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Asthma - Management
How should I start treatment for asthma?

  • Explain that lifestyle changes and medication are meant to control asthma symptoms and prevent an exacerbation.
  • Explain the difference between reliever therapy and preventive therapy, and demonstrate how to use inhalers and spacer devices.
  • Prescribe an effective delivery system on the basis of convenience, cost, and suitability.
  • Prescribe a short-acting beta2-agonist for use as required to treat daytime symptoms (twice weekly or less often) of short duration (lasting only a few hours).
  • Prescribe a regular inhaled corticosteroid with the short-acting beta2-agonist if symptoms are at least three times weekly, or waking the person one night weekly.
  • Prescribe a peak flow meter; record the person's best peak expiratory flow rate; and advise regular monitoring, especially during an exacerbation, worsening symptoms, or a medication change.
  • Provide education about asthma, such as how to monitor symptoms and recognize an exacerbation.
Clarification / Additional information
  • Demonstrate how to use inhalers and spacer devices. Ask the person to repeat the technique back to you. For more information on how to use inhalers (with demonstrations), see www.asthma.org.uk or www.ginasthma.org.
  • Encourage people to monitor asthma control on the basis of their symptoms and peak expiratory flow rate (PEFR):
    • Symptoms that worsen at night, or exercise-induced asthma, may suggest poor asthma control. The frequency of short-acting beta2-agonist use is a useful guide to asthma control. Ideally, people should not be using reliever medication in controlled asthma.
    • Encourage monitoring of PEFR as part of an action plan, especially in people with a poor perception of symptoms. Assess PEFR every 5 years in adults to compensate for decreases in lung function with age. Ideally, record PEFR annually in children whilst they are still growing [Pinnock and Shah, 2007].
  • A short-acting beta2-agonist should be started on an as required basis for mild, intermittent symptoms. People should have normal lung function and no nocturnal awakening. When symptoms are more frequent or are worsening, people require treatment at a level based on the severity of symptoms. See Managing uncontrolled asthma.
Basis for recommendation
  • These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].
    • Measuring peak expiratory flow rate (PEFR): monitoring of PEFR and symptoms is associated with similar outcomes in adults and children older than 2 years [Buist et al, 2006]. A prospective study (n = 660 adults) suggested that a single PEFR reading does not provide additional benefit in predicting an exacerbation, over symptoms alone. The study did not assess changes in PEFR over time and thus did not adequately evaluate the role of PEFR for monitoring asthma control [Tierney et al, 2004]. Little evidence shows benefit of using a peak flow meter at home over the long term, or of its use in younger children [Warner, Personal Communication, 2006].
    • Short-acting bronchodilators: inhaled short-acting beta2-agonists are the preferred treatment for rapid symptom relief. The evidence suggests that short-acting beta2-agonists have a quicker onset of action and fewer adverse effects than other reliever drugs (inhaled anticholinergics, short-acting oral beta2-agonists, and short-acting theophylline). An as required regimen is at least as effective as regular use in people with asthma [GINA, 2006].

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