Asthma
Questionnaire/history:
Wheeze?
Cough?
Breathlessness?
Chest tightness?
Symptoms:
- Episodic?
- Diurnal (worse at night or in the early morning)?
- Triggered or exacerbated by exercise, viral infection and/or exposure to cold air or
allergens?
Past medical history (eg atopic disorders)?
Family history (eg atopic disorders)?
Current medication?
Drug allergies?
Examination:
Expiratory, polyphonic wheeze?
Investigations (17+ years): objective tests for diagnosing asthma:
Fractional exhaled nitric oxide (FeNO): >= 40 parts per billion (ppb)?
Spirometry:
- FEV1/FVC < 70% (or below the lower limit of normal if available)?
- Below FEV1/FVC lower limit of normal (LLN)?
- Bronchodilator reversibility (BDR) (if FEV1/FVC < 70%): improvement in FEV1 of 12% or more, together with an increase in volume of 200 ml or more?
Peak expiratory flow variability at least twice daily for 2 to 4 weeks (if either normal spirometry or obstructive spirometry and positive BDR with FeNO level of 39 ppb or less, or obstructive spirometry and negative BDR and a FeNO level btw 25 and 29 ppb): > 20% variability?
Diagnosis:
FeNO >= 40 + either positive bronchodilator reversibility, positive peak flow variability or bronchial hyperreactivity or
FeNO 25-39 + positive bronchial hyperreactivity or Positive bronchodilator reversibility + positive peak flow variability irrespective of FeNO level
Suspicion: Obstructive spirometry +
Negative bronchodilator reversibility with either a FeNO level of >= 40 or
FeNO 25-39 + positive peak flow variability or FeNO 25-39 + negative peak flow variability + positive bronchodilator reversibility
Management (17+ years):
Short-acting beta-2 agonist (SABA) as reliever
If use of SABA 3+ x/week and/or asthma symptoms 3+ x/week and/or woken at night by asthma symptoms once weekly or more:
Low dose inhaler corticosteroid (ICS)
Symptoms not controlled?
- Low dose ICS + Leukotriene receptor antagonists (LTRA), review in 4-8 weeks
Symptoms not controlled?
- Low dose ICS + long-acting beta-agonist (LABA) +/- LTRA
Symptoms not controlled?
- Maintenance and reliever therapy (MART): low dose ICS + LABA (eg Symbicort) for both daily maintenance therapy + relief when required
Symptoms not controlled?
- Increase ICS to moderate dose (either on a MART regime or as fixed dose + LABA + SABA as a reliever therapy)
Symptoms not controlled?
- Trial of an additional drug (eg muscarinic receptor antagonist or theophylline OR Increase ICS to high dose fixed-dose regime (with specialist supervision, who may
also recommend continuous or frequent use of oral steroids)
Review response to treatment after 4-8 weeks
Consider decreasing maintenance therapy if symptoms have been controlled for at least 3 months
Resource(s):
Clinical Effectiveness (CE) Southwark: Asthma