Asthma (Read Code H33)

Diagnosis objective tests should be used to support the diagnosis but this is not
mandatory in patients deemed to be high probability of having asthma (BTS
2008)
PFR based diagnosis is the most useful test in a Primary Care setting
>20% diurnal variation in recorded EU Peak Flow Rate (am and pm prior to any Beta
agonists!) on 3 or more days each week for 2 weeks
Variation % = (maximum PFR minimum PFR)/maximum PFR x 100
In children (< 6 years), where PFR is not feasible, diagnosis relies on the presence of
key features (audible wheeze, symptoms related to exercise, nocturnal symptoms etc),
chronicity of symptoms (cough or wheeze) or response to trials of treatment always
be prepared to question the diagnosis if management is ineffective.
Do not add children to the asthma register unless you are confident of the
diagnosis!
Spirometry based diagnosis (may be falsely negative in a patient who is well at
time of assessment)
Fev1/FVC < 70% = an obstructive picture (Asthma or COPD) but in asthma there is
reversibility in the lung function.
>15% or > 200mls improvement in FEV1 after 400mcg (4 puffs via an MDI) of
salbutamol via a volumatic.
>15% or > 200mls deterioration in FEV1 after 15mins of exercise.

Having made the diagnosis please place them on the asthma register and
put the H33 Asthma Read code in their Problem page.
Arrange a New Patient Asthma clinic appointment with the Practice
Nurse.

Dont forget basic health promotion!

1. Smoking status and cessation advice Read code.
2. Flu vaccination.
3. Pneumovax.
4. Life style and exercise.
5. Asthma self management plan.
6. Patient information leaflets.
7. Pre-payment certificates for script costs.

Treatment delivery options

(Patient choice is the most important factor in stable asthma)
1. Metered Dose Inhaler and spacer 60% of patients have the correct technique
but this can be improved to 75% with technique assessment and education.
2. Inhaler (MDI) alone 30 to 40% of patients have the correct technique.
3. Dry Powder Inhaler DPI) as effective as MDI and spacer but costs more, not
as useful during acute attacks but socially a lot more convenient. Remember
the patient must have the respiratory function to be able to activate the DPI.
4. Use the Easi-Breathe delivery system for the elderly or infirm.
An MDI & spacer is the preferred option in adults and should be used in all <
12s.
Advantages of a spacer: greater delivery to the bronchioles, less oral deposition, so
reduced frequency of oral thrush and it is as good as a nebuliser during acute
exacerbations.
But the spacer:
Should be demonstrated and technique checked.
Should be washed weekly with detergent and allowed to air dry (NOT wiped dry).
Should be changed every six months.
Inspiration should take place as soon as possible after MDI actuation.
Tidal breathing (x5) is as effective as and more preferable than deep breathing.
Indication for consultant referral
1.
2.
3.
4.
5.
6.

Diagnosis unclear.
Failure to control symptoms beyond Step 4.
Consideration for home nebs or home oxygen.
Acute severe exacerbations.
Troublesome drug side effects or complications of Rx/asthma.
Suspected occupational asthma

Treatment of chronic Stable asthma

A stepwise approach is used with entry at the level most likely to abolish symptoms
and optimise peak flows. Treatment is stepped up if symptoms persist or down if
control is good.
Indications to progress to a higher step.
Usage of > two B2 agonist MDIs per month = poor control.
Usage of a B2 agonist 3x/week or more = poor control.
Nocturnal symptoms, daytime symptoms, limitation of normal activity = poor control
Please note the preferred CFC free beclomethasone inhaler is Clenil Modulite (should
be prescribed as brand) and is dose for dose equivalent to Becotide. Avoid QVAR
which is expensive and not bio equivalent to Becotide.

Adult asthma guidelines BTS 2009

Step 1

Inhaled short acting B2 agonist as required

Step 2

Add inhaled steroid 200-800mcg BDP equivalent/day bearing in mind

that 400mcg is the starting dose for many patients

Step 3

Add inhaled Long Acting B2 agonist (LABA) .

Continue LABA if there is a good response
Discontinue LABA if no response and increase inhaled steroid
to 800mcg a day
If some benefit form LABA but control inadequate increase
inhaled steroids to 800mcg/day and then consider adding in
other therapies e.g. leukotriene receptor antagonists or SR
theophylline.

In patients at Step 2 (on BDP 400 mcg/day or more) or patients at Step 3 who have an
exacerbation the use of Symbicort Smart (budesonide/formoterol) as a rescue
medication instead of a short acting B2 agonist can be considered. This is in addition
to their existing inhaled steroid and is continued until the exacerbation has resolved.
Symbicort Smart can therefore be used for maintenance therapy and the dose
temporarily increased to provide relief of exacerbations simplifying management
and reducing prescription cost to patients.
Step 4

Increase inhaled steroid up to 2000mcg a day and consider adding in

other therapies e.g. leukotriene receptor antgonists, B agonist tablets or
SR theophylline.

Step 5

Refer

Children 5-12 years asthma guidelines BTS 2009

Step 1

Inhaled short acting B2 agonist as required

Step 2

Add inhaled steroid 200-400mcg BDP equivalent/day bearing in mind

that 200mcg is the starting dose for many patients

Step 3

Add inhaled Long Acting B2 agonist (LABA) .

Continue LABA if there is a good response
Discontinue LABA if no response and increase inhaled steroid
to 400mcg a day
If some benefit form LABA but control inadequate increase
inhaled steroids to 400mcg/day and then consider adding in
other therapies e.g. leukotriene receptor antgonists or SR
theophylline.

In patients at Step 2 (on BDP 400 mcg/day or more) or patients at Step 3 who have an
exacerbation the use of Symbicort Smart (budesonide/formoterol) as a rescue
medication instead of a short acting B2 agonist can be considered. This is in addition
to their existing inhaled steroid and is continued until the exacerbation has resolved.
Step 4

Increase inhaled steroid up to 800mcg a day.

Step 5

Refer

Children under 5 years BTS asthma guidelines 2009

Step 1

Inhaled short acting B2 agonist as required

Step 2

Add inhaled steroid 200-400mcg BDP equivalent/day bearing in mind

that 200mcg is the starting dose for many patients or leukotriene
receptor antagonist if inhaled steroid cant be used.

Step 3

Step 4

In those children taking inhaled steroids 200-400mcg/day

consider adding leukotriene receptor antagonists.
In those children taking leukotriene receptor antagonists alone
reconsider the addition of inhaled steroid 200-400mcg/day.
In children under 2 years consider going to Step 4.

Refer

Factors to assess on asthma/medication review 7 points!

1. Patient understanding of preventers and relievers and their appropriate
usage, also ask about any side effects.
2. Check inhaler technique.
3. Compliance as per computer and patient history number of salbutamol MDIs
used.
4. Smoking status and cessation advice.
5. Any exacerbations, hospital admissions or oral steroid use since last review.
The RCP 3 Questions
Has your asthma interfered with your usual activities (e.g. housework,
work, school, hobbies etc)?
Have you had difficulties sleeping because of your asthma symptoms
(including cough)?
Have you had your usual asthma symptoms during the day (cough,
wheeze, chest tightness or breathlessness?)
6. Having to use a reliever more than 3 x per week?
7. The need to step up or step down treatment - ? change self management plan.
Osteoporosis risk
Remember adults who have used oral steroids for > 3 months or have had 3 or
more courses of oral steroids in a life time need a DEXA scan and consideration
for osteoporosis prophylaxis e.g. biphosphonates. Furthermore, patients on
beclomethasone doses greater than 800mcg a day should be considered for
osteoporosis prevention lifestyle advice +/- Calcichew D3 forte.
Stepping down Rx
If symptoms control excellent over a period of at least three months then consider
dropping the inhaled steroid dose by 25 to 50% and review after another three
months.
Structure of the asthma service
All patients with proven asthma will be tagged with the H33 Read code, as this is
required for Read code QOF based recall which identifies patients who have not had a
formal asthma review (questionnaire or face to face) in the last 15 months.
At repeat medication re-authorisation doctors must look at:
i)
ii)
iii)
iv)
v)
vi)

Beta 2 agonist over usage arrange asthma clinic review?

Oral steroid/high dose inhaled steroid usage and need for osteoporosis
prophylaxis.
Correct Read H33 Read coding & is it in the Problem page?
On the asthma register?
Recall in place?
If seeing the patient ask and document the seven point review.

Until May 2009 all doses of inhaled steroids in the pharmacological management
section have been referenced against beclometasone (BDP) given via metered dose
inhalers using a CFC-propellant. As BDP-CFC is phased out, the reference inhaled
steroid will be the BDP-HFA equivalent, which can be used at the same dosage.