NEW asthma guidelines

Question 1

asthma in pregnancy

Answer 1

✅ Monitoring & Support
Offer asthma reviews in early pregnancy and postpartum.

Reassure that asthma medication is safe and important to prevent harm to mother and baby.

🚭 Smoking
Strongly advise against smoking and offer support to quit.

💊 Medications to Continue
Safe to continue as normal:

SABA and LABA (short/long-acting beta2 agonists)

ICS (inhaled corticosteroids)

Oral theophyllines

💥 During Exacerbations
Oral corticosteroids should be used if needed – benefits outweigh risks.

➕ Other Add-ons
If already on LTRA (e.g. montelukast) or LAMA, continue them if needed for control.

Question 1

Guidance for under 5s

Answer 1

🟢 Step 1: Initial Trial
Trial low-dose ICS (twice daily for 8–12 weeks) + SABA if:

Interval symptoms (esp. with atopy), or

Severe acute wheeze (e.g. hospitalised or ≥2 steroid courses).

🔵 Step 2: After the Trial
If no improvement:

✅ Check inhaler use & adherence

✅ Check for triggers (e.g. smoke, damp)

✅ Reconsider diagnosis

➡️ Refer to specialist if still uncontrolled

If improved:

🛑 Stop ICS + SABA

🔁 Review in 3 months

🟡 Step 3: If Symptoms Return
If symptoms recur or acute attack occurs:

🔄 Restart regular ICS (low → moderate dose as needed)

🗓️ Reassess & consider stopping again within 12 months

🔴 Step 4: If Still Uncontrolled
➕ Add LTRA for 8–12 weeks

⚠️ Monitor for neuropsychiatric side effects (e.g. with montelukast)

❌ Stop if ineffective

⛔ If LTRA fails: refer to specialist

Question 2

guidance for 5-11

Answer 2

🟢 Start:

💊 Low-dose ICS + 💨 SABA as needed

🟡 If uncontrolled:

🔁 Try low-dose MART (⚠️ off-label; child must manage regimen)

⬆️ Step up to moderate-dose MART if needed

🔴 If MART not suitable:

➕ Add LTRA (🕒 trial 8–12 weeks)

🔄 Or switch to low-dose ICS/LABA + SABA

⬆️ Step up to moderate-dose ICS/LABA if still uncontrolled

⚠️ Refer to specialist if symptoms persist on

🔸 Moderate-dose MART or

🔸 Moderate-dose ICS/LABA (with or without LTRA)

Question 3

Guidance aged over 12

Answer 3

🟢 Initial Treatment
Offer as-needed low-dose ICS/formoterol (AIR therapy) for mild asthma

⚠️ Only specific budesonide/formoterol dry powder inhalers are licensed (others = off-label)

🔸 If Highly Symptomatic or Severe at Presentation
Start with low-dose MART + treat acute symptoms (e.g. oral steroids)

Consider stepping down to as-needed AIR later if well-controlled

🔁 Stepwise Escalation
Low-dose MART
👉 Offer if asthma not controlled on as-needed ICS/formoterol

Moderate-dose MART
👉 If not controlled on low-dose MART

If still uncontrolled despite good adherence:

🔬 Check FeNO & eosinophils:

If high → refer to specialist

If normal → trial LTRA or LAMA for 8–12 weeks:

✅ If controlled → continue

➕ If partial response → add trial of the other

❌ If no response → stop and try the alternative

⚠️ Monitor for neuropsychiatric effects (esp. with montelukast)

🚨 Referral
Refer to specialist if asthma remains uncontrolled after:

Moderate-dose MART

Trials of both LTRA and LAMA

Question 4

COPD guidance

Answer 4

Suspect COPD in individuals over 35 with risk factors (e.g., smoking) presenting with symptoms like:

Exertional breathlessness

Chronic cough

Regular sputum production

Frequent winter bronchitis

Wheeze

Confirm diagnosis with post-bronchodilator spirometry showing an FEV₁/FVC ratio below 0.7.
NICE

🛠️ Non-Pharmacological Management
Smoking cessation: Offer treatment and support to stop smoking.

Vaccinations: Offer pneumococcal and influenza vaccinations.

Pulmonary rehabilitation: Offer if indicated.

Self-management: Co-develop a personalised plan.

Comorbidities: Optimise treatment for coexisting conditions.

💊 Pharmacological Treatment
Initial therapy: Offer a short-acting bronchodilator (SABA or SAMA) as needed.

If symptoms persist:

For those without asthmatic features:

Offer a long-acting beta₂ agonist (LABA) + long-acting muscarinic antagonist (LAMA).

For those with asthmatic features:

Consider LABA + inhaled corticosteroid (ICS).

If still symptomatic or frequent exacerbations:

Consider triple therapy: LAMA + LABA + ICS.

Note: Ensure proper inhaler technique and adherence throughout treatment.

🧪 Additional Therapies
Roflumilast: Consider for adults with chronic bronchitis, severe COPD, and frequent exacerbations despite triple inhaled therapy.

Azithromycin: Consider for non-smokers with frequent exacerbations despite optimal therapy.

🧘‍♂️ Supportive Care
Anxiety and depression: Be alert for these conditions; consider appropriate interventions.

Nutritional support: Monitor weight changes; provide dietary advice as needed.

Palliative care: Use opioids and other therapies to relieve breathlessness in end-stage COPD unresponsive to other treatments.

📈 Monitoring and Follow-Up
Regular reviews: Assess symptoms, exacerbation frequency, inhaler technique, and adherence.

Oxygen therapy: Assess need in individuals with very severe airflow obstruction or hypoxaemia.
NICE