Note from the National Guideline Clearinghouse (NGC): In July 2007, the Scottish Intercollegiate Guidelines Network (SIGN) released an update of their 2005 asthma guideline. The changes made in the 2007 update have been incorporated into the summary below. In addition, a document identifying changes made in the July 2007 update of this guideline is available on the SIGN Web site.

Note from SIGN and NGC: In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.

The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.

Diagnosis and Natural History

Diagnosis of Asthma in Adults

GPP - Record the presence of wheeze in the patient's notes.

GPP - Objective tests should be used to try to confirm a diagnosis of asthma before long-term therapy is started.

GPP - Failure to respond to asthma treatment should prompt a search for an alternative, or additional, diagnosis.

GPP - Perform chest x-rays in all patients with atypical symptoms.

Diagnosis of Asthma in Children

GPP - Asthma should be suspected in any child with wheezing, ideally heard by a health professional on auscultation, and distinguished from upper airway noises

D - Base the diagnosis of asthma in children on:

• The presence of key features and careful consideration of alternative diagnoses (see table 2 in the original guideline document)
• Assessment of the response to trials of treatment, and ongoing assessment
• Repeated reassessment of the child, questioning the diagnosis if management is ineffective

GPP - Record the criteria on which the diagnosis has been made.

Non-pharmacological Management

Primary Prophylaxis

A - Breastfeeding should be encouraged and its benefits include a protective effect in relation to early life wheezing.

B - Parents and parents-to-be who smoke should be advised of the many adverse effects of smoking on their children, including increased wheezing in infancy, and be offered appropriate support to stop smoking.

Secondary Non-Pharmacological Prophylaxis

GPP - In committed families with evidence of house dust mite allergy and who wish to try mite avoidance, the following are recommended (Warner, 2000):

• Complete barrier bed-covering systems
• Removal of carpets
• Removal of soft toys from bed
• High temperature washing of bed linen
• Acaricides to soft furnishings
• Dehumidification

Environmental Factors

B - Parents who smoke should be advised about the dangers for themselves and their children and offered appropriate support to stop smoking.

GPP - Smoking cessation should be encouraged as it is good for general health and may decrease asthma severity.

Complementary and Alternative Medicine

GPP - The use of ionisers cannot be encouraged, as there is no evidence of benefit and a suggestion of adverse effect.

GPP - In difficult childhood asthma, there may be a role for family therapy as an adjunct to pharmacotherapy.

Dietary Manipulation

C - Weight reduction is recommended in obese patients with asthma to improve asthma control.

Gastro-oesophageal Reflux in Asthma

B - Gastro-oesophageal reflux should be treated if present but this will generally have no impact on asthma control.

Pharmacological Management

GPP - Lung function measurements cannot be reliably used to guide asthma management in children under 5 years of age

In this and the following section ("Inhaler Devices"), each recommendation has been graded for adults (> 12 years old), children 5 to 12 years, and children under 5 years. See Figures 4, 5, and 6 in the original guideline document for a summary of stepwise management in each of the age segments.

Step 1: Mild Intermittent Asthma

Adults: A; Children aged 5 to 12 years: B; Children under 5 years: D - Prescribe an inhaled short acting beta₂ agonist as short term reliever therapy for all patients with symptomatic asthma.

Adults: B; Children aged 5 to 12 years: D; Children under 5 years: D - Patients with high usage of inhaled short acting beta₂ agonists should have their asthma management reviewed.

Step 2: Introduction of Regular Preventer Therapy

Adults: A; Children aged 5 to 12 years: A; Children under 5 years: A - Inhaled steroids are the recommended preventer drug for adults and children for achieving overall treatment goals.

Adults: B; Children aged 5 to 12 years: C; Children under 5 years: Good Practice Point - Inhaled steroids should be considered for patients with any of the following: exacerbations of asthma in the last two years; using inhaled beta₂ agonists three times a week or more; symptomatic three times a week or more, or waking one night a week.

Adults: A; Children aged 5 to 12 years: D; Children under 5 years: D - Give inhaled steroids initially twice daily, except ciclesonide which is given once daily.

Adults: A; Children aged 5 to 12 years: D; Children under 5 years: D - Once a day inhaled steroids at the same total daily dose can be considered if good control is established.

GPP - Titrate the dose of inhaled steroid to the lowest dose at which effective control of asthma is maintained.

GPP - Monitor children's height on a regular basis.

GPP - Specific written advice about steroid replacement in the event of a severe intercurrent illness should be part of the management plan for children treated with ≥800 micrograms per day of beclomethasone (BDP) or equivalent.

GPP - Any child on this dose should be under the care of a specialist paediatrician for duration of the treatment.

GPP - Consider the use of a steroid warning card.

GPP - Consider the possibility of adrenal insufficiency in any child maintained on inhaled steroids presenting with shock or a decreased level of consciousness; serum biochemistry and blood glucose levels should be checked urgently.

GPP - Consider whether intramuscular (IM) hydrocortisone is required.

GPP - Titrate the dose of inhaled steroid to the lowest dose at which effective control of asthma is maintained.

B - Clinicians should be aware that higher doses of inhaled steroids may be needed in patients who are smokers/ex-smokers.

GPP - Patients should be advised that smoking reduces the effectiveness of therapy

GPP - Long-acting inhaled beta-2 agonists should only be started in patients who are already on inhaled corticosteroids.

Step 3: Add-on Therapy

Adults: A; Children aged 5 to 12 years: B; Children under 5 years: Good Practice Point - Carry out a trial of other treatments before increasing the inhaled steroid dose above 800 micrograms/day in adults and 400 micrograms/day in children.

Adults: A; Children aged 5 to 12 years: B; Children under 5 years: Recommendation does not apply to this age group. - The first choice as add-on therapy to inhaled steroids in adults and children (5 to 12 years) is an inhaled long acting beta₂ agonist.

Adults: D; Children aged 5 to 12 years: D; Children under 5 years: Recommendation does not apply to this age group. - If asthma control remains sub-optimal after the addition of an inhaled long acting beta₂ agonist, then the dose of inhaled steroids should be increased to 800 micrograms/day in adults or 400 micrograms/day in children (5 to 12 years).

Step 4: Poor Control on Moderate Dose of Inhaled Steroid + Add-on Therapy: Addition of Fourth Drug

Adults: D; Children aged 5 to 12 years: D; Children under 5 years: Recommendation does not apply to this age group. - If control remains inadequate on 800 micrograms daily (adults) and 400 micrograms daily (children) of an inhaled steroid plus a long acting beta₂ agonist, consider the following interventions:

• Increasing inhaled steroids to 2,000 micrograms/day (adults) or 800 micrograms/day (children 5-12 years)
• Leukotriene receptor antagonists
• Theophyllines
• Slow release beta₂ agonist tablets, though caution needs to be used in patients on long acting beta₂ agonists.

GPP - If a trial of an add-on treatment is ineffective, stop the drug (or in the case of increased dose of inhaled steroid, reduce to the original dose).

GPP - Before proceeding to step 5, consider referring patients with inadequately controlled asthma, especially children, to specialist care.

Step 5: Continuous or Frequent Use of Oral Steroids

Adults: A; Children aged 5 to 12 years: D; Children under 5 years: Recommendation does not apply to this age group. - In adults the recommended method of eliminating or reducing the dose of steroid tablets is inhaled steroids, at doses of up to 2,000 micrograms/day if required. In children aged 5 to 12, consider very carefully before going above a dose of 1,000 micrograms/day.

Adults: D; Children aged 5 to 12 years: D; Children under 5 years: D - There is a role for a trial of treatment with long acting beta₂ agonists, leukotriene receptor antagonists, and theophyllines for about six weeks. They should be stopped if no improvement in steroid dose, symptoms, or lung function is detected.

GPP - Immunosuppressants (methotrexate, ciclosporin and oral gold) may be given as a three month trial, once other drug treatments have proved unsuccessful. Their risks and benefits should be discussed with the patient and their treatment effects carefully monitored. Treatment should be in a centre with experience of using these medicines.

Stepping Down

GPP - Regular review of patients as treatment is stepped down is important. When deciding which drug to step down first and at what rate, the severity of asthma, the side-effects of the treatment, the beneficial effect achieved, and the patient's preference should all be taken into account.

GPP - Patients should be maintained at the lowest possible dose of inhaled steroid. Reduction in inhaled steroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every three months, decreasing the dose by approximately 25 to 50% each time.

Specific Management Problems

GPP - For most patients, exercise-induced asthma is an expression of poorly controlled asthma and regular treatment including inhaled steroids should be reviewed.

If exercise is a specific problem in patients taking inhaled steroids who are otherwise well controlled, consider the following therapies:

Adults: A; Children aged 5 to 12 years: C; Children under 5 years: Recommendation does not apply to this age group. - Leukotriene receptor antagonists

Adults: A; Children aged 5 to 12 years: A; Children under 5 years: Recommendation does not apply to this age group. - Long acting beta₂ agonists

Adults: C; Children aged 5 to 12 years: C; Children under 5 years: Recommendation does not apply to this age group. - Chromones

Adults: A; Children aged 5 to 12 years: A; Children under 5 years: Recommendation does not apply to this age group. - Oral beta₂ agonists

Adults: C; Children aged 5 to 12 years: C; Children under 5 years: Recommendation does not apply to this age group. - Theophyllines

Adults: A; Children aged 5 to 12 years: A; Children under 5 years: Good practice point - Immediately prior to exercise, inhaled short acting beta₂ agonists are the drug of choice

Adults: C; Children aged 5 to 12 years: Recommendation does not apply to this age group; Children under 5 years: Recommendation does not apply to this age group. - In adult patients with allergic bronchopulmonary aspergillosis (ABPA), a four month trial of itraconazole should be considered.

GPP - Careful monitoring for side-effects, particularly hepatic is recommended.

Inhaler Devices

Technique and Training

Adults: B; Children aged 5 to 12 years: Good practice point; Children under 5 years: Good practice point. - Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique.

Beta₂ Agonist Delivery

Adults: A; Children aged 5 to 12 years: A; Children under 5 years: B. - Children and adults with mild and moderate exacerbations of asthma should be treated by pressurized metered dose inhaler (pMDI) + spacer with doses titrated according to clinical response.

Adults: Recommendation does not apply to this age group; Children aged 5 to 12 years: A; Children under 5 years: Recommendation does not apply to this age group. - In children aged 5 to 12, pMDI + spacer is as effective as any other hand held inhaler.

Adults: A; Children aged 5 to 12 years: Recommendation does not apply to this age group; Children under 5 years: Recommendation does not apply to this age group. - In adults, pMDI + spacer is as effective as any other hand held inhaler, but patients may prefer some types of dry powder inhaler (DPI).

GPP - Choice of reliever inhaler for stable asthma should be based on patient preference and assessment of correct use. Many patients will not be prepared to carry a spacer.

Inhaled Steroids for Stable Asthma

Adults: Recommendation does not apply to this age group; Children aged 5 to 12 years: A; Children under 5 years: Recommendation does not apply to this age group. - In children aged 5 to 12 years, pMDI + spacer is as effective as any DPI.

Adults: A; Children aged 5 to 12 years: Recommendation does not apply to this age group; Children under 5 years: Recommendation does not apply to this age group. - In adults, a pMDI + spacer is as effective as any DPI.

Chlorofluorocarbon (CFC) Propellant pMDI versus Hydrofluoroalkane (HFA) Propellant pMDI

Adults: A; Children aged 5 to 12 years: Recommendation does not apply to this age group; Children under 5 years: Recommendation does not apply to this age group. - Salbutamol HFA can be substituted for salbutamol CFC at 1:1 dosing.

Adults: A; Children aged 5 to 12 years: Recommendation does not apply to this age group; Children under 5 years: Recommendation does not apply to this age group. - HFA beclomethasone (BDP) pMDI (Qvar) may be substituted for CFC BDP pMDI at 1:2 dosing. This ratio does not apply to reformulated HFA BDP pMDIs.

Adults: A; Children aged 5 to 12 years: Recommendation does not apply to this age group; Children under 5 years: Recommendation does not apply to this age group. - Fluticasone HFA can be substituted for fluticasone CFC at 1:1 dosing.

Prescribing Devices

GPP - The choice of device may be determined by the choice of drug.

GPP - If the patient is unable to use a device satisfactorily an alternative should be found.

GPP - The patient should have their ability to use an inhaler device assessed by a competent health care professional.

GPP - The medication needs to be titrated against clinical response to ensure optimum efficacy.

GPP - Reassess inhaler technique as part of structured clinical review

GPP - In children aged 0 to 5 years, pMDI and spacer are the preferred method of delivery of beta-2 agonists or inhaled steroids. A face mask is required until the child can breathe reproducibly using the spacer mouthpiece. Where this is ineffective a nebuliser may be required.

Use and Care of Spacers

GPP - The spacer should be compatible with the pMDI being used.

GPP - The drug should be administered by repeated single actuations of the metered dose inhaler into the spacer, each followed by inhalation.

GPP - There should be minimal delay between pMDI actuation and inhalation.

GPP - Tidal breathing is as effective as single breaths.

GPP - Spacers should be cleaned monthly rather than weekly as per manufacturer's recommendations or performance is adversely affected. They should be washed in detergent and allowed to dry in air. The mouthpiece should be wiped clean of detergent before use.

GPP - Drug delivery may vary significantly due to static charge. Metal and other antistatic spacers are not affected in this way

GPP - Plastic spacers should be replaced at least every 12 months but some may need changing at six months

Management of Acute Asthma

Lessons from Studies of Asthma Deaths and Near Fatal Asthma

B - Health care professionals must be aware that patients with severe asthma and one or more adverse psychosocial factors are at risk of death.

GPP - Keep patients who have had near fatal asthma or brittle asthma under specialist supervision indefinitely.

Acute Asthma in Adults

D - Refer to hospital any patients with features of acute severe or life threatening asthma.

B - Admit patients with any feature of a life threatening or near fatal attack. (Wareham et al., 1993; Mohan et al., 1996; Bucknall et al., 1999; Burr et al., 1999; "Accuracy of death certificates," 1984; Campbell et al., 1997; Innes et al., 1998)

B - Admit patients with any feature of a severe attack persisting after initial treatment. (Wareham et al., 1993; Mohan et al., 1996; Bucknall et al., 1999; Burr et al., 1999; "Accuracy of death certificates," 1984; Campbell et al., 1997; Innes et al., 1998)

C - Patients whose peak flow is greater than 75% best or predicted one hour after initial treatment may be discharged from accident and emergency (A&E), unless they meet any of the following criteria, when admission may be appropriate:

• Still have significant symptoms
• Concerns about compliance
• Living alone/socially isolated
• Psychological problems
• Physical disability or learning difficulties
• Previous near fatal or brittle asthma
• Exacerbation despite adequate dose steroid tablets pre-presentation
• Presentation at night
• Pregnancy

Treatment of Acute Asthma in Adults

C - Give high flow oxygen to all patients with acute severe asthma.

A -

• In hospital, ambulance and primary care, nebulised beta₂ agonist bronchodilators should be driven by oxygen.
• Outside hospital, high dose beta₂ agonist bronchodilators may be delivered via large volume spacers or nebulisers.

C - Whilst supplemental oxygen is recommended, its absence should not prevent nebulised therapy being given if indicated.

A - Use high dose inhaled beta₂ agonists as first line agents in acute asthma and administer as early as possible. Intravenous beta₂ agonists should be reserved for those patients in whom inhaled therapy cannot be used reliably.

GPP - In acute asthma with life threatening features the nebulised route (oxygen-driven) is recommended

A - In severe asthma (peak expiratory flow [PEF] or forced expiratory volume in one second [FEV₁] <50% best or predicted) and asthma that is poorly responsive to an initial bolus dose of beta₂ agonist, consider continuous nebulisation, using an appropriate nebuliser system.

A - Give steroid tablets in adequate doses in all cases of acute asthma.

GPP - Continue prednisolone 40 to 50 mg daily for at least five days or until recovery

A - Nebulised ipratropium bromide (0.5 mg 4–6 hourly) should be added to beta₂ agonist treatment for patients with acute severe or life threatening asthma or those with a poor initial response to beta₂ agonist therapy.

A - Consider giving a single dose of intravenous (IV) magnesium sulphate for patients with:

• Acute severe asthma who have not had a good initial response to inhaled bronchodilator therapy
• Life threatening or near fatal asthma

GPP - IV magnesium sulphate (1.2 to 2 g IV infusion over 20 minutes) should only be used following consultation with senior medical staff.

GPP - Use IV aminophylline only after consultation with senior medical staff.

B - Routine prescription of antibiotics is not indicated for acute asthma.

C - All patients transferred to intensive care units should be accompanied by a doctor suitably equipped and skilled to intubate if necessary.

Further Investigation and Monitoring

GPP - Measure and record PEF 15 to 30 minutes after starting treatment, and thereafter according to the response. Measure and record PEF before and after nebulised or inhaled beta-2 agonist bronchodilator (at least four times daily) throughout the hospital stay and until controlled after discharge.

GPP - Record oxygen saturation by oximetry and maintain arterial SaO₂ >92%

GPP - Repeat measurements of blood gas tensions within two hours of starting treatment if:

• The initial PaO₂ is <8 kPa unless SaO₂ is >92%; or
• The initial PaCO₂ is normal or raised; or
• The patient's condition deteriorates

GPP - Measure them again if the patient's condition has not improved by 4 to 6 hours.

GPP - Measure and record the heart rate.

GPP - Measure serum potassium and blood glucose concentrations.

GPP - Measure the serum theophylline concentration if aminophylline is continued for more than 24 hours (aim at a concentration of 55 to 110 micromol/l)

GPP - It is essential that the patient's primary care practice is informed within 24 hours of discharge from Accident & Emergency (A&E) or hospital following an asthma exacerbation treated in hospital. Ideally this communication should be directly with a named individual responsible for asthma care within the practice, by means of fax or e-mail.

Acute Asthma in Children Aged Over 2 Years

B - Consider intensive inpatient treatment for children with SpO₂ <92% on air after initial bronchodilator treatment.

GPP - Decisions about admission should be made by trained physicians after repeated assessment of the response to further bronchodilator treatment.

GPP - Attempt to measure PEF or FEV₁ in all children aged >5 years, taking the best of three measurements, ideally expressed as percentage of personal best for PEF (as detailed in a written action plan) or alternatively as percentage of predicted for PEF or FEV₁.

D - The use of structured care protocols detailing bronchodilator usage, clinical assessment, and specific criteria for safe discharge is recommended.

GPP - Children with life threatening asthma or SpO₂ <92% should receive high flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations.

A - Inhaled beta₂ agonists are the first line treatment for acute asthma. (Schuh et al., 1989; Schuh et al., 1990; Robertson et al., 1985; Schuh et al., 1999)

A - pMDI + spacer are the preferred option in mild to moderate asthma.

B - Individualise drug dosing according to severity and adjust according to the patient's response.

GPP - Children with acute asthma in primary care who have not improved after receiving up to 10 puffs of beta-2 agonist should be referred to hospital. Further doses of bronchodilator should be given as necessary whilst awaiting transfer.

GPP - Treat children transported to hospital by ambulance with oxygen and nebulised beta-2 agonists during the journey.

GPP - Transfer children with severe or life threatening asthma urgently to hospital to receive frequent doses of nebulised beta-2 agonists (2.5 to 5 mg salbutamol or 5 to 10 mg terbutaline).

B - The early addition of a bolus dose of intravenous salbutamol (15 micrograms/kg) can be an effective adjunct to treatment in severe cases.

A - Give prednisolone early in the treatment of acute asthma attacks.

GPP - Use a dose of 20 mg prednisolone for children aged 2 to 5 years and a dose of 30 to 40 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.

GPP - Repeat the dose of prednisolone in children who vomit and consider intravenous steroids in those who are unable to retain orally ingested medication.

GPP - Treatment 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.

GPP - Do not initiate inhaled steroids in preference to steroid tablets to treat acute childhood asthma.

A - If symptoms are refractory to initial beta-2 agonist treatment, add ipratropium bromide (250 micrograms/dose mixed with the nebulised beta-2 agonist solution).

GPP - Repeated doses of ipratropium bromide should be given early to treat children poorly responsive to beta-2 agonists.

A - Aminophylline is not recommended in children with mild to moderate acute asthma.

C - Consider aminophylline in a High Dependency Unit or pediatric intensive care unit (PICU) setting for children with severe or life threatening bronchospasm unresponsive to maximal doses of bronchodilators and steroid tablets.

GPP - Do not give antibiotics routinely in the management of acute childhood asthma

GPP - Electrocardiograph (ECG) monitoring is mandatory for all intravenous treatments.

Treatment of Acute Asthma in Children Aged  Less Than 2 Years

B - Oral beta-2 agonists are not recommended for acute asthma in infants.

A - For mild to moderate acute asthma, a pMDI + spacer is the optimal drug delivery device.

B - Consider steroid tablets in infants early in the management of moderate to severe episodes of acute asthma in the hospital setting.

GPP - Steroid tablet therapy (10 mg of soluble prednisolone for up to three days) is the preferred steroid preparation for use in this age group

B - Consider inhaled ipratropium bromide in combination with an inhaled beta-2 agonist for more severe symptoms.

Asthma in Pregnancy

Natural History

D - Offer prepregnancy counselling to women with asthma regarding the importance and safety of continuing their asthma medications during pregnancy to ensure good asthma control.

C - Monitor pregnant women with asthma closely so that any change in course can be matched with an appropriate change in treatment.

GPP - Advise women who smoke about the dangers for themselves and their babies and give appropriate support to stop smoking

Management of Acute Asthma in Pregnancy

C - Give drug therapy for acute asthma as for the non-pregnant patient.

D - Deliver oxygen immediately to maintain saturation above 95%.

D - Acute severe asthma in pregnancy is an emergency and should be treated vigorously in hospital.

GPP - Continuous fetal monitoring is recommended for severe acute asthma.

GPP - For women with poorly controlled asthma during pregnancy there should be close liaison between the respiratory physician and obstetrician.

Drug Therapy in Pregnancy

C - Use beta-2 agonists as normal during pregnancy.

C - Use inhaled steroids as normal during pregnancy.

C - Use oral and intravenous theophyllines as normal during pregnancy.

D - Check blood levels of theophylline in acute severe asthma and in those critically dependent on therapeutic theophylline levels.

C - Use steroid tablets as normal when indicated during pregnancy for severe asthma. Steroid tablets should never be withheld because of pregnancy.

D - Do not commence leukotriene antagonists during pregnancy. They may be continued in women who have demonstrated significant improvement in asthma control with these agents prior to pregnancy not achievable with other medications.

C - Use chromones as normal during pregnancy.

Management During Labour

GPP - Advise women that acute asthma is rare in labour.

GPP - Advise women to continue their usual asthma medications in labour.

GPP - In the absence of acute severe asthma, reserve caesarean section for the usual obstetric indications.

C - If anaesthesia is required, regional blockade is preferable to general anaesthesia in women with asthma.

GPP - Women receiving steroid tablets at a dose exceeding prednisolone 7.5 mg per day for more than two weeks prior to delivery should receive parenteral hydrocortisone 100 mg 6–8 hourly during labour.

D - Use prostaglandin F2-alpha with extreme caution in women with asthma because of the risk of inducing bronchoconstriction.

Drug Therapy in Breastfeeding Mothers

C - Encourage women with asthma to breastfeed.

C - Use asthma medications as normal during lactation, in line with manufacturer's recommendations.

Occupational Asthma

Incidence

B - In patients with adult onset asthma, or reappearance of childhood asthma, clinicians should be suspicious that there may be an occupational cause.

Diagnosis

GPP - Adults with airflow obstruction should be asked:

• Are you better on days away from work?
• Are you better on holiday?

Those with positive answers should be investigated for occupational asthma.

D - In suspected work-related asthma, the diagnosis of asthma should be confirmed using standard objective criteria.

D - Objective diagnosis of occupational asthma should be made using serial peak flow measurements, with at least four readings per day.

D - A negative specific bronchial challenge in a worker with otherwise good evidence of occupational asthma is not sufficient to exclude the diagnosis.

Management of Occupational Asthma

D - Relocation away from exposure should occur as soon as diagnosis is confirmed, and ideally within 12 months of the first work-related symptoms of asthma.

Organisation and Delivery of Care

Routine Primary Care

B - All people with asthma should have access to primary care delivered by clinicians with appropriate training in asthma management.

B - In primary care, people with asthma should be reviewed regularly by a nurse or doctor with appropriate training in asthma management.

C - General practices should maintain a list of people with asthma.

C - Clinical review should be structured and utilise a standard recording system.

B - Feedback of information to clinicians should link individual patients with recommendations from guidelines.

D - Health professionals who provide asthma care should have heightened awareness of the complex needs of ethnic minorities, socially disadvantaged groups, and those with communication difficulties.

Acute Exacerbations

C - Manage hospital inpatients in specialist rather than general units, where available.

GPP - All services involved in the care of acute asthma should be staffed by appropriately trained personnel and have access to all the equipment needed to manage acute asthma.

B - Clinicians in primary and secondary care should treat asthma according to recommended guidelines.

B - Discharge from hospital or the emergency department should be a planned, supervised event.

B - All people attending hospital with acute exacerbations of asthma should be reviewed by a clinician with expertise in asthma management, preferably within 30 days.

Patient Education and Self-management

Personalised Asthma Action Plans

A - Patients with asthma should be offered self-management education that should focus on individual needs, and be reinforced by a written action plan.

A - Prior to discharge, in-patients should receive individualised asthma action plans, given by clinicians with appropriate training in asthma management.

B - Introduce asthma action plans as part of a structured educational discussion.

Patient Education and Self-Management in Practice

GPP - A hospital admission represents a window of opportunity to review self-management skills. No patient should leave hospital without a written asthma action plan.

GPP - An acute consultation offers the opportunity to determine what action the patient has already taken to deal with the exacerbation. Their self-management strategy may be reinforced or refined and the need for consolidation at a routine follow up considered.

GPP - A consultation for an upper respiratory tract infection or other known trigger is an opportunity to rehearse with the patient their self-management in the event of their asthma deteriorating.

GPP - Brief simple education linked to patient goals is most likely to be acceptable to patients.

Concordance and Compliance

GPP - Prescription counting is a useful index of compliance

GPP - Provide simple, verbal and written instructions and information on drug treatment for patients and carers.

Definitions:

Grades of Recommendation

The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.

Grade A: At least one meta-analysis, systematic review of randomised controlled trials (RCTs), or randomised controlled trial rated as 1++ and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

Grade B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

Grade C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

Grade D: Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group.

Levels of Evidence

1++ - High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+ - Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1- - Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ - High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+ - Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2- - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3 - Non-analytic studies (e.g. case reports, case series)

4 - Expert opinion

References open in a new window

Electronic copies of the updated guideline: Available from the Scottish Intercollegiate Guidelines Network (SIGN) Web site.

• Quick reference guide: British guideline on the management of asthma. Edinburgh (UK): Scottish Intercollegiate Guidelines Network, 2004 May. 20 p. Available in Portable Document Format (PDF) from the Scottish Intercollegiate Guidelines Network (SIGN) Web site. Addendum to the April 2004 Guideline available from the SIGN Web site.
• SIGN 50: a guideline developers' handbook. Edinburgh ( UK): Scottish Intercollegiate Guidelines Network. (SIGN publication; no. 50). Available from the SIGN Web site.
• Appraising the quality of clinical guidelines. The SIGN guide to the AGREE (Appraisal of Guidelines Research and Evaluation) guideline appraisal instrument. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network, 2001. Available from the SIGN Web site.

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