Acute exacerbation of asthma

• Treat an acute exacerbation of asthma aggressively. Use high dose short-acting beta2-agonists (inhaled or nebulizer), oral corticosteroids, oxygen, and consider the need for an admission to hospital.

Chronic asthma

• The aim of treatment of chronic asthma is to achieve early control, maintain control and to prevent exacerbations.
• All people with a new presentation of suspected asthma need an assessment. The aim is to assess the pattern of asthma symptoms, detect possible trigger factors, and determine the impact of asthma on activities of daily living and psychological wellbeing.
• Manage uncontrolled asthma using a step-wise approach based on the person's age and asthma severity:
• Step 1: Treat with a short-acting beta₂-agonist.
• Step 2: Regular preventative therapy: prevent asthma using inhaled corticosteroids (ICS).
• Step 3: Add-on therapy: this consists of several treatment options, such as a trial of long-acting beta2-agonists, increasing the dose of ICS, or adding one of a leukotriene receptor antagonist (especially in children under 5 years of age), theophylline, or an oral beta2–agonist (adults only). Consider referral for children under 2 years of age.
• Step 4: Persistent poor control: increase to maximum dose of ICS and consider a trial of two add-on drugs. Refer all children under 5 years of age.
• Step 5: Regular oral corticosteroids: add oral corticosteroids to existing treatment only after specialist advice if symptoms are not controlled.
• Before starting a new drug, check that trigger factors have been eliminated as far as possible, check inhaler technique, and assess concordance with medication.
• Step-down treatment when symptoms are controlled.
• In addition to drug treatment, offer self-management education, including written asthma action plans; tailor these plans to the needs and preferences of the individual.
• Provide advice about stopping smoking, vaccinations, comorbidities, allergen avoidance and weight reduction, diet, and exercise.
• People who have exercise-induced asthma or occupational asthma, or women who are pregnant may require specific management.

• Assess the person for features that increase or decrease the probability of asthma. For more information, see:
• Features that increase or decrease the probability of asthma in children.
• Features that increase or decrease the probability of asthma in adults.
• Ask about the frequency and pattern of symptoms. For example, do symptoms occur every day, and are there nocturnal symptoms?
• Exclude other diagnoses, such as chest infection or pneumothorax.
• Exclude co-existing conditions, such as gastro-oesophageal reflux disease or allergic rhinitis.
• Ask people to keep a record of when their asthma symptoms are worse, to try to identify trigger factors, such as smoking, drugs, allergens, exercise, or occupation.
• Assess the impact of asthma on activities of daily living, such as work or school, exercise, sleep, and psychological well-being.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].

• Consider an alternative diagnosis, or refer to secondary care for further investigations.

• This recommendation is based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].

• Start a trial of asthma treatment for 2–3 months. The choice of treatment depends on the severity and frequency of symptoms. For more information, see Starting asthma treatment.
• If response is good, continue treatment.
• If response is poor:
• Assess compliance and inhaler technique.
• Consider checking airway reversibility, or refer to secondary care for additional tests.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].

• The following options may be tried depending on the frequency and severity of symptoms:
• Watchful waiting — review the child after an interval agreed with the parents or carers.
• Start a trial of asthma treatment for 2–3 months. The choice of treatment depends upon the severity and frequency of symptoms:
• If response is good, continue treatment.
• If response is poor, assess compliance and inhaler technique, and consider referral to secondary care for additional tests.
• If it is unclear whether a child has improved, careful observation during a trial of treatment withdrawal may clarify whether they have responded to asthma treatment.

• Watchful waiting with review: in children with mild, intermittent wheeze and other respiratory symptoms which occur only with viral upper respiratory tract infections, it is reasonable to give no specific treatment and then review the child.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• Measuring lung function in young children is difficult and not usually possible in children younger than 5 years of age.

• Check for airway obstruction using spirometry:
• Spirometry should be done by a trained healthcare professional; if this is not possible, seek advice.
• If there is no evidence of airway obstruction, consider referring to secondary care for additional tests.
• If there is evidence of airway obstruction, assess for reversibility to either bronchodilator therapy (e.g. salbutamol 400 micrograms via metred-dose inhaler and spacer) and/or to a trial of asthma treatment for 2–3 months:
• If there is significant reversibility (greater than 12% increase in forced expiratory volume in 1 second [FEV₁]) or clinical response to a trial of asthma treatment is good, a diagnosis of asthma is probable. Continue to treat as asthma.
• If there is no significant reversibility (less than 12% increase in FEV₁) and a trial of treatment is not beneficial, refer to secondary care for additional tests.
• If it is unclear whether a child has improved on a trial of asthma treatment, careful observation during a trial of treatment withdrawal may clarify whether they have responded to asthma treatment.

• The choice of asthma treatment (e.g. inhaled short-acting beta₂-agonist or inhaled corticosteroid) depends on the severity and frequency of symptoms. For more information, see Starting asthma treatment.
• Normal spirometry results obtained when the child is asymptomatic do not exclude a diagnosis of asthma. Repeated measurements of lung function may be more helpful to interpret than a single measurement.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].
• In children, tests of airway obstruction (spirometry or measuring peak expiratory flow) may provide support for a diagnosis of asthma.
• Spirographs require calibration to allow accurate interpretation of the results (e.g. Rosenthal normal values based on the child's sex and height). Healthcare professionals require training on how to calibrate and interpret the results from a spirogram. CKS recommend that advice should be sought regarding carrying out spirometry in children and interpreting the results, unless the healthcare professional has received appropriate training.

• 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.

• 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.

• 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].

• Consider an alternative diagnosis or refer to secondary care for further investigations.

• This recommendation is based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].

• Start a trial of asthma treatment for 2–3 months. The choice of treatment depends on the severity and frequency of symptoms. For more information, see Starting asthma treatment.
• If response is good, continue treatment.
• If response is poor:
• Assess compliance and inhaler technique.
• Consider checking airway reversibility (in addition to spirometry at the initial diagnosis), or refer to secondary care for additional tests.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].

• If the person has an intermediate probability of asthma, consider performing a reversibility test (in addition to spirometry at the initial diagnosis) and/or a trial of treatment for 2–3 months:
• If a trial of treatment is offered, the choice of treatment depends on the severity and frequency of symptoms (see Starting asthma treatment).
• If a reversibility test shows significant reversibility (a greater than 400 mL improvement in forced expiratory volume in 1 second [FEV₁]), start a trial of asthma treatment.
• If a reversibility test shows no reversibility (less than 400 mL improvement in FEV₁), consider referring to secondary care for additional tests.
• If a trial of asthma treatment has been started and:
• Response is good, continue treatment.
• Response is poor, check for reversibility. If there is insignificant reversibility, consider referral to secondary care for additional tests. If there is significant reversibility, assess compliance and inhaler technique.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].

• Assess forced expiratory volume in 1 second (FEV₁) and/or symptoms before and 15 minutes after inhalation of a short-acting beta₂-agonist (salbutamol 400 micrograms by metered-dose inhaler delivered via a spacer, or 2.5 mg by nebulizer) at the time of assessment. A greater than 400 mL improvement in FEV₁ strongly suggests underlying asthma.
• If response to inhaled salbutamol is incomplete, assess FEV₁ after either inhaled corticosteroids (beclometasone equivalent 200 micrograms twice daily for 6–8 weeks) or oral prednisolone (30 mg/day for 14 days).

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].

• 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.

• 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.

• 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].

• Adjust treatment using the step-wise approach outlined below.
• Before starting a new drug or stepping up treatment, confirm with the parents their understanding of the role of treatment, adherence to treatment, inhaler technique, and appropriate elimination of trigger factors.
• Choose an effective delivery system on the basis of convenience, cost, and suitability:
• Step 1: Prescribe a short-acting beta2-agonist to all children, for rapid symptom relief.
• Step 2: Consider starting an inhaled corticosteroid (ICS) at a dose that is appropriate for the severity of symptoms (usually equivalent to beclometasone CFC-free as Clenil Modulite^® 200 to 400 micrograms/day). Indications for ICS include:
• Having symptoms three times weekly or more, or
• Awakening with symptoms one night weekly or more, or
• Having an exacerbation in the last 2 years, or
• Using inhaled short-acting beta₂-agonist three times weekly or more.
• If ICS are not tolerated or are contraindicated, consider starting a leukotriene receptor antagonist at step 2 (but do so only in children aged 2–5 years).
• Step 3: If the child still has symptoms while using regular ICS (equivalent to Clenil Modulite^® [beclometasone CFC-free] 400 micrograms/day), consider:
• For children younger than 2 years: Move to step 4.
• For children aged 2–5 years: Initiating a trial of a leukotriene receptor antagonist; if asthma remains inadequately controlled, move to step 4.
• Step 4: Refer to a paediatrician with knowledge about respiratory diseases.
• Offer self-management education, including written action plans focusing on the child's and the family's needs.

• Inhaled corticosteroids should be used twice a day, at the lowest dose that maintains effective control of asthma. Higher doses may be needed in young children to ensure adequate drug delivery.
• Leukotriene receptor antagonists: montelukast is the only drug in this class that is licensed for use in children 2–5 years of age.
• Choose an effective delivery system on the basis of availability, the child's ability to use the device, convenience, and cost. For details, see Delivery system for children under 5 years.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• Evidence is limited for all types of treatment for asthma in children younger than 5 years compared with older children and adults.
• Inhaled corticosteroids (ICS): the evidence now suggests that ICS are safe and effective in younger children. These agents are beneficial even in mild asthma, but there is no benefit in starting treatment at very high doses and then stepping down. Concerns remain about the adverse effects of ICS in children.

• Adjust treatment using the step-wise approach outlined below.
• Before starting a new drug or stepping up treatment, confirm with the parents their understanding of the role of treatment, adherence to treatment, inhaler technique, and appropriate elimination of trigger factors.
• Choose an effective delivery system on the basis of convenience, cost, and suitability:
• Step 1: Prescribe a short-acting beta2-agonist to all children with asthma, for rapid symptom relief.
• Step 2: Consider starting therapy with an inhaled corticosteroid (ICS) at a dose most appropriate to the severity of symptoms; for beclometasone CFC-free as Clenil Modulite^® this is 200 to 400 micrograms/day. Indications include:
• Having symptoms three times weekly or more, or
• Awakening with symptoms one night a week or more, or
• Having an exacerbation in the past 2 years, or
• Using inhaled beta₂-agonist three times weekly or more.
• If ICS therapy is not tolerated, consider starting a leukotriene receptor antagonist or a cromone. Long-acting beta₂-agonists (LABA) should only be prescribed with an ICS and therefore should not be considered an alternative to ICS.
• Step 3: Consider starting Long-acting beta2-agonists (LABA) if symptoms are still uncontrolled when using an ICS at 400 micrograms/day:
• If the child has a good response to the LABA with adequate symptom control, continue the LABA and current dose of the ICS.
• If the child has a good response to the LABA but symptom control is still inadequate and the child is receiving 400 micrograms/day of an ICS, continue the LABA and go to step 4.
• If the child does not respond to LABA, stop the LABA. If symptom control is inadequate and the child is receiving 400 micrograms/day of an ICS, then consider an alternative add-on treatment, such as a leukotriene receptor antagonist or modified-release theophylline, before moving to step 4.
• Step 4: Consider increasing the ICS to the maximum recommended daily dose. For beclometasone CFC-free as Clenil Modulite^® this is 800 micrograms/day.
• Step 5: Refer to a paediatrician with knowledge of respiratory medicine.
• Offer self-management education, including written action plans focusing on the individual's needs.

• The duration of a trial of add-on therapy depends on the desired outcome. A trial of days to weeks may be sufficient for symptom relief, whilst it may take weeks to months for benefits to be seen in exacerbation rates. For most preventive therapies, improvements begin within days, but the full benefit may only be evident after 3 or 4 months, especially in severe and chronically under-treated disease [GINA, 2006].
• Short-acting beta₂-agonists may be needed on a regular basis to provide temporary relief of uncontrolled symptoms. The aim is to stop the need for reliever medication by using adequate preventive therapy.
• Inhaled corticosteroids are usually prescribed at the lowest dose needed to achieve control.
• Inhaled long-acting beta₂-agonists: when starting therapy with these drugs, it may be more practical to prescribe separate inhalers to allow titration of doses, and separate inhalers makes it easier to step down treatment if symptoms improve.
• Leukotriene receptor antagonists may be preferred over modified-release theophylline because they have fewer adverse effects.
• Oral corticosteroids (daily) are an option for children whose asthma remains inadequately controlled after step 4, but they should not be prescribed without specialist advice.

• These recommendations are based on the British Guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2009]:
• For steps 2, 3, and 4, the benefits of treatment in trials are based on improvements in symptoms and lung function, reduced exacerbations, and a good safety profile. The British Thoracic Society based their add-on regimens on extrapolated evidence from trials of add-on therapy to inhaled corticosteroids (ICS) and on previous guidelines. Few clinical trials in specific patient groups are available to guide management.
• Inhaled corticosteroids (ICS): The evidence suggests that ICS are the most effective preventive treatment for all people with asthma. Nevertheless, there are concerns about local and systemic adverse effects when ICS are used in high doses.
• Long-acting beta₂-agonists (LABA): The evidence suggests that adding a LABA provides better asthma control than increasing ICS above 400 micrograms. In children the dose at which add-on therapy appears to be more beneficial is when ICS exceed 400 micrograms/day (beclometasone equivalent). Use of a LABA alone (without ICS) appears to be associated with increased risk of asthma-related death. Larger prospective studies are needed to confirm these findings.
• Leukotriene receptor antagonists (LTRA): The evidence suggests that leukotriene receptor antagonists improve asthma symptoms and lung function when added to ICS, but they do not provide greater benefit than increasing ICS alone.
• Theophylline: The evidence suggests that increasing the ICS dose provides better asthma control than adding in theophylline. Comparison studies with other add-on therapies are limited, but theophylline appears to have a worse adverse effect profile than other drugs.
• Cromones: Limited and inconclusive evidence suggests that cromones may provide some benefit in controlling asthma symptoms.

• Adjust treatment using the step-wise approach outlined below.
• Before starting a new drug or stepping up treatment, confirm with the person their understanding of the role of treatment, adherence to treatment, inhaler technique, and appropriate elimination of trigger factors.
• Choose an effective delivery system on the basis of convenience, cost, and suitability:
• Step 1: Prescribe a short-acting beta2-agonist to all people with asthma, for rapid symptom relief.
• Step 2: Consider starting an inhaled corticosteroid (ICS) at a dose most appropriate to the severity of symptoms (for beclometasone-CFC free as Clenil Modulite^®, this is 200 to 800 micrograms/day, with 400 micrograms/day being appropriate for most people older than 12 years of age). Use half the equivalent dose for Qvar^®. Indications include:
• Having symptoms three times weekly or more, or
• Awakening with symptoms one night weekly or more, or
• Having an exacerbation in the past 2 years, or
• Using inhaled beta₂-agonist three times weekly or more.
• If ICS are not tolerated, consider starting a leukotriene receptor antagonist or cromone. Long-acting beta₂-agonists (LABA) should only be prescribed with an ICS and therefore should not be considered an alternative to ICS.
• Step 3: Consider starting a long-acting beta2-agonist (LABA) if symptoms are still uncontrolled with the ICS (irrespective of the dose used):
• If the person has a good response to the LABA with adequate symptom control, continue the LABA and current dose of the ICS.
• If the person has a good response to the LABA but control remains inadequate, continue the LABA, but increase ICS up to 800 micrograms/day (half the dose for Qvar^®). If the person is receiving 800 micrograms/day and control remains poor, move to step 4.
• If the person does not respond to LABA, stop LABA therapy and increase ICS up to 800 micrograms/day (unless the person is already receiving this dosage). If control remains poor, consider an alternative add-on treatment, such as a leukotriene receptor antagonist or modified-release theophylline, before moving to step 4.
• The Symbicort SMART ^® regimen (a budesonide/formoterol combination inhaler used as a preventer and reliever) is an alternative in selected adults (18 years of age and older) who respond to a LABA but are poorly controlled, or in adults who are taking an ICS alone (above 400 micrograms/day) but are poorly controlled. The regular maintenance dose of budesonide should not be decreased, and may be budesonide 200 or 400 micrograms twice a day, depending on symptom severity. If the person regularly uses Symbicort^® as a reliever once a day or more, review treatment.
• People using the Symbicort SMART^® regimen should be advised to continue using the inhaler regularly twice a day, as well as when required. Careful explanation is needed about why Symbicort^® can be used as a reliever as well as a preventer, and why it is important to arrange a review if Symbicort^® regularly needs to be used as a reliever (to review control of asthma and the risk of dose-related adverse effects).
• Step 4: If control is still inadequate, either increase ICS to the maximum dose (for beclometasone CFC-free as Clenil Modulite^®, this is 2000 micrograms/day) or consider starting a fourth drug that the person is not already using, such as a leukotriene receptor antagonist, modified-release theophylline, or an oral modified-release beta₂-agonist.
• Symbicort SMART^® is not suitable (or licensed) for use in people who require more than 800 micrograms/day of budesonide for prevention.
• Step 5: Refer to a specialist in respiratory medicine. Consider stopping any add-on therapy (or reducing the ICS dose) if these options are ineffective, whilst referring to a specialist.
• Offer self-management education, including written action plans focusing on the individual's needs.

• The duration of a trial of add-on therapy depends on the desired outcome. A trial of days to weeks may suffice for symptom relief, whilst it may take weeks to months for benefit to be seen in exacerbation rates. For most preventive therapies, improvements begin within days, but the full benefit may only be evident after 3 or 4 months, especially in severe and chronically undertreated disease [GINA, 2006].
• Short-acting beta₂-agonists may be needed on a regular basis to provide temporary relief of uncontrolled symptoms. The aim is to stop the need for reliever medication by using adequate preventive therapy.
• Inhaled corticosteroids are usually prescribed at the lowest dose needed to achieve control and are rarely not tolerated.
• Inhaled long-acting beta₂-agonists (LABA): when starting therapy with LABA, it may be more practical to prescribe separate LABA and ICS inhalers to allow titration of doses.
• Leukotriene receptor antagonists may be preferred to modified-release theophylline or oral modified-release beta₂-agonist because they are associated with fewer adverse effects. In practice modified-release theophylline and oral modified-release beta₂-agonists are not routinely prescribed in primary care.
• Oral corticosteroids are an option for people whose asthma remains inadequately controlled after step 4, but they should not be prescribed without specialist advice.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• For steps 2, 3, and 4, the benefits of treatment in trials are based on improvements in symptoms and lung function, reduced exacerbations and a good safety profile. The British Thoracic Society based their add-on regimens on extrapolated evidence from trials of add-on therapy to ICS and on previous guidelines. Few clinical trials are available in specific patient groups to guide specific management.
• Inhaled corticosteroids (ICS): The evidence suggests that ICS are the most effective preventive treatment for all people with asthma. Nevertheless, there are concerns about local and systemic adverse effects when ICS are used in high doses.
• Long-acting beta₂-agonists (LABA): The evidence suggests that adding a LABA controls asthma better than increasing the ICS dose. Use of LABA alone (without ICS) appears to be associated with an increased risk of asthma-related death.
• Leukotriene receptor antagonists: The evidence suggests that these agents improve asthma symptoms and lung function when added to ICS; however, they do not provide any greater benefit than increasing ICS alone.
• Theophylline: The evidence suggests that increasing the ICS dose provides better asthma control than adding in theophylline. Comparison studies with other add-on therapy are limited, but theophylline appears to have a worse adverse effect profile than other drugs used.
• Cromones: Limited and inconclusive evidence suggest that cromones may provide some benefit in controlling asthma symptoms.
• Always refer people to a specialist before starting therapy with oral corticosteroids, as they require close monitoring for such adverse effects as hypertension, diabetes, reduced growth (in children), and cataracts.
• Combination inhalers: evidence indicates that using the combination inhaler Symbicort^® (budesonide and formoterol) as a maintenance and reliever therapy (Symbicort SMART^®) may be similarly effective to conventional methods at reducing exacerbation rates in people with moderate to severe asthma.

• Review a person with stable asthma at least once a year. More frequent follow up may be needed after the initial diagnosis e.g. reassess within 2–3 months, when there is a change to medication, or in people with severe asthma or recurrent exacerbations.
• Review asthma control:
• Ask about symptoms during the day; difficulty sleeping; and the impact of asthma on such activities as exercise, work, school, and psychological well-being in the past week or month.
• Assess lung function using spirometry or Peak Expiratory Flow.
• Ask about past exacerbations and their frequency, and whether oral corticosteroids or hospital admission was needed.
• Ask about possible trigger factors, such as exercise, work, and allergens.
• Ask about other conditions that are known to co-exist with asthma and aggravate symptoms e.g. allergic rhinitis, sleep apnoea, and gastro-oesophageal reflux disease.
• Look for signs of complications which may necessitate referral to a specialist.
• Review asthma medication:
• Ask about the use of reliever medication, any benefits seen with changes in medication, and compliance with treatment (which can be assessed by reviewing prescription refill frequency).
• Assess inhaler technique and check peak expiratory flow rate to compare with the previously recorded value.
• Review smoking habit. Encourage people with asthma or parents of children with asthma to stop smoking.
• Review self-management education and make any necessary changes to written action plans.

• Some people may not wish to attend for regular review. A structured interview by telephone may be an alternative approach. Ideally, candidates should have stable asthma, and face-to-face contact should be encouraged at a later date to assess their inhaler technique.
• Control of asthma can be assessed by reviewing symptoms or a person's peak flow diary. Tailor the approach and questions asked to the individual's age and severity of disease:
• In adults (over 16 years), use the Royal College of Physicians' 'three questions' approach (Table 1). Responses can be recorded easily and can form the basis of a symptom diary.
• In children (16 years or younger), ask about symptoms and how they affect school, sport, and play.
• Reinforce the correct use of inhalers at each review. Ask the person to show you how they use their inhaler, and correct any problems by demonstrating the technique and having the person repeat it back to you. For more information on how to use inhalers (with demonstrations), see www.asthma.org.uk or www.ginasthma.org.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].
• The aim of a structured review is to assess how well a person's asthma is controlled and to identify possible triggers of poor control. Then, if needed, treatment can be changed (stepped up, down or changed) to help optimize control and reduce exacerbations and hospitalizations.
• Structured reviews: The evidence shows that people have fewer exacerbations, have improved symptoms, and miss less school or work if they undergo structured asthma reviews, especially if the assessments are done by trained professionals. Telephone consultations may be as effective as face-to-face consultations [Pinnock and Shah, 2007].
• Assessing lung function: Reduced lung function compared to previously recorded values may indicate current bronchoconstriction or a long term decline in lung function and should prompt detailed assessment [SIGN and BTS, 2009].
• Asthma morbidity questionnaires: Questionnaires have been developed to standardize the assessment of asthma symptom control. Asking people about asthma symptoms and their effects on everyday life is important to improve asthma management [Rees, 2006].
• Comorbidities: Gastro-oesophageal reflux disease, allergic rhinitis, obesity, and obstructive sleep apnoea have been reported in greater proportions of people with difficult-to-treat asthma. It is important to recognize such conditions because they appear to aggravate asthma symptoms and need treatment. However, to date, no evidence indicates that treating these conditions improves asthma control [GINA, 2006; SIGN and BTS, 2009].
• Smoking: Smoking may cause poor asthma control. Past smoking can be associated with poor control due to fixed airway obstruction, and current smoking reduces the effectiveness of inhaled and oral corticosteroids [GINA, 2006].

• Do NOT step down treatment for people who have ongoing symptoms or need inhaled short-acting beta₂-agonists, and those who have had a recent exacerbation.
• If a person has controlled symptoms, consider the following approach to step-down treatment:
• Make sure the person feels that their asthma is controlled and that they are willing to try step-down treatment.
• Reduce the dose of inhaled corticosteroids slowly.
• The usual protocol is to decrease the dose by 25–50% per 3-month visit. Explain the potential for worsening symptoms and the increased risk of an exacerbation.
• Some children with milder asthma and a clear seasonal pattern to their symptoms may tolerate a more rapid dose reduction during their 'good' season.
• Review the person on a regular basis; promote lifestyle advice, assess for worsening symptoms, and consider increasing medication if the person's asthma deteriorates.
• If stepping down is not possible, and the person is stable on an inhaled corticosteroid and a long-acting beta₂-agonist, consider prescribing a combination inhaler.

• Discuss the reason for reducing medication (to minimize adverse effects), and always take the person's preference into consideration.
• Update the person's written 'action plan' and reinforce how to recognize and manage an exacerbation.
• Tailor the management to the individual, on the basis of their combination of drugs and the doses needed to achieve asthma control:
• If a person is on a combination of inhaled corticosteroids (ICS) and add-on therapy, slowly reduce the ICS to the lowest dose possible; if asthma control is maintained consider stopping add-on therapy [GINA, 2006]. Some experts (although there is no clear evidence to do so) recommend discontinuing any regular use of a beta–agonist (short or long–acting) before reducing the inhaled corticosteroid dose below 400 micrograms daily.
• Preventive ICS treatment may possibly be stopped if asthma remains controlled on the lowest possible dose and symptoms do not recur for one year [GINA, 2006].

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• The reduced need for medication once control is achieved is not fully understood. Possibilities include a reversal of long-term inflammation in the airways or spontaneous improvement as part of the cyclical natural history of asthma [GINA, 2006].
• Few studies have investigated the most appropriate way of stepping down treatment. One study in adults with stable asthma who used at least 900 micrograms of inhaled corticosteroids daily showed that the dose could be halved every 3 months with no significant deterioration in symptoms [SIGN and BTS, 2009].

• Ask about possible trigger factors, such as a recent upper respiratory tract infection.
• Ask about the type and duration of symptoms, what treatment has been started (if any), and whether treatment has improved symptoms.
• Assess the severity of the exacerbation:
• Look for signs of exhaustion (inability to complete sentences) and cyanosis (bluish lips or extremities).
• Examine the person's chest and record the respiratory rate, pulse, and blood pressure.
• Record the peak expiratory flow rate (if the person is old enough to comply) and use the best of three recordings to grade the severity of the attack on the basis of the person's best or predicted value:
• Moderate: more than 50–75%.
• Acute severe: 33–50%.
• Life-threatening: < 33%.
• Measure a person's oxygen saturation in room air using pulse oximetry (if available).
• Ask about depression, alcohol misuse, poor compliance with medication, social isolation and any previous exacerbations. Together with the severity of the exacerbation, this will help to determine the risk of death and the need for hospital admission.

• Symptoms are a more sensitive measure than peak expiratory flow rate (PEFR) of the onset of an exacerbation, as the increase in symptoms usually precedes the deterioration in PEFR. Symptoms vary among individuals and age ranges. No symptom or sign alone (or together) is specific, and their absence does not exclude a severe exacerbation.
• Signs to look for and record include:
• Pulse rate (increasing suggests worsening asthma, whilst a decrease indicates a life-threatening situation).
• Respiratory rate and use of accessory muscles.
• Degree of wheeze (less apparent with increasing obstruction).
• Degree of agitation and consciousness.
• Peak expiratory flow rate is a more reliable indicator of severity than symptoms. Use a predicted PEFR value only if the person's recent (within 2 years) best PEFR is unknown. Ideally, use the person's own peak flow meter or a similar type.
• Pulse oximetry may not be available in primary care, especially for young children.
• When deciding to admit someone to hospital, assess the severity of this current exacerbation and also review the person's history. If they have any associated medical, behavioural, or psychosocial factors that are of concern, lower the threshold for admission.
• Use the criteria in Table 1 to grade and record the severity of an asthma exacerbation.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• Trigger factors: the evidence from small case-controlled studies shows that sensitization and exposure to allergens (house dust mites, cats, dogs) and respiratory viruses are independently and synergistically associated with asthma exacerbations [Green et al, 2002]. The role of atypical bacteria is much less certain [GINA, 2006].
• Symptoms: early intervention (via an action plan) at signs of a possible exacerbation is essential, as most (88–92%) asthma attacks severe enough to require hospital admission develop relatively slowly, over 6 hours or more. In one study, more than 80% developed over 48 hours [SIGN and BTS, 2009].
• Peak expiratory flow rate improves recognition of asthma severity and helps with decisions about management at home or in hospital. The most clinically useful value is peak expiratory flow rate measured as a percentage of the person's best [SIGN and BTS, 2009].
• Pulse oximetry can help diagnose life-threatening asthma if a person's saturation is below 92%. A prospective study (n = 1184) of children aged 2–17 years suggested that low oxygen saturation predicts hospital admission, but no specific cut-off value is sufficiently accurate for clinical decision making [Keahey et al, 2002].

• Admit all people with a life-threatening asthma exacerbation (peak expiratory flow rate [PEFR] usually < 33% best or predicted and/or oxygen saturation < 92%).
• Admit people with a severe asthma exacerbation (PEFR usually 33–50% best or predicted) who do not rapidly respond to initial treatment or who have a factor that warrants a lower threshold for admission.
• Admit people with a moderate asthma exacerbation (PEFR usually > 50% best or predicted) who have a factor that warrants a lower threshold for admission.
• The following factors should lower the threshold for admission:
• People under 18 years.
• Poor concordance.
• Person lives alone.
• Psychological problems such as depression, and alcohol or drug misuse.
• Physical or learning disability.
• Previous near-fatal attack or brittle asthma.
• Persistent exacerbation despite an adequate dose of oral corticosteroids before presentation.
• Presentation at night or in the afternoon.
• Pregnancy.

• Some people with a moderate to severe exacerbation (and no risk factors for a lower threshold of admission) may be managed in primary care only if they show a good response to initial treatment. The primary healthcare professional needs to make that decision on an individual basis. Their decision should be based on the knowledge of the person and how quickly they respond to initial treatment. If the healthcare professional has any doubt, does not have the appropriate facilities to assess and monitor treatment response, or cannot safely follow up the individual, admission to hospital is needed for further assessment.
• Determine whether a person is at further risk of deterioration or death by assessing their medical, behavioural, and psychosocial history. See Table 1.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• Case-controlled studies have shown that people who die of asthma attacks or have near-fatal attacks are more likely to have associated adverse behavioural or psychological features. Deaths were also related to inadequate use of oral corticosteroids and poor follow up.
• People who die of asthma are also likely to have had severe disease, poor compliance with medication, a hospital admission or visit to an accident and emergency department for asthma in the previous year, or a previous near-fatal attack.
• An oxygen saturation (SpO2) of less than 92% is associated with a risk of hypercapnoea, which is a feature of life-threatening asthma. Hypercapnoea can only be detected by arterial blood gas measurement, not by pulse oximetry.

• Organize urgent hospital admission.
• Give high-flow oxygen (40–60%) with a tight-fitting mask.
• If pulse oximetry is available, adjust the flow rate to maintain an oxygen saturation of 94–98%.
• Lack of pulse oximetry should not prevent the use of oxygen.
• Give a short-acting inhaled beta₂-agonist:
• For life-threatening asthma, give via a nebulizer, if available. Repeat every 20–30 minutes according to clinical response.
• Ideally, nebulizers should be oxygen driven (flow rate of 6 L/min usually needed) to avoid worsening hypoxia.
• For severe attacks, give via a nebulizer (preferred for children if available) or use a pressurized metered-dose inhaler with a large-volume spacer.
• For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs.
• For a child, give 2 puffs every 2 minutes according to response, up to 10 puffs.
• Each puff should be given one at a time and inhaled with five tidal breaths. Repeat every 10–20 minutes according to clinical response.
• For moderate attacks, use a pressurized metered-dose inhaler with a large-volume spacer.
• Give the first dose of a course of prednisolone.
• Monitor peak expiratory flow rate (if the person can comply) and oxygen saturation (if available) to assess response to treatment.
• If the person does not respond to a beta₂-agonist, consider continuous nebulized beta₂-agonists or addition of ipratropium bromide (via a nebulizer). However, aim to get the person to hospital urgently.

• High-flow oxygen: there is very little risk of causing high carbon dioxide retention with high-flow oxygen in people with asthma (unlike chronic obstructive pulmonary disease). Aim to keep the person's oxygen saturation between 94% and 98% (measured by pulse oximetry) by giving 6 L/min or a 40–60% flow rate whilst en route to hospital.
• Inhaled short-acting beta₂-agonist:
• In life-threatening asthma, the agent should be delivered ideally by a high-flow oxygen-driven nebulizer. If an oxygen-driven nebulizer is unavailable, deliver by air-driven nebulizer (although be alert that oxygen desaturation may occur). Continuous nebulization is preferred in severe obstruction, but not all nebulizer systems can do this.
• In severe asthma, the agent should be delivered by high-flow oxygen-driven nebulizer (preferred for children) or pressurized metered-dose inhaler with a large-volume spacer. If multiple puffs are needed, they should be given as single puffs into the spacer and inhaled with five tidal breaths after each, repeating until the prescribed number of puffs has been given. A short pause between puffs may be necessary to avoid hyperventilation.
• In moderate asthma, the agent should be delivered by pressurized metered-dose inhaler with a large volume spacer.
• Oral corticosteroids should be given as soon as possible. Oral administration is as effective as the intravenous route, provided that medication can be swallowed. If medication cannot be swallowed, consider intramuscular methylprednisolone 160 mg as an alternative to a course of oral prednisolone.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline. Because most of the studies were small, had diverse designs, and involved people in secondary care settings, it is difficult to generalize findings to primary care [SIGN and BTS, 2009]:
• If a person does not respond to initial treatment, the main aim is to get the person to hospital urgently for further support, such as intravenous medication and possibly ventilation.
• Oxygen: people with a severe asthma attack are hypoxaemic; this should be corrected urgently with high-flow oxygen. Limited evidence (one randomized controlled trial, n = 74 adults) shows that 100% oxygen may worsen carbon dioxide retention, and improve peak expiratory flow rate to a lesser extent, compared with 28% oxygen [Rodolfo et al, 2005].
• Inhaled beta₂-agonists quickly correct bronchospasm with very few adverse effects. The evidence suggests salbutamol and terbutaline do not differ in efficacy. Delivery via a pressurized metered-dosed inhaler with a large-volume spacer appears to be as effective as delivery via a nebulizer. Continuous nebulization is at least as effective as bolus nebulization in relieving acute asthma. However, continuous nebulization appears to be more effective than bolus nebulization in asthma that is severe or unresponsive to treatment [SIGN and BTS, 2009].
• Inhaled ipratropium bromide: the evidence suggests that combining nebulized ipratropium bromide with nebulized beta₂-agonists in an acute attack may lead to a faster recovery and shorter duration of admission [SIGN and BTS, 2009].

• Prescribe a short course of oral prednisolone (see Table 1 for doses).
• Do not prescribe antibiotics routinely, unless symptoms and signs suggest a bacterial infection.
• Advise the person (or parent of a child) to use their short-acting beta₂-agonist via a large-volume spacer.
• For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs.
• For a child, give 2 puffs every 2 minutes according to response, up to 10 puffs.
• Each puff should be given one at a time and inhaled with five tidal breaths.
• After the short-acting beta₂-agonist has been given (up to 10 puffs), advise the person (or parent of a child):
• To return to using their short-acting beta₂-agonist as-required, up to four times a day (not exceeding 4-hourly use).
• To monitor their peak expiratory flow rate (PEFR) and symptoms. If symptoms worsen, or PEFR decreases after starting treatment, they should seek further medical advice.
• Follow up a person (ideally) within 24 hours, or sooner if they deteriorate, and within 1 week after an exacerbation.

• People whose condition deteriorates despite treatment normally need admission to hospital. Ideally, all people should be followed up after an exacerbation by telephone or, preferably, in person.
• Inhaled beta₂-agonists can be used on a regular basis to alleviate persistent symptoms during an exacerbation. Many people may have already implemented this procedure as part of their action plan.
• Oral corticosteroids should be given for at least 5 days in adults, whilst 3 days is usually sufficient for children. Nevertheless, the length of a course should be tailored to the number of days necessary to bring about recovery. The benefits of corticosteroids can occur within 3–4 hours, and most people do not need tapering of the dose at the end of such a short course.
• The dose of inhaled corticosteroids (ICS) does not need to be increased during an exacerbation, and people should remain on their usual dose. Treatment with ICS should not be used as an alternative to oral corticosteroids.
• Antibiotics: explain to the individual that most exacerbations of asthma are not caused by a bacterial infection and antibiotics will not hasten recovery. If a person has a productive cough and elevated body temperature, consider an alternative diagnosis — see Differential diagnosis.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• Oral corticosteroids: the evidence shows that oral corticosteroids reduce mortality, relapse, subsequent hospital admission, and requirement for beta₂-agonist therapy. The earlier oral corticosteroids are given in an acute attack, the better the outcome. Larger doses than those stated in the recommendation do not appear to provide any additional benefit.
• Inhaled corticosteroids: no evidence indicates that doubling the dose of inhaled corticosteroids is effective in treating acute symptoms of asthma [SIGN and BTS, 2009].
• Antibiotics: the evidence suggests that when an infection precipitates an exacerbation of asthma, it is likely to be viral. The role of bacterial infections has been overestimated [SIGN and BTS, 2009].

• One week after an asthma exacerbation in all people:
• Assess the exacerbation:
• Ask about the duration and severity of the exacerbation compared with any previous episodes. Record the number of exacerbations and hospital admissions.
• Identify possible trigger factors, such as exercise, work, or allergens.
• Optimize treatment:
• Ask about compliance with treatment before the exacerbation and review the person's inhaler technique (correcting problems).
• Provide advice on lifestyle, vaccinations, diet, exercise, and smoking. If the individual or parent of the child smokes, advise them to stop.
• Consider stepping-up treatment by increasing inhaled corticosteroids or adding in new preventive therapy.
• Review self-management education and written action plan:
• Review the person's understanding of how to recognize an exacerbation and what to do at the early signs of an exacerbation (increase beta₂-agonist and start oral corticosteroids).
• Reinforce understanding by updating the written action plan.

• Some people may not need follow up during a mild exacerbation. However, if there are signs of deterioration, review is necessary to determine whether admission to hospital is appropriate.
• Ideally, people should be seen within 1 week, but this may be impractical. Consider a telephone consultation to review the individual early, and schedule a clinic consultation for a later date to assess inhaler technique and perform an examination.
• People who attended hospital do not require such an early follow up, as they will have received appropriate changes to medication and been given self-management advice. All people should receive a follow-up appointment with a respiratory specialist within 1–2 months following admission to hospital.

• These recommendations are based on the British Guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2009]. Many follow up studies have involved small numbers of people, mainly in a secondary care setting, and follow up was done by specialists using different methods. Evidence is scant on following up people who have not been admitted to hospital:
• Follow up is necessary after an exacerbation, as the evidence suggests that more than 15% of people will have a relapse within 2 weeks [SIGN and BTS, 2009]. The follow up process should aim to identify a possible cause of the exacerbation so that strategies to prevent further exacerbations can be developed.
• The evidence suggests that follow up after an exacerbation which involves providing self-management education and a written action plan may reduce hospital re-admissions and improve symptom control and self-management of asthma. Outcomes appear to differ little by the place or personnel involved [Bernard-Bonnin et al, 1995; Nathan et al, 2006].

• Give all people with asthma self-management education and a written action plan.
• At each review, repeat education and advise on:
• Taking medication and avoiding known trigger factors.
• Recognizing poor asthma control (worsening symptoms or peak flow readings) and early signs of an exacerbation (sudden persistent worsening symptoms).
• Presenting for follow up annually or more frequently if symptoms are not controlled.
• A typical asthma action plan should include:
• When to increase treatment (as defined by symptoms or peak expiratory flow rate).
• How to change treatment in case of deterioration and when to go back to maintenance medication.
• When to seek medical help.

• Tailor self-management education and written action plans to the needs of the individual. Such plans may be particularly helpful in some high-risk people with a history of insidious deterioration of asthma, poor perception of deteriorating breathing, and poor adherence to medication, and in people with frequent exacerbations. Provide such people with a 'crash course' of oral corticosteroids and instructions, preferably in writing, on when to start treatment:
• Advise people that poor asthma control may be suggested by:
• Worsening symptoms (cough, wheeze, breathlessness), especially at night or during exercise.
• Worsening peak expiratory flow rate (PEFR) compared with previous readings.
• Advise people with worsening symptoms for a couple of days or a decrease in PEFR to initiate their personalized action plan. This plan should be based on the person's current medication, history, and severity of an exacerbation. Consider the following approach:
• If a person's PEFR is > 75% (best or predicted), advise regular use of a short-acting beta₂-agonist for 1–2 days until symptoms improve. If there is no benefit, start a course of oral prednisolone.
• If a person's PEFR is 50–75% (best or predicted), advise starting a course of oral prednisolone with regular use of their short-acting beta₂-agonist. If no benefit is seen after 1–2 days, seek medical help.
• If a person's PEFR is < 50%, advise starting a course of oral prednisolone along with regular use of their short-acting beta₂-agonist and seek medical help.
• Examples of asthma action plans are available online from the National Asthma Campaign (www.asthma.org.uk).

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• Studies vary widely in populations, setting, and disease severity. One approach cannot be assumed to be successful in all circumstances. Less evidence is available from primary care settings, and results are less consistent. Overall, self-management education packages appear to be effective, but no one individual component is consistently shown to be effective in isolation. A consistent finding in many studies has been improvements in people's self efficacy, knowledge, and confidence [SIGN and BTS, 2009].
• Increasing low-dose inhaled corticosteroids (ICS) by as much as fourfold at the beginning of an exacerbation may be suitable for some people on low doses of maintenance ICS, but doubling ICS during an exacerbation has not been shown to provide benefit and is no longer recommended [SIGN and BTS, 2009].

• Advise smokers with asthma to stop smoking and provide them with the appropriate help. For more information, see the CKS topic on Smoking cessation.
• Advise people with asthma to, as far as possible, avoid exposure to tobacco smoke. For parents who smoke and have a child with asthma, this means either stopping smoking (the best option), or not smoking in the same room as the child (or, preferably, not smoking in the house).

• Parents and parents-to-be who smoke should be advised about the many adverse effects of smoking on themselves and their children. They should be offered appropriate support to stop smoking.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• The evidence suggests that exposure to tobacco smoke in the home contributes to increased wheezing in infancy, increased risk of persistent asthma, increased severity of childhood asthma, and that starting smoking as a teenager increases the risk that asthma will persist. Active smoking in asthma results in worsening symptoms and decline in lung function, and it may inhibit the short-term response to inhaled or oral corticosteroids (although the mechanism of this effect is not certain) [Thomson et al, 2004].

• Advise all people with asthma and parents looking after children with asthma that an influenza and a pneumococcal vaccination is advisable if asthma is severe and requires hospital admission or frequent use of corticosteroids.

• Influenza vaccination is recommended for all people older than 6 months who have required hospital admission for an exacerbation of asthma, or who need continuous or frequently repeated use of inhaled or oral corticosteroids [DH, 2006a]. For more information, see the CKS topic on Immunizations - seasonal influenza.
• Pneumococcal vaccination is recommended in the following groups [DH, 2006b]:
• People (of any age) whose asthma is so severe that they require continuous or frequent repeated use of oral corticosteroids (i.e. at a dose equivalent to 20 mg or more of prednisolone daily).
• Children weighing less than 20 kg, a dose prednisolone of 1 mg or more per kilogram body weight per day, for more than a month.
• Note that pneumococcal vaccine is now part of the childhood immunization programme — see www.dh.gov.uk [CMO et al, 2006]. For more information, see the CKS topic on Immunizations - pneumococcal.

• These recommendations are based on government policy as discussed in the 'Green Book', published by the Department of Health [DH, 2006b].
• A yearly influenza vaccination does not appear to protect people from exacerbations or improve asthma control [GINA, 2006].

• Advise all people with asthma and parents looking after children with asthma to avoid (if possible) known trigger factors, especially at times when asthma is poorly controlled.
• Advise all adults to report promptly any worsening asthma control during work.

• The person with asthma should identify trigger factors, where possible, by noting worsening symptoms or decreasing peak expiratory flow rates (PEFR) during exposure to certain situations. Some triggers cannot be avoided (e.g. air pollution, weather, viral illness), but at times of poor asthma control, it is prudent to do so if possible. Uncontrolled asthma is more sensitive to possible trigger factors.
• Dust mites: sensitization to house dust mite is an important risk factor for the development of asthma, however in the absence of benefit from domestic aeroallergen avoidance, it is not possible to recommend it as a strategy for preventing childhood asthma. Overall, measures to decrease house dust mites have not been shown to have an effect on asthma severity. If a household member shows evidence of house dust mite allergy and wishes to try mite avoidance, strategies include complete barrier bed-covering systems, ensuring that susceptible children do not sleep in a lower bunk bed, removal of carpets or soft toys from beds, high-temperature washing of bed linen, application of acaricides (chemical agents that kill mites) to soft furnishings, and good ventilation.
• Animal allergens, particularly cat and dog allergens, are potent inducers of asthma symptoms. Many experts recommend the removal of pets from the home of allergic people with asthma, but the reported effects are inconsistent.
• Food and food additives (e.g. sulphites found in wine, beer, processed potatoes, shrimps) as an exacerbating factor for asthma are uncommon and occur primarily in young children. Do not recommend food avoidance unless there is a proven allergy, and then only with the supervision of a dietitian, especially in children.
• Air pollutants (ozone, nitrogen oxide, acidic aerosols) and occasional weather changes have been associated with asthma symptoms and exacerbations, although there is no evidence to support a link between exposure to air pollutants and the induction of allergy. There is no need to recommend avoidance in people with stable asthma. Advise people with poorly controlled asthma who are troubled by outdoor triggers to minimize exposure, such as by not doing strenuous exercise or smoking in cold weather, low humidity, or times of high air pollution.
• An occupational trigger will usually worsen asthma at work, and improvements will occur when the person is away from the work environment. Identify people with occupational triggers early and refer them to a respiratory specialist.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• Allergen avoidance: the evidence that reducing allergen exposure can reduce morbidity and mortality is tenuous. In uncontrolled studies, children and adults have shown some benefit from exposure to very-low-allergen environments. However, the benefits cannot be necessarily attributed to allergen avoidance. Larger, well-designed studies of combined-allergen avoidance strategies in different groups are needed [GINA, 2006; SIGN and BTS, 2009].

• Advise overweight people that a healthy diet and regular exercise will help with weight reduction and improve asthma control:
• Advise people (if possible) to take 30 minutes of exercise to increase their heart rate at least five times weekly. For more information on weight loss, see the CKS topic on Obesity.

• Exercise — no specific exercise regimen can be recommended apart from that needed to adopt a healthier lifestyle (30 minutes of exercise to increase heart rate at least five times weekly). Advise people about precautions against exercise-induced asthma. See Managing exercise-induced asthma.
• Diet — no specific dietary recommendation can be given to people with asthma apart from a balanced diet, or a low-fat diet for people needing to lose weight. Observational studies in both adults and children have consistently shown that a high intake of fresh fruit and vegetables is associated with less asthma and better lung function. No intervention studies have yet been reported.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• Weight reduction, diet, and exercise: the evidence is limited and based on small numbers of people with asthma. Weight reduction appears to improve asthma control, lung function, and symptoms in obese people. However, no convincing trial evidence shows that any specific diet or specific exercise regimen improves asthma control or symptoms [GINA, 2006; SIGN and BTS, 2009].

• Advise all people with asthma and parents looking after children with asthma to report symptoms of conditions that could worsen asthma, such as rhinitis, sinusitis, gastro-oesophageal reflux disease, and sleep apnoea.

• Explain that such symptoms as facial pain, nasal symptoms, indigestion, and snoring suggest co-existing conditions that may worsen asthma and need treatment.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• Associated conditions, such as sinusitis, rhinitis, and gastro-oesophageal reflux disease, worsen asthma control. However, there is no conclusive evidence that managing these conditions results in significant clinical improvements in asthma symptoms.

• For both group 1 (car or motorcycle) or group 2 (lorry or bus) entitlement:
• The Driver and Vehicle Licensing Agency (DVLA) need not been informed unless attacks are associated with disabling giddiness, fainting, or loss of consciousness.
• If the DVLA need to be notified, advise the person that it is their responsibility to do so.
• The latest information from the DVLA regarding medical fitness to drive can be obtained at www.dvla.gov.uk/medical/ataglance.

• This information on medical rules is from the Driver and Vehicle Licensing Agency's guidance for medical practitioners, At a glance guide to the current medical standards of fitness to drive [DVLA, 2010].

• The decision to refer is influenced by local referral pathways, the individual, and the experience of the primary healthcare provider.
• In addition to respiratory physicians and paediatricians with a specialist interest in respiratory medicine, such specialists as dietitians, physiotherapists, occupational therapists, and respiratory nurse specialists may be involved in the management of asthma at any stage.
• Admit or refer adults for specialist assessment or further investigation in the following situations:
• The diagnosis is unclear or in doubt:
• Unexpected clinical findings (e.g. crackles, clubbing, cyanosis, cardiac disease).
• Persistent non-variable breathlessness.
• Monophonic, unilateral or fixed wheeze or stridor.
• Persistent chest pain or atypical features.
• Prominent systemic features e.g. weight loss, myalgia, fever.
• Persistent cough or sputum production.
• Spirometric or peak expiratory flow measurements that do not fit the clinical picture e.g. unexplained restrictive spirometry.
• Suspected occupational asthma.
• Non-resolving pneumonia.
• Inadequate response to maximum guideline treatment.
• Admit or refer children for specialist assessment or further investigation in the following situations:
• The diagnosis is unclear or in doubt (the younger the child, the more difficult it is to be sure that wheezing is due to asthma):
• Unexpected clinical findings (e.g. abnormal voice, focal chest signs, dysphagia, inspiratory wheeze, stridor).
• Symptoms present from birth, or perinatal lung problem.
• Excessive vomiting or posseting.
• Severe upper respiratory tract infection.
• Persistent productive cough.
• Family history of unusual chest disease.
• Failure to thrive.
• Parental anxiety.
• Inadequate response to maximum guideline treatment, particularly if oral corticosteroids are needed frequently, or use of the maximum dose of inhaled corticosteroids.

• The urgency of a referral to secondary care or admission to hospital should be appropriate to the clinical situation.
• For indications of when to admit someone with an acute exacerbation of asthma, see Hospital admission.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].

• Other tests available in secondary care include:
• Indirect testing for bronchoconstriction, e.g. more than 15% decrease in the forced expiratory value in 1 second after 6 minutes of running.
• Testing for bronchial hyper-responsiveness using histamine or methacholine.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].

• If exercise-induced asthma is a symptom of poor asthma control, manage it as uncontrolled asthma.
• If a person has otherwise well-controlled asthma, but finds exercise-induced asthma to be a problem:
• Advise short-burst activities, exercising in humid environments, and breathing through the nose to avoid hyperventilation.
• Prescribe use of a short-acting beta2-agonist 10–15 minutes before the start of exercise and after 2 hours of prolonged exercise, or after exercise has finished.
• If exercise-induced symptoms persist despite use of a short-acting beta₂-agonist (adequate dosage with good concordance):
• Consider starting an inhaled corticosteroid.
• If the individual is still symptomatic despite using an inhaled corticosteroid, consider prescribing a long-acting beta2-agonist or leukotriene receptor antagonist for regular use.
• Other options, such as theophylline, sodium cromoglicate, or nedocromil sodium, and oral modified-release beta2-agonist (adults only) can be used but are less effective in exercise-induced asthma.
• If the person does not respond to treatment and exercise-induced asthma is still problematic (especially in athletes), consider referral to a respiratory specialist.

• Confirming the diagnosis of exercise-induced asthma can be difficult:
• Ask about a cough (usually starting 6–10 minutes after the start of exercise) and associated chest tightness (up to 1–2 hours afterwards). Some people may have symptoms starting after exercise.
• Ask about other symptoms not related to exercise, such as nocturnal cough, wheeze, or breathlessness, that might indicate poorly controlled asthma.
• Give the person a peak flow diary and ask them to measure their peak flow before and 5 minutes after exercise to help support the diagnosis.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• Very little evidence supports the use of any medication in exercise-induced asthma in children younger than 5 years. Most of the evidence is from poor-quality trials involving small numbers of people with or without poorly controlled asthma and using different doses of medication over different durations.
• Exercise-induced asthma is often an indication of poorly controlled asthma. If control of asthma is improved, the symptoms of exercise-induced asthma will usually cease.
• Inhaled short-acting beta₂-agonists are the most effective therapy for prevention of exercise-induced asthma. Regular use offers no advantage over as-required regimens and may result in tolerance [SIGN and BTS, 2009].
• Long-acting beta₂-agonists, leukotriene receptor antagonists, and cromones are more effective than placebo in controlling exercise-induced asthma in small randomized controlled trials, but they are no more effective than short-acting beta₂-agonists [SIGN and BTS, 2009].

• Refer any individual with suspected occupational asthma to a respiratory specialist for confirmation.
• Suspect occupational asthma in adults who developed asthma in adulthood or have a recurrence of childhood asthma and have:
• Asthma symptoms that are better on days away from work or on holidays.
• A high-risk occupation, such as paint sprayers, bakers and pastry makers, nurses, chemical workers, animal handlers, welders, food processing workers, and timber workers.
• Ask the person to keep a peak flow diary, recording their peak flow at work and away from work to show the specialist.

• Work-aggravated asthma occurs when pre-existing asthma is aggravated by non-specific dust or fumes at work. In contrast, occupational asthma is pre-existing asthma which becomes additionally sensitized to an occupational agent.
• Refer people with suspected occupational asthma to the occupational health service at the workplace (if available) or a respiratory specialist.
• Occupational asthma is diagnosed in secondary care when all the following are true:
• The diagnosis of asthma is confirmed.
• A relationship between asthma and work exposures is confirmed, for example, by:
• Serial measurements of peak expiratory flow rate at home and at work (at least three series of consecutive days at work with three periods away from work, at least four evenly spaced readings per day, and at least 3 days in each consecutive work period).
• Specific and non-specific bronchial provocation tests.
• A specific cause is identified.
• Following confirmation, the person should relocate away from exposure as soon as possible, and ideally within 12 months of the first work-related symptoms of asthma. Sometimes, substitution of the hazard may be an alternative option.
• Children may be affected by occupational allergens brought home by their parents.
• More information and a computer tool for analysing data are available from www.occupationalasthma.com.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• The aim of management is to identify the cause, to remove the worker from exposure, and for the person to have worthwhile employment. Early identification and avoidance of the exposure offers the best chance of complete recovery. Studies have shown that the prognosis is worse for people who remain exposed after 1 year of symptoms compared with those removed earlier.
• History: asking about symptoms improving away from work is more sensitive than asking about worsening symptoms at work, as many symptoms deteriorate in the hours after work or during sleep. However, these questions are not specific for occupational asthma and also identify people with asthma due to agents at home (who may improve on holidays) and those who do much less physical activity away from work (exercise-induced asthma).
• Investigations: serial peak flow measurements are the most sensitive and specific initial investigation. Lung function tests away from work may have false-negative results. Specific bronchial provocation testing is the gold standard, but few facilities in the UK do such testing. Most cases of occupational asthma can be diagnosed in secondary care without such a test.

• Manage a woman who is pregnant like any other person with asthma:
• Continue the use of all medication as normal in pregnancy, but do not start leukotriene receptor antagonists. However, if the woman is already taking a leukotriene receptor antagonist and it is considered essential, continue treatment.
• Advise women that the benefits of treatment with oral corticosteroids for an acute attack outweigh the risks.
• Advise women who smoke about the dangers that smoking poses to themselves and their children. Give appropriate support for stopping smoking.
• Encourage women with asthma to breastfeed their babies and use asthma medications as normal during breastfeeding.

• These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
• The risks from uncontrolled asthma are much greater than the risks from asthma treatments during pregnancy.
• The risks of uncontrolled asthma in pregnancy include hyperemesis, hypertension, pre-eclampsia, vaginal haemorrhage, complicated labour, fetal growth restriction, pre-term birth, increased perinatal mortality, and neonatal hypoxia [Schatz et al, 1990; Perlow et al, 1992; Demissie et al, 1998; Dombrowski et al, 2004].
• Women who have a severe exacerbation of asthma during pregnancy are at a significantly increased risk of having a low-birthweight baby compared with women without asthma [Murphy et al, 2006].
• In contrast, if asthma is well controlled throughout pregnancy there is little or no increased risk of adverse maternal or fetal complications [Schatz et al, 1988; Schatz et al, 1995].
• A case-control study including 2460 infants exposed to short-acting beta₂-agonists found no increased risk of congenital malformation in exposed infants [Dombrowski et al, 2004].
• A meta-analysis of four studies of inhaled corticosteroid use in pregnancy showed no increase in the rate of major malformations, pre-term delivery, low birth weight or pregnancy-induced hypertension [Rahimi et al, 2006]. A large UK population based case-control study found no increased risk of major congenital malformations in children of women receiving asthma treatment with inhaled beta₂-agonists and inhaled corticosteroids in the year before or during pregnancy [Tata et al, 2008].
• A systematic review of studies including 190 exposure to long-acting beta₂-agonists demonstrated no increased risk of congenital malformations, pre-term delivery or per-eclampsia [Gluck and Gluck, 2005].
• Oral corticosteroids are not teratogenic, although there are conflicting data on whether oral corticosteroids are associated with oral clefts. Expert opinion is that the association is not definite and, even if it is real, the benefit to the mother and her baby of using corticosteroids to treat a potentially life-threatening disease, justify their use in pregnancy [Schatz et al, 1990].
• Leukotriene receptor antagonists should not be started during pregnancy because data on their safety in pregnant or breastfeeding women are limited [SIGN and BTS, 2009].
• In two small prospective studies no increase in the rates of congenital malformation, preterm birth, or low-birthweight was found [Schaefer et al, 2007].
• There have been several case reports of limb defects in women taking a leukotriene receptor antagonist during pregnancy, but a causal relationship has not been established [Schaefer et al, 2007].

• Evidence is insufficient to recommend herbal and traditional Chinese medicine; acupuncture; ionizers; Alexander technique; homeopathy; hypnosis; manual therapy, including massage and spinal manipulation; physical exercise training; breathing exercises, including yoga and the Buteyko method (the latter may help control the symptoms of asthma); or dietary supplementation with vitamins, minerals, or n-3 fatty acids in the management of asthma [Dennis and Cates, 2000; Markham and Wilkinson, 2004; Hondras et al, 2005].
• Risks associated with some complementary therapies include drug interactions, inconsistent dosing, contamination, and natural toxicity [Arnold et al, 2006].
• People with asthma should not be treated solely with any of the above therapies.

[SIGN and BTS, 2009]

• When choosing an inhaler device for a person with asthma, consider:
• The availability of the drug and dose in the specific device.
• The ability of the person to develop and maintain an effective technique with the specific device — this may depend on such factors as age, dexterity, coordination, and inspiratory flow.
• The suitability of the device to the person's (and carer's) lifestyles, considering such factors as portability and convenience.
• The person's preference for and willingness to use a particular device.
• Cost — choose the device with the lowest overall cost (taking into account daily required dose and product price per dose).
• Good technique is essential in ensuring the correct use of inhaler devices. Only prescribe inhalers after the person using them (or their carer) has received training in the use of the device and has demonstrated acceptable technique.

• A wide variety of devices, masks, and spacers are used to deliver inhaled drugs, including:
• Pressurized metered-dose inhalers.
• Breath-actuated metered-dose inhalers.
• Dry-powder inhalers.
• Spacer devices with a variety of different volumes.
• Face masks with a variety of designs.
• Nebulizers, driven by air or oxygen.
• For a full list of available devices, see www.bnf.org.
• Prescribers should familiarize themselves with a selection of these devices so they can inform, supervise, and assist patients appropriately.
• Dry-powder devices and breath-actuated metered-dose inhalers require an inspiratory flow of at least 30 L/min to activate the device. Some frail people and younger children cannot consistently achieve the required minimum inspiratory flow rate [NICE, 2002].
• Table 1 shows suggested minimum age requirements for the correct use of inhaled drug delivery devices.

[Dolovich et al, 2005]

• A number of factors guiding the choice of inhaler device have been identified in the literature [MeReC, 2002; Dolovich et al, 2005; SIGN and BTS, 2009].
• Systematic reviews have found no evidence that alternative inhaler devices are clinically more effective than standard pressurized metered-dose inhalers (pMDIs) for delivering beta₂-agonist bronchodilators or inhaled corticosteroids [Brocklebank et al, 2001; Ram et al, 2001]. On this basis, if used correctly, pMDIs are the most cost-effective inhaler devices:
• Studies often select for people who can use each of the devices appropriately, or they provide intensive training to ensure that the appropriate technique is used [Dolovich et al, 2005]. Therefore, in practice, efficacy may differ among individuals.

• A pressurized metered-dose inhaler (pMDI) with or without a spacer is recommended for delivery of inhaled corticosteroids and bronchodilators in adults, provided that the person can use the method adequately.
• A dry-powder inhaler (DPI) or a breath-actuated metered-dose inhaler may be more acceptable to people who are unable or unwilling to use a standard pMDI and spacer:
• Because large-volume spacer devices are not easily portable, a DPI or a breath-actuated metered-dose inhaler (which are smaller and therefore more portable) may be appropriate for bronchodilator (reliever) use during the day or when travelling.
• Using such a device for portable bronchodilation does not necessitate use of the same device for inhaled corticosteroid treatment or for bronchodilator treatment at home.
• Nebulizers are rarely required for the routine management of asthma in primary care:
• If available, a nebulizer may be used in a severe exacerbation of asthma for the combined delivery of short-acting bronchodilators and anticholinergic drugs.

• Good evidence from systematic reviews shows that, when used correctly, pressurized metered-dose inhalers (pMDIs) and alternative inhaler devices do not differ clinically in effectiveness [Brocklebank et al, 2001; Ram et al, 2001]. The pMDIs are generally less expensive than alternative inhaler devices.
• Up to 70% of people cannot use a pMDI correctly. A common problem is the timing of actuation with inspiration [Giraud and Roche, 2002; Molimard et al, 2003]. Use of a spacer with a pMDI largely overcomes problems with poor technique.

• A pressurized metered-dose inhaler (pMDI) with a suitable spacer device is recommended for the delivery of inhaled corticosteroids.
• If the child's use of the pMDI and spacer is likely to be so poor as to undermine effective asthma control, consider alternative devices (e.g. dry-powder inhaler [DPI] or breath-actuated metered-dose inhaler [MDI]), bearing in mind the need to minimize the adverse effects of corticosteroids.
• For bronchodilators, consider a wider range of devices (e.g. DPI, breath-actuated MDI), which allow for more frequent spontaneous use and greater portability.

• These recommendations are based on the National Institute for Health and Clinical Excellence guidance Inhaler devices for routine treatment of chronic asthma in older children (aged 5–15 years), and are based on findings from limited evidence, clinical opinion, and pharmacological considerations [NICE, 2002].

• A pressurized metered-dose inhaler (pMDI) plus suitable spacer device, with a face mask where necessary, is recommended for the delivery of inhaled corticosteroid and bronchodilators in children younger than 5 years.
• If this is not clinically effective for the child, consider nebulized therapy. Few children younger than 5 years can use a dry-powder inhaler adequately.

• A face mask is required until the child can breathe reproducibly using the spacer mouthpiece [SIGN and BTS, 2009]. Most children older than 3 years can use a mouthpiece.

• These recommendations are based on the National Institute for Health and Clinical Excellence, Guidance on the use of inhaler systems in children under the age of 5 years with chronic asthma, and are based on limited evidence from small, poor-quality studies [NICE, 2000].

• A large-volume spacer is recommended for the administration of inhaled corticosteroids in all children younger than 16 years, and for giving high doses of inhaled corticosteroids (> 800 micrograms of beclometasone or equivalent daily) in adults.
• Consider spacer devices for people who have difficulty coordinating actuation of a pressurized metered-dose inhaler with inhalation.
• Use a pressurized metered-dose inhaler plus a large-volume spacer device as an alternative to a nebulizer in an acute exacerbation of asthma. See Managing acute exacerbations for more information.

• By filtering out larger particles, large-volume spacer devices reduce oropharyngeal deposition of the drug and the amount of drug absorbed from the gastrointestinal tract at all doses [DTB, 2000]. This is particularly important for inhaled corticosteroids because:
• Reducing oropharyngeal deposition of inhaled corticosteroids decreases the incidence of local adverse effects, such as oral candidiasis.
• Reducing the amount of drug absorbed from the gut reduces the risk of systemic adverse effects.

• Where possible, prescribe the spacer that the manufacturer recommends as suitable for use with the particular pressurized metered-dose inhaler.
• Table 1 shows which spacer devices are compatible with which pressurized metered-dose inhalers.

• The Committee on the Safety of Medicines has raised concerns that drug delivery to the lung may be changed if alternative spacer devices are used [MHRA, 2006b]. This is most likely to be clinically significant with high-dose inhaled corticosteroids.

• Drugs should be administered as single actuations into the spacer and inhaled with minimum delay after each actuation, repeating until the prescribed number of puffs has been given. The canister should be shaken between actuations.
• When multiple puffs are being given, as during exacerbations, there should be a short pause between puffs to avoid hyperventilation.
• Spacer devices should be washed before they are first used, and once a month thereafter. They should be replaced every 6–12 months.

• Plastic or polycarbonate spacers (including Volumatic^®, AeroChamber^®, and Nebuhaler^®) should be washed in washing-up liquid and allowed to air-dry (i.e. without rinsing or wiping). Any residual detergent should be wiped from the mouthpiece.

[DTB, 2000; Rees, 2005; SIGN and BTS, 2009]

• Multiple actuations of the metered-dose inhaler into the spacer before inhalation may reduce the proportion of the drug inhaled [DTB, 2000].
• Static charge builds up on the walls of the spacer, potentially reducing the output of medication from the spacer. Washing the spacer as advised reduces this charge for at least 4 weeks, increasing the delivery of drug to the lungs [DTB, 2000].

• In general, inhaled corticosteroids/long-acting beta₂-agonist (LABA) combination inhalers are reserved for use in people who are stabilized on the component drugs in the same dose ratio and who have difficulty using separate inhalers.
• Three combined products are available in the UK [BNF 57, 2009]:
• Symbicort^® is a combination of budesonide and formoterol delivered as a dry-powder inhaler.
• Seretide^® is a combination of fluticasone and salmeterol and is delivered by a dry-powder inhaler or pressurized metered-dose inhaler (pMDI).
• Fostair^® is a combination of beclometasone and formoterol delivered as a CFC-free pMDI. It is licensed for use only in adults aged 18 years and older. It is not dose equivalent to beclometasone delivered by CFC pMDI; Fostair^® 100/6 may be substituted for Clenil Modulite^® (CFC-free beclometasone pMDI) at 1:2 dosing.
• The Symbicort SMART^® regimen (a combination inhaler as maintenance and reliever therapy) may be considered in adults who respond to LABAs but still have inadequate control of their asthma (step 3) [SIGN and BTS, 2009].

• Efficacy and adverse effects do not differ according to whether inhaled corticosteroids (ICS) and long-acting beta₂-agonists (LABA) for maintenance therapy are given in combination or in separate inhalers [SIGN and BTS, 2009].
• Potential benefits of giving ICS with LABA in a combination inhaler include:
• Improved adherence to drug treatment, as fewer inhalations and inhaler devices are needed [Currie et al, 2005]. However, no direct evidence substantiates this idea.
• Lower risk of serious asthma-related adverse effects, which can occur when a LABA inhaler is used on its own [MHRA, 2005].
• The main disadvantage of the combination inhalers is that the doses of the component drugs cannot be individually titrated without changing the inhaler (e.g. during stepping-up or stepping-down of ICS). This is more easily done with separate inhalers.
• There is evidence that using the combination inhaler, Symbicort^® (budesonide and formoterol) as a maintenance and reliever therapy (Symbicort SMART^®) is similarly effective to conventional methods at reducing exacerbation rates in people with moderate to severe asthma symptoms. It is recommended for use as Step 3 of the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].