What are the guidelines for managing bronchial asthma according to the National Institute for Health and Care Excellence (NICE)?

NICE Guidelines for Bronchial Asthma Management

The British Thoracic Society (BTS) guidelines recommend a stepwise approach to asthma management, with the primary aims being to prevent death, restore optimal lung function, and maintain the best possible clinical condition while preventing relapses. 1

Diagnosis and Assessment

• Look for key diagnostic clues:

  • Family history of asthma or atopy
  • Recurrent wheeze or cough
  • Night-time disturbance by wheeze or cough
  • Symptoms triggered by viral infections, exercise, allergens, or irritants 1

• Assess severity using these criteria:

  • Severe asthma features: Too breathless to complete sentences, respiratory rate >25/min, PEF <50% predicted/best, heart rate >110/min
  • Life-threatening features: PEF <33% predicted/best, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 1

Stepwise Management Approach

Step 1: Mild Intermittent Asthma

• Short-acting beta-agonist (SABA) as needed
• No regular controller medication required

Step 2: Regular Preventer Therapy

• Add low-dose inhaled corticosteroid (ICS)
• Continue SABA as needed

Step 3: Initial Add-on Therapy

• Add long-acting beta-agonist (LABA) to ICS
• Important: Never use LABA as monotherapy due to increased risk of asthma-related deaths 2
• If response is inadequate, increase ICS dose to medium level

Step 4: Persistent Poor Control

• Increase ICS to high dose
• Add fourth drug (e.g., leukotriene receptor antagonist, theophylline)

Step 5: Continuous or Frequent Oral Steroids

• Add daily oral steroid in lowest dose providing adequate control
• Consider referral for specialist care 2

Acute Asthma Management

Immediate Treatment for Severe Asthma

1. High-dose inhaled beta-agonists (salbutamol 5mg or terbutaline 10mg) via nebulizer with oxygen or multiple actuations via spacer
2. Systemic steroids: prednisolone 30-60mg or IV hydrocortisone 200mg
3. Oxygen therapy to maintain saturation >92% 1

Additional Measures for Life-Threatening Asthma

• Add nebulized ipratropium (0.5mg) to beta-agonist
• Consider IV aminophylline (250mg over 20 minutes) or IV salbutamol/terbutaline (250μg over 10 minutes)
• Do not give bolus aminophylline to patients already taking oral theophyllines 1

Monitoring Treatment Response

• Measure PEF 15-30 minutes after starting treatment and regularly thereafter
• Monitor oxygen saturation
• Consider arterial blood gases if:
  • Initial PaO₂ <8 kPa despite oxygen
  • PaCO₂ normal or high
  • Patient deteriorating 1

Criteria for Hospital Admission

• Any life-threatening features
• Severe symptoms persisting after initial treatment
• PEF <33% of predicted/best 15-30 minutes after treatment
• Lower threshold for admission in:
  • Afternoon/evening presentations
  • Recent onset of nocturnal symptoms
  • Previous severe attacks
  • Concerns about symptom assessment
  • Inadequate home support 1

Discharge Planning

Patients should only be discharged when:

• On discharge medications for at least 24 hours
• Inhaler technique checked and documented
• PEF >75% of predicted/best with diurnal variation <25%
• Treatment plan includes oral/inhaled medications and written self-management plan
• GP follow-up arranged within 1 week
• Respiratory clinic follow-up within 4 weeks 1

Rescue Courses of Oral Steroids

Indications for "rescue" oral steroids include:

• Progressively worsening symptoms
• PEF <60% of patient's best
• Sleep disturbed by asthma
• Morning symptoms persisting until midday
• Diminishing response to inhaled bronchodilators
• Emergency use of nebulized/injected bronchodilators 1

Common Pitfalls to Avoid

• Sedation is contraindicated in acute asthma management
• Antibiotics should only be given if bacterial infection is present
• Percussive physiotherapy is unnecessary in acute asthma
• Never use LABA without concurrent ICS therapy
• Don't delay oral steroids in moderate-severe exacerbations
• Don't underestimate severity - normal or high PaCO₂ in a breathless asthmatic indicates a very severe attack 1, 2

Special Considerations for Children

• Symptoms develop in 50% of children with asthma by age 3 and in 80% by age 5
• Dosing for children: prednisolone 1-2mg/kg for 1-5 days (no tapering needed)
• Age-appropriate inhaler devices are essential for effective treatment 1

The management of asthma requires a partnership between the patient/family and healthcare professionals, with education focusing on understanding the condition, proper inhaler technique, and developing a written action plan for exacerbations.