GPAtlas
ASTHMA
gpatlas.co.uk
🔍 When to Suspect
Episodic wheeze, cough, breathlessness, or chest tightness, often worse at night or with triggers like viral infections, allergens, or exercise
🩺 Assessment
- ◉ Symptoms + triggers → Episodic wheeze, cough, shortness of breath, chest tightness; triggered by viruses, allergens, exercise, NSAIDs
- ◉ Risk factors/history → Personal or family history of atopy (eczema, rhinitis), occupational exposure (baker, welder), smoking
- ◉ Impact + mimics → Affects sleep, work, and quality of life; mimics: COPD, GORD, heart failure, dysfunctional breathing
- ◉ Exam findings → Expiratory polyphonic wheeze and signs of atopy (nasal polyps, eczema); may be normal between episodes
💊 Management
🔸Key tests:
➤ Spirometry + bronchodilator reversibility (BDR), Fractional exhaled Nitric Oxide (FeNO), peak flow variability (2-4 weeks), blood eosinophils, chest X-ray (CXR) to exclude others
🔸Lifestyle:
➤ Provide Personalised Asthma Action Plan (PAAP), advise on trigger avoidance, smoking cessation, weight management
🔸Pharmacological:
➤ Adults (≥12y): Step 1: As-needed low-dose ICS/formoterol reliever → Step 2: Low-dose ICS/formoterol maintenance and reliever therapy (MART) (maintenance & reliever) → Step 3: Moderate-dose MART → Step 4: Add leukotriene receptor antagonist (LTRA) or LAMA (if Eosinophils or fractional exhaled nitric oxide [FENO]: normal, Or REFER if either raised)
➤ Children (5-11y): Step 1: Low-dose inhaled corticosteroid (ICS) BD + short-acting beta-agonist (SABA) PRN → Step 2: Paediatric low-dose MART if the child can manage the regimen → Step 3: Paediatric moderate-dose MART, then refer. If MART is not manageable: LTRA for an 8 to 12 week trial, then low-dose ICS/LABA, then moderate-dose ICS/LABA, then refer
➤ Children (<5y): 8-week trial of low-dose ICS; if symptoms recur, restart at low-dose; consider LTRA if poor response
🔸Exacerbation/emergency:
➤ High-flow oxygen (target 94–98%), nebulised salbutamol and ipratropium bromide, oral prednisolone
🔸Follow-up/safety-net:
➤ Conduct annual asthma review, check inhaler technique and adherence, ensure annual flu/COVID-19 vaccinations
⚠️ Red Flags
• Life-threatening attack → Peak expiratory flow rate (PEFR) <33%, SpO₂ <92%, cyanosis, exhaustion, silent chest
• Acute severe attack → PEFR 33–50%, respiratory rate (RR) ≥25/min, heart rate (HR) ≥110/min, unable to complete sentences
• Fever with purulent sputum
• Unexplained weight loss or persistent hoarseness
• In children → Symptoms from birth, failure to thrive, excessive vomiting
➡️ Referral Criteria
Urgent: Acute severe or life-threatening attacks; children with symptoms from birth, failure to thrive, or vomiting
Routine: Diagnostic uncertainty, suspected occupational asthma, poor control on Step 4 (adults) or Step 3 (children) treatment
📌 GP Tips
🔹Poor inhaler technique and adherence are the most common reasons for treatment failure; always check before escalating therapy
🔹Asthma is a clinical diagnosis supported by tests; normal spirometry or Fractional exhaled Nitric Oxide (FeNO) between attacks does not rule out the condition