• Scenario: New presentation of asthma: covers the management of adults and children with a new presentation of asthma and who have a high, intermediate or low probability of having asthma.
• Scenario: Uncontrolled asthma on current treatment: covers how to step up asthma therapy in adults and children with uncontrolled asthma.
• Scenario: Controlled asthma on current treatment: covers how to follow up people with asthma and when to consider stepping down asthma therapy.
• Scenario: Acute asthma exacerbation: covers how to assess someone with acute asthma, when admission to hospital is required, and how to manage people with acute asthma who do not require hospital admission.
• Scenario: Management of exercise-induced asthma: covers the management of people with exercise induced asthma.
• Scenario: Suspected occupational asthma: covers the management of occupational asthma.
• Scenario: Pregnancy and breastfeeding: covers the management of asthma in a pregnant or breastfeeding woman.

• 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

• 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: initiate 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.

In depth

• Review a child with stable asthma at least once a year. More frequent follow up may be needed after the initial diagnosis, when there is a change to medication, or in children 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 and schooling in the past week or month.
• Ask about past exacerbations and their frequency, and whether oral corticosteroids or hospital admission was needed.
• Ask about possible trigger factors such as exercise and allergens.
• Ask about other conditions, that are known to co-exist with asthma and aggravate symptoms: for example, allergic rhinitis.
• 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.
• Assess the child's inhaler technique and check peak expiratory flow rate to compare with the previously recorded value.
• Review smoking habit. Encourage parents of children with asthma to stop smoking.
• Review self-management education and make any necessary changes to written action plans.

• 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 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 their inhaled beta₂-agonist three times weekly or more.
• If ICS therapy is not tolerated, consider starting a leukotriene receptor antagonist or cromones. 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 the 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.

In depth

• Review a child with stable asthma at least once a year. More frequent follow up may be needed after the initial diagnosis, when there is a change to medication, or in children 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 and schooling in the past week or month.
• Ask about past exacerbations and their frequency, and whether oral corticosteroids or hospital admission was needed.
• Ask about possible trigger factors such as exercise and allergens.
• Ask about other conditions, that are known to co-exist with asthma and aggravate symptoms: for example, allergic rhinitis.
• 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.
• Assess the child's inhaler technique and check peak expiratory flow rate to compare with the previously recorded value.
• Review smoking habit. Encourage parents of children with asthma to stop smoking.
• Review self-management education and make any necessary changes to written action plans.

• 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). Use half the 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 year 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.
• 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.

In depth

• Review a person with stable asthma at least once a year. More frequent follow up may be needed after the initial diagnosis, 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 wellbeing in the past week or month.
• 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: for example, 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.
• Assess the person's 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.

• 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.

• Do not prescribe a long-acting beta₂ agonist (LABAs) for someone who is not already using an ICS.
• Do not stop inhaled corticosteroid treatment whilst an individual is using a LABA.
• Do not start anyone with acutely deteriorating asthma on LABA therapy.
• Closely monitor anyone started on an LABA, especially during the first 3 months of treatment.
• Only continue therapy with LABAs if they have shown benefit.
• Advise people who have been prescribed salmeterol that they should not use it to relieve an acute asthma attack.

For full details see Prescribing information.

• When prescribing theophylline, the brand should be specified on the prescription.
• Serum levels of theophylline are increased in people with heart failure or hepatic impairment, in elderly people, and by drugs that inhibit hepatic enzymes (e.g. cimetidine, ciprofloxacin, erythromycin):
• If people whose disease is stable during theophylline therapy begin to take one of these drugs, consider reducing the dose of theophylline.
• Serum levels of theophylline are decreased in people who smoke, in chronic alcoholism, and by drugs that induce hepatic enzymes (e.g. phenytoin, carbamazepine, rifampicin):
• If people whose disease is stable during theophylline therapy begin to take one of those drugs, consider increasing the dose of theophylline.
• If people whose disease is stable during theophylline therapy stop smoking, a reduction in dose may be necessary.
• Once a maintenance dose has been reached, check serum theophylline concentration every 6 to 12 months, or if the person is experiencing adverse effects that might suggest toxicity (e.g. nausea, vomiting, tremor, palpitations, or arrhythmias).

For full details see Prescribing information.

• Zafirlukast: if clinical symptoms or signs suggestive of liver dysfunction occur (e.g. anorexia, nausea, vomiting, right upper quadrant pain, fatigue, lethargy, flu-like symptoms, enlarged liver, pruritus, or jaundice), stop zafirlukast and immediately measure serum transaminases, (in particular, serum alanine aminotransferase). Routine monitoring of liver function is not recommended.
• Use in children: montelukast is the only leukotriene receptor antagonist licensed for use in children (aged 6 months and older).
• Use in pregnancy: do not start a leukotriene receptor antagonist during pregnancy. However, if a woman is already taking a leukotriene receptor antagonist and it is considered essential, treatment can be continued during pregnancy.

For full details see Prescribing information.

• Advise people that inhaled sodium cromoglicate or nedocromil sodium should be used regularly, usually four times a day.
• Cromone inhalers should not be used to relieve an acute attack of asthma.
• If inhalation of the dry powder form of sodium cromoglicate causes bronchospasm, advise the person to use their short-acting btea₂ agonist inhaler (salbutamol or terbutaline) a few minutes prior to using the sodium cromoglicate inhaler.

For full details see Prescribing information.

• Adverse effects are uncommon with infrequent, short courses of oral corticosteroids.
• After recovery from an acute exacerbation, prednisolone can be stopped abruptly, without tapering the dose, unless the course was longer than 3 weeks or the person was previously receiving maintenance oral corticosteroid treatment.

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

Prescription details for the initiation of new drugs only are included. Prescription details for dose increases are not included, although this may be a more appropriate action to take. See the relevant Clinical summary for details of recommendations.

• 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% to 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.

In depth

• Review a person with stable asthma at least once a year. More frequent follow up may be needed after the initial diagnosis, 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, or school 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.
• 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.

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

Prescription details are provided only for combined inhalers. In many people it may be more appropriate to step down treatment. See the Clinical summary recommendation for details of how to step down treatment.

• 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 previous exacerbations as these factors will reduce the threshold for hospital admission.

In depth

• 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.

In depth

• Prescribe a short course of oral prednisolone. The usual dose for someone not taking a regular corticosteroid is:
• Child < 2 years: 10 mg once a day for 3 days
• Child 2–5 years: 20 mg once a day for 3 days
• Child 6–12 years: 30–40 mg once a day for 3 days
• Adult or child > 12 years: 40–50 mg once a day for 5 days
• 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. Repeat every 10–20 minutes according to clinical response.
• 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.

In depth

• 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.

In depth

• 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%.
• 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.

In depth

• 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.

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

• 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.

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

Exercise-induced symptoms are often a sign of poor asthma control. If this is thought to be the case, see Scenario: Uncontrolled asthma on current treatment.

• 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.

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

• Manage a woman who is pregnant like any other individual 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.

In depth

• 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