Do not diagnose asthma without objective test. 

Feno (if available) >35ppb diagnostic, age 5+. If not diagnostic, measure BDR with spirometry. Diagnose asthma if the FEV1 increase is 12% or more from baseline (or if the FEV1 increase is 10% or more of the predicted normal FEV1). 

If spirometer not available, measure PEF twice daily for 2 weeks. Diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more.

Failing that, either perform skin prick testing to house dust mite or measure total IgE level plus blood eosinophil count. Raised total IgE plus Eos >0.5 considered diagnostic! [Because highlights underlying atopy cf viral wheeze?]

Under 5, prescribe steroids [not just salbutamol!] for 8-12 weeks and review. [No dosage guide for under 5s!?] Then do objective test when they reach 5! If no response, check technique, consider environmental triggers (mould, smoke etc), consider alternative diagnosis, refer.

If making asthma diagnosis, record basis for this in notes.

Suggests stopping after initial trial or else within 12 months, if symptoms settled.

If helps but then symptoms recur, can try moderate ICS dose. After that, 8-12 week trial LTRA.

Uncontrolled = exacerbation requiring oral steroids, or use of SABA 3 days a week or more, or night waking once per week or more.

New section on diagnosis at time of acute presentation!

Refer to a specialist respiratory paediatrician any preschool child with an admission to hospital, or 2 or more emergency department admissions in a 12-month period.

Age 5-11, after low dose ICS, assess ability to manage MART (maintenance and reliever therapy) regimen (none licensed under 12, so would be off label). Start low, go to moderate.

Otherwise would be trial of LRTA, then add LABA, then increase ICS to moderate.

12+, start Anti-inflammatory reliever (AIR) therapy with prn combination ICS/LABA inhaler (only budesonide/formoterol licensed for this). This strategy had lowest rate of severe exacerbations (plus cheaper). If highly symptomatic at presentation could start MART +/- oral steroids with view to stepping down.

If MART required and still symptomatic on moderate dose, check FENO and eosinophil count – refer if either high. Otherwise trial of either a LTRA or a long-acting muscarinic receptor antagonist (LAMA, eg tiotropium).

Beware neuropsychiatric side effects of LTRA/montelukast. Review annually. 

Inhalers

Duoresp Spiromax 160/4.5 (powder, 12+) – For MART, 2 inhalations daily in 1-2 divided doses (up to 2 BD); 1 inhalation PRN for relief up to 8 in a day (up to 12 for a limited time but medical assessment recommended).

Symbicort 200/6 (powder, 12+) MART as above. Else AIR – 1 puff PRN, up to 6-8 (up to 12 for limited time).

Symbicort 100/3 MDI 12+ MART – 4 puffs daily in 1-2 divided doses, up to 4 BD. 2 puffs PRN for relief up to 12-16 in a day (max 24)

Wockair 160/4.5 (powder) MART 2 inhalations daily in 1-2 divded doses, up to 2 BD. 1 inhalation PRN up to 6-8 (max 12). Else AIR – as above

Non-pharmacological measures

House dust mite reduction measures not routinely recommended. Evidence on removal of pets from homes “paradoxical” – no benefit or tolerance if continued presence. If detectable cat antigens without cat, might be benefit to high efficiency vacuum cleaning or additional measures.

Air pollution linked to worse symptoms.

High sodium and low magnesium intake linked to asthma symptoms but poor/no evidence that intervention makes a difference. High intake of fresh fruit and vegetables is associated with less asthma and better pulmonary function but no interventional studies.

Weight loss interventions may help asthma symptoms in overweight/obese, and should be considered, but may require >10% loss for benefit.

Breathing exercises eg Papworth/Buteyko methods can lead to modest improvements in asthma symptoms and quality of life, and reduce bronchodilator requirement, in adults with asthma. Less evidence for effect on lung function or airway inflammation. Insufficient evidence in children.

Monitoring

Monitor asthma symptoms, plus check:

• any admissions to hospital or attendance at an emergency department due to asthma.

• time off work or school due to asthma
• amount of reliever inhaler used, including a check of the prescription record
• number of courses of oral corticosteroids
• Asthma Control Questionnaire, the Asthma Control Test etc can be used.

FENO can be considered for monitoring in adults only. Peak flows not routinely indicated for monitoring.

Transition

Not much! Separate section on self management. Vaping/smoking. Factors that affect inhaler use eg school/social. Career plans.