Acute Asthma in Adults - Management in Primary Care: Page 1 of 11

Acute asthma in adults - management in primary care
A-Z Local Care Maps - NDCCG & HCCG > Asthma > Acute Asthma in Adults - Management in Primary Care
Care map Information resources Updates to this care

information for patients and carers map
Acute asthma
- primary care
management
Assess severity
Life threatening Acute severe asthma Moderate asthma

asthma
Treatment Treatment
Refer immediately
to Emergency
department
Reassess patient Reassess patient
Refer to Emergency
department
If poor response - Good response If poor response - Good response
R
arrange admission arrange admission
Arrange review with Arrange review with

Refer to Emergency patient Refer to Emergency patient
department department
R R
Published: 15-Apr-2016 Valid until: 02-Apr-2017 Printed on: 04-May-2016 © Map of Medicine Ltd
This care map was published by NDCCG and HCCG. A printed version of this document is not controlled so may not be up-to-date with the
latest clinical information.
Page 1 of 11
1 Care map information

Quick info:
Scope:
• diagnosis, assessment and management of acute and chronic asthma, in adults over age 16 years, in primary and secondary
care, including:
• non-pharmacological and pharmacological management
• choice of inhaler devices
• considerations for the care of adolescents over the age of 12 years
Out of scope:
• management of asthma in pregnancy
• management of asthma in children − see 'Asthma in children' care map
Definition:
• asthma is a chronic inflammatory disorder of the airways:
• airway obstruction is widespread but variable
• increase in airways hyper-responsiveness to certain triggers
• obstruction is usually reversible, either spontaneously or with treatment
• acute asthma exacerbation is a term used to describe onset of worsening asthma symptoms
Prevalence:
• the most recent report states that 5.9% or 3.85 million people in the UK have asthma [20]
• about 2% of adults consult their GP annually with asthma [1]
Risk factors:
• family history of atopic disease, eg:
• asthma
• eczema
• allergic rhinitis
• allergic conjunctivitis
• co-existence of atopic disease
• male sex, for pre-pubertal asthma, and female sex, for persistence of asthma from childhood to adulthood
• bronchiolitis in infancy
• parental smoking, including perinatal exposure to tobacco smoke
• low birthweight − associated with intrauterine growth retardation
• premature birth, especially in extreme-preterm infants who required ventilatory support, with consequent chronic lung disease of
prematurity
Complications:
• death − more than 1400 people died of asthma in the UK in 2002 [1]
• respiratory complications:
• pneumonia
• pulmonary collapse − atelectasis caused by mucus plugging of the airways
• respiratory failure
• pneumothorax
• status asthmaticus − repeated asthma attacks without respite, or non-response to appropriate treatment
• pneumomediastinum
• growth and pubertal delay in children may be a direct result of chronic disease or secondary to use of inhaled corticosteroids or
repeated short courses of systemic corticosteroids − the growth-suppressive effects of the latter may be relatively short-lived
• impaired quality of life (QoL) may result from suboptimal control of asthma − this may include:
• fatigue:
• poor sleep
Page 2 of 11
• tiredness
• impaired day activities
• school or work poor performance and increased absenteeism
• under-performance and time off school
• psychological problems, including stress, anxiety, and depression − children may experience social exclusion because they
cannot participate in activities and sports
References:
[1] Clinical Knowledge Summaries (CKS). Asthma. Newcastle upon Tyne: CKS; 2011.
[2] Scottish Intercollegiate Guidelines Network (SIGN), British Thoracic Society (BTS). British guideline on the management of
asthma (revised January 2012). SIGN Publication no. 101. Edinburgh: SIGN; 2012.
[20] The NHS Information Centre. Quality and Outcome Framework 2011-12. London; The NHS Information Centre: 2012.
2 Information resources for patients and carers

Quick info:
Recommended resources for patients and carers, produced by organisations certified by The Information Standard:
• 'Asthma' (URL) from Asthma UK at http://www.asthma.org.uk
• 'Asthma' (URL) from Bupa at http://www.bupa.co.uk/
• 'Asthma'(PDF) from Patient UK at http://www.patient.co.uk
• 'Asthma - Peak Flow Diary'(PDF) from Patient UK at http://www.patient.co.uk
• 'Asthma - Peak Flow Meter'(PDF) from Patient UK at http://www.patient.co.uk
• 'Asthma medicines' (URL) from Bupa at http://www.bupa.co.uk/
• ‘Healthtalkonline' (URL) from DIPEx at http://www.healthtalkonline.org
• 'Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and over' (PDF) from
National Institute for Health and Clinical Excellence (NICE) at http://www.nice.org.uk
• 'Inhalers for Asthma' (URL) from Patient UK at http://www.patient.co.uk
For details on how these resources are identified, please see Map of Medicine's document on Information Resources for Patients
and Carers (URL).
https://www.asthma.org.uk/globalassets/health-advice/adult-asthma-action-plan.pdf(URL).
3 Updates to this care map

Quick info:
Date of publication: 31-Jul-2014
The clinical content of this care map has been accredited by the Royal College of Physicians (RCP).
Information on measuring fractional exhaled nitric oxide concentration in asthma has been added from:
• [32] National Institute for Health and Care Excellence (NICE). Measuring fractional exhaled nitric oxide concentration in asthma.
Diagnostic guidance 12. London: NICE; 2014.
Please see the care map’s Provenance for additional information on references, accreditations from national clinical bodies,
contributors, and the editorial methodology.
Date of publication: 31-Jul-2013
Information on the use of omalizumab for the treatment of allergic asthma has been added from:
• [15] National Institute for Health and Care Excellence (NICE). Omalizumab for treating severe persistent allergic asthma (review
of technology appraisal guidance 133 and 201). NICE technology appraisal guidance 278. London: NICE; 2013.
Date of publication: 30-Apr-2013
The clinical content of this care map has been accredited by the Royal College of Physicians (RCP).
Date of publication: 31-Jan-2013
Information on inhaler use has been added from:
• [19] National Institute for Health and Clinical Excellence (NICE). Asthma: fluticasone/formoterol (Flutiform) combination inhaler.
Evidence summaries: new medicines 3. London: NICE; 2012.
Page 3 of 11
Information on oxygen use has been added from:

• [25] Royal College of Physicians (RCP). Emergency Oxygen Use in Adult Patients. London: RCP; 2012.
• [26] British Thoracic Society Emergency Oxygen Guideline Group. Guideline for emergency oxygen use in adult patients.
Thorax. 2008: 63; Suppl. VI.
Diagnosis details have been added from:
• [23] National Institute for Health and Clinical Excellence (NICE). Chronic obstructive pulmonary disease. Clinical guideline 101.
London: NICE; 2010.
Information on occupational asthma has been added from:
• [22] Royal College of Physicians (RCP). Diagnosis, management and prevention of occupational asthma. London: RCP; 2012.
Evidence for lifestyle interventions has been added from:
• [27] Chandratilleke MG, Carson KV, Picot J et al. Physical training for asthma. Cochrane Database Syst Rev 2012; 5:
CD001116.
• [28] Burgess J, Ekanayake B, Lowe A et al. Systematic review of the effectiveness of breathing retraining in asthma
management. Expert Rev Respir Med 2011; 5: 789-807.
• [29] Prem V, Sahoo RC, Adhikari P. Effect of diaphragmatic breathing exercise on quality of life in subjects with asthma: A
systematic review. Physiother Theory Pract 2012
Guidelines on the use of bronchial thermoplasty have been added from:
• [31] National Institute for Health and Clinical Excellence (NICE). Bronchial thermoplasty for severe asthma. Interventional
Procedure Guidance 419. London: NICE; 2012.
Information on prevention of osteoporosis has been added from:
• [30] Clinical Knowledge Summaries (CKS). Osteoporosis - preventing steroid-induced. Version 1.3. Newcastle upon Tyne:
CKS; 2009.
Updated epidemiological data has been added from:
• [20] The NHS Information Centre. Quality and Outcome Framework 2011-12. London; The NHS Information Centre: 2012.
Expert opinion has been provided by:
• [21] Contributors representing the Royal College of Physicians (RCP); 2013.
• [24] Practice-informed recommendation; 2013.
Please see the care map’s Provenance for additional information on references, accreditations from national clinical bodies,
contributors, and the editorial methodology.
4 Acute asthma - primary care management

Quick info:
Patients who exhibit a combination of severe asthma and behavioural and psychosocial features are at risk of developing near-fatal
or fatal asthma [2]:
• severe asthma is recognised by one or more of the following:
• previous near-fatal asthma, eg previous ventilation or respiratory acidosis
• previous admission for asthma especially if within the last year
• requirement for three or more classes of asthma medication
• heavy use of beta2 agonists
• repeated attendances at A&E for asthma care especially if in the last year
• adverse behavioural or psychosocial features are recognised by one or more of the following:
• non-compliance with treatment or monitoring
• failure to attend appointments
• fewer GP appointments
• frequent home visits
• psychosis, depression, other psychiatric illnesses or deliberate self-harm
• current or recent major tranquiliser use
• denial
Page 4 of 11
• alcohol or substance misuse

• obesity
• learning difficulties
• social isolation
An acute asthma exacerbation is characterised by [2]:
• sudden onset of shortness of breath and wheeze
• increased respiratory effort and decreased exercise tolerance
NB: Healthcare professionals must be aware that patients with severe asthma and one or more adverse psychosocial factors are at
risk of death [2].
Reference:
5 Assess severity
Quick info:
Assess and record [2]:
• peak expiratory flow (PEF)
• symptoms and response to self-treatment
• heart and respiratory rates
• oxygen saturation (by pulse oximetry)
Reference:
6 Life threatening asthma

Quick info:
Assessment [2,4]:
• silent chest, cyanosis or poor respiratory effort
• arrhythmia or hypotension
• exhaustion, altered consciousness
• peak expiratory flow (PEF) less than 33% best or predicted
• oxygen saturation (SpO2) less than 92%
NB: Patients may not be distressed [24].
References:
[4] Contributors representing the Royal College of Physicians; 2011.
[24] Practice-informed recommendation; 2013.
7 Acute severe asthma

Quick info:
Assessment [2,4]:
• cannot complete sentences
• respiration equal to or more than 25 breaths/minute
• pulse of 110 beats/minute or more
• peak expiratory flow (PEF) 33-50% best or predicted
Page 5 of 11
• oxygen saturation (SpO2) equal to or more than 92%

References:
8 Moderate asthma
Quick info:
Assessment [2,4]:
• speech normal
• respiration less than 25 breaths/minute
• pulse less than 110 beats/minute
• peak expiratory flow (PEF) more than 50-75% best or predicted
• oxygen saturation (SpO2) equal to or more than 92%
References:
9 Treatment
Quick info:
Consider admission to A&E [2].
Treatment [2]:
• if available provide patient with oxygen to maintain an oxygen saturation (SpO2) level of 94-98%
• beta2 agonist either by nebuliser or via spacer:
• nebuliser:
• should be delivered by piped oxygen, cylinder capable of delivering a flow rate of 6L/min or greater, or air-driven nebuliser
with supplemental oxygen [25]
• salbutamol 5mg or terbutaline 10mg
• via spacer − give 4 puffs initially (given separately, inhaled via tidal breathing [4]) and give a further 2 puffs every 2 minutes
according to responses up to maximum of 10 puffs
• prednisolone 40-50mg or intravenous (IV) hydrocortisone 100mg
References:
[25] Royal College of Physicians (RCP). Emergency Oxygen Use in Adult Patients. London: RCP; 2012.
10 Treatment
Quick info:
Treat at home or in surgery and assess response to treatment [2].
Treatment [2]:
• beta2 agonist bronchodilator:
• via nebuliser:
Page 6 of 11
• if peak expiratory flow (PEF) more than 50-75% best or predicted − give prednisolone 40-50mg
• continue or step up usual treatment
'Breathing exercise programmes (including physiotherapist-taught methods) can be offered to people with asthma as an adjuvant to
pharmacological treatment to improve quality of life and reduce symptoms.
Grade A Evidence
5.2.13 Breathing Exercises

Behavioural programmes centred on breathing exercises and hyperventilation reduction techniques (including physiotherapist-
delivered breathing programmes such as the Papworth method, and the Butekyo method) can improve asthma symptoms, quality
of life and reduce bronchodilator requirement in adults with asthma, although have little effect on lung function. These techniques
involve instruction by a trained therapist in exercises to reduce respiratory rate, minute volume and to promote nasal, diaphragmatic
breathing. Trials that include more than five hours of intervention appeared more likely to be effective. They can help patient’s
experience of their condition and quality of life although do not affect lung function or airways inflammation. They should ideally be
provided as part of integrated medical care.'
References:
11 Refer immediately to Emergency department

Quick info:
Refer any patients with features of acute severe or life threatening asthma to hospital [2].
Immediate treatment whilst waiting for ambulance [2]:
• if available provide patient with oxygen to maintain an oxygen saturation (SpO2) level of 94-98%
• beta2 agonist either by nebuliser or via spacer:
• nebuliser:
Reference:
12 Reassess patient
Quick info:
Measure and record peak expiratory flow (PEF) 15-30 minutes after starting treatment, and thereafter according to the response [2].
Admit to hospital if no response and progression to acute severe asthma [2].
Reference:
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13 Reassess patient
Quick info:
Measure and record peak expiratory flow (PEF) 15-30 minutes after starting treatment, and thereafter according to the response [2].
Admit to hospital if no response and progression to acute severe asthma [2].
Reference:
15 If poor response - arrange admission

Quick info:
Criteria for admission:
• admit to hospital if there are any [2]:
• life threatening features
• features of acute severe asthma present after initial treatment
• previous episodes of near-fatal asthma
• admission may be appropriate for patients who meet any of the following criteria:
• still have significant symptoms [2]
• concerns about compliance [2]
• living alone/socially isolated [2]
• psychological problems [2]
• physical disability or learning difficulties [2]
• exacerbation despite adequate dose of corticosteroid tablets prior to presentation [2]
• presentation at night [2]
• pregnancy [2]
• patients with a history of severe uncontrolled asthma who live alone or where home circumstances do not allow adequate
supervision [5]
Lower threshold for admission if [2]:
• attack occurs in late afternoon or at night
• recent hospital admission or previous severe attack
• concern over social circumstances or ability to cope at home
If admitting the patient to hospital [2]:
• stay with the patient until ambulance arrives
• send written assessment and referral details
• repeat beta2 agonist via oxygen-driven nebuliser in ambulance
NB: If a patient has signs and symptoms across categories, always treat according to their most severe features [2].
References:
[5] British Thoracic Society (BTS) Standards of Care Committee. BTS statement on criteria for specialist referral, admission,
discharge and follow-up for adults with respiratory disease. Thorax 2008; 63: i1-i16.
16 Good response
Quick info:
Observe to ensure that improvement continues until complete recovery achieved [2].
Consider repeating bronchodilator therapy after 10-20 minutes if needed [2].
Continue prednisolone 40-50mg daily for at least 5 days, or until recovery [2].
Reference:
Page 8 of 11
17 If poor response - arrange admission

Quick info:
Criteria for admission:
• admit to hospital if there are any [2]:
• life threatening features
• features of acute severe asthma present after initial treatment
• previous episodes of near-fatal asthma
• admission may be appropriate for patients who meet any of the following criteria:
• still have significant symptoms [2]
• concerns about compliance [2]
• living alone/socially isolated [2]
• psychological problems [2]
• physical disability or learning difficulties [2]
• exacerbation despite adequate dose of corticosteroid tablets prior to presentation [2]
• presentation at night [2]
• pregnancy [2]
• patients with a history of severe uncontrolled asthma who live alone or where home circumstances do not allow adequate
supervision [5]
Lower threshold for admission if [2]:
• attack occurs in late afternoon or at night
• recent hospital admission or previous severe attack
• concern over social circumstances or ability to cope at home
If admitting the patient to hospital [2]:
• stay with the patient until ambulance arrives
• send written assessment and referral details
• repeat beta2 agonist via oxygen-driven nebuliser in ambulance
NB: If a patient has signs and symptoms across categories, always treat according to their most severe features [2].
References:
[5] British Thoracic Society (BTS) Standards of Care Committee. BTS statement on criteria for specialist referral, admission,
discharge and follow-up for adults with respiratory disease. Thorax 2008; 63: i1-i16.
18 Good response
Quick info:
If good response to first treatment (symptoms improved, respiration and pulse settling and PEF more than 50%) continue or step up
usual treatment and continue prednisolone [2].
Reference:
19 Arrange review with patient

Quick info:
Follow-up [2]:
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• advise regular bronchodilators

• review prednisolone
• address any trigger factors
• arrange review within 1 week
• discuss a clear plan for what to do if symptoms worsen
Reference:
20 Arrange review with patient

Quick info:
Follow-up [2]:
• advise regular bronchodilators
• review prednisolone, if given
• address any trigger factors
• arrange review within 1 week
• discuss a clear plan for what to do if symptoms worsen
Reference:
Page 10 of 11
Key Dates
Published: 15-Apr-2016, by NDCCG and HCCG
Valid until: 02-Apr-2017
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Acute Asthma in Adults - Management in Primary Care: Page 1 of 11

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Acute asthma in adults - management in primary care

Care map Information resources Updates to this care

Life threatening Acute severe asthma Moderate asthma

Arrange review with Arrange review with

1 Care map information

2 Information resources for patients and carers

3 Updates to this care map

Information on oxygen use has been added from:

4 Acute asthma - primary care management

• alcohol or substance misuse

6 Life threatening asthma

7 Acute severe asthma

• oxygen saturation (SpO2) equal to or more than 92%

5.2.13 Breathing Exercises

11 Refer immediately to Emergency department

15 If poor response - arrange admission

17 If poor response - arrange admission

19 Arrange review with patient

• advise regular bronchodilators

20 Arrange review with patient

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