN NORMAL LIMITS. Management of acute severe asthma in adults in A&E Time PEF >75% best or predicted mild Measure Peak Expiratory Flow and Arterial Saturations PEF 33-75% best or predicted moderate severe: features of severe asthma PEF<50% best or predicted Respiration 25/min Pulse 110 breaths/min Cannot complete sentence in one breath PEF <33% best or predicted OR any life threatening features: SpO2<92% Silent chest, cyanosis, poor respiratory effort Bradycardia, arrhythmia, hypotension Exhaustion, confusion, coma 5 mins Give usual bronchodilator Give salbutamol 5 mg by oxygendriven nebuliser Obtain senior/icu help now if any life-threatening features are present 15-30 mins Clinically stable AND PEF >75% Clinically stable AND PEF <75% No life threatening features AND PEF 50-75% Life threatening features OR PEF <50% IMMEDIATE MANAGEMENT High concentration oxygen (>60% if possible) Give salbutamol 5 mg plus ipratropium 0.5 mg via oxygendriven nebuliser AND prednisolone 40-50 mg orally or IV hydrocortisone 100 mg Repeat salbutamol 5 mg nebuliser Give prednisolone 40-50 mg orally Measure arterial blood gases Markers of severity: - Normal or raised PaCO2 (Pa CO2>4.6 kpa; 35 mmhg) - Severe hypoxia (PaO2 <8 kpa; 60 mmhg) - Low ph (or high H + ) 60 mins Patient recovering AND PEF >75% No signs of severe asthma AND PEF 50-75% OBSERVE monitor SpO2, heart rate and respiratory rate Signs of severe asthma OR PEF <50% Give/repeat salbutamol 5 mg with ipratropium 0.5 mg by oxygen-driven nebuliser after 15 minutes Consider continuous salbutamol nebuliser 5-10 mg/hr Consider IV magnesium sulphate 1.2-2 g over 20 minutes Correct fluid/electrolytes, especially K + disturbances Chest x-ray 120 mins Patient stable AND PEF>50% Signs of severe asthma OR PEF <50% ADMIT Patient should be accompanied by a nurse or doctor at all times Peak expiratory flow in normal adults 660 650 75 190 660 650 POTENTIAL DISCHARGE 640 630 620 72 69 66 183 175 167 MEN 640 630 620 In all patients who received nebulised β 2 agonists prior to presentation, consider an extended observation period prior to discharge 610 600 590 580 570 560 63 Ht. (ins) 160 Ht. (cms) 610 600 590 580 570 560 If PEF<50% on presentation, prescribe prednisolone 40-50 mg/day for 5 days 550 540 530 PEF 520 L/min 510 550 540 530 520 510 In all patients ensure treatment supply of inhaled steroid and β 2 agonist and check inhaler technique 500 490 480 470 460 69 66 63 60 175 167 160 152 WOMEN 500 490 480 470 460 Arrange GP follow up for 2 days post presentation Fax discharge letter to GP Refer to asthma liaison nurse/chest clinic 450 440 430 420 410 400 390 380 57 145 Ht. Ht. (ins) (cms) 450 440 430 420 410 400 390 380 15 20 25 30 35 40 45 50 55 60 65 70 AGE IN YEARS Nunn AJ, Gregg I. New regression equations for predicting peak expiratory flow in adults. BMJ 1989;298:1068-70.

Management of acute severe asthma in adults in hospital Features of acute severe asthma Peak expiratory flow (PEF) 33-50% of best (use % predicted if recent best unknown) Can t complete sentences in one breath Respirations 25 breaths/min Pulse 110 beats/min Life threatening features PEF < 33% of best or predicted SpO2 < 92% Silent chest, cyanosis, or feeble respiratory effort Bradycardia, dysrhythmia, or hypotension Exhaustion, confusion, or coma If patient has any life threatening feature, If a patient has any life threatening feature, measure measure arterial arterial blood blood gases. gases. No No other other investigations are are needed needed for for immediate immediate management. Blood gas markers of a life threatening attack: Normal (4.6-6 kpa, 35-45 mmhg) PaCO2 Severe hypoxia: PaO2< 8 kpa (60mmHg) irrespective of treatment with oxygen A low ph (or high H + ) Caution: Patients with severe or life threatening attacks may not be distressed and may not have all these abnormalities. The presence of any should alert the doctor. Near fatal asthma Raised PaCO2 Requiring IPPV with raised inflation pressures IMMEDIATE TREATMENT Oxygen 40-60% (CO2 retention is not usually aggravated by oxygen therapy in asthma) Salbutamol 5 mg or terbutaline 10 mg via an oxygen-driven nebuliser Ipratropium bromide 0.5 mg via an oxygen-driven nebuliser Prednisolone tablets 40-50 mg or IV hydrocortisone 100 mg or both if very ill No sedatives of any kind Chest radiograph only if pneumothorax or consolidation are suspected or patient requires IPPV IF LIFE THREATENING FEATURES ARE PRESENT: Discuss with senior clinician and ICU team Add IV magnesium sulphate 1.2-2 g infusion over 20 minutes (unless already given) Give nebulised β 2 agonist more frequently e.g. salbutamol 5 mg up to every 15-30 minutes or 10 mg continuously hourly SUBSEQUENT MANAGEMENT IF PATIENT IS IMPROVING continue: 40-60% oxygen Prednisolone 40-50mg daily or IV hydrocortisone 100 mg 6 hourly Nebulised β 2 agonist and ipratropium 4-6 hourly IF PATIENT NOT IMPROVING AFTER 15-30 MINUTES: Continue oxygen and steroids Give nebulised β 2 agonist more frequently e.g. salbutamol 5 mg up to every 15-30 minutes or 10 mg continuously hourly Continue ipratropium 0.5 mg 4-6 hourly until patient is improving IF PATIENT IS STILL NOT IMPROVING: Discuss patient with senior clinician and ICU team IV magnesium sulphate 1.2-2 g over 20 minutes (unless already given) Senior clinician may consider use of IV β 2 agonist or IV aminophylline or progression to IPPV Peak expiratory flow in normal adults 660 660 75 190 650 650 72 183 640 640 MEN 69 175 630 630 620 66 167 620 610 63 160 610 Ht. Ht. 600 (ins) (cms) 600 590 590 580 580 570 570 560 560 550 550 540 540 STANDARD DEVIATION MEN 48 litres/min STANDARD DEVIATION WOMEN 42 litres/min 530 530 PEF 520 520 L/min 510 510 500 500 69 175 WOMEN 490 490 66 167 480 480 63 160 470 470 MONITORING Repeat measurement of PEF 15-30 minutes after starting treatment Oximetry: maintain Sp02 >92% Repeat blood gas measurements within 2 hours of starting treatment if: - initial PaO2 <8 kpa (60 mmhg) unless subsequent Sp02 >92% - PaC02 normal or raised - patient deteriorates 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: Deteriorating PEF, worsening or persisting hypoxia, or hypercapnea Exhaustion, feeble respirations, confusion or drowsiness Coma or respiratory arrest 460 60 152 460 450 440 430 420 410 400 390 380 57 145 450 Ht. Ht. (ins) (cms) 440 430 420 IN MEN, VALUES OF PEF UP TO 100 LITRES/MIN, LESS THAN PREDICTED, AND IN WOMEN LESS THAN 85 LITRES/MIN, LESS 410 THAN PREDICTED, ARE WITHIN NORMAL LIMITS. 400 390 380 15 20 25 30 35 40 45 50 55 60 65 70 AGE IN YEARS Nunn AJ, Gregg I. New regression equations for predicting peak expiratory flow in adults. BMJ 1989;298:1068-70. DISCHARGE When discharged from hospital, patients should have: Been on discharge medication for 24 hours and have had inhaler technique checked and recorded PEF >75% of best or predicted and PEF diurnal variability <25% unless discharge is agreed with respiratory physician Treatment with oral and inhaled steroids in addition to bronchodilators Own PEF meter and written asthma action plan GP follow up arranged within 2 working days 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 Determine reason(s) for exacerbation and admission Send details of admission, discharge and potential best PEF to GP

Management of acute asthma in children in general practice Age 2-5 years Age >5 years ASSESS ASTHMA SEVERITY ASSESS ASTHMA SEVERITY Moderate exacerbation SpO2 92% Able to talk Heart rate 130/min Respiratory rate 50/min Severe exacerbation SpO2 <92% Too breathless to talk Heart rate >130/min Respiratory rate >50/min Use of accessory neck muscles Life threatening asthma SpO2 <92% Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis Moderate exacerbation SpO2 92% PEF 50% best or predicted Able to talk Heart rate 120/min Respiratory rate 30/min Severe exacerbation SpO2 <92% PEF <50% best or predicted Too breathless to talk Heart rate >120/min Respiratory rate >30/min Use of accessory neck muscles Life threatening asthma SpO2 <92% PEF <33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis β 2 agonist 2-4 puffs via spacer ± facemask Consider soluble prednisolone 20 mg Increase β 2 agonist dose by 2 puffs every 2 minutes up to 10 puffs according to response Oxygen via face mask β 2 agonist 10 puffs via spacer ± facemask or nebulised salbutamol 2.5 mg or terbutaline 5 mg Soluble prednisolone 20 mg Assess response to treatment 15 mins after β 2 agonist Oxygen via face mask Nebulise: salbutamol 2.5 mg or terbutaline 5 mg + ipratropium 0.25 mg Soluble prednisolone 20 mg or IV hydrocortisone 50 mg β 2 agonist 2-4 puffs via spacer Consider soluble prednisolone 30-40 mg Increase β 2 agonist dose by 2 puffs every 2 minutes up to 10 puffs according to response Oxygen via face mask β 2 agonist 10 puffs via spacer ± facemask or nebulised salbutamol 2.5-5 mg or terbutaline 5-10 mg Soluble prednisolone 30-40 mg Assess response to treatment 15 mins after β 2 agonist Oxygen via face mask Nebulise: salbutamol 5 mg or terbutaline 10 mg + ipratropium 0.25 mg Soluble prednisolone 30-40 mg or IV hydrocortisone 100 mg IF POOR RESPONSE ARRANGE ADMISSION IF POOR RESPONSE REPEAT β 2 AGONIST AND ARRANGE ADMISSION REPEAT β 2 AGONIST VIA OXYGEN-DRIVEN NEBULISER WHILST ARRANGING IMMEDIATE HOSPITAL ADMISSION IF POOR RESPONSE ARRANGE ADMISSION IF POOR RESPONSE REPEAT β 2 AGONIST AND ARRANGE ADMISSION REPEAT β 2 AGONIST VIA OXYGEN-DRIVEN NEBULISER WHILST ARRANGING IMMEDIATE HOSPITAL ADMISSION GOOD RESPONSE Continue up to 10 puffs of nebulised β 2 agonist as needed, not exceeding 4 hourly If symptoms are not controlled repeat β 2 agonist and refer to hospital Continue prednisolone for up to 3 days Arrange follow-up clinic visit POOR RESPONSE Stay with patient until ambulance arrives Send written assessment and referral details Repeat β 2 agonist via oxygen-driven nebuliser in ambulance GOOD RESPONSE Continue up to 10 puffs of nebulised β 2 agonist as needed, not exceeding 4 hourly If symptoms are not controlled repeat β 2 agonist and refer to hospital Continue prednisolone for up to 3 days Arrange follow-up clinic visit POOR RESPONSE Stay with patient until ambulance arrives Send written assessment and referral details Repeat β 2 agonist via oxygen-driven nebuliser in ambulance LOWER THRESHOLD FOR ADMISSION IF: Attack in late afternoon or at night Recent hospital admission or previous severe attack Concern over social circumstances or ability to cope at home NB: If a patient has signs and symptoms across categories, always treat according to their most severe features LOWER THRESHOLD FOR ADMISSION IF: Attack in late afternoon or at night Recent hospital admission or previous severe attack Concern over social circumstances or ability to cope at home NB: If a patient has signs and symptoms across categories, always treat according to their most severe features

Moderate exacerbation SpO2 92% No clinical features of severe asthma NB: If a patient has signs and symptoms across categories, always treat according to their most severe features β 2 agonist 2-10 puffs via spacer ± facemask Reassess after 15 minutes ASSESS ASTHMA SEVERITY Severe exacerbation SpO2 <92% Too breathless to talk or eat Heart rate >130/min Respiratory rate >50/min Age 2-5 years Use of accessory neck muscles Management of acute asthma in children in A&E Life threatening asthma SpO2 <92% Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis Give nebulised β 2 agonist: salbutamol 2.5 mg or terbutaline 5 mg with oxygen as driving gas Continue O2 via face mask/nasal prongs Give soluble prednisolone 20 mg or IV hydrocortisone 50 mg Moderate exacerbation SpO2 92% PEF 50% best or predicted No clinical features of severe asthma NB: If a patient has signs and symptoms across categories, always treat according to their most severe features β 2 agonist 2-10 puffs via spacer Reassess after 15 minutes ASSESS ASTHMA SEVERITY Severe exacerbation SpO2 <92% PEF <50% best or predicted Age >5 years Heart rate >120/min Respiratory rate >30/min Use of accessory neck muscles Life threatening asthma SpO2 <92% PEF <33% best or predicted Silent chest Poor respiratory effort Altered consciousness Cyanosis Give nebulised β 2 agonist: salbutamol 2.5 mg or terbutaline 5 mg with oxygen as driving gas Continue O2 via face mask/nasal prongs Give soluble prednisolone 30-40 mg or IV hydrocortisone 100 mg RESPONDING Continue inhaled β 2 agonist 1-4 hourly Give soluble oral prednisolone 20 mg DISCHARGE PLAN Continue β 2 agonist 4 hourly prn Consider prednisolone 20 mg daily for up to 3 days Advise to contact GP if not controlled on above treatment Provide a written asthma action plan Review regular treatment Check inhaler technique Arrange GP follow up NOT RESPONDING Repeat inhaled β 2 agonist Give soluble oral prednisolone 20 mg ARRANGE ADMISSION (lower threshold if concern over social circumstances) IF LIFE THREATENING FEATURES PRESENT Discuss with senior clinician, PICU team or paediatrician Consider: Chest x-ray and blood gases Repeat nebulised β 2 agonist Plus: ipratropium bromide 0.25 mg Bolus IV salbutamol 15 mcg/kg of 200 mcg/ml solution over 10 minutes Arrange immediate transfer to PICU/HDU if poor response to treatment Admit all cases if features of severe exacerbation persist after initial treatment RESPONDING Continue inhaled β 2 agonist 1-4 hourly Add 30-40 mg soluble oral prednisolone DISCHARGE PLAN Continue β 2 agonist 4 hourly prn Consider prednisolone 30-40 mg daily for up to 3 days Advise to contact GP if not controlled on above treatment Provide a written asthma action plan Review regular treatment Check inhaler technique Arrange GP follow up NOT RESPONDING Repeat inhaled β 2 agonist Add 30-40 mg soluble oral prednisolone ARRANGE ADMISSION (lower threshold if concern over social circumstances) IF LIFE THREATENING FEATURES PRESENT Discuss with senior clinician, PICU team or paediatrician Consider: Chest x-ray and blood gases Bolus IV salbutamol 15 mcg/kg of 200 mcg/ml solution over 10 minutes Repeat nebulised β 2 agonist Plus: ipratropium bromide 0.25 mg nebulised Arrange immediate transfer to PICU/HDU if poor response to treatment Admit all cases if features of severe exacerbation persist after initial treatment

Management of acute asthma in children in hospital Age 2-5 years Age >5 years ASSESS ASTHMA SEVERITY ASSESS ASTHMA SEVERITY Moderate exacerbation SpO2 92% No clinical features of severe asthma NB: If a patient has signs and symptoms across categories, always treat according to their most severe features Severe exacerbation SpO2 <92% Too breathless to talk or eat Heart rate >130/min Respiratory rate >50/min Use of accessory neck muscles Life threatening asthma SpO2 <92% Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis Oxygen via face mask/nasal prongs to achieve normal saturations Moderate exacerbation SpO2 92% PEF 50% best or predicted No clinical features of severe asthma NB: If a patient has signs and symptoms across categories, always treat according to their most severe features Severe exacerbation SpO2 <92% PEF <50% best or predicted Heart rate >120/min Respiratory rate >30/min Use of accessory neck muscles Life threatening asthma SpO2 <92% PEF <33% best or predicted Silent chest Poor respiratory effort Altered consciousness Cyanosis Oxygen via face mask/nasal prongs to achieve normal saturations β 2 agonist 2-4 puffs via spacer ± facemask Increase β 2 agonist dose by 2 puffs every 2 minutes up to 10 puffs according to response Consider soluble oral prednisolone 20 mg Reassess within 1 hour β 2 agonist 10 puffs via spacer ± facemask or nebulised salbutamol 2.5 mg or terbutaline 5 mg Soluble prednisolone 20 mg or IV hydrocortisone 4 mg/kg Repeat β 2 agonist up to every 20-30 minutes according to response If poor response add 0.25 mg nebulised ipratropium bromide Nebulised β 2 agonist: salbutamol 2.5 mg or terbutaline 5 mg plus ipratropium bromide 0.25 mg nebulised IV hydrocortisone 4 mg/kg Discuss with senior clinician, PICU team or paediatrician Repeat bronchodilators every 20-30 minutes β 2 agonist 2-4 puffs via spacer Increase β 2 agonist dose by 2 puffs every 2 minutes up to 10 puffs according to response Oral prednisolone 30-40 mg Reassess within 1 hour β 2 agonist 10 puffs via spacer or nebulised salbutamol 2.5-5 mg or terbutaline 5-10 mg Oral prednisolone 30-40 mg or IV hydrocortisone 4 mg/kg if vomiting If poor response nebulised ipratropium bromide 0.25 mg Repeat β 2 agonist and ipratropium up to every 20-30 minutes according to response Nebulised β 2 agonist: salbutamol 5 mg or terbutaline 10 mg plus ipratropium bromide 0.25 mg nebulised IV hydrocortisone 4 mg/kg Discuss with senior clinician, PICU team or paediatrician Repeat bronchodilators every 20-30 minutes ASSESS RESPONSE TO TREATMENT Record respiratory rate, heart rate and oxygen saturation every 1-4 hours ASSESS RESPONSE TO TREATMENT Record respiratory rate, heart rate, oxygen saturation and PEF/FEV every 1-4 hours RESPONDING Continue bronchodilators 1-4 hours prn Discharge when stable on 4 hourly treatment Continue oral prednisolone for up to 3 days At discharge Ensure stable on 4 hourly inhaled treatment Review the need for regular treatment and the use of inhaled steroids Review inhaler technique Provide a written asthma action plan for treating future attacks Arrange follow up according to local policy NOT RESPONDING Arrange HDU/PICU transfer Consider: Chest x-ray and blood gases IV salbutamol 15 mcg/kg bolus over 10 minutes followed by continuous infusion 1-5 mcg/kg/min (dilute to 200 mcg/ml) IV aminophylline 5 mg/kg loading dose over 20 minutes (omit in those receiving oral theophyllines) followed by continuous infusion 1 mg/kg/hour RESPONDING Continue bronchodilators 1-4 hours prn Discharge when stable on 4 hourly treatment Continue oral prednisolone 30-40 mg for up to 3 days At discharge Ensure stable on 4 hourly inhaled treatment Review the need for regular treatment and the use of inhaled steroids Review inhaler technique Provide a written asthma action plan for treating future attacks Arrange follow up according to local policy NOT RESPONDING Continue 20-30 minute nebulisers and arrange HDU/PICU transfer Consider: Chest x-ray and blood gases Bolus IV salbutamol 15 mcg/kg if not already given Continuous IV salbutamol infusion 1-5 mcg/kg/min (200 mcg/ml solution) IV aminophylline 5 mg/kg loading dose over 20 minutes followed by continuous infusion 1mg/kg/hour (omit in those receiving oral theophyllines) Bolus IV infusion of magnesium sulphate 40 mg/kg (max 2 g) over 20 minutes

Management of acute asthma in infants aged <2 years in hospital ASSESS ASTHMA SEVERITY NB: If a patient has signs and symptoms across categories, always treat according to their most severe features Moderate Sp02 92% Audible wheezing Using accessory muscles Still feeding Severe Sp02 <92% Cyanosis Marked respiratory distress Too breathless to feed Most infants are audibly wheezy with intercostal recession but not distressed Life threatening features include apnoea, bradycardia and poor respiratory effort Immediate management Oxygen via close fitting face mask or nasal prongs to achieve normal saturations Give trial of β 2 agonist: salbutamol up to 10 puffs via spacer and face mask or nebulised salbutamol 2.5 mg or nebulised terbutaline 5 mg Repeat β 2 agonist every 1-4 hours if responding If poor response: Add nebulised ipratropium bromide 0.25 mg Consider: soluble prednisolone 10 mg daily for up to 3 days Continuous close monitoring heart rate pulse rate pulse oximetry supportive nursing care with adequate hydration Consider the need for a chest x-ray If not responding or any life threatening features discuss with senior paediatrician or PICU team

ACTION PLAN Symptoms are: Peak Flow is: Action is: No symptoms Normal _ continue your treatment or talk to your doctor/nurse about taking less treatment Getting a cold, symptoms during daytime and/ or nightime Take of (times a day) and blue inhaler for relief of symptoms Out of breath Blue inhaler does not help Too breathless to speak Continue as above and start steroid tablets mgs x and contact This needs emergency action straight away. See back page WHAT ELSE IS IMPORTANT TO KEEP YOUR ASTHMA WELL CONTROLLED? HOW TO USE YOUR PEAK FLOW METER AVOID TRIGGERS It is likley that there will be many different things that trigger your asthma so you probaly won t be able tor avoid them all. The main ones are: Colds and viral infections House dust mite Tobacco smoke Pets Pollen If anything in particular seems to make your asthma worse, make a note on your chart and talk to your doctor or nurse. 1 2 3 4 5 6 7 Push the number pointer on the peak flow meter backr to zero Take a good breath in Seal your lips around the mouthpiece Blow as hard and fast as you can Write down the number score next to the number pointrer Do steps 1-5 again two more times Mark down your highest number score with a dot or ar cross on the peak flow graph on the other side of thris card KEEP ACTIVE Exercise is the best way to keep your body in tip torp condition. It is fun and leaves you feeling good aboutr yourself. However, exercise is also a common asthma trigger. But that dosen t mean you should stop! Exercise is good for everyone, including people with asthma. STOP SMOKING If you have asthma and smoke, you will be damaging yorur airways and are increasing the risk of an asthma atrtack. Within a few weeks of giving up you should notice a hurge difference. See your doctor or nurse for advice or ring quitline on: 0800 002200 (in England) 0800 848 484 (in Scotland) 0345 697 500 (in Wales) IS IT AN EMERGENCY? AN EMERGENCY IS WHEN ANY OF THE FOLLOWING HAPPENS: 3 1 2 Your reliever (blue) inhaler does not help Your symptoms get worse (cough, breathless, wheeze, tight chest) You re too breathless to speak WHAT TO DO: 1 Continue to take your reliever (blue) inhaler 2 Call your doctor or an ambulance if no better after five minutes FINDING OUT MORE There are lots of ways to find out more about your asthma, your treatment and ways you can help yourserlf to be in control. Ask your doctor or nurse for leaflets. Contact the National Asthma Campaign Asthma Helpline - 0845 701 02 03 - for advice that's right for you Monday to Friday 9am to 7pm (charged at local rates) Look at the National Asthma Campaign's website www.asthma.org.uk for up-to-date asthma information 24 hours a day. SURGERY CONTACT NUMBER NATIONAL ASTHMA CAMPAIGN conquering asthma National Asthma Campaign 2001 Registed charity number 802364 Name: YOUR PERSONAL ASTHMA DIARY AND ACTION PLAN CONTENTS Inside: Peak flow and symptom diary Treatment Diary Action Plan On the back: What to do in an emergency How to use your peak flow meter How to find out more about your asthma NATIONAL ASTHMA CAMPAIGN conquering asthma

Date you started this diary Blow your peak flow first thing in the morning and in the evening before your treatment. When you blow your peak flow do it 3 times and write down the best one, mark a cross or a dot on the chart opposite. What to use on an every day basis How much? When? 8/11 9/11 10/11 11/11 12/11 13/11 14/11 AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM Have you had difficulty sleeping because of your asthma symptoms (including coughing) Have you had your usual asthma symptoms during the rday (cough, wheeze, tight chest or feeling breathless) Circle Y for Yes or N for No 1 2 Has your asthma interfered with your usual activitires (eg housework, work or school) 3 700 600 500 400 300 200 100 180 160 140 120 1 2 3 Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N X X X X X X X X X X X X X X Write down the total number of times you took your treatment each day Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N Y Y Y Y Y Y Y N N N N N N N

AUDIT AND OUTCOMES Audit points for asthma care in primary care and hospital respiratory clinics Organisational level Is there a practice nurse with recognised asthma training/diploma? How much time has he/she for seeing patients with asthma? Do you have a system for identifying: 1 Children having frequent consultations with respiratory infection so that the possibility of asthma can be considered 2 Patients with asthma and psychiatric disease or learning disability for surveillance of asthma control 3 Those requesting β 2 agonists inhalers frequently so that the need for other treatment (usually inhaled steroids) can be reviewed How do you identify the following groups of patients in order to optimise their treatment and teach self-management skills? 1 Patients on step 3 or above 2 Those having steroid courses for acute asthma/emergency nebulisation/unscheduled appointments for asthma 3 Patients seen in A&E or hospitalised 4 Patients seeing different doctors Do you have a structured record for patients with asthma, that includes symptom questions? What is the nature of asthma related CME undertaken by partners in past five years? Has an audit of asthma care been completed in the past year? Is there any evidence of changes in practice in response to findings? Audit dataset for asthma care in primary care and hospitals Audit point RCP 3 questions stratify responses as 0-3/3 Comment on inhaler technique, for all devices in use (within past year) PEF when stable (within one year) FEV 1 when stable (within three years) PEF or FEV 1 expressed as percentage of above Treatment step Number of courses of steroid tablets within past year Number of emergency nebulisations within past year* Number of A&E attendances or hospitalisations with asthma within past year Documented asthma action plan Seen in secondary care respiratory clinic within past year (Y/N) Output from audit Distribution of patient scores % patients judged to have satisfactory inhaler technique Mean (SD) PEF as % predicted or best Mean (SD) FEV 1 as % predicted or best Mean (SD) PEF or FEV 1 expressed as percentage of above Distribution of patients across treatment steps % patients having courses of oral steroids in one year % patients having emergency nebulisations in one year % patients seen in A&E or admitted to hospital in one year % of patients with action plans % patients attending hospital asthma/respiratory clinics *Denominator = all patients on or above step 3 plus any others who have had an emergency nebulisation, a course of steroid tablets, an A&E attendance or hospital admission with asthma in the past 12 months

Audit dataset for acute asthma managed in primary care Audit point Record the following items in patients receiving emergency nebulisation or unscheduled/urgent appointment: Output from audit Proportion of patients for whom these actions were taken PEF measurement Whether or not oral steroids are prescribed Whether or not reviewed within two weeks Convalescent PEF Documented review of action plan Audit points for A&E asthma management Organisational level Structured records for patients with asthma should include information on: previous A&E attendances/hospital admissions with asthma/whether currently attending respiratory clinic home nebuliser use number of courses of systemic corticosteroid within 12 months/currently on long term oral steroids (more than three months) admission pulse, PEF, oxygen saturations/gases, if appropriate referral to respiratory clinic and/or respiratory nurse specialist Is there a policy for referrals, agreed with respiratory physicians and nurse specialists? Audit dataset for outcomes for A&E asthma management Audit point Triage time and category Time of administration of systemic corticosteroids taken with time of triage, to allow calculation of the time interval) Output from audit Overall % of patients in appropriate triage category* and treated with steroid tablets and % treated within one hour of attendance Referral to respiratory clinic Referral to respiratory nurse specialist for self management training % of cases not already attending, who are referred to respiratory clinic % of all cases referred to respiratory nurse specialist for self-management training * Different departments may use different triage systems; these reports should refer to patients judged to be unwell with acute asthma and should exclude those attending because they have run out of inhaled treatment and who are not judged to have any sign of poorly controlled asthma

Audit points for hospital inpatients with asthma Organisational level Are acute asthma patients triaged to the care of respiratory physician, either on admission or within 24 hours? If not, is there a hospital wide protocol for the care of asthma patients, agreed with respiratory physicians? Is there a respiratory nurse specialist? Do they have time to see inpatients before they are discharged? Are stamps, proformas or integrated care pathways used to collect relevant details of admission and discharge plans (including dataset items)? Is there an outpatient programme for teaching self-management skills to those who have had a recent hospital admission? Audit dataset for hospital inpatients with asthma Audit point See BTS/BPRS audit datasets (www.brit-thoracic.org.uk ) Hospital activity analysis data on readmission within two months Output from audit A comparison of key items of process of care with national data % of patients readmitted within two months % of patients with acute asthma managed by % of patients managed by respiratory physicians respiratory specialists