British guideline on the management of asthma: SIGN Clinical Guideline 141, 2014

### Clinical bottom line

This latest revision of national guidance on asthma management was produced jointly by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) in October 2014 and marks the largest revision to date including changes to the guideline structure.1 Established standards for guideline development were followed to produce recommendations for the emergency and long-term management of asthma in children, adolescents and adults. There was wide stakeholder input from national and international individuals and institutions, with opportunity for feedback via conferences and websites; the guideline was also reviewed by independent expert referees and underwent editorial review to ensure comments were addressed and bias was minimised. It provides a basis for high-quality care for acute and chronic asthma, and a stimulus for research in the areas in which evidence is still lacking.

The first joint BTS/SIGN asthma guideline was published in 2003 as a ‘living guideline’, with annual updates between 2004 and 2012, and every two years since; this is the first such update. In this revision, BTS/SIGN have helpfully presented a new section of key recommendations for implementation and linked these to the National Institute for Health and Care Excellence (NICE) Quality Standard (QS) for asthma, which was published in February 2013.2

### Diagnosis


INFORMATION ABOUT THE CURRENT GUIDELINE
This latest revision of national guidance on asthma management was produced jointly by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) in October 2014 and marks the largest revision to date including changes to the guideline structure. 1 Established standards for guideline development were followed to produce recommendations for the emergency and long-term management of asthma in children, adolescents and adults. There was wide stakeholder input from national and international individuals and institutions, with opportunity for feedback via conferences and websites; the guideline was also reviewed by independent expert referees and underwent editorial review to ensure comments were addressed and bias was minimised. It provides a basis for highquality care for acute and chronic asthma, and a stimulus for research in the areas in which evidence is still lacking.

PREVIOUS GUIDELINES AND ASSOCIATED RESOURCES
The first joint BTS/SIGN asthma guideline was published in 2003 as a 'living guideline', with annual updates between 2004 and 2012, and every two years since; this is the first such update. Supported self-management ▸ Offer children with asthma self-management education and offer parents/carers education on managing their child's asthma. Include a written personalised asthma action plan (PAAP) (box 1) and support this with regular professional review (at least annually). ▸ Give patients (and parents/carers) written PAAPs before discharge; this should be done by healthcare professionals with expertise in providing asthma education (box 1). ▸ Assess adherence to long-term asthma treatment regularly; every clinical encounter presents an opportunity to do so (box 2).

Non-pharmacological management
▸ Advise parents and children who smoke about the consequent danger to their children and themselves, and offer support to stop. ▸ Support weight loss in overweight patients; this may lead to improved symptoms. ▸ Offer breathing exercise programmes such as the Papworth and Butyeko techniques (often physiotherapist delivered) as an adjuvant to pharmacological therapy; these may improve quality of life and reduce symptoms.

Pharmacological management
▸ Consider inhaled corticosteroids if ongoing symptoms are problematic or frequent, or if there has been an asthma attack in the last two years. Give these twice a day and increase as necessary -there is no benefit from starting at high dose with subsequent reductions.
▸ When adding second-line preventer therapy to inhaled corticosteroids: give a long-acting β2 agonist to children aged 5 years or older give a leukotriene receptor antagonist to children younger than 5 years. ▸ Use metered dose inhalers with a spacer for inhaled drugs, with a facemask until the child can breathe reproducibly using the spacer mouthpiece; where this is ineffective, a nebulizer may be required. ▸ Give children and parents training on the use of these devices and ensure they demonstrate satisfactory technique (box 2).
Acute asthma ▸ Give oxygen to children with life-threatening asthma or oxygen saturations <94% to achieve normal saturations of 94-98%. ▸ Give inhaled short-acting β2 agonists as the first-line treatment for acute asthma attacks. ▸ Give oral steroids early in acute asthma attacks in children older than 2 years and consider these early for severe asthma attacks in children under 2 years. ▸ Notify the child's primary care practitioner (ideally a named individual responsible for asthma care) within 24 h of discharge following an asthma attack. (Patients should be followed up by their general practitioner within two days of being treated in hospital or out-of-hours services for an acute asthma attack.)

Difficult asthma
▸ Evaluate patients with difficult asthma (existing diagnosis of asthma with asthma-like symptoms, but persistent attacks despite high-dose asthma therapy) to confirm the diagnosis, identify mechanisms of persisting symptoms and assess adherence to therapy. (Offer patients with difficult asthma an assessment by a multidisciplinary difficult asthma service.)

UNDERLYING EVIDENCE BASE
The evidence for this guidance is reviewed for each iteration, and the full details of updated topics and search strategies are in the guideline and on the SIGN website. A systematic literature review was done in accordance with SIGN methodology, including searches of databases and websites. Prior to inclusion as evidence, each paper was evaluated by two members of the guideline development group using SIGN methodological checklists. This evidence was used to formulate final recommendations, though in the absence of evidence consensus was reached, and the group presented recommendations for future research.

WHAT DO I NEED TO KNOW
What should I stop doing?
▸ Stop promoting any physical or chemical means of house dust mite removal for primary or secondary prevention. ▸ Stop offering advice on pet ownership as a means of primary prevention. There is no guidance on secondary prevention.
Box 2 Asthma-related factors that should be routinely monitored and recorded ▸ Check at every clinical encounter -Inhaler technique -Possession and use of a personalised asthma action plan and understanding of symptoms -Interval symptoms, frequency of attacks, oral steroid use and time off school/nursery due to asthma symptoms -Adherence to prescribed treatment -Exposure to tobacco smoke -Asthma attack triggers ▸ On discharge from unscheduled care -Consider the need to start or increase preventer treatment -Arrange a primary care appointment within 48 h -Arrange follow-up in a paediatric asthma clinic in 1-2 months -Arrange follow-up with a paediatric respiratory specialist if life-threatening features present ▸ Additional items to be checked at planned reviews -Height and weight centiles Box 1 What to include in written personalised asthma action plans (PAAPs) Features associated with beneficial outcomes including reduced emergency healthcare use and improved asthma control are: ▸ Specific advice on how to recognise loss of control of asthma symptoms: -This should be symptom based in younger children -This may include peak flow measurement in older children (based on percentage personal best, not predicted) ▸ Two to three specific action points to take if asthma control deteriorates such as -What to do with reliever inhalers (eg, salbutamol) as regards dose and frequency -Whether to increase inhaled corticosteroids -When to start oral steroids -When to seek emergency help (eg, if symptoms not controlled with 10 puffs of reliever given four hourly) A good example of a written PAAP can be downloaded from the Asthma UK website: https://www.asthma.org.uk/advice/manage-your-asthma/ action-plan/ who smoke, and support weight management for overweight or obese patients. ▸ Monitor height and weight annually. ▸ Follow current stepwise management of asthma to optimise interval symptoms and prevent asthma attacks, with regular review of adherence. ▸ Use inhaled salbutamol as first-line treatment in asthma attacks coupled with early administration of oral steroids, add ipratropium bromide every 20-30 min for the first 2 h in severe attacks. ▸ Use each healthcare encounter as an opportunity to review and monitor asthma symptoms and treatment (box 2).

UNRESOLVED CONTROVERSIES
There are a number of areas in which this guideline has been unable to provide definitive and/or detailed recommendations as the evidence is lacking or imprecise. In acute severe asthma, the most pressing area for research is to determine which intravenous therapy (salbutamol, aminophylline or magnesium sulfate) should be used as the first-line agent, and at which dose. It has been suggested elsewhere that this choice should be pragmatic at present, taking into account factors such as ease of prescription, preparation and administration, availability of high-dependency beds and nursing preference. 3 This and other international guidance suggests considering addition of 150 mg nebulised magnesium sulfate to each dose of inhaled therapy in the first hour of treatment of severe asthma, especially in children with hypoxia (saturations <92% in air) and a short duration of symptoms (<6 h). This is derived from the MAGNETIC study, 4 which showed non-clinically significant benefit other than in the specific population identified, though this is being further explored by other studies that are currently recruiting patients. This also leads to further questions including what constitutes maximal inhaled bronchodilator therapy and whether any existing assessment tools for acute asthma are meaningful to clinicians and families. A usable assessment tool could be helpful to develop asthma attack risk stratification tables, which may facilitate communication between patients and healthcare professionals and result in better standardised core outcomes.

Critique
Asthma remains the most common chronic medical condition of childhood and is consequently a significant cause of unscheduled or emergency healthcare attendance and hospitalisation. It still carries significant morbidity and mortality, and so documents such as the International Consensus on Pediatric Asthma, Global Strategy for Asthma Management and Prevention, NICE Quality Standards and this BTS/SIGN guideline are welcomed by clinicians and patients. These aim to present recommendations to improve asthma care based on best available evidence, but there are several areas in which the evidence base is small or absent. This inevitably leads to variation in practice throughout the asthma pathway, as demonstrated in recent work from Paediatric Emergency Research in the UK & Ireland 5 6 in which the greatest variations were at the severe end of the spectrum; multiple dosages and regimens for intravenous therapy were a key finding, though variation also existed in inhaled and oral therapies, assessment and other supportive therapies. These variations can and should be used to inform the future research agenda in childhood asthma, but it is also essential to consider what we could be doing better today, especially given the striking variation in admission rates and length of stay evidenced in the NHS Atlas of Variation in Healthcare. 7 While we should aim to implement the latest research findings such as those from the MAGNETIC study, it is also helpful to consider other simple measures. In order to better understand circumstances surrounding asthma deaths and identify avoidable factors, the National Review of Asthma Deaths (NRAD) 8 was performed in 2013; this identified 28 children who died of an asthma attack in 1 year, of whom only 4 had been provided with a written PAAP. This is congruent with the most recent BTS childhood asthma audit, 9 in which only 53% of children received a written PAAP at discharge, and 50% had their inhaler technique checked. Perhaps then this is the area where all health professionals can make the biggest immediate impact-by putting aside extra time to spend with patients and families to review and discuss all the factors of a well-rounded asthma care package (box 2). Several other areas provoke perennial debate and require further attention. Two Australasian studies are currently examining the role of oral steroids in preschool wheeze, and recent studies have examined the effectiveness of dexamethasone as an alternative to prednisolone. The use of sub-dissociative doses of ketamine in extremis, and of adrenaline in cases where anaphylaxis may be a possibility, appears to merit further exploration. Recent work in bronchiolitis that demonstrated the safety of lower oxygen saturation targets should make us question whether thresholds for supportive intervention in asthma requires modification. Finally, non-invasive ventilation is a therapeutic option that has divided opinion, but the advent of high-flow nasal cannula therapy and its uptake for multiple respiratory diseases now make this an area urgently in need of further research.
Twitter Follow Mark Lyttle at @mdlyttle and David James @DrDaveJames Contributors MDL conceived the idea for the paper. DJ provided the first draft, and both authors crafted this further to arrive at the final version.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.