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 + BDR, Fractional exhaled Nitric Oxide (FeNO), peak flow variability (2-4 weeks), blood eosinophils, 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 MART (maintenance & reliever) → Step 3: Moderate-dose MART → Step 4: Add LTRA or LAMA (if Eosinophils or FENO: normal, Or REFER if either raised)
➤ Children (5-11y): Step 1: Low-dose ICS BD + SABA PRN → Step 2: Add LTRA for 8–12 week trial → Step 3: Stop LTRA, switch to ICS/LABA combo
➤ 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 → PEFR <33%, SpO₂ <92%, cyanosis, exhaustion, silent chest
• Acute severe attack → PEFR 33–50%, RR ≥25/min, 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 FeNO between attacks does not rule out the condition