Systemic nasal decongestants 181 tion is inadequate or inappropriate. If the patient is

3.10 Systemic nasal decongestants 181 tion is inadequate or inappropriate. If the patient is

being treated in the community, urgent transfer to This chapter also includes advice on the drug man-

hospital should be arranged. agement of the following: acute severe asthma, p. 151 anaphylaxis, p. 173

Pregnancy and breast-feeding

angioedema, p. 175 chronic asthma, p. 149

It is particularly important that asthma should be well chronic obstructive pulmonary disease, p. 151

controlled during pregnancy; when this is achieved croup, p. 152

asthma has no important effects on pregnancy, labour, or on the fetus. Drugs for asthma should preferably be administered by inhalation to minimise exposure of the

BNF 57

3.1 Bronchodilators 149

Man agement of ch ron ic a st hm a

Start at step most appropriate to initial severity; before initiating a new drug consider whether diagnosis is correct, check compliance and inhaler technique, and eliminate trigger factors for acute exacerbations

C hi l d u nd e r 5 y ea rs Step 1: occasional relief bronchodilator

A d u l t an d C h il d o v er 5 y ea r s

Step 1: occasional relief bronchodilator Inhaled short-acting beta agonist as required (up to once

Short-acting beta agonist as required (not more than once daily)

daily)

Note Move to step 2 if needed more than twice a week, or if Note Preferably by inhalation (less effective and more side- night-time symptoms more than once a week, or if exacerbation

effects when given by mouth) in the last 2 years requiring systemic corticosteroid or nebulised bronchodilator

Move to step 2 if needed more than twice a week, or if night-time symptoms more than once a week, or if exacerbation in the last 2

Step 2: regular inhaled preventer therapy

years

Inhaled short-acting beta agonist as required Step 2: regular preventer therapy plus

Inhaled short-acting beta agonist as required Regular standard-dose inhaled corticosteroid (alternatives

plus are considerably less effective)

Either regular standard-dose inhaled corticosteroid Step 3: inhaled corticosteroid + long-acting inhaled

Or (if inhaled corticosteroid cannot be used) leukotriene beta agonist

receptor antagonist

Inhaled short-acting beta agonist as required Step 3: add-on therapy plus

Child under 2 years:

Regular standard-dose inhaled corticosteroid Refer to respiratory paediatrician plus

Child 2–5 years:

Regular inhaled long-acting beta agonist (salmeterol or Inhaled short-acting beta agonist as required formoterol)

plus If asthma not controlled

Regular inhaled corticosteroid in standard dose Increase dose of inhaled corticosteroid to upper end of

plus standard dose range

Leukotriene receptor antagonist and

Either stop long-acting beta agonist if of no benefit Step 4: persistent poor control

Or continue long-acting beta agonist if of some benefit Refer to respiratory paediatrician

Respiratory

If asthma still not controlled and long-acting beta agonist

Stepping down

stopped, add one of Regularly review need for treatment Leukotriene receptor antagonist

Modified-release oral theophylline Modified-release oral beta agonist

syst

Step 4: high-dose inhaled corticosteroid + regular

em

bronchodilators

1. Standard-dose inhaled corticosteroids (given through a Inhaled short-acting beta agonist as required

metered-dose inhaler and in children a large-volume spacer): with

Beclometasone dipropionate or budesonide 100–400 micr- Regular high-dose inhaled corticosteroid

ograms twice daily; CHILD under 12 years 100–200 micr- plus

ograms twice daily

Inhaled long-acting beta agonist Fluticasone propionate 50–200 micrograms twice daily; plus

CHILD 4–12 years 50–100 micrograms twice daily In adults 6-week sequential therapeutic trial of one or more

Mometasone furoate (given through a dry-powder inhaler) of

200 micrograms twice daily Leukotriene receptor antagonist

2. Alternatives to inhaled corticosteroid are leukotriene receptor antagonists, theophylline, inhaled cromoglicate, or inhaled

Modified-release oral theophylline

Modified-release oral beta agonist

nedocromil

Step 5: regular corticosteroid tablets

3. High-dose inhaled corticosteroids (given through a metered- Inhaled short-acting beta agonist as required

dose inhaler and a large-volume spacer): with

Regular high-dose inhaled corticosteroid Beclometasone dipropionate or budesonide 0.4–1 mg twice daily; CHILD 5–12 years 200–400 micrograms twice daily and

One or more long-acting bronchodilators (see step 4) Fluticasone propionate 200–500 micrograms twice daily; CHILD 5–12 years 100–200 micrograms twice daily plus

Mometasone furoate (given through a dry powder inhaler) Regular prednisolone tablets (as single daily dose)

200–400 micrograms twice daily Note In addition to regular prednisolone, continue high-dose inhaled corticosteroid (in exceptional cases may exceed licensed

Note. Doses of inhaled corticosteroids here are for CFC- doses); these patients should normally be referred to an asthma

containing metered-dose inhalers; dose adjustments may be clinic

required for other inhaler devices, see under individual preparations, section 3.2.

Stepping down Failure to achieve control with these doses is unusual, see also Review treatment every 3 months; if control achieved

Side-effects of Inhaled Corticosteroids, section 3.2 stepwise reduction may be possible; reduce dose of inhaled

corticosteroid slowly (consider reduction every 3 months,

4. Lung-function measurements cannot be used to guide decreasing dose by up to 50% each time)

management in those under 5 years Advice on the management of chronic asthma is based on the recommendations of the British Thoracic Society and Scottish

Intercollegiate Guidelines Network (updated May 2008); updates available at www.brit-thoracic.org.uk

3.1 Bronchodilators BNF 57 Management o f acute as thma

Important Patients with severe or life-threatening acute asthma may not be distressed and may not have all of these abnormalities; the presence of any should alert the doctor. Regard each emergency consultation as being for severe acute asthma until shown otherwise

Moderate acute asthma

Severe acute asthma

Life-threatening acute asthma

. Able to talk

. Silent chest, feeble respiratory effort, . Respiration < 25 breaths/minute;

. Cannot complete sentences in one

cyanosis CHILD

breath; CHILD too breathless to talk or

feed

. Hypotension, bradycardia, dysrhyth-

mia, exhaustion, agitation (in chil- . Pulse < 110 beats/minute; CHILD 2–5

. Use of accessory breathing muscles

in children

dren), confusion, reduced level of

consciousness, or coma CHILD 2–5 years > 50 breaths/minute; . Arterial oxygen saturation < 92% .

. Peak flow < 33% of predicted or . Peak flow > 50% of predicted or

5–12 years > 30 breaths/minute

best; CHILD 5–12 years < 33% of best; CHILD

CHILD 2–5

predicted or best predicted or best

years > 130 beats/minute; 5–12 years

> 120 beats/minute

Send immediately to hospital; consult with

tem senior medical staff and refer to intensive Treat at home or in surgery and assess response to treatment

. Arterial oxygen saturation < 92%

. Peak flow 33-50% of predicted or

care

sys

best; CHILD 5–12 years < 50% of pre- dicted or best

atory

Send immediately to hospital

Treatment Respir

Treatment

Treatment

. Inhaled short-acting beta agonist

. High-flow oxygen (if available)

. High-flow oxygen (if available)

3 via a large-volume spacer or oxygen-

driven nebuliser (if available); give 4– . Inhaled short-acting beta agonist . Short-acting beta agonist via oxy-

gen-driven nebuliser (if available); ograms/metered inhalation each

10 puffs of salbutamol 100 micr-

via a large-volume spacer or oxygen-

give salbutamol 5 mg ( CHILD under 5 inhaled separately, and repeat at 10–

driven nebuliser (if available); give 4–

10 puffs of salbutamol 100 micr-

years 2.5 mg, 5–12 years 2.5–5 mg)

or terbutaline 10 mg ( CHILD under 5 give nebulised salbutamol 5 mg

years 5 mg, 5–12 years 5–10 mg), ( CHILD under 5 years 2.5 mg, 5–12

20 minute intervals if necessary or

ograms/metered inhalation each

inhaled separately, and repeat at 10–

and repeat at 10–20 minute intervals years 2.5–5 mg) or terbutaline

20 minute intervals if necessary or

if necessary; reserve intravenous ( 10 mg ( CHILD CHILD under 5 years 5 mg, 5– under 5 years 2.5 mg, 5–12

give nebulised salbutamol 5 mg

beta agonists for those in whom

12 years 5–10 mg), and repeat at 10–

years 2.5–5 mg) or terbutaline 10 mg

inhaled therapy cannot be used reli-

20 minute intervals if necessary

( CHILD under 5 years 5 mg, 5–12 years

ably

. Prednisolone 40–50 mg by mouth as for at least 5 days; CHILD 1–2 mg/kg

5–10 mg), and repeat at 10–20 minute

. Prednisolone 40–50 mg by mouth

for moderate acute asthma or intra- by mouth for 3–5 days, if the child

intervals if necessary

. Prednisolone 40–50 mg by mouth as

venous hydrocortisone (preferably

has been taking an oral cortico- CHILD as sodium succinate) 100 mg (

for moderate acute asthma or intra-

steroid for more than a few days, under 1 year 25 mg, 1–5 years 50 mg, CHILD

venous hydrocortisone (preferably

give prednisolone 2 mg/kg ( 6–12 years 100 mg) every 6 hours under 2 years max. 40 mg, over 2

as sodium succinate) 100 mg ( CHILD

under 1 year 25 mg, 1–5 years 50 mg,

until conversion to oral prednisolone

years max. 50 mg) is possible

6–12 years 100 mg) every 6 hours

. Give ipratropium bromide via oxy- gen-driven nebuliser (if available) If response is poor or a relapse occurs in Monitor response for 15–30 minutes

until conversion to oral prednisolone

Monitor response for 15–30 minutes

is possible

500 micrograms ( CHILD under 12 3–4 hours, send immediately to hospital

years 250 micrograms) for assessment and further treatment

If response is poor:

. Give ipratropium bromide via oxy-

Monitor response for 15–30 minutes

gen-driven nebuliser (if available)

. Consider aminophylline (p. 159) or

500 micrograms ( CHILD under 12

magnesium sulphate [unlicensed

years 250 micrograms)

indication] (p. 151) only after con-

. Consider intravenous beta agonists,

sultation with senior medical staff

Follow up aminophylline (p. 159) or magnes-

If symptoms improve, follow up as for ium sulphate [unlicensed indication] moderate acute asthma Monitor symptoms and peak flow

(p. 151) only after consultation with

Set up asthma action plan and check

senior medical staff

inhaler technique

Refer those who fail to respond and require

Review by general practitioner within

ventilatory support to an intensive care or

48 hours; modify treatment according

high-dependency unit

to the Management of Chronic Asthma If symptoms improve, follow up as for table, p. 149

moderate acute asthma

Advice on the management of acute asthma is based on the recommendations of the British Thoracic Society and Scottish Intercollegiate Guidelines Network (updated May 2008); updates available at www.brit-thoracic.org.uk Advice on the management of acute asthma is based on the recommendations of the British Thoracic Society and Scottish Intercollegiate Guidelines Network (updated May 2008); updates available at www.brit-thoracic.org.uk

Severe exacerbations of asthma can have an adverse effect on pregnancy and should be treated promptly with conventional therapy, including oral or parenteral administration of a corticosteroid and nebulisation of a beta agonist; prednisolone is the preferred cortico- steroid for oral administration since very little of the drug reaches the fetus. Oxygen should be given imme- diately to maintain arterial oxygen saturation of 94–98% and prevent maternal and fetal hypoxia.

Inhaled drugs, theophylline, and prednisolone can be taken as normal during pregnancy and breast-feeding.

Management of acute severe asthma

Important Regard each emergency consultation as being for acute severe asthma until shown otherwise. Failure to respond adequately at any time requires immediate transfer to hospital.

Acute severe asthma can be fatal and must be treated promptly and energetically. All patients with acute severe asthma should be given high-flow oxygen (if available) and an inhaled short-acting beta agonist via a large-volume spacer or nebuliser; give 4–10 puffs of salbutamol 100 micrograms/metered inhalation, each puff inhaled separately via a large-volume spacer, and repeat at 10–20 minute intervals if necessary. If there are life-threatening features, give salbutamol or terbutaline via an oxygen-driven nebuliser every 10–

20 minutes, see p. 154 and p. 156. In all cases, a systemic corticosteroid (section 6.3.2) should be given. For adults, give prednisolone 40–50 mg by mouth for at least 5 days, or intravenous hydrocorti- sone 100 mg (preferably as sodium succinate) every 6 hours until conversion to oral prednisolone is possible. For children, give prednisolone 1–2 mg/kg by mouth (max. 40 mg) for 3–5 days or intravenous hydrocorti- sone (under 1 year 25 mg, 1–5 years 50 mg, 6–12 years 100 mg) (preferably as sodium succinate) every 6 hours until conversion to oral prednisolone is possible. If the child has been taking an oral corticosteroid for more than a few days, then give prednisolone 2 mg/kg (CHILD under 2 years max. 40 mg, over 2 years max.

50 mg). In life-threatening asthma, also consider initial treatment with ipratropium by nebuliser (section 3.1.2).

Most patients do not require and do not benefit from the addition of intravenous aminophylline or of intra- venous beta agonist; both cause more adverse effects than nebulised beta agonists. Nevertheless, an occa- sional patient who has not been taking theophylline may benefit from aminophylline infusion (see p. 159). Patients with severe asthma may be helped by magnes- ium sulphate [unlicensed indication] 1.2–2 g given by intravenous infusion over 20 minutes, but evidence of benefit is limited.

Treatment of acute severe asthma is safer in hospital where resuscitation facilities are immediately available. Treatment should never be delayed for investigations, patients should never be sedated, and the possibility of

a pneumothorax should be considered.

If the patient’s condition deteriorates despite pharma- cological treatment, intermittent positive pressure ven- tilation may be needed.

For a table outlining the management of acute asthma, see p. 150.