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

In depth

• Start a trial of asthma treatment for 2–3 months. The choice of treatment depends on the severity and frequency of symptoms.
• 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.

In depth

• The following options may be tried depending on the frequency and severity of symptoms:
• Watchful waiting — review the child after a time 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 for additional tests to secondary care.
• 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.

In depth

• 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 metered-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.

In depth

• Explain that lifestyle changes and medication are meant to control asthma symptoms and prevent an exacerbation.
• Explain the difference between reliever 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 reading; 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.

In depth

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

In depth

• Start a trial of asthma treatment for 2–3 months. The choice of treatment depends on the severity and frequency of symptoms.
• 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.

In depth

• 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.
• 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.

In depth

• Explain that lifestyle changes and medication are meant to control asthma symptoms and prevent an exacerbation.
• Explain the difference between reliever 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 reading; 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.

In depth

• 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.
• 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
• The suitability of the device to the person's (and carer's) lifestyles
• The person's preference for and willingness to use a particular device
• Cost
• For adults:
• A pressurized metered-dose inhaler (pMDI) with or without a spacer is generally recommended for delivery of inhaled corticosteroids and bronchodilators.
• A dry-powder inhaler (DPI) or a breath-actuated MDI is recommended for people who are unable or unwilling to use a standard pMDI and spacer.
• For children aged 5 to 15 years:
• For inhaled corticosteroids, a pMDI with a suitable spacer device is recommended. If the child is unable or unwilling to use a standard pMDI and spacer, consider a DPI or a breath-actuated MDI.
• For bronchodilators, consider a wider range of devices (e.g. DPI, breath-actuated MDI), taking into account the need for portability (for symptomatic relief when needed).
• For children younger than 5 years:
• A pMDI with a suitable spacer device, with a face mask where necessary, is recommended for the delivery of inhaled corticosteroid and bronchodilators.

For more information on delivery devices see Choice of inhaled delivery system.

• Use the lowest dose of inhaled corticosteroid (ICS) that maintains effective control of asthma.
• Prescribe CFC-free beclometasone inhalers by brand name (Clenil Modulite^® or Qvar^®); they are not equivalent and must not be interchanged.
• To reduce the risk of oral candidiasis, especially with high doses of ICS:
• Recommend a large-volume spacer device for people using a pMDI.
• Advise people to rinse their mouth with water (or clean children's teeth) after inhalation of a dose of ICS.
• In people using high doses of ICS for prolonged periods, advise on general measures to counteract osteoporosis (such as regular exercise, smoking cessation, and adequate calcium intake).
• In all children receiving prolonged treatment with ICS measure height regularly and record on a growth chart. If there is any slowing of growth reduce the dose if possible and/or refer to a specialist.
• For children treated with 800 micrograms or more of beclometasone or equivalent daily, provide specific written advice about steroid replacement in the event of a severe intercurrent illness. Consider use of a steroid warning card. Note: any child receiving this dose should be under the care of a specialist paediatrician.
• Consider the possibility of adrenal insufficiency in any child maintained on inhaled steroids presenting with shock or decreased consciousness:
• Check serum biochemistry and blood glucose levels urgently.
• Consider whether intramuscular hydrocortisone is required.
• Advise parents to immediately report non-specific symptoms, such as anorexia, abdominal pain, weight loss, tiredness, headache, nausea, vomiting, decreased consciousness, hypoglycaemia, and seizures, in children using ICS.

For full details see Prescribing information.

• 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.

In depth

• 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.

In depth

• 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).

In depth

• Advise an influenza and a pneumococcal vaccination if asthma is severe and requires hospital admission or frequent use of corticosteroids.
• For more information, see the CKS topics on:
• Immunizations - seasonal influenza.
• Immunizations - pneumococcal.

In depth

• Advise to report symptoms of conditions that could worsen asthma, such as rhinitis, sinusitis, gastro-oesophageal reflux disease, and sleep apnoea.

In depth

• Advise 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.

In depth