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.