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release theophylline p. 274. h
Monoclonal antibodies and immunosuppressants
g BTS/SIGN (2016) recommend, that under specialist
initiation, immunosuppressants such as methotrexate p. 913
[unlicensed], and monoclonal antibodies such as
omalizumab p. 267 (child over 6 years for severe persistent
allergic asthma) can be considered in children with severe
asthma to achieve control and reduce the use of oral
corticosteroids. hSee omalizumab p. 267 National
g A short-acting beta2 agonist (such as salbutamol p. 252)
as reliever therapy should be offered to children under
5 years with suspected asthma. A short-acting beta2 agonist
should be used for symptom relief alongside maintenance
Children using more than one short-acting beta2 agonist
inhaler device a month should have their asthma urgently
assessed and action taken to improve poorly controlled
Regular preventer (maintenance) therapy
NICE (2017) define inhaled corticosteroid doses for
children under 5 years as paediatric low or moderate.
BTS/SIGN (2016) instead define inhaled corticosteroid
doses for children under 5 years as very low (refer to
individual guidelines for inhaled corticosteroid dosing
g Consider an 8-week trial of a paediatric moderate
dose of inhaled corticosteroid in children presenting with
any of the following features: asthma-related symptoms
three times a week or more, experiencing night-time
awakening at least once a week, or suspected asthma that is
uncontrolled with a short-acting beta2 agonist alone.
BTS/SIGN (2016) recommend the prescribing of inhalers
After 8 weeks, stop inhaled corticosteroid treatment and
continue to monitor the child’s symptoms:
. if symptoms did not resolve during the trial period, review
whether an alternative diagnosis is likely;
. if symptoms resolved then reoccurred within 4 weeks of
stopping inhaled corticosteroid treatment, restart the
inhaled corticosteroid at a paediatric low-dose as first-line
. if symptoms resolved but reoccurred beyond 4 weeks after
stopping inhaled corticosteroid treatment, repeat the
8-week trial of a paediatric moderate dose of inhaled
BTS/SIGN (2016) instead recommend starting a very low
dose of inhaled corticosteroid as initial regular preventer
therapy in children presenting with any one of the following
features: using an inhaled short-acting beta2 agonist three
times a week or more, symptomatic three times a week or
more, or waking at night due to asthma symptoms at least
once a week. In children unable to take an inhaled
corticosteroid, a leukotriene receptor antagonist (such as
montelukast p. 269) may be used an alternative. h
g If suspected asthma is uncontrolled in children under
5 years on a paediatric low dose of inhaled corticosteroid as
maintenance therapy, consider a leukotriene receptor
antagonist (such as montelukast p. 269) in addition to the
If suspected asthma is uncontrolled in children under
5 years on a paediatric low dose of inhaled corticosteroid and
a leukotriene receptor antagonist as maintenance therapy,
stop the leukotriene receptor antagonist and refer the child
g Consider decreasing maintenance therapy when a
patient’s asthma has been controlled with their current
BNF 78 Airways disease, obstructive 239
maintenance therapy for at least three months. When
deciding which drug to decrease first and at what rate, the
severity of asthma, the side-effects of treatment, duration on
current dose, the beneficial effect achieved, and the patient’s
preference, should be considered. Patients should be
regularly reviewed when decreasing treatment.
Patients should be maintained at the lowest possible dose
of inhaled corticosteroid. Reductions should be considered
every three months, decreasing the dose by approximately
25–50% each time. Reduce the dose slowly as patients
deteriorate at different rates. Only consider stopping inhaled
corticosteroid treatment completely for people who are
using a paediatric or adult low dose inhaled corticosteroid
alone as maintenance therapy and are symptom-free. h
g For most patients, exercise-induced asthma is an
illustration of poorly controlled asthma and regular
treatment including inhaled corticosteroids should therefore
be reviewed. If exercise is a specific problem in patients
already taking inhaled corticosteroids who are otherwise well
controlled, consider adding either a leukotriene receptor
antagonist, a long-acting beta2 agonist, an oral beta2 agonist,
sodium cromoglicate p. 270 or nedocromil sodium p. 270, or
theophylline p. 274. An inhaled short-acting beta2 agonists
used immediately before exercise is the drug of choice. h
g Women with asthma should be closely monitored
during pregnancy. It is particularly important that asthma be
well controlled during pregnancy; when this is achieved
there is little or no increased risk of adverse maternal or fetal
Women should be counselled about the importance and
safety of taking their asthma medication during pregnancy
to maintain good control. Women who smoke should be
advised about the dangers to themselves and to their baby
and be offered appropriate support to stop smoking. h For
further information, see Smoking cessation p. 497.
g Short-acting beta2 agonists, LABAs, oral and inhaled
corticosteroids, sodium cromoglicate p. 270 and nedocromil
sodium p. 270, and oral and intravenous theophylline p. 274
(with appropriate monitoring) can be used as normal during
pregnancy. There is limited information on use of a
leukotriene receptor antagonist during pregnancy, however,
where indicated to achieve adequate control, they should not
Patients with asthma may be eligible for the New Medicines
Service / Medicines Use Review service provided by a
community pharmacist. For further information, see
Advanced Pharmacy Services in Guidance on prescribing p. 1.
Asthma: diagnosis, monitoring and chronic asthma
management. National Institute for Health and Care
Excellence. NICE guideline 80. November 2017.
British guideline on the management of asthma. British
Thoracic Society and Scottish Intercollegiate Guidelines
Network. Full guidance - A national clinical guideline 153.
www.sign.ac.uk/assets/sign153.pdf
The nature of treatment required for the management of
acute asthma depends on the level of severity, described as
. Peak flow > 50-75% best or predicted
. No features of acute severe asthma
. Peak flow 33-50% best or predicted
. Inability to complete sentences in one breath
Any one of the following, in a patient with severe asthma:
. Peak flow < 33% best or predicted
. Arterial oxygen saturation (SpO2) < 92%
. Partial arterial pressure of oxygen (PaO2) < 8 kPa
. Normal partial arterial pressure of carbon dioxide (PaCO2)
. Raised PaCO2, requiring mechanical ventilation with
raised inflation pressures, or both
g Patients with moderate asthma should be treated at
home or in primary care according to response to treatment,
while patients with severe or life-threatening acute asthma
should start treatment as soon as possible and be admitted
to hospital immediately following initial assessment.
Supplementary oxygen should be given to all hypoxaemic
patients with acute severe asthma to maintain a SpO2 level
First-line treatment for acute asthma is a high-dose
inhaled short-acting beta2 agonist (salbutamol p. 252 or
terbutaline sulfate p. 255) given as soon as possible. A
pressurised metered dose inhaler with spacer device is
preferred in patients with non-life-threatening acute
asthma. Whereas, in patients with life-threatening acute
asthma, a beta2 agonist administered by an oxygen-driven
nebuliser is recommended. If the response to an initial dose
of short-acting beta2 agonist is poor, consider continuous
nebulisation with an appropriate nebuliser. Intravenous
beta2 agonists are reserved for those patients in whom
inhaled therapy cannot be used reliably.
In all cases of acute asthma, patients should be prescribed
an adequate dose of oral prednisolone p. 678 once daily for
at least 5 days or until recovery. Parenteral hydrocortisone
p. 676 or intramuscular methylprednisolone p. 678 are
alternatives in patients who are unable to take oral
Nebulised ipratropium bromide p. 246 may be combined
with a nebulised beta2 agonist in patients with acute severe
or life-threatening asthma or in those with a poor initial
response to beta2 agonist therapy to provide greater
There is some evidence that magnesium sulfate p. 1051
has bronchodilator effects. A single intravenous dose of
magnesium sulfate may be considered in patients with
severe acute asthma (peak flow < 50% best or predicted) who
240 Airways disease, obstructive BNF 78
have not had a good initial response to inhaled
bronchodilator therapy [unlicensed use]. In an acute asthma
attack, intravenous aminophylline p. 272 is not likely to
produce any additional bronchodilation compared to
standard therapy with inhaled bronchodilators and
corticosteroids. However, in some patients with near-fatal or
life-threatening acute asthma with a poor response to initial
therapy, intravenous aminophylline may provide some
benefit. Magnesium sulfate by intravenous infusion or
aminophylline should only be used after consultation with,
or on the recommendation of, senior medical staff. h
The nature of treatment required for the management of
acute asthma depends on the level of severity, described as
. Arterial oxygen saturation (SpO2) 92%
. Peak flow 50% best or predicted
. Heart rate 140/minute in children aged 2–5 years; heart
rate 125/minute in children over 5 years
. Respiratory rate 40/minute in children aged 2–5 years;
respiratory rate 30/minute in children over 5 years
. Can’t complete sentences in one breath or too breathless
. Peak flow 33–50% best or predicted
. Heart rate > 140/minute in children aged 2–5 years; heart
rate > 125/minute in children aged over 5 years
. Respiratory rate > 40/minute in children aged 2–5 years;
respiratory rate > 30/minute in children aged over 5 years
Any one of the following in a child with severe asthma:
. Peak flow < 33% best or predicted
g Following initial assessment, supplementary high flow
oxygen should be given to all children with life-threatening
acute asthma or SpO2< 94% to achieve normal saturations of
as soon as possible, ideally via a metered dose inhaler and
spacer device in mild to moderate acute asthma. Children
with severe or life-threatening acute asthma should be
transferred to hospital urgently.
In all cases of acute asthma, children should be prescribed
an adequate once daily dose of oral prednisolone. Treatment
for up to 3 days is usually sufficient, but the length of course
should be tailored to the number of days necessary to bring
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