Asthma in adults (Guidelines)

What's new / Latest updates

27/02/2052:

Steps 1 to 4 asthma guidance

The new BTS/NICE/SIGN Asthma Guidance recommends a preferred pathway for asthma management which removes the need for short acting beta 2 agonists (SABA). This is to reduce the risks associated with SABA overuse.
The preferred pathway should be followed for all patients aged >16 years with a new diagnosis of asthma. These patients should be offered a combination inhaled corticosteroid (ICS) with the long acting beta 2 agonist (LABA) formoterol. Patients can be managed with as required use of ICS/LABA in a regimen called AIR (Anti-inflammatory reliever) or can be escalated to MART (Maintenance and Reliever Therapy). The only inhaler that currently holds a license for AIR is Symbicort 200/6, whilst for MART there is the option to use Symbicort 200/6 or Fostair 100/6 NEXThaler or MDI (if MDI device required).
There is the option to escalate up and down therapy from AIR to low-dose MART to moderate-dose MART, all using the same device, and in line with an individual asthma action plan.
Patients should NOT be prescribed a SABA on the preferred pathway, and will manage symptoms by taking additional doses of ICS/LABA as part of AIR or MART regimens.
Patients who already have a diagnosis of asthma, and are well controlled and happy with their current inhaled therapy, on ICS or ICS/LABA maintenance, plus SABA reliever, and using less than 3 x SABA reliever inhalers per year, do not need to switch to the preferred pathway. However, if patients are identified as being poorly controlled, this is an opportunity to switch to the preferred pathway outlined above.
Patients on the traditional pathway, and prescribed SABA monotherapy, should be reviewed and switched to the preferred pathway at the lowest step; AIR (anti-inflammatory reliever).
For patients on either pathway, it remains key to review inhaler technique and compliance regularly, to ensure all patients have an appropriate asthma action plan in place (options available for AIR, MART and Traditional) and to consider environmental impact when prescribing inhalers.

Severe Asthma Pathway for Scotland:

Primary care management remains on the whole unchanged from version 1, focusing on treatment optimisation, modifiable risk factors and referral criteria.
Secondary care management: addition of clinical governance and a comprehensive data set collection standard prior to MDT discussion.
Enhanced biologic assessment tool to encapsulate the SMC approval of tezepelumab.
Addition of structured OCS weaning protocol using PONENTE, where appropriate, and sequential weaning of asthma medications, as appropriate, following response to biologics.

Audience

Highland HSCP only
Primary and Secondary Care
Adults only (16 year old and older)

With thanks and adapted from NHS GGC guidance.

NHS Highland Asthma Guidelines are separated into two pathways:

the Preferred AIR/MART Pathway
the Traditional Pathway

See: 'What's New' section above.

It is NO longer recommended that a SABA inhaler be prescribed alone, without a concomitant prescription for an ICS inhaler.

ALL patients should receive an ICS device on initiation of inhaled therapy.
Remind patients to rinse their mouth after using an ICS to avoid oral thrush.

Good asthma control = green asthma control
The right inhaler is the one the patient can use

What good asthma control looks like:

NO daytime symptoms
NO sleep disturbance due to asthma
Unimpaired physical activity
NO exacerbations
Triggers managed (eg, hay fever)

Dry Powder Inhalers (DPIs) have the lowest global warming potential and should therefore be considered first choice

Ensure technique is consistently correct, reinforce at each opportunity
Counsel patients to be adherent with therapy despite 'feeling better'
Choose an inhaler that contains the lowest dose of ICS to adequately control symptoms
If a patient cannot use or doesn't tolerate a DPI, consider a Metered Dose Inhaler (MDI)
- NB using a spacer device with MDI is usually beneficial

Open all

Assessment

Obtain a structured clinical history in people with suspected asthma

Symptoms to check for include: 

Wheeze: reported/on auscultation
Noisy breathing
Cough
Breathlessness
Chest tightness
Nocturnal symptoms

Specifically check for:

Any variation in symptoms (for example, diurnal, daily or seasonal) or any triggers
A personal or family history of atopic disorders
Symptoms to suggest alternative diagnoses e.g. Heart Failure
Exposure history: smoking, occupational, pollutants, etc.

Diagnosis

Made by clinical assessment and supported by 1 or more objective test.

Normal results DO NOT exclude asthma, and tests may need to be repeated.

We suggest working through the following objective tests, in order, if available:

Blood eosinophil count (≥0.3 x 10⁹/L) (as part of full blood count)
Expired nitric oxide (FeNo)
- A level ≥ 50 ppb is supportive of asthma diagnosis
Spirometry with bronchodilator reversibility (BDR)
- initial spirometry should be obstructive [FEV1/FVC <0.7 or below Lower Limit of Normal (LLN)]
- if there is >12% and >200mL change in FEV1 from baseline following BDR, this confirms reversibility and is supportive of an asthma diagnosis
Peak flow (PEF): ideally conducted prior to pharmacological treatment:
- Peak flow variability calculator

Referral

If all of the above tests are inconclusive: consider a referral to respiratory, via SCI Gateway, for Bronchial Challenge testing.

Management

If asthma is suspected: complete initial clinical assessment, confirm diagnosis then follow the pathway below

Primary Care: initial assessment, management & criteria for hospital referral: Acute asthma in adults | Right Decisions (scot.nhs.uk)

It is NO longer recommended that a SABA inhaler be prescribed alone, without a concomitant prescription for an ICS inhaler.
ALL patients should receive an ICS device on initiation of inhaled therapy.

Annual review

Aim: Good asthma control

What to include in a review, especially Annual Review:

✓ Review of inhaler technique and check inhaler adherence
✓ Check peak flow (PEF)
✓ Review of Personalised Asthma Action Plan
✓ Symptom assessment (ACT/ACQ)
✓ Address co-morbidities e.g. anxiety, Gastroesophageal Reflux Disease (GORD), obesity,
breathing pattern disorder, rhinitis
✓ Address triggers and trigger avoidance e.g. occupational, allergens
✓ Review of exacerbations and Out Of Hours/Emergency Dept. attendances and admission
✓ Smoking cessation advice if applicable: Smoking cessation (Guidelines)
✓ Consideration of steroid side effects
✓ Consider DEXA referral if high dose ICS for >10 years or OCS >3 months in last year
and 10-year risk of major fracture >10% (FRAX or Qfracture

What good asthma control looks like:

NO daytime symptoms
NO sleep disturbance due to asthma
Unimpaired physical activity
NO exacerbations
Triggers managed (eg, hay fever)

Assess control using:

This encompasses updated guidance from BTS / SIGN / NICE 2024 and GINA 2024 and should be considered for newly diagnosed patients and opportunistically when any change is being made at review, particularly in patients with poor control, or for those patients who would be suited to just one device combining maintenance and reliever actions.

Benefits:

One device for maintenance and relief of symptoms; one inhaler technique and reduced inhaler burden
Dual action: Effective in relieving symptoms, due to quick onset of action with formoterol, while ICS targets airways inflammation
Overall reduction in asthma exacerbations and asthma-related hospital admissions
Reduces long-term costs
Promotes green prescribing

When to use AIR or MART

AIR: Anti-Inflammatory Reliever

MART: Maintenance And Reliever Therapy

New approach

For patients with mild and infrequent symptoms
Regimen: low dose ICS/LABA, as required, for relief of symptoms

For patients who are regularly symptomatic
Regimen: ICS/LABA regular maintenance therapy, AND as required, for relief of symptoms

It is NO longer recommended that a SABA inhaler be prescribed alone, without a concomitant prescription for an ICS inhaler.

ALL patients should receive an ICS device on initiation of inhaled therapy.
Remind patients to rinse their mouth after using an ICS to avoid oral thrush.

Step 1 Mild / infrequent symptoms <3 days/week	Step 2 Need for rescue therapy ≥3 days/week	Step 3 Remains uncontrolled, despite intervention	Step 4 Remains uncontrolled, despite intervention	Step 5 Continues to be uncontrolled
DPI: Symbicort Turbohaler Budesonide/ formoterol 200/6 microgram ONE puff when required Max 8 puffs daily (up to 12 short-term)	DPI: Symbicort Turbohaler Budesonide/ formoterol 200/6 microgram ONE puff twice a day & ONE puff when required Max 8 puffs daily (up to 12 short-term)	DPI: Symbicort Turbohaler Budesonide/ formoterol 200/6 microgram TWO puffs twice a day & ONE puff when required. Max 8 puffs daily (up to 12 short-term)	Look for ongoing inflammation by testing FeNO or eosinophil count, where these tests are available.	Follow: Severe Asthma Pathway for Scotland Includes referral criteria and management in primary and secondary care.
	DPI: Fostair NEXThaler (Licensed 18+ only) Beclometasone/ formoterol 100/6 microgram ONE puff twice a day & ONE puff when required Max 8 puffs daily	DPI: Fostair NEXThaler (Licensed 18+ only) Beclometasone/ formoterol 100/6 microgram TWO puffs twice a day & ONE puff when required Max 8 puffs daily	If evidence of ongoing inflammation and compliance and technique good: consider specialist review
MDI: Fostair (Licensed 18+ only) Beclometasone/ formoterol 100/6 microgram ONE puff twice a day & ONE puff when required Max 8 puffs daily	MDI: Fostair (Licensed 18+ only) Beclometasone/ formoterol 100/6 microgram TWO puffs twice a day & ONE puff when required Max 8 puffs daily	If FeNO/ eosinophils normal: Consider trial of montelukast or LAMA
		Montelukast: 10mg at night If night-time symptoms, eg dreams: take in the morning Review at 4 to 8 weeks: Stop if no benefit shown Evaluate neuropsychiatric reactions as per MHRA
SMI: Spiriva Respimat Tiotropium 2.5 microgram TWO puffs once a day
If uncontrolled: Review inhaler technique and check compliance / concordance Review every 8 to 12 weeks until well controlled Then move to annual review. If uncontrolled, despite good adherence and technique, step up therapy. Control asthma symptoms on the lowest effective dose of ICS. Step down when appropriate. Remind patients to rinse their mouth after using an ICS to avoid oral thrush. Carbon footprint data for Global Warming Potential taken from Presquipp.info

Step 1

Mild / infrequent symptoms <3 days/week

Step 2

Need for rescue therapy ≥3 days/week

Step 3

Remains uncontrolled, despite intervention

Step 4

Remains uncontrolled, despite intervention

Step 5

Continues to be uncontrolled

AIR

Low-dose ICS/LABA

Low-dose MART

Low-dose ICS/LABA

Moderate-dose MART

Moderate-dose ICS/LABA

Step 3 PLUS FeNO / Blood eosinophil testing

Step 4 PLUS identify patients at risk of severe asthma

DPI: Symbicort Turbohaler

Budesonide/ formoterol 200/6 microgram

ONE puff when required
Max 8 puffs daily (up to 12 short-term)

DPI: Symbicort Turbohaler

Budesonide/ formoterol 200/6 microgram

ONE puff twice a day & ONE puff when required
Max 8 puffs daily (up to 12 short-term)

DPI: Symbicort Turbohaler

Budesonide/ formoterol 200/6 microgram

TWO puffs twice a day & ONE puff when required.
Max 8 puffs daily (up to 12 short-term)

Look for ongoing inflammation by testing FeNO or eosinophil count, where these tests are available.

Follow: Severe Asthma Pathway for Scotland

Includes referral criteria and management in primary and secondary care.

DPI: Fostair NEXThaler
(Licensed 18+ only)

Beclometasone/
formoterol 100/6 microgram

ONE puff twice a day & ONE puff when required
Max 8 puffs daily

DPI: Fostair NEXThaler
(Licensed 18+ only)

Beclometasone/
formoterol 100/6 microgram

TWO puffs twice a day & ONE puff when required
Max 8 puffs daily

If evidence of ongoing inflammation and compliance and technique good:

consider specialist review

MDI: Fostair
(Licensed 18+ only)

Beclometasone/
formoterol 100/6 microgram

ONE puff twice a day & ONE puff when required
Max 8 puffs daily

MDI: Fostair
(Licensed 18+ only)

Beclometasone/
formoterol 100/6 microgram

TWO puffs twice a day & ONE puff when required
Max 8 puffs daily

If FeNO/ eosinophils normal:

Consider trial of montelukast or LAMA

Montelukast: 10mg at night

If night-time symptoms, eg dreams: take in the morning

Review at 4 to 8 weeks: Stop if no benefit shown

Evaluate neuropsychiatric reactions as per MHRA

SMI: Spiriva Respimat

Tiotropium 2.5 microgram

TWO puffs once a day

If uncontrolled:
- Review inhaler technique and check compliance / concordance
Review every 8 to 12 weeks until well controlled
Then move to annual review.
If uncontrolled, despite good adherence and technique, step up therapy.
Control asthma symptoms on the lowest effective dose of ICS.
Step down when appropriate.
Remind patients to rinse their mouth after using an ICS to avoid oral thrush.

Carbon footprint data for Global Warming Potential taken from Presquipp.info

The Traditional Pathway is suitable to continue for stable patients:

with good adherence
infrequent need for reliever SABA device (using <3 SABA inhalers per year)
and no exacerbations in the last year on their current therapy.

Poorly controlled patients should be switched to the AIR / MART pathway.

It is NO longer recommended that a SABA inhaler be prescribed alone, without a concomitant prescription for an ICS inhaler.

ALL patients should receive an ICS device on initiation of inhaled therapy.
Remind patients to rinse their mouth after using an ICS to avoid oral thrush.

Step 1 Mild / infrequent symptoms <3 days/ week	Step 2 Need for rescue therapy ≥3 days/ week	Step 3 Remains uncontrolled, despite intervention	Step 4 Remains uncontrolled, despite intervention	Step 5 Continues to be uncontrolled
DPI: Easyhaler Budesonide 100 microgram ONE to TWO puffs twice daily	DPI: Symbicort Turbohaler Budesonide/ formoterol 200/6 microgram ONE puff twice a day	DPI: Symbicort Turbohaler Budesonide/ formoterol 200/6 microgram TWO puffs twice a day	SMI: Spiriva Respimat Tiotropium 2.5 microgram TWO puffs once a day	Follow: Severe Asthma Pathway for Scotland Includes referral criteria and management in primary and secondary care.
DPI: Pulmicort Turbohaler Budesonide 100 microgram ONE to TWO puffs twice daily	DPI: Fostair NEXThaler (Licensed 18+ only) Beclometasone/ formoterol 100/6 microgram ONE puff twice a day	DPI: Fostair NEXThaler (Licensed 18+ only) Beclometasone/ formoterol 100/6 microgram TWO puffs twice a day	If NO response to LAMA & able to tolerate LABA: Maintenance high-dose ICS/LABA
MDI: Clenil Modulite Beclometasone 200 microgram ONE puff twice a day	MDI: Fostair (Licensed 18+ only) Beclometasone/ formoterol 100/6 microgram ONE puff twice a day	DPI: Relvar Ellipta Fluticasone/ vilanterol 92/22 microgram ONE puff once a day	DPI: Symbicort Turbohaler Budesonide/ formoterol 400/12 microgram TWO puffs twice a day
		MDI: Fostair (Licensed 18+ only) Beclometasone/ formoterol 100/6 microgram TWO puffs twice a day	DPI: Fostair NEXThaler (Licensed 18+ only) Beclometasone/ formoterol 200/6 microgram TWO puffs twice a day
If intolerant to LABA: High-dose ICS	DPI: Relvar Ellipta Fluticasone/ vilanterol 184/22 microgram ONE puff once a day
DPI: Easyhaler Budesonide 100 microgram TWO puffs twice a day	If still symptomatic: Consider montelukast trial
DPI: Pulmicort Turbohaler Budesonide 200 or 400 microgram ONE to TWO puffs twice daily	Montelukast: 10mg at night If night-time symptoms, eg dreams: take in the morning Review at 4 to 8 weeks: Stop if no benefit shown Evaluate neuropsychiatric reactions as per MHRA
If still symptomatic: Consider montelukast trial
Montelukast: 10mg at night If night-time symptoms, eg dreams: take in the morning Review at 4 to 8 weeks: Stop if no benefit shown Evaluate neuropsychiatric reactions as per MHRA
If uncontrolled: Review inhaler technique and check compliance / concordance Review every 8 to 12 weeks until well controlled Then move to annual review. If uncontrolled, despite good adherence and technique, step up therapy. Control asthma symptoms on the lowest effective dose of ICS. Step down when appropriate. Remind patients to rinse their mouth after using an ICS to avoid oral thrush. Carbon footprint data for Global Warming Potential taken from Presquipp.info

Step 1

Mild / infrequent symptoms <3 days/ week

Step 2

Need for rescue therapy ≥3 days/ week

Step 3

Remains uncontrolled, despite intervention

Step 4

Remains uncontrolled, despite intervention

Step 5

Continues to be uncontrolled

Maintenance low-dose ICS

Maintenance low-dose ICS/LABA

Maintenance moderate-dose ICS/LABA

Step 3 PLUS consider 3-month trial LAMA

Step 4 PLUS identify patients at risk of Severe Asthma

DPI: Easyhaler

Budesonide 100 microgram

ONE to TWO puffs twice daily

DPI: Symbicort Turbohaler

Budesonide/ formoterol 200/6 microgram

ONE puff twice a day

DPI: Symbicort Turbohaler

Budesonide/ formoterol 200/6 microgram

TWO puffs twice a day

SMI: Spiriva Respimat

Tiotropium 2.5 microgram

TWO puffs once a day

Follow: Severe Asthma Pathway for Scotland

Includes referral criteria and management in primary and secondary care.

DPI: Pulmicort Turbohaler

Budesonide 100 microgram

ONE to TWO puffs twice daily

DPI: Fostair NEXThaler
(Licensed 18+ only)

Beclometasone/
formoterol 100/6 microgram

ONE puff twice a day

DPI: Fostair NEXThaler
(Licensed 18+ only)

Beclometasone/
formoterol 100/6 microgram

TWO puffs twice a day

If NO response to LAMA & able to tolerate LABA:

Maintenance high-dose ICS/LABA

MDI: Clenil Modulite

Beclometasone 200 microgram

ONE puff twice a day

MDI: Fostair
(Licensed 18+ only)

Beclometasone/
formoterol 100/6 microgram

ONE puff twice a day

DPI: Relvar Ellipta

Fluticasone/ vilanterol 92/22 microgram

ONE puff once a day

Relvar Ellipta 92/22

DPI: Symbicort Turbohaler

Budesonide/ formoterol 400/12 microgram

TWO puffs twice a day

MDI: Fostair
(Licensed 18+ only)

Beclometasone/
formoterol 100/6 microgram

TWO puffs twice a day

DPI: Fostair NEXThaler
(Licensed 18+ only)

Beclometasone/
formoterol 200/6 microgram

TWO puffs twice a day

If intolerant to LABA:

High-dose ICS

DPI: Relvar Ellipta

Fluticasone/ vilanterol 184/22 microgram

ONE puff once a day

DPI: Easyhaler

Budesonide 100 microgram

TWO puffs twice a day

If still symptomatic:

Consider montelukast trial

DPI: Pulmicort Turbohaler

Budesonide 200 or 400 microgram

ONE to TWO puffs twice daily

Montelukast: 10mg at night

If night-time symptoms, eg dreams: take in the morning

Review at 4 to 8 weeks: Stop if no benefit shown

Evaluate
neuropsychiatric reactions as per MHRA

If still symptomatic:

Consider montelukast trial

Montelukast: 10mg at night

If night-time symptoms, eg dreams: take in the morning

Review at 4 to 8 weeks: Stop if no benefit shown

Evaluate
neuropsychiatric reactions as per MHRA

If uncontrolled:
- Review inhaler technique and check compliance / concordance
Review every 8 to 12 weeks until well controlled
Then move to annual review.
If uncontrolled, despite good adherence and technique, step up therapy.
Control asthma symptoms on the lowest effective dose of ICS.
Step down when appropriate.
Remind patients to rinse their mouth after using an ICS to avoid oral thrush.

Carbon footprint data for Global Warming Potential taken from Presquipp.info

NOTE: SABA, when required for symptomatic relief and rescue therapy, should be prescribed at ALL steps of the traditional pathway
DPI: Easyhaler Salbutamol 100 microgram ONE to TWO puffs when required	DPI: Ventolin Accuhaler Salbutamol 200 microgram ONE puff when required	DPI: Bricanyl Turbohaler Terbutaline 500 microgram ONE puff when required	MDI: Salamol CFC-Free inhaler PLUS spacer device Salbutamol 100 microgram ONE to TWO puffs when required

NOTE: SABA, when required for symptomatic relief and rescue therapy, should be prescribed at ALL steps of the traditional pathway

DPI: Easyhaler

Salbutamol 100 microgram
ONE to TWO puffs when required

DPI: Ventolin Accuhaler

Salbutamol 200 microgram
ONE puff when required

Ventolin Accuhaler

DPI: Bricanyl Turbohaler

Terbutaline 500 microgram
ONE puff when required

MDI: Salamol CFC-Free inhaler

PLUS spacer device

Salbutamol 100 microgram
ONE to TWO puffs when required

AIR / MART regimen	When required SABA regimen
ONE puff of ICS / LABA every 1 to 3 minutes, up to a maximum of 6 puffs. If no improvement after 6 puffs, call 999 for an ambulance. If the ambulance has not arrived after 10 minutes and symptoms are not improving, repeat dosing.	ONE puff of the rescue inhaler every 30 to 60 seconds, up to a maximum of 10 puffs. If available, use spacer with MDI reliever. If no improvement at any point OR not feeling better after 10 puffs, call 999 for an ambulance. If the ambulance has not arrived after 10 minutes and symptoms are not improving, repeat dosing.

AIR / MART regimen

When required SABA regimen

ONE puff of ICS / LABA every 1 to 3 minutes, up to a maximum of 6 puffs.

If no improvement after 6 puffs, call 999 for an ambulance.

If the ambulance has not arrived after 10 minutes and symptoms are not improving, repeat dosing.

ONE puff of the rescue inhaler every 30 to 60 seconds, up to a maximum of 10 puffs.

If available, use spacer with MDI reliever.

If no improvement at any point OR not feeling better after 10 puffs, call 999 for an ambulance.

If the ambulance has not arrived after 10 minutes and symptoms are not improving, repeat dosing.

Guidelines:

Primary Care: initial assessment, management & criteria for hospital referral:Acute asthma in adults | Right Decisions (scot.nhs.uk)
Secondary Care: Management of acute asthma in adults in the emergency department | Right Decisions (scot.nhs.uk)
Secondary Care: Management of acute asthma in adults in hospital | Right Decisions (scot.nhs.uk)

All patients with Acute Asthma presenting to Secondary Care (ED or MAU): Refer to Asthma Specialist Nurse team for follow up post discharge (copy of IDL or discharge letter)

All patients requiring admission to MAU: Refer to Respiratory team (nhsh.raigmorerespiratory@nhs.scot) for consideration of inpatient review.

All patients being considered for IV Magnesium therapy: discuss / review by a senior doctor (Senior Middle-grade or Consultant).

Patients who have had >2 salbutamol nebulisers and/or have been treated with IV Magnesium for Acute Asthma on that attendance: are NOT suitable for discharge from ED.

Review patient’s regular therapy and consider whether an escalation in therapy is required as per asthma guidelines.

Discharge criteria: inpatient admission:

Patient has been off nebulised bronchodilators for 24 hours
Inhaler technique assessment carried out
PEF >75% of Best value OR Consultant-led
Smoking status discussed and Smoking Cessation referral
Asthma Action Plan discussed & issued
Inhealthcare Remote monitoring considered
Discharge letters and medication prescribed on IDL, including:
- Prednisolone 40mg once daily for 7 days: for current illness
- Prednisolone 40mg once daily for 5 days: emergency supply as per Action Plan
Inform patient to attend GP/Nurse within 2 to 3 days following discharge
Follow up with ARNS (Advanced Respiratory Nurse Specialist) arranged for 4 weeks

Local recommendation: All patients discharged from ED:

Supply Prednisolone 40mg once daily for 7 days: for current illness
Supply Prednisolone 40mg once daily for 5 days: emergency supply as per Action Plan
Inform patient to attend GP/Nurse within 2 to 3 days following discharge
Refer for follow up with ARNS (Advanced Respiratory Nurse Specialist)

Severe Asthma Pathway for Scotland

Includes referral criteria and management in primary and secondary care.

Available in multiple languages from: Asthma + Lung UK (asthmaandlung.org.uk

Traditional: Adult Action Plan
AIR regimen: Your AIR Asthma Action Plan
MART regimen: Download MART asthma action plan

How to use your inhaler - www.asthmaandlung.org.uk/living-with/inhaler-videos
Highland Respiratory Resource Hub
Smoking Cessation: Quit Your Way Scotland | NHS inform

Return USED inhalers to Community Pharmacy for safe disposal

AIR: Anti-Inflammatory Reliever
DPI: Dry powder inhaler
FEV1: Forced Expiry Volume in 1 second
FVC: Forced Vital Capacity
ICS: Inhlaed corticosteroid
LABA: Long-Acting Beta2 agonist
LAMA: Long-Acting Muscarinic Antagonist
MART: Maintenance and Reliever Therapy
MDI: Metered dose inhaler
OCS: Oral corticosteroid
ppb: parts per billon
SABA: Short-Acting Beta2 Agonist

Last reviewed: 27/02/2025

Next review date: 29/02/2028

Author(s): Respiratory Department .

Version: 3

Approved By: TAMSG of the ADTC

Reviewer name(s): C Clark, Advanced Respiratory Nurse Specialist , C Wheelan, Specialist Pharmacist, Respiratory, Dr K Griffiths, ST7, Respiratory.

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Asthma in adults (Guidelines)

Audience

Good asthma control = green asthma controlThe right inhaler is the one the patient can use

What good asthma control looks like:

Primary care management

Assessment

Diagnosis

Referral

Management

Annual review

What good asthma control looks like:

AIR / MART pathway

When to use AIR or MART

Step 1

Step 2

Step 3

Step 4

Step 5

AIR

Low-dose MART

Moderate-dose MART

Step 3 PLUS FeNO / Blood eosinophil testing

Step 4 PLUS identify patients at risk of severe asthma

consider specialist review

Consider trial of montelukast or LAMA

Traditional pathway

Step 1

Step 2

Step 3

Step 4

Step 5

Maintenance low-dose ICS

Maintenance low-dose ICS/LABA

Maintenance moderate-dose ICS/LABA

Step 3 PLUS consider 3-month trial LAMA

Step 4 PLUS identify patients at risk of Severe Asthma

Maintenance high-dose ICS/LABA

High-dose ICS

Consider montelukast trial

Consider montelukast trial

NOTE: SABA, when required for symptomatic relief and rescue therapy, should be prescribed at ALL steps of the traditional pathway

Dosing in exacerbations

AIR / MART regimen

When required SABA regimen

Acute asthma management

Guidelines:

Discharge criteria: inpatient admission:

Local recommendation: All patients discharged from ED:

Severe Asthma Pathway for Scotland

Personal Asthma Action Plan

Patient information

ABBREVIATIONS

Editorial Information

Good asthma control = green asthma control
The right inhaler is the one the patient can use