Emergency Asthma Care PDF

Emergency Asthma Care
Access to Emergency Asthma Care
Asthma Treatment Pathways
Discharge and follow-up

Contents
Introduction 2
How to improve your emergency asthma care 3
Access to emergency asthma care 4

Process of emergency asthma care 4
Process of emergency care for a person with asthma (Table 1) 5
Identifying asthma patients at risk 6
Risk factors for fatal or near fatal asthma attacks 6
Initial assessment of a patient having an asthma attack 7
Admission criteria 7
– including example assessment form 8
Levels of asthma severity in adults (Table 2) 9
Levels of asthma severity in children aged 2–12 years (Table 3) 10
Levels of asthma severity in children aged under 2 years (Table 4) 11
Asthma treatment pathways 13

Developing emergency asthma treatment pathways 13
How to develop your own emergency asthma treatment pathway 13
Management of severe asthma in adults in pharmacy (Table 5) 15
Management of wheezing in children (Table 6) 16
Management of asthma in children in pharmacy (Table 7) 17
Discharge and follow-up after an 18

asthma attack
Information for people with asthma before discharge 19
– including example of discharge letter 20
Acknowledgments 21
Appendices (contents) 22
Further resource materials are contained within this pack – including an

Emergency Asthma Care Checklist poster, Emergency Asthma Care
Training CD-Rom and sample copies of After Your Asthma Attack and
After Your Child’s Asthma Attack
1
Introduction
It is shocking that 1 in 6 people with asthma who have received treatment

for an asthma attack need emergency treatment again within two weeks.
As a healthcare professional you can work in partnership with Asthma UK
to bring this statistic down and make a real difference to the lives of the
5.2 million people in the UK with asthma.
Professor Martyn Partridge MD FRCP

Chief Medical Adviser, Asthma UK
This pack is for all healthcare professionals, working in any setting, who
come into contact with people with asthma at the time of an asthma attack.
It shows the process of care from when a person with asthma first presents,
to their follow-up arrangements and discharge.
It contains:
• guidance on evidence-based standards of emergency asthma care, no

matter where a person with asthma is being treated
• templates to adapt to your own setting – eg assessment form, discharge

letter, patient group directions (PGD), and an audit tool
• Emergency Asthma Care CD-Rom – including presentation on

how to use the pack
• patient information booklets (After Your Asthma Attack and After Your
Child’s Asthma Attack)
• Emergency Asthma Care Checklist poster.
2
How to improve your emergency asthma care
At the start of your process to improve emergency asthma care it is useful to
meet with all stakeholders (people involved in asthma care) to gather ideas
and put forward suggestions for improvement. This can then form the basis
of an asthma working party to evaluate the service as it progresses, ensure
realistic timelines are set and resources are available to support any changes.
Working party meetings can positively influence asthma care at a strategic level
and can help improve standards. Involving people with asthma who have used
the service in these meetings and gathering their feedback is also valuable.
Some areas of the UK have audited their emergency asthma care to work out
the times and seasons of greatest need. This can aid workforce planning and
enable proactive asthma review for those with predicted seasonal difficulties
to ensure effective care is available when and where it is needed.
Your clinical team should have a current asthma training programme,

ideally with support and experiential learning from the asthma interest group
(asthma training courses are listed in the appendices). We have included
an emergency asthma care training resource CD-Rom about this pack.
Permanent clinical staff can use this to train others who may work in your
department/practice for a short time, but need to know your current
emergency asthma guidelines. It is helpful to ensure all staff, including
non-clinical staff such as receptionists, are clear on their role in
asthma emergencies.
3
Access to emergency
asthma care
People experiencing an asthma attack may use any of the following settings:
• GP surgery
• out-of-hours service
• walk-in-centre/urgent care centre
• hospital emergency department
• ambulance service
• medical or paediatric assessment unit
• may also present at a pharmacy.
All staff should be aware that if a person with asthma is complaining of

respiratory symptoms they need immediate access to a doctor or trained
respiratory nurse as they may be at risk of an asthma attack. This includes
receptionists, ambulance call takers and pharmacists.
Process of emergency asthma care

Fatal asthma attacks rarely occur suddenly in people with mild or moderately
severe asthma. Most deaths occur in patients with chronic or severe asthma,
where the onset of the attack has developed over a period of six hours or
more. There should therefore be enough time to initiate appropriate action.
It is important to treat each asthma consultation as you would for severe

Access to emergency asthma care
asthma, until it is shown to be otherwise.
4
TABLE 1
Process of emergency care for a person having an
asthma attack
Non-clinical
Clinical
staff
staff
1. Identify patients at risk
2. Inform appropriate healthcare professional
3. Prioritise patients needing urgent attention
4. Transfer to emergency care, maintaining condition
5. Assess
6. Treat
7. Educate
8. Arrange follow-up (GP/asthma nurse or secondary

care) or urgent admission to secondary care
9. Refer on if necessary
5
Identify asthma patients at risk
The following list will help your practice/department identify people with
asthma who are at risk of an asthma attack. It is useful to develop an asthma
register which allows your practice/department to systematically target the
issues contributing to frequent asthma presentation, improving the chances
of survival for people with asthma who frequently attend for emergency care.
Risk factors for fatal or near fatal asthma attacks

A combination of severe asthma recognised by one or more of the following:
• previous supported ventilation, respiratory acidosis or other indicator
of a near fatal episode
• requiring three or more classes of asthma medicines
• heavy use of Beta2 agonist
• previous admission to hospital for asthma, especially in the last year
• repeated attendances for emergency asthma care, especially in the
last year.
and...
Adverse behavioural or psychosocial features recognised by one or more of:

• non-concordance with treatment or monitoring
• failure to attend appointments
• self discharge from hospital
• psychosis, depression, other psychiatric illness or deliberate self-harm

• current or recent major tranquilliser use
• denial
• alcohol or drug abuse
• obesity
• learning difficulties
• employment problems
• income problems
• social isolation
• childhood abuse
• severe domestic, marital or legal stress.
6
Initial assessment
Delay in treatment and under-dosing in an asthma attack can adversely affect
outcomes. By using objective measures, the level of asthma severity is less
likely to be underestimated. This will enable prompt treatment at the right
dose to be effective. On the following page an example assessment form can
be used for your records or adapted to suit your needs, a template is enclosed
within the appendices of this pack. It can also be used for audit purposes to:
• indicate which areas of assessment are commonly missed

• help with staff training
• audit risk factors in people with asthma frequently attending for an
asthma attack.
Admission criteria
• Refer to hospital any patients with features of severe or
life-threatening asthma.
• Admit patients with any feature of a life-threatening or near fatal
asthma attack.
• Admit patients with any feature of a severe asthma attack persisting after
initial treatment.
See tables 2, 3 and 4 for levels of severity of asthma attacks.

7
Assessment form for emergency asthma care
Patient name: Anne Smith

DOB: 07-03-1966
Date/time: 25-11-2006
1. Date(s) of last asthma attack requiring emergency treatment 20-09-2006
2. PEF before initial reliever treatment 200
PEF after treatment 350
3. Best PEF (or predicted)* 400
4. Pulse oximetry. SpO2 (in room air or specify dose of O2 if given) 95%
5. Arterial Blood Gas readings if SpO2 <92% or any other feature of life threatening asthma
6. Pulse rate 98
7. Respiratory rate 23
8. Poor, dislikes using large volume spacer
Inhaler technique observed (good, moderate, poor)
9. Inhaler device(s) Large volume spacer and pMDI
10. Current medication including dose Salbutamol 2 puffs PRN Flixotide 50mcg 2 puffs BD
11. Triggers Cats, smoke, house dust mite, dust, walking up hills
12. In the last week or month:
asthma symptoms at night Awakes twice nightly – coughing

asthma symptoms during the day Coughing in morning, breathless on exercise in last week
asthma symptoms interfering with usual activity? Takes longer to climb stairs – has to stop twice
13. Smoker (current, ex, passive) Non smoker
Smoking pack years
14. Asthma (self/in family) Yes, diagnosed Sept 06, no family history
Eczema (self/in family) Yes, her mum had it
Hayfever (self/in family) No

15. Allergies Plasters
16. Past medical history (PMH) Childhood bronchitis, diagnosed with depression in 2000
17. Psychological factors Feels depressed and lonely
18. Social factors Lives alone, 5th floor flat, unemployed IT consultant
19. Other significant factors eg pregnant, a carer, away from home
Owns two cats

20. Communication difficulties Nil known
* See appendix of Emergency Asthma Care Pack for peak flow chart
8
TABLE 2
Levels of severity of asthma exacerbations in adults
(taken from BTS/SIGN British Guideline on the Management of Asthma 2005)
Near fatal asthma Raised PaCO2 and/or requiring mechanical

ventilation with raised inflation pressures.
Life-threatening Any one of the following in a patient with

asthma severe asthma:
• peak flow <33% best or predicted
• SpO2 < 92%
• PaO2 < 8 kPa
• normal PaCO2 (4.6 – 6.0 kPa)
• silent chest
• cyanosis
• feeble respiratory effort
• bradycardia
• dysrhythmia
• hypotension
• exhaustion
• confusion
• coma.
Severe asthma Any one of:

• peak flow 33–50% best or predicted
• respiratory rate > 25/min
• heart rate > 110/min
• inability to complete sentences in one breath.
Moderate asthma Increasing symptoms

exacerbation • peak flow 50–75% best or predicted
• no features of severe asthma.
Brittle asthma • Type 1: wide peak flow variability (>40%

diurnal variation for >50% of the time over
a period >150 days) despite intense therapy.
• Type 2: sudden severe attacks on a background
of apparently well-controlled asthma.
9
TABLE 3
Levels of severity of asthma exacerbations
in children aged 2–12 years
Life-threatening • silent chest

asthma • cyanosis
• poor respiratory effort
• hypotension
• exhaustion
• confusion/agitation
• coma
• SpO2 < 92%
• peak flow < 33% best or predicted
(can only be measured in children >5 years).
Severe asthma • unable to complete sentences in one

breath or too breathless to talk or feed
• use of accessory muscles
• pulse >120 in children aged >5 years
>130 in children aged 2–5 years
• respiration >30 breaths/min aged >5 years
>50 breaths/min aged 2–5 years
• SpO2 < 92%
• peak flow <50% best or predicted
(can only be measured in children >5 years).
Moderate asthma • able to talk

exacerbation • no features of severe asthma
• pulse < 120 in children aged >5 years
< 130 in children aged 2–5 years

• respiration < 30 breaths/min aged >5 years
< 50 breaths/min aged 2–5 years
• SpO2 > 92%
• peak flow > 50% best or predicted
(can only be measured in children >5 yrs).
10
TABLE 4
Levels of severity of asthma exacerbations
in children aged under 2 years
Life-threatening • apnoea
asthma • bradycardia
• poor respiratory effort.
Severe asthma • SpO2 < 92%

• cyanosis
• marked respiratory distress
• too breathless to feed.
Moderate asthma • SpO2 > 92%

exacerbation • audible wheezing
• using accessory muscles
• still feeding.
11
12
Asthma treatment
pathways
Developing emergency asthma treatment pathways
The BTS/SIGN British Guideline on the Management of Asthma (2005) gives
suggested pathways for treating asthma in adults and children both
in emergency departments and GP surgeries; these are included in the
appendices for your reference.
These pathways can be adapted for other settings in which asthma

emergency care is delivered. It is recommended that you develop your own
pathways according to the skills and resources available in your particular
practice area.
How to develop your own treatment pathway

• Identify within your own locality an ‘Asthma Champion’ – to raise the
profile of asthma care.
• Discuss with the whole team, including receptionists, what needs to be
included in your treatment pathway.
• Clarify the role and the responsibility of each individual team member
in the management of asthma attacks.
• Anticipate changes which will impact upon support services and ensure
that these are negotiated and agreed in advance, for example, performing
arterial blood gas analysis, providing 24 hour specialist advice at the end
of a phone or for patient transport between departments.
• Clarify the admission and discharge policies and ensure all staff are
aware of them.
Asthma treatment pathways
• Use evidence-based information such as the BTS/SIGN British Guideline

on the Management of Asthma (2005) as a basis for your pathway.
These are contained within the appendices of this pack.
• Develop patient group directions (PGDs) if necessary. PGDs are documents
that enable medicines to be given to groups of patients in particular
circumstances (eg salbutamol to people with diagnosed asthma in an
attack) without having to wait for an individual prescription. This will
allow appropriate team members to give emergency care as soon as it is
needed, ensuring improved outcomes for people with asthma. An example
is contained within the appendices of this pack.
13
• Identify at least one team member to take responsibility for enabling good
communication between primary and secondary care, ensuring that
relevant follow-up appointments are made and there is clear
communication between services and the person with asthma.
• Identify local specialists and relevant follow-up services and referral
procedures for them. You can list your local contacts in the space provided
in the appendices.
• Pilot your pathway, and evaluate it to ensure it meets your needs, adapting
it as necessary.
The following section features examples of pathways developed in discussion

with key clinicians for use both in the emergency department and in primary
care settings.
It also includes a sample pathway that might be used in a community pharmacy

setting and practical tips on how to develop your own treatment pathways.
‘Using the skills of all our staff

and the available resources,
we have been able to create
pathways for the management
of asthma that really work for
us and our patients.’
SADIE CLAYTON, PAEDIATRIC RESPIRATORY

NURSE SPECIALIST, UNIVERSITY HOSPITAL
OF NORTH STAFFORDSHIRE NHS TRUST
14
TABLE 5
Management of severe asthma in adults in pharmacy
Assess and record: • Peak flow

• Symptoms and response to treatment
• Pulse and respiratory rates
Caution: Patients with severe or life-threatening attacks may not be distressed and
may not have all the abnormalities listed below.
Moderate asthma Severe asthma Life-threatening asthma
Peak flow >50% best or Peak flow 33–50% best or Peak flow < 33% best
predicted predicted or predicted
Speech normal Cannot complete sentences Cyanosis, or poor
respiratory effort,
Resps <25 breaths/min Resps >25 breaths/min
bradycardia, exhaustion,
Pulse <110 beats/min Pulse >110 beats/min
confusion or coma
Treat in pharmacy Call Dr _______________ Dial 999

Give salbutamol via spacer, on__________________ While waiting for help give
1 puff 10 –20 times While waiting for help give salbutamol, via spacer
salbutamol via spacer,
1 puff 10–20 times
Better Worse 1 puff 10–20 times
Continue to give salbutamol
If peak flow If peak flow If no improvement
>50–75% 1 puff every minute until
<50% continue to give 1 puff
predicted ambulance arrives
predicted every minute until
best, arrange or best Dr_____________________
for patient
to see arrives or dial 999
Dr________
__________
for oral
prednisolone

Dial 999 if: Give written assessment to Send written assessment
Life-threatening features or Dr ____________________ to hospital with patient
features of severe asthma
present after initial
treatment or previous near
fatal asthma
Send written assessment
with patient to
Dr _____________________
15
TABLE 6 – Management of acute wheezing in children
Mild/Moderate Severe Life-threatening
• Normal vital signs • Too breathless to talk/feed • Cyanosis/pallor

• Mild wheeze • Use of accessory muscles • Silent chest
• Speaks in complete sentences • Resp rate: >50/min <5yrs • Poor respiratory effort
• SaO2 >92% in air >30/min >5yrs • Reduced consciousness
• Heart rate: >130/min <5yrs • Irritable/exhausted
>120/min >5yrs • SaO2 <92%
• SaO2 <92% in air
Immediate medical assessment,

Assessment Medical assessment
consulting with senior medical staff
Within 10 minutes Within 10 mins
• ß2 agonist within 10 mins via • High flow O2 via face mask • High flow O2 via face mask
spacer +/- mask • ß2 agonist within 10 mins via • Full monitoring in resuscitation bay
• Salbutamol 100mcg per puff (2–10 puffs) spacer +/- mask • Inform consultant on call and anaesthetists, involve
• Tidal breathing 1 puff to every 5 breaths • Salbutamol 100mcg per puff (6–10 puffs) PICU early
• Record peak flow if >5yrs • Tidal breathing 1 puff to every 5 breaths • Continuous ß2 agonist via nebuliser driven by 6–8
• O2 if SaO2 <92% • If not tolerated/no response l/min O2
• Prednisolone 1–2mg/kg Salbutamol nebulised • Site IV line, use venous sample in blood gas machine
or 1–5 yrs 20mg (2.5mg <5yrs) for CO2, pH, K +
>5yrs 40mg (max dose) driven by 6–8L/min O2 • Send blood to lab for U+Es including Mg
• Prednisolone 1.0mg/kg • IV hydrocortisone 100mg (50mg if <5 yrs)
or 1–5yrs 20mg • Nebulise Ipratropium Bromide 250mcg (125mcg for
>5yrs 40 mg (max dose) infants)
• IV salbutamol 15mcg/Kg bolus over 10 minutes
followed by salbutamol infusion 1–5mcg/Kg/min
Re-assess Re-assess
15–30 mins 15–30 mins
No Re-assessment after bolus

Discharge criteria met Improving 10 mins
• SaO2 in air <92%
• Resp rate: <50/min <5yrs
Yes
<30/min >5yrs
• Heart rate: <130/min <5yrs No Improving No change/worsening
• Admit
<120/min >5yrs • Admit to HDU • Ensure anaesthetists present if
• High flow O2 via face mask to maintain
• Stable on 4 hourly treatment or ward not already
SaO2 <92% • Inhaled salbutamol • Arrange PICU/HDU transfer
Yes • 1–2 hourly ß2 agonist
1–2 hourly • IV magnesium sulphate

• IV hydrocortisone 100mg (50mg <5yrs) if • +/- ipratropium 40mg/Kg (max 2g) over 20
• Oral prednisolone + bronchodilators tablets not tolerated bromide 250mcg minutes
• Review long term asthma control (125mcg for • Chest X-ray
• Education and written management plan infants) every 6 • Reassess, if no improvement on
• Follow-up: nurse-led/consultant/GP hours maximum salbutamol infusion
No
• Complete respiratory discharge letter Symptoms improving • Recheck K + •IV aminophylline bolus 5mg/Kg
• Regular review loading dose over 20 minutes
especially if followed by infusion
Yes needing nebulisers 1mg/Kg/hour (omit if on oral
more than every theophyllines)
Reduce frequency of bronchodilator therapy 2 hours. • Repeat blood gases
Yes No Admit to ward

Discharge home Discharge criteria met
Consider further investigations
16
TABLE 7
Management of asthma in children in pharmacy
Assess and record: • Peak flow

• Symptoms and response to treatment
• Pulse and respiratory rates
Caution: Children with severe or life threatening attacks may not be distressed, appear
to be unusually quiet and may not have all the abnormalities listed below.
Moderate exacerbation Severe exacerbation Life-threatening asthma
Peak flow >50% best or Peak flow <50% best or Peak flow <33% best or
predicted predicted predicted
Speech normal Cannot complete sentences Poor respiratory effort
No clinical features of Use of accessory muscles Altered consciousness
severe asthma Cyanosis
Resps >30/min >5yrs
Resps <30/min >5yrs >50/min <5yrs Agitation
<50/min <5yrs
Pulse >120/min >5yrs
Pulse <120/min >5yrs >130/min <5yrs
<130/min <5yrs
Treat in pharmacy Dial 999 Dial 999

Give salbutamol 2–4 puffs While waiting for ambulance While waiting for ambulance
via spacer ± face mask give salbutamol 10 puffs via give salbutamol 10 puffs via
spacer ± face mask spacer + face mask
Refer to
Continue to give salbutamol Continue to give salbutamol
Dr _____________________
1 puff every minute until 1 puff every minute until
on _____________________ ambulance arrives ambulance arrives
for oral prednisolone
If no response to initial
Treatment call
Dr _____________________
on _____________________
or dial 999 if symptoms of
severe or life threatening
asthma continue to give
1 puff of salbutamol every
minute until
Dr ___________________/
ambulance arrives
Send written assessment Send written assessment Send written assessment

with patient to with patient to hospital with patient to hospital
Dr _____________________
17
People with asthma should not be discharged if:
• they still have significant symptoms

• there are concerns about concordance
• they live alone or are socially isolated
• they have behavioural or psychological problems
• they have a physical disability or learning difficulties
• they have had a previous near fatal asthma attack or they have brittle asthma
• they have had an asthma attack despite adequate doses of steroid tablets
before presentation
• they present at night
• they are pregnant.
The appropriate primary care practice should be informed within 24 hours

of the patient’s discharge.
Before discharge a follow-up appointment with the patient’s GP or asthma

nurse should be arranged so that they are seen within 48 hours.
A follow-up appointment with a hospital asthma nurse specialist or

respiratory physician should be made for about one month after discharge.
A copy of the discharge letter should be sent to each of the following:
• the person with asthma or their carer

• the patient’s named GP
• the patient’s named asthma nurse/practice nurse
• school nurse/health visitor/physiotherapist, where appropriate

• professional carers eg care home/community nurses, where appropriate.
BTS/SIGN recommend direct communication with a named individual

responsible for asthma care within the practice by fax or email.
18
Information for people with asthma before discharge
Patient education should be given by trained clinical staff eg respiratory/
asthma nurses or physiotherapists. Any staff managing asthma emergencies
should make themselves familiar with asthma education through local
specialists and use of After Your Asthma Attack and After Your Child’s Asthma
Attack booklets from Asthma UK.
People with asthma and parents of children with asthma are at their most
receptive to information following an asthma attack. By covering the following
issues you can help people with asthma get their asthma back under control.
Discuss:
• medicines management – how, when and how much to take
• potential side effects of their asthma medicines and how to minimise them
• triggers and trigger avoidance
• inhaler and spacer technique and how to improve it
• the importance of carrying a reliever inhaler at all times and taking
preventer medicine regularly even when they are feeling well
• when to go for an asthma review (they need a review within 48 hours after
their asthma attack and then again within one to two weeks)
• how to recognise when their asthma symptoms are getting worse and
what actions to take. Discuss the importance of asking for a written
personal asthma action plan at their asthma review (or fill one in with
them if appropriate)
• what to do if they have another asthma attack.
Make sure:
• a follow-up review appointment is made for them to see their GP/asthma

nurse within 48 hours of discharge. Ensure they have written details of the
date, time, place and contact details
• they have enough medicine to last until their follow-up appointment
• you give them and fill in with them the medicines section in Asthma UK’s
After your Asthma Attack or After your Child’s Asthma Attack booklet
• you check inhaler and spacer technique and make adjustments if necessary.
19
Discharge letter following emergency asthma care
Patient name: Anne Smith DOB: 07-03-1966
Date/time: 25-11-2006
Dear
This patient was treated today for an asthma attack.
Age 41 Height 150 cm Predicted peak flow 433
Initial assessment On discharge

PEF 250 375
SpO2 95% (room air) 99% (room air)
Pulse 98 80
Respiratory rate 23 17
We have discussed
inhaler use/technique with (type) Large volume spacer

medicines including potential side effects Concerned about oral thrush
trigger avoidance
smoking cessation n/a
how to recognise worsening asthma and what to do in an asthma attack. Has leaflet detailing
a simple management plan (copy enclosed)
Other important issues

1.Discussed trigger avoidance. Anne is reluctant to get rid of her pet cats but will consider this.
2.Is actively job seeking and has two interviews in the next month
3.Anne has booked an appointment with you to review her depression
They have been given written information and details of the Asthma UK Adviceline (08457 01 02 03)
and the Asthma UK website (asthma.org.uk).
They have a follow up appointment

with Dr James (name)
on 27-11-2006 at 15-00 (date and time)
at The Medical Practice, London DE45 6FG (venue) 020 7123 456 (phone)
They have been discharged with the following medicines

Prednisolone 50 mg – x10 5mg tablets taken all at once in the morning (with food), every day
for 5 days (or until better). Fluticasone 125 mcg – 2 puffs twice a day using a large volume
spacer. Salbutamol 100mcg – 2 puffs as required, using a large volume spacer
Yours sincerely Contact details Accident and Emergency Department, The General
Dr A Evans SHO Hospital, London AB1 23C
020 7010 203 Bleep 1234
20
We hope you have found the Emergency Asthma Care Pack useful.
Please make it your own by adding relevant local information, paperwork
or references to the following appendices.
This pack is also available as a download from asthma.org.uk/emergencycare.

Examples of local good practice will be posted on this website as well as
updates to the pack.
We are grateful to Susan and Stuart Balmforth whose experience provided

the inspiration for this pack and without whom it would not have been
possible. We would also like to thank all the healthcare professionals who
contributed to the project.
If you have any comments or suggestions for improvements to the pack or

examples of good practice you would like to share, please email
emergencycare@asthma.org.uk.
Asthma UK Adviceline
Ask an asthma nurse specialist
08457 01 02 03
asthma.org.uk/adviceline
Asthma UK website
Read the latest independent advice and news on asthma
asthma.org.uk
Asthma UK publications
Asthma UK has produced emergency care information booklets for you to
use with patients after they have had an asthma attack. For free copies of
After your Asthma Attack and After your Child’s Asthma Attack or any other
Asthma UK publications contact Asthma UK’s Supporter & Information Team
020 7786 5000 info@asthma.org.uk
Asthma UK Asthma UK Cymru Asthma UK Northern Ireland Asthma UK Scotland

Summit House Eastgate House Peace House 4 Queen Street
70 Wilson Street 34–43 Newport Road 224 Lisburn Road Edinburgh EH2 1JE
London EC2A 2DB Cardiff CF24 0AB Belfast BT6 6GE scotland@asthma.org.uk
T 020 7786 4900 wales@asthma.org.uk ni@asthma.org.uk
F 020 7256 6075
Registered charity number 802364
21
Emergency Asthma Care Pack
Appendices
1. BTS/SIGN Asthma Management Guidelines

1.1 Adults in general practice 2
1.2 Adults in A&E 3
1.3 Adults in hospital 4
1.4 Children in general practice 5
1.5 Children in A&E 6
1.6 Children in hospital 7
1.7 Infants under 2 years 8
2. Medicines for asthma

2.1 Asthma medicines table 9
2.2 Inhaler technique 10
3. Templates
3.1 Assessment form 13
3.2 Discharge letter 14
3.3 Audit form 15
3.4 Patient group directions (PGD) 17
4. Contact details
4.1 Useful contacts – national 23
4.2 Useful contacts – local 25
4.3 Useful websites 26
5. Peak flow reference tables

5.1 For adults 27
5.2 For children 28
6. Read codes for asthma

6.1 Diagnosis codes 29
6.2 Monitoring codes 31
6.3 Procedure codes 34
7. Training presentation on CD-Rom

7.1 How to use your Emergency Asthma Care Pack
Appendix 1.1 – Emergency Asthma Care Pack 2
British Guideline on the Management of Asthma 2005

Management of acute severe asthma in adults in A&E
Time Measure Peak Expiratory Flow and Arterial Saturations

PEF >75% best or predicted PEF 33-75% best or predicted PEF <33% best or predicted
mild moderate – severe: OR any life threatening features:
features of severe asthma ! SpO2<92%
! PEF<50% best or predicted ! Silent chest, cyanosis, poor
! Respiration ≥ 25/min respiratory effort
! Pulse ≥ 110 breaths/min ! Bradycardia, arrhythmia, hypotension
! Cannot complete sentence in one breath ! Exhaustion, confusion, coma
5 mins Give usual bronchodilator Give salbutamol 5 mg by oxygen- Obtain senior/ICU help now if any
driven nebuliser life-threatening features are present
IMMEDIATE MANAGEMENT
! High concentration oxygen
(>60% if possible)
! Give salbutamol 5 mg plus
ipratropium 0.5 mg via oxygen-
15-30 Clinically Clinically No life Life threatening
driven nebuliser
stable stable threatening features
mins AND PEF AND PEF features OR PEF <50% ! AND prednisolone 40-50 mg
orally or IV hydrocortisone 100 mg
>75% <75% AND PEF 50-75%
Repeat salbutamol Measure arterial blood gases

5 mg nebuliser Markers of severity:
Give prednisolone - Normal or raised PaCO2
40-50 mg orally (Pa CO 2>4.6 kPa; 35 mmHg)
- Severe hypoxia
(PaO 2 <8 kPa; 60 mmHg)
- Low pH (or high H +)
No signs of severe Signs of severe ! Give/repeat salbutamol 5 mg

Patient recovering with ipratropium 0.5 mg
AND PEF >75% asthma asthma
60 mins AND PEF 50-75% OR PEF <50% by oxygen-driven nebuliser
after 15 minutes
! Consider continuous
OBSERVE
salbutamol nebuliser 5-10 mg/hr
monitor SpO 2,
heart rate and ! Consider IV magnesium
respiratory rate sulphate 1.2-2 g over 20 minutes
! Correct fluid/electrolytes,
especially K + disturbances
! Chest x-ray
ADMIT
Patient stable Signs of severe asthma Patient should be accompanied by a
120 mins AND PEF>50% OR PEF <50% nurse or doctor at all times
Peak expiratory flow in normal adults

660 660
75 190
650 650
72 183
640 640
69
MEN
175
POTENTIAL DISCHARGE 630

620 66 167
630
620
610 63 160 610
Ht. Ht.
! In all patients who received nebulised β2 agonists prior to 600 (ins) (cms) 600
590 590
presentation, consider an extended observation period prior 580 580

570 570
to discharge 560 560
550 550
540 540
! If PEF<50% on presentation, prescribe prednisolone 40-50
STANDARD DEVIATION MEN 48 litres/min
STANDARD DEVIATION WOMEN 42 litres/min
530 530
520 520
mg/day for 5 days PEF
L/min 510 510
500 500
69 175 WOMEN
! In all patients ensure treatment supply of inhaled steroid and 490

480
66 167
490
480
63 160
β2 agonist and check inhaler technique 470

460 60 152
470
460
450 57 145 450
Ht. Ht.
! Arrange GP follow up for 2 days post presentation 440

430
(ins) (cms) 440
430
420 420
! Fax discharge letter to GP 410
IN MEN, VALUES OF PEF UP TO 100 LITRES/MIN, LESS THAN
PREDICTED, AND IN WOMEN LESS THAN 85 LITRES/MIN, LESS
THAN PREDICTED, ARE WITHIN NORMAL LIMITS.
410
400 400
! Refer to asthma liaison nurse/chest clinic 390

380
390
380
15 20 25 30 35 40 45 50 55 60 65 70
AGE IN YEARS
Nunn AJ, Gregg I. New regression equations for predicting peak expiratory flow in adults. BMJ 1989;298:1068-70.
Management of acute severe asthma in adults in hospital
Features of acute severe asthma IMMEDIATE TREATMENT

! Peak expiratory flow (PEF) 33-50% of best
! Oxygen 40-60%
(use % predicted if recent best unknown)
(CO2 retention is not usually aggravated by oxygen therapy in asthma)
! Can’t complete sentences in one breath
! Salbutamol 5 mg or terbutaline 10 mg via an oxygen-driven nebuliser
! Respirations ≥ 25 breaths/min
! Ipratropium bromide 0.5 mg via an oxygen-driven nebuliser
! Pulse ≥ 110 beats/min ! Prednisolone tablets 40-50 mg or IV hydrocortisone 100 mg or both if very ill
! No sedatives of any kind
Life threatening features ! Chest radiograph only if pneumothorax or consolidation are suspected
! PEF < 33% of best or predicted or patient requires IPPV
! SpO2 < 92%
! Silent chest, cyanosis, or feeble respiratory IF LIFE THREATENING FEATURES ARE PRESENT:
effort ! Discuss with senior clinician and ICU team
! Bradycardia, dysrhythmia, or hypotension ! Add IV magnesium sulphate 1.2-2 g infusion over 20 minutes
! Exhaustion, confusion, or coma (unless already given)
! Give nebulised β2 agonist more frequently e.g. salbutamol 5 mg up to every
15-30 minutes or 10 mg continuously hourly
If a patient has any life threatening feature,
If a patient has any life threatening feature,
measure arterialblood
measure arterial bloodgases.
gases.No No other
other
investigations areneeded
investigations are neededfor forimmediate
immediate SUBSEQUENT MANAGEMENT
management.
management.
Blood gas markers
Blood gas markers ofof aa life
life threatening
threatening attack:
attack: IF PATIENT IS IMPROVING continue:
! Normal (4.6-6 kPa, 35-45 mmHg) PaCO2 ! 40-60% oxygen
! Severe hypoxia: PaO2< 8 kPa (60mmHg) ! Prednisolone 40-50mg daily or IV hydrocortisone 100 mg 6 hourly
irrespective of treatment with oxygen ! Nebulised β2 agonist and ipratropium 4-6 hourly
! A low pH (or high H+) IF PATIENT NOT IMPROVING AFTER 15-30 MINUTES:
Caution: Patients with severe or life threatening ! Continue oxygen and steroids
attacks may not be distressed and may not have ! Give nebulised β2 agonist more frequently e.g. salbutamol 5 mg up to
all these abnormalities. The presence of any every 15-30 minutes or 10 mg continuously hourly
should alert the doctor. ! Continue ipratropium 0.5 mg 4-6 hourly until patient is improving
IF PATIENT IS STILL NOT IMPROVING:
! Discuss patient with senior clinician and ICU team
Near fatal asthma ! IV magnesium sulphate 1.2-2 g over 20 minutes (unless already given)
! Raised PaCO2
! Senior clinician may consider use of IV β2 agonist or IV aminophylline
! Requiring IPPV with raised inflation pressures
or progression to IPPV
Peak expiratory flow in normal adults MONITORING

660
650
75 190
660
650
! Repeat measurement of PEF 15-30 minutes after starting treatment
640 72 183
MEN
640 ! Oximetry: maintain Sp02 >92%
69 175
630
620 66 167
630
620
! Repeat blood gas measurements within 2 hours of starting treatment if:
610 63
Ht.
160
Ht.
610 - initial PaO2 <8 kPa (60 mmHg) unless subsequent Sp02 >92%
600 (ins) (cms) 600
590 590
- PaC02 normal or raised
580 580 - patient deteriorates
570 570
560 560 ! Chart PEF before and after giving β2 agonists and at least 4 times daily
550 550
throughout hospital stay
540 STANDARD DEVIATION MEN 48 litres/min
540
530
520
STANDARD DEVIATION WOMEN 42 litres/min
530
520
Transfer to ICU accompanied by a doctor prepared to intubate if:
PEF
L/min 510 510 ! Deteriorating PEF, worsening or persisting hypoxia, or hypercapnea
500
490
69 175 WOMEN
500
490
! Exhaustion, feeble respirations, confusion or drowsiness
480
66 167
480 ! Coma or respiratory arrest
63 160
470 470
60 152
460 460
450 57 145 450
Ht. Ht.
440 440
DISCHARGE
(ins) (cms)
430 430
420 420
When discharged from hospital, patients should have:

IN MEN, VALUES OF PEF UP TO 100 LITRES/MIN, LESS THAN
410 PREDICTED, AND IN WOMEN LESS THAN 85 LITRES/MIN, LESS 410
THAN PREDICTED, ARE WITHIN NORMAL LIMITS.
400 400
390 390 ! Been on discharge medication for 24 hours
380 380
and have had inhaler technique checked and recorded
15 20 25 30 35 40 45 50 55 60 65 70
! PEF >75% of best or predicted and PEF diurnal variability <25%
AGE IN YEARS
Nunn AJ, Gregg I. New regression equations for predicting peak expiratory flow in adults. BMJ 1989;298:1068-70.
unless discharge is agreed with respiratory physician
! Treatment with oral and inhaled steroids in addition to bronchodilators
! Own PEF meter and written asthma action plan
! GP follow up arranged within 2 working days
! Follow up appointment in respiratory clinic within 4 weeks
Patients with severe asthma (indicated by need for admission) and adverse
behavioural or psychosocial features are at risk of further severe or fatal attacks
! Determine reason(s) for exacerbation and admission
! Send details of admission, discharge and potential best PEF to GP

Management of acute asthma in children in A&E
Age 2-5 years Age >5 years

ASSESS ASTHMA SEVERITY ASSESS ASTHMA SEVERITY
Moderate exacerbation Severe exacerbation Life threatening asthma Moderate exacerbation Severe exacerbation Life threatening asthma
! SpO2 ≥92% ! SpO2 <92% ! SpO2 <92% ! SpO2 ≥92% ! SpO2 <92% ! SpO2 <92%
! No clinical features of ! Too breathless to talk or eat ! Silent chest ! PEF ≥50% best or predicted ! PEF <50% best or predicted ! PEF <33% best or predicted
severe asthma ! Heart rate >130/min ! Poor respiratory effort ! No clinical features of ! Heart rate >120/min ! Silent chest
! Respiratory rate >50/min ! Agitation severe asthma ! Respiratory rate >30/min ! Poor respiratory effort
NB: If a patient has signs and Altered consciousness ! Use of accessory neck ! Altered consciousness
! Use of accessory neck ! NB: If a patient has signs and
symptoms across categories, muscles muscles
! Cyanosis symptoms across categories, ! Cyanosis
always treat according to
Appendix 1.5 – Emergency Asthma Care Pack
their most severe features

! Give nebulised β2 agonist: ! Give nebulised β2 agonist:
salbutamol 2.5 mg or terbutaline 5 mg salbutamol 2.5 mg or terbutaline 5 mg
with oxygen as driving gas with oxygen as driving gas
! β2 agonist 2-10 puffs ! β2 agonist 2-10 puffs
! Continue O2 via face mask/nasal prongs via spacer ! Continue O2 via face mask/nasal prongs
via spacer ± facemask
! Give soluble prednisolone 20 mg ! Give soluble prednisolone 30-40 mg
! Reassess after 15 minutes ! Reassess after 15 minutes or IV hydrocortisone 100 mg
or IV hydrocortisone 50 mg
RESPONDING NOT RESPONDING IF LIFE THREATENING RESPONDING NOT RESPONDING IF LIFE THREATENING
FEATURES PRESENT ! Continue inhaled ! Repeat inhaled FEATURES PRESENT
! Continue inhaled β2 ! Repeat inhaled β2
agonist 1-4 hourly agonist β2 agonist 1-4 hourly β2 agonist Discuss with senior
Discuss with senior clinician, PICU team or
! Give soluble oral clinician, PICU team or ! Add 30-40 mg soluble ! Add 30-40 mg soluble
! Give soluble oral paediatrician
prednisolone 20 mg paediatrician oral prednisolone oral prednisolone
prednisolone 20 mg
Consider:
Consider: ARRANGE ADMISSION ! Chest x-ray and blood
ARRANGE ADMISSION
! Chest x-ray and blood gases
(lower threshold if concern (lower threshold if concern
gases ! Bolus IV salbutamol
over social circumstances) over social circumstances)
! Repeat nebulised β2 15 mcg/kg of 200 mcg/ml
agonist solution over 10
DISCHARGE PLAN Plus: DISCHARGE PLAN minutes
! ipratropium bromide ! Continue β2 agonist 4 hourly prn ! Repeat nebulised β2
! Continue β2 agonist 4 hourly prn 0.25 mg
! Consider prednisolone 30-40 mg daily agonist
! Consider prednisolone 20 mg daily ! Bolus IV salbutamol
for up to 3 days Plus:
for up to 3 days 15 mcg/kg of 200 mcg/ml

! ipratropium bromide
! Advise to contact GP solution over 10 minutes ! Advise to contact GP 0.25 mg nebulised
if not controlled on above treatment if not controlled on above treatment
! Provide a written asthma action plan ! Provide a written asthma action plan
Arrange immediate transfer to PICU/HDU Arrange immediate transfer to PICU/HDU
! Review regular treatment if poor response to treatment ! Review regular treatment
if poor response to treatment
! Check inhaler technique Admit all cases if features of severe ! Check inhaler technique
Admit all cases if features of severe
! Arrange GP follow up exacerbation persist after initial treatment ! Arrange GP follow up exacerbation persist after initial treatment
6
Management of acute asthma in children in hospital
Age 2-5 years Age >5 years

ASSESS ASTHMA SEVERITY ASSESS ASTHMA SEVERITY
Moderate exacerbation Severe exacerbation Life threatening asthma Moderate exacerbation Severe exacerbation Life threatening asthma
! SpO2 ≥92% ! SpO2 <92% ! SpO2 <92% ! SpO2 ≥92% ! SpO2 <92% ! SpO2 <92%
! No clinical features of ! Too breathless to talk or eat ! Silent chest ! PEF ≥50% best or predicted ! PEF <50% best or predicted ! PEF <33% best or predicted
severe asthma ! Heart rate >130/min ! Poor respiratory effort ! No clinical features of ! Heart rate >120/min ! Silent chest
! Respiratory rate >50/min ! Agitation severe asthma ! Respiratory rate >30/min ! Poor respiratory effort
NB: If a patient has signs and ! Use of accessory neck ! Altered consciousness ! Use of accessory neck ! Altered consciousness
symptoms across categories, muscles ! Cyanosis muscles ! Cyanosis
NB: If a patient has signs and
symptoms across categories,
Oxygen via face mask/nasal prongs to achieve normal saturations
their most severe features Oxygen via face mask/nasal prongs to achieve normal saturations
! β2 agonist 2-4 puffs ! β2 agonist 10 puffs ! Nebulised β2 agonist:

! β2 agonist 2-4 puffs ! β2 agonist 10 puffs ! Nebulised β2 agonist:
via spacer ± facemask via spacer ± facemask salbutamol 2.5 mg
via spacer via spacer salbutamol 5 mg
or nebulised salbutamol or terbutaline 5 mg plus or nebulised salbutamol 2.5-5 or terbutaline 10 mg plus
! Increase β2 agonist dose
2.5 mg or terbutaline 5 mg ipratropium bromide ! Increase β2 agonist dose mg or terbutaline 5-10 mg ipratropium bromide
by 2 puffs every 2
! Soluble prednisolone 20 mg 0.25 mg nebulised by 2 puffs every 2 0.25 mg nebulised
minutes up to 10 puffs ! Oral prednisolone 30-40 mg
according to response or IV hydrocortisone 4 mg/kg ! IV hydrocortisone 4 mg/kg minutes up to 10 puffs
or IV hydrocortisone 4 mg/kg ! IV hydrocortisone 4 mg/kg
according to response
! Repeat β2 agonist up to if vomiting
! Consider soluble oral Discuss with senior clinician,
every 20-30 minutes ! Oral prednisolone ! If poor response nebulised Discuss with senior clinician,
prednisolone 20 mg PICU team or paediatrician
according to response 30-40 mg ipratropium bromide 0.25 mg PICU team or paediatrician
! If poor response add 0.25 ! Repeat bronchodilators ! Repeat β2 agonist and
Reassess within 1 hour mg nebulised ipratropium ipratropium up to every 20-30 ! Repeat bronchodilators
every 20-30 minutes Reassess within 1 hour
bromide minutes according to response every 20-30 minutes
ASSESS RESPONSE TO TREATMENT ASSESS RESPONSE TO TREATMENT

Record respiratory rate, heart rate and oxygen saturation every 1-4 hours Record respiratory rate, heart rate, oxygen saturation and PEF/FEV every 1-4 hours
RESPONDING NOT RESPONDING RESPONDING NOT RESPONDING

! Continue bronchodilators 1-4 hours prn ! Arrange HDU/PICU transfer ! Continue bronchodilators 1-4 hours prn ! Continue 20-30 minute nebulisers and
! Discharge when stable on 4 hourly treatment Consider: ! Discharge when stable on 4 hourly arrange HDU/PICU transfer
treatment Consider:
! Continue oral prednisolone for up to 3 days ! Chest x-ray and blood gases
! Continue oral prednisolone 30-40 mg ! Chest x-ray and blood gases
At discharge ! IV salbutamol 15 mcg/kg bolus for up to 3 days ! Bolus IV salbutamol 15 mcg/kg
over 10 minutes if not already given

! Ensure stable on 4 hourly inhaled treatment At discharge
followed by continuous infusion ! Continuous IV salbutamol infusion
! Review the need for regular treatment and ! Ensure stable on 4 hourly inhaled treatment
1-5 mcg/kg/min (dilute to 200 mcg/ml) 1-5 mcg/kg/min (200 mcg/ml solution)
the use of inhaled steroids ! Review the need for regular treatment and
! IV aminophylline 5 mg/kg loading the use of inhaled steroids ! IV aminophylline 5 mg/kg loading dose
! Review inhaler technique dose over 20 minutes (omit in those over 20 minutes followed by continuous
! Review inhaler technique
! Provide a written asthma action plan for receiving oral theophyllines) ! Provide a written asthma action plan for infusion 1mg/kg/hour (omit in those
treating future attacks followed by continuous infusion treating future attacks receiving oral theophyllines)
! Arrange follow up according to local policy 1 mg/kg/hour ! Arrange follow up according to local policy ! Bolus IV infusion of magnesium sulphate
40 mg/kg (max 2 g) over 20 minutes
7
Management of acute asthma in infants aged <2 years in hospital
ASSESS ASTHMA SEVERITY

NB: If a patient has signs and symptoms across categories, always treat according to their most severe features
Moderate Severe
! Sp02 ≥ 92% ! Sp02 <92%
! Audible wheezing ! Cyanosis
! Using accessory muscles ! Marked respiratory distress
! Still feeding ! Too breathless to feed
Most infants are audibly wheezy with intercostal recession but not distressed
Life threatening features include apnoea, bradycardia and poor respiratory effort
Immediate management
Oxygen via close fitting face mask or nasal prongs to achieve normal saturations
Continuous close monitoring

Give trial of β 2 agonist: salbutamol up to 10 puffs
via spacer and face mask or nebulised salbutamol ! heart rate
2.5 mg or nebulised terbutaline 5 mg ! pulse rate
Repeat β2 agonist every 1-4 hours if responding ! pulse oximetry
! supportive nursing care with adequate
If poor response:
hydration
Add nebulised ipratropium bromide 0.25 mg ! Consider the need for a chest x-ray
Consider: soluble prednisolone 10 mg daily for
up to 3 days If not responding or any life threatening features
discuss with senior paediatrician or PICU team
Asthma medicines in emergency asthma care
Medicine / Generic name Adult dose Paediatric dose
Oxygen High flow High flow Adults and children with severe asthma are
hypoxaemic and should be given high flow
oxygen to maintain oxygen saturation at 92%
or above
ß2 agonist bronchodilators/ Ideally salbutamol 5mg or terbutaline 10mg via Two to four puffs repeated every 20–30 minutes according These act quickly to relieve bronchospasm and
salbutamol, terbutaline oxygen driven nebuliser or 4–6 puffs spacer to clinical response for mild attacks, up to 10 puffs for have few side effects and should be adminis-
Repeat doses should be given at 15–30 minute more severe asthma via a pMDI* + spacer ± facemask. tered as early as possible in an asthma attack.
intervals or continuous nebulisation of salbutamol Children who have not improved after receiving 10 puffs Used as first line treatment
at 5–10mg/hour if inadequate response to initial should be referred to hospital and further doses given
treatment In children pMDI + spacer is preferable method
while awaiting transfer of delivery
During transfer to hospital 2.5–5mg salbutamol or 10 PUFFS VIA SPACER IS JUST AS EFFECTIVE AS
5–10mg terbutaline via nebuliser NEBULISER UNLESS FEATURES OF
In severe asthma a bolus dose of IV salbutamol (15mcg/kg) LIFE-THREATENING ASTHMA ATTACK
in addition to nebulised salbutamol can be effective in

children over 2 years.
Bronchodilators/Ipratrapium 0.5mg 4–6 hourly mixed with nebulised beta 2 0.25mg used in first two hours of severe asthma
agonist in severe or life threatening asthma or those attack mixed with nebulised beta 2 agonist
with a poor initial response to beta 2 agonist therapy every 20–30 minutes
Steroids/Prednisolone 40–50mg daily for 3–7 days or until recovery Soluble prednisolone Steroid tablets reduce mortality, relapses and
30–40mg daily for children 5–12 years old hospital admissions, and the earlier they are
20mg for children 2–5 years old given in an attack the better the outcome.
10mg for children < 2years old Following recovery steroid tablets can be
dropped abruptly and do not need tapering
provided that the patient is receiving inhaled
steroids (apart from those patients on
maintenance steroid tablets or where steroids
tablets are needed for more than three weeks)
Steroids/Hydrocortisone IV 400mg* (100mg, 6 hourly) 4mg/kg body weight, 4 hourly ONLY IV IF COMATOSE OR VOMITING AS ORAL
PREDNISOLONE IS JUST AS EFFECTIVE
IV Magnesium sulphate 1.2–2g IV infusion over 20 minutes but should Use only after consultation with senior medical staff Consider giving single IV dose for patients with
only be used following consultation with senior severe asthma who have not had a good initial
medical staff response to inhaled bronchodilator therapy or
for life-threatening or near fatal asthma attacks
IV aminophylline Use only after consultation with senior medical staff Use only after consultation with senior medical staff
Antibiotics Routine prescription of antibiotics is not

indicated for asthma. Infection often triggers
an episode but is more likely to be viral rather
than bacterial in type
* IV = intravenous * pMDI = pressurised metered dose inhaler

9
Inhaler technique
The most effective way of taking most asthma medicines is to inhale them so they get straight
into the lungs. The best inhaler device is one that the patient can and will use. The correct
inhaler and technique is central to achieving the greatest benefit from asthma medicines.
Before discharge ask the patient to demonstrate their technique and correct accordingly.
Metered dose inhaler

1. Remove cap and shake inhaler.
2. Breathe out gently.
3. Put mouthpiece in mouth and as you begin to breathe in, which
should be slow and deep, press canister down and continue to
inhale steadily and deeply.
4. Hold breath for 10 seconds, or as long as is comfortable, and
remove inhaler from mouth.
5. For a second dose wait for approximately 30 seconds before
repeating steps 1–4.
6. Replace cap. Only use the inhaler for the total number of doses
on the label, then start a new inhaler.
Accuhaler
1. Hold the outer casing of the accuhaler in one hand while
pushing the thumb grip away with thumb of other hand until a
click is heard.
2. Holding accuhaler with mouthpiece towards you, slide lever
away until it clicks. This makes the dose available for inhalation
and moves the dose counter on.
3. Breathe out gently. Holding device horizontally put mouthpiece
in mouth and suck in quickly and deeply.
4. Remove accuhaler from mouth and hold breath for about 10
seconds or as long as is comfortable.
5. To close, slide thumb grip back towards you as far as it will go
until it clicks.
6. For a second dose, repeat steps 1–5. The counter on top of the
accuhaler tells you how many doses are left. Numbers 5 to 0 will
appear in red, to warn you the inhaler is almost empty.
Turbohaler
1. Unscrew and lift off white cover. Hold turbohaler upright and
twist grip forwards and backwards as far as it will go. You
should hear a click.
2. Breathe out gently, put in mouth and breathe in as deeply as
possible. Even when a full dose is taken there may be no taste.
3. Remove from mouth and breathe out slowly.
4. Replace white cover. To take another dose repeat steps 1–3.
When a red line appears at top of window on inhaler, there are
approximately 20 doses left. Some turbohalers have a dose
counter to tell you how many doses are left.
Easi-breathe
1. Shake inhaler, hold upright and open cap.
2. Breathe out gently. Hold inhaler upright, put mouthpiece in
mouth and close lips and teeth around it. Do not block the air
holes on top.
3. Breathe in steadily through mouthpiece. Do not stop breathing
when the inhaler ‘puffs’ but continue taking a deep breath. Hold
breath for 10 seconds or as long as is comfortable and remove
inhaler from mouth.
4. After use, hold inhaler upright and immediately close cap.
For a second dose, wait for approximately 30 seconds before
repeating sections 1–3. Only use the inhaler for the total
number of doses on the label, then start a new inhaler.
Autohaler
1. Remove cap. Hold autohaler upright and push grey lever up.
Shake inhaler.
2. Breathe out gently. Keeping inhaler upright, put in mouth and
close lips around it (the air holes at the bottom must not be
blocked by your hand).
3. Breathe in steadily through mouthpiece. Do not stop breathing
when inhaler ‘clicks’ – continue taking a deep breath. Hold
breath for 10 seconds or for as long as is comfortable and
remove inhaler from mouth. Lower grey lever.
4. To take another dose repeat steps 1–3. Wait for approximately
30 seconds before taking another dose. The lever must be
pushed up (‘on’) before each dose, and pushed down again
(‘off’) afterwards. Only use the inhaler for the total number of
doses on the label, then start a new inhaler.
Spacer (small volume)

1. Remove caps from inhaler and spacer. Shake inhaler and insert
in back of spacer.
2. Breathe out gently. Place mouthpiece of spacer in mouth.
3. Press canister once to release a dose of medicine.
4. Take a deep, slow breath in. If you hear a whistling sound, you
are breathing in too quickly. Hold breath for 10 seconds or as
long as is comfortable. Remove spacer and breathe out.
5. To take another dose, wait for about 30 seconds then repeat
steps 1–4.
Spacer – young children (small volume)

1. Remove cap from inhaler, shake inhaler and insert into back of
spacer.
2. Place mask of spacer over mouth and nose of child and ensure
there is a good seal.
3. Encourage child to breathe in and out slowly and gently.
4. Once breathing pattern is established, press canister and keep
it in same position as child continues to breathe in and out
slowly five more times.
5. Remove mask from child’s face.
6. To take another dose, wait approximately 30 seconds then
repeat steps 1–5.
Spacer (large volume)

1. Remove cap from inhaler, shake inhaler and insert into back of
spacer.
2. Breathe out gently. Place mouthpiece of spacer into mouth.
3. Press inhaler canister once to release one puff of medicine.
4. Take one deep, slow breath in, then hold breath for about 10
seconds or as long as is comfortable. This is the ‘single breath
technique’ of using a spacer.
5. Remove inhaler from mouth and breathe out.
6. To take another dose, wait approximately 30 seconds then
repeat steps 1–5. NB. Refer to manufacturers’ instructions for
the ‘multiple breath technique’.
A demonstration of correct inhaler technique for the eight most popular devices is part of the
Emergency Asthma Care Training CD-Rom and can also be found at Asthma UK’s website
www.asthma.org.uk/inhalerdemo
Assessment form for emergency asthma care
Patient name:
DOB:
Date/time:
1. Date(s) of last asthma attack requiring emergency treatment
2. PEF before initial reliever treatment
PEF after treatment
3. Best PEF (or predicted)*
4. Pulse oximetry. SpO2 (in room air or specify dose of O2 if given)
5. Arterial Blood Gas readings if SpO2 <92% or any other feature of life threatening asthma
6. Pulse rate
7. Respiratory rate
8. Inhaler technique observed (good, moderate, poor)
9. Inhaler device(s)
10. Current medication including dose
11. Triggers
12. In the last week or month:
asthma symptoms at night
asthma symptoms during the day
asthma symptoms interfering with usual activity?
13. Smoker (current, ex, passive)
Smoking pack years
14. Asthma (self/in family)
Eczema (self/in family)
Hayfever (self/in family)
15. Allergies
16. Past medical history (PMH)
17. Psychological factors
18. Social factors
19. Other significant factors eg pregnant, a carer, away from home
20. Communication difficulties
* See appendix of Emergency Asthma Care Pack for peak flow chart
Discharge letter following emergency asthma care
Patient name: DOB:
Date/time:
Dear
This patient was treated today for an asthma attack.
Age Height Best or predicted peak flow
Initial assessment On discharge

PEF
SpO2
Pulse
Respiratory rate
We have discussed
inhaler use/technique with (type)

medicines including potential side effects
trigger avoidance
smoking cessation
how to recognise worsening asthma and what to do in an asthma attack.
Other important issues
They have been given written information and details of the Asthma UK Adviceline (08457 01 02 03)
and the Asthma UK website (asthma.org.uk).
They have a follow up appointment

with (name)
on (date and time)
at (venue) (phone)
They have been discharged with the following medicines
Yours sincerely Contact details

Audit form for emergency asthma care (sample)
Patient name: Anne Smith

DOB: 07-03-1966 Date/time: 25-11-2006 23.00
YES NO NA
1 PEF on admission and after treatment (in anyone over 5 years)
2 Pulse rate, respiratory rate and SpO2 . Where SpO2 < 92% check arterial
blood gases and give oxygen as appropriate
3 Inhaler technique checked and recorded
4 Relevant past medical history recorded (asthma and atopy in particular)
5 Triggers identified and avoidance discussed
6 Current medicines recorded, including dose, frequency
7 Concordance issues addressed
8 Psycho-social or other risk factors (or their absence) recorded
9 Stable on four hourly treatment or when PEF >75% of best or predicted
10 Steroid tablets given as appropriate, as per BTS/SIGN British Guideline on
the Management of Asthma
11 Provided written information and action plan
12 Follow-up with GP for 48 hours after discharge arranged and

discharge letter sent
Where you have ticked N/A (not applicable) please explain here eg No Peak flow as under 5
2. Sp O2 of 95% therefore no blood gases taken.

Audit form for emergency asthma care
Patient name:
DOB: Date/time:
YES NO NA
1 PEF on admission and after treatment (in anyone over 5 years)
2 Pulse rate, respiratory rate and SpO2 . Where SpO2 < 92% check arterial
blood gases and give oxygen as appropriate
3 Inhaler technique checked and recorded
4 Relevant past medical history recorded (asthma and atopy in particular)
5 Triggers identified and avoidance discussed
6 Current medicines recorded, including dose, frequency
7 Concordance issues addressed
8 Psycho-social or other risk factors (or their absence) recorded
9 Stable on four hourly treatment or when PEF >75% of best or predicted
10 Steroid tablets given as appropriate, as per BTS/SIGN British Guideline on
the Management of Asthma
11 Provided written information and action plan
12 Follow-up with GP for 48 hours after discharge arranged and
discharge letter sent
Where you have ticked N/A (not applicable) please explain here eg No Peak flow as under 5
Patient Group Directions
Prescription-only medicines are normally supplied and administered in response to a

prescription written by a doctor. However, it is now possible, in some circumstances, for
medicines to be supplied or administered in accordance with a ‘patient group direction’ (PGD).
A PGD is a written instruction for the supply or administration of medicines to groups of

patients who may not be individually identified before presentation for treatment (ie without a
prescription written by a doctor).
When writing up a PGD you will need to:
1. Reach agreement within your team on the need for a PGD and the benefits it may bring as
well as identifying potential disadvantages.
2. Identify clinical situations which require a PGD eg salbutamol and oxygen as first line
treatment in an asthma attack.
3. Identify which named staff will be able to use the PGD in your area and ensure clear lines
of accountability/responsibility. (PGDs can be used by a variety of healthcare professionals
eg nurses, pharmacists and physiotherapists.)
4. Clarify the parameters or circumstances in which the particular medicine(s) can be given.
eg If SpO2 is 92% or below give high flow oxygen.
5. Agree on the content of your PGD with the lead clinician or prescribing clinicians involved.
6. Ensure that all PGDs comply with the criteria listed in HSC 2000/026 and in Appendix A
of the first report of the Department of Health’s Review of prescribing, supply and
administration of medicines (1999).
7. Once written, use the PGD on a trial basis to identify where changes may be necessary.
The following pages contain an example PGD which can be adapted for your use.
Patient group direction for

the supply and administration
of salbutamol
Adopted by:
On:
Review date:
Department:
Responsible for review:
Signature 1:
Signature 2:
Direction for the administration of; Salbutamol via pMDI and large volume
spacer (+/-mask)
Clinical need which this direction is intended Emergency intervention in asthma

to address
Objectives of care this direction will provide Relief of symptoms in asthma
Relevant national guidance British Thoracic Society/SIGN Guidelines (2005)

Summary of Product Characteristics (SPC)
Department of Health guidance
CLINICAL CONDITION
1. Definition of condition Pre diagnosed asthma (reversible airways

obstruction)
2. Criteria for confirming condition Registered nurse (RN) assessment of patient
3. Clinical criteria under which patient will be Male & female patients over the age
eligible for inclusion in this direction (eg of 18 months
age, gender, clinical need etc)
4. Criteria which exclude the patient from Patients with a known allergy to Salbutamol
treatment under this direction
5. Details of action to be followed for Refer to doctor or A&E

patients excluded under this direction
6. Details of action to be followed for • Discuss alternatives with doctor and patient
patients who do not wish to receive, or do • Document in patient notes
not adhere to care under this direction
7. Professional qualification to be held by RN who has received the appropriate training

staff undertaking this direction (eg and is deemed competent to administer or
Registered Nurse, additional qualifications) supply this medicine under Patient Group
Direction.
8. (Alternatively) Competencies required to RN with one of the following;

be held by staff undertaking this direction Diploma in Asthma Care or Emergency Care
(eg list of skills expected of staff qualification eg Nurse Practitioner
undertaking this direction)
9. Specialist qualifications, training, Nurses will undertake a course designed to equip

experience and competence considered them to safely supply and administer medicines
necessary and relevant to the clinical under group direction at least every two years. The
condition treated under this direction and course will have input from Respiratory Doctor
competence assured.
The course will include:
• Professional accountability/the principles of
using Patient Group Directions
• Differential diagnosis / patient assessment
• Local guidelines
• Pharmacology
• Interactions / possible side effects
Staff should reflect on times they have used this

PGD in practice and how, if at all, it may need to
be reviewed or adapted to suit ongoing needs.
TREATMENT
10. Name of medicine(s) supplied under this Salbutamol 100mcg pMDI + Large volume
direction Spacer
11. Method of obtaining supplies Requisition from pharmacy
12. How is informed consent Informed consent on patient records/notes

obtained/documented (state known allergies)
13. Name of medicine(s) administered under Salbutamol

this direction
14. Legal status of medicine(s) eg GSL Prescription only medicine (POM)
15. Doses of medicine(s) which can be Up to 10 puffs

administered where a range of dose
is permissible, the criteria for deciding
the dose
16. Method or route of administration Inhalation through large volume spacer;
In patients under three years a mask should

also be used
17. If more than a single dose is permitted - One treatment only while seeking emergency
the frequency of dosing medical help ie 10 puffs
18. Total dose of medicine to be Up to 1000 mcg

supplied/administered
20. Number of times treatment may be Once only – urgent referral if not improved
administered
21. Period of time over which medicines may Administered on site at time – generally over a
be administered period of 5–10 minutes.
22. Follow-up treatment which may be Measurement of general observations including

required (eg review of symptoms and peak flow 15–20 minutes after treatment for
referral, if necessary) comparison against initial observations. Arrange
for a doctor to physically examine the patient to
continue appropriate treatment. Refer to BNF and
SPC for complete list of possible adverse events.
23. Advice (including any written advice) to be • Medicine is only provided for symptom relief
given to the patient or carer before or after in this event and follow up treatment through
treatment (use product information leaflet the GP or practice nurse must be obtained if
if available) the patient was not referred to hospital as a
result of this event.
• Give a copy of Asthma UK’s After Your Asthma
Attack or After Your Child’s Asthma Attack
booklet and fill in with patient.
• Discuss the importance of asking for a written
asthma action plan at their next asthma
review (or fill one in with them if appropriate).
24. Instructions on identifying and managing • Tremor

possible adverse outcomes (see BNF) • Tension headache
• Arrhythmias
• Palpitations
Contact the Doctor
25. Arrangements for referral to medical advice Patient advised to attend GP or A&E
26. Site for treatment (eg Health centre) A&E Department
27. Facilities and supplies which should be Diagnostic and examination facilities, including
available at the site where this direction is anaphylaxis cover in A&E Department
operated
28. Treatment records completed Patient records/notes

30. Audit trail for treatment records Records may be traced through hospital
manager/practice manager/nurse lead
31. Special precautions concerning • Beta blockers

concurrent medicine and (checks to • Patients with hyperthyroidism
ensure patient is not currently taking • Cardiovascular disease/arrhythmias
medicine which duplicates or interacts • Diabetes
with direction medicine)
MANAGEMENT AND MONITORING
32. Authors of this PGD (names and job title of

authors)
33. Professional advisory groups and

professionals who have contributed to
this PGD
34. Name of manager authorising the use of Dr A Evans

this PGD (eg Medical Director)
35. Identify healthcare professional providing Patient notes

treatment (eg by signature)
36. How can the patient receiving treatment Patient notes

be identified? (eg by name/address on
record, cross ref, medical card no)
37. How can the medicine be identified Batch Number and expiry date to be recorded on
(including its batch number etc)? patient notes
38. Instructions on reporting suspected Refer to Doctor

adverse drug reactions
39. Date of PGD May 2007
40. Date this direction becomes due for review March 08
References
Patient Group Directions (England Only) HSC 2000/026
British National Formulary (BNF) No. 53 March 2007
British Guideline for the Management of Asthma 2005
Asthma UK 2007
Useful contacts – national
Asthma UK Adviceline Asthma UK

Ask an asthma nurse specialist Summit House, 70 Wilson Street,
08457 01 02 03 London EC2A 2DB
asthma.org.uk/adviceline T020 7786 4900
F 020 7256 6075
Asthma UK website
Read the latest independent advice Asthma UK Cymru
and news on asthma Eastgate House, 34-43 Newport Road,
asthma.org.uk Cardiff CF24 0AB
wales@asthma.org.uk
Asthma UK publications
Asthma UK Northern Ireland
Peace House, 224 Lisburn Road,
Belfast BT6 6GE
ni@asthma.org.uk
Asthma UK Scotland
4 Queen Street, Edinburgh EH2 1JE
scotland@asthma.org.uk
Asthma UK has produced emergency Allergy UK

care information booklets for you to use 3 White Oak Square
with patients after they have had an London Road,
asthma attack. Swanley, Kent BR8 7AG
Allergy Helpline: 01322 619898
For free copies of After your Asthma Attack info@allergyuk.org
and After your Child’s Asthma Attack or any
other Asthma UK publications contact: Association of Respiratory Nurse Specialists
17 Doughty Street
Supporter & Information Team London WC1N 2PL
020 7786 5000 T 020 7269 5793
info@asthma.org.uk info@arns.co.uk
Asthma Society of Ireland

26 Mountjoy Square,
Dublin 1
T 01 -8788511
office@asthmasociety.ie
British Lung Foundation

73–75 Goswell Road
London EC1V 7ER
T 08458 50 50 20
T 020 7688 5555
The British Thoracic Society MedicAlert®

17 Doughty Street 1 Bridge Wharf
London 156 Caledonian Road
WC1N 2PL London N1 9UU
T 020 7831 8778 T 0800 581420
bts@brit-thoracic.org.uk T 020 7833 3034
info@medicalert.org.uk
Child Death Helpline
Great Ormond Street Hospital Medicines and Healthcare Products
Great Ormond Street Regulatory Agency
London WC1N 3JH Information Centre
T 020 7813 8551 10–2 Market Towers
1 Nine Elms Lane
Citizens Advice London
Myddelton House, SW8 5NQ
115–123 Pentonville Road, T 020 7084 2000
London, N1 9LZ info@mhra.gsi.gov.uk
For your local branch visit
www.citizensadvicebureau.org.uk NHS Direct
or call 020 7833 2181 T 0845 46 47
Education for Health (formerly National NHS 24

Respiratory Health Centre) T 0845 4242429
The Athenaeum
10 Church Street NHS Smoking Helpline
Warwick T 0800 169 0 169
CV34 4AB
T 01926 493313 Quit
enquiries@educationforhealth.org.uk 4th Floor
211 Old Street
General Practice Airways Group (GPIAG) London EC1V 9NR
Smithy House T 020 7251 1551
Waterbeck
Lockerbie DG11 3EY Respiratory Education UK
T 01461 600639 University Hospital Aintree, Lower Lane,
info@gpiag.org Liverpool L9 7AL
T 0151 529 2598
Global Initiative For Asthma (GINA) www.respiratoryeduk.com
www.ginasthma.com
Samaritans
Latex Allergy Support Group T 0845 90 90 90
PO Box 27 jo@samaritans.org
Filey YO14 9YH
07071 225838
latexallergyfree@hotmail.com
T 07071 225838 – available between

7.00pm and 10.00pm
Useful contacts – local
Allergist Paediatrician (respiratory)

........................................................................................... ...........................................................................................
........................................................................................... ...........................................................................................
Asthma nurse specialist Pharmacist

........................................................................................... ...........................................................................................
........................................................................................... ...........................................................................................
Consultant physician (respiratory) Physiotherapist

........................................................................................... ...........................................................................................
........................................................................................... ...........................................................................................
ENT specialist School nurse

........................................................................................... ...........................................................................................
........................................................................................... ...........................................................................................
GP with special interest in asthma Support group

........................................................................................... ...........................................................................................
........................................................................................... ...........................................................................................
Health visitor Respiratory Clinic (adults)

........................................................................................... ...........................................................................................
........................................................................................... ...........................................................................................
Lung Function Department Respiratory Clinic (paediatrics)

........................................................................................... ...........................................................................................
........................................................................................... ...........................................................................................
Useful websites
General asthma resources Stop smoking resources

Asthma UK Local NHS Stop Smoking Service – Locator
www.asthma.org.uk https://data.gosmokefree.co.uk/
localservicesearch.aspx
British Thoracic Society (BTS)
www.brit-thoracic.org.uk NHS Stop Smoking Service
www.gosmokefree.co.uk
BTS/SIGN Guideline on Asthma
Management, November 2005 Update Medicine resources
www.brit-thoracic.org.uk/
Guidelinessince%201997_asthma_html British National Formulary (BNF)
www.bnf.org
General Practice Airways Group (GPIAG)
www.gpiag.org British National Formulary for Children
(BNFC)
Global Allergy & Asthma European Network www.bnfc.org
www.ga2len.net
MIMS
Global Initiative For Asthma (GINA) www.healthcarerepublic.com/mims
www.ginasthma.com
Electronic Medicines Compendium – access
Lung & Asthma Information Agency (LAIA) to most summaries of product characteristics
www.laia.ac.uk www.emc.medicines.org.uk
Miscellaneous
Asthma training resources
Patient Group Directions
Education For Health (incorporates National www.portal.nelm.nhs.uk/PGD/default.aspx
Respiratory Training Centre)
www.educationforhealth.org.uk
Respiratory Education UK
www.respiratoryeduk.com
Underoak UK Training Index

www.underoak.co.uk
Practitioner Development UK Ltd

www.pduk.net
Normal values for peak expiratory flow on the EU scale
AGE HEIGHT (CM)
(yrs) 135 140 145 150 155 160 165 170 175 180 185 190 195
(4ft 5in) (4ft 7in) (4ft 9in) (4ft 11in) (5ft 1in) (5ft 3in) (5ft 5in) (5ft 7in) (5ft 9in) (5ft 11in) (6ft 1in) (6ft 3in) (6ft 5in)
15 454 467 479 491 502 512 523 532 542 551 559 568 576
20 508 522 536 549 561 573 585 596 606 616 626 635 644
25 541 557 571 585 598 611 623 635 646 656 667 677 686
30 559 575 590 604 618 631 644 656 667 678 689 699 709
35 566 582 597 611 625 638 651 663 675 686 697 707 717
40 563 579 594 609 622 636 648 660 672 683 694 707 714
45 554 570 585 599 612 625 638 650 661 672 683 693 703
Male
50 540 556 570 584 597 610 622 633 645 655 666 676 685
55 523 538 551 565 578 590 602 613 624 634 644 654 663
60 503 517 530 543 555 567 578 589 600 610 619 628 637
65 481 494 507 519 531 542 553 564 574 583 592 601 610
70 458 471 483 495 506 516 527 537 546 555 564 572 580
75 434 446 458 469 480 490 500 509 518 527 535 543 551
80 410 422 433 443 453 463 472 481 490 498 506 513 520
15 379 387 394 401 408 414 420 426 431 437 442 447 451
20 402 410 418 426 433 440 446 452 458 464 469 474 479
25 414 422 430 438 445 452 459 465 471 477 483 488 493
30 417 426 434 442 449 456 463 469 475 481 487 492 497
35 415 424 432 440 447 454 461 467 473 479 484 490 495
40 409 417 425 433 440 447 454 460 566 472 477 482 487
45 400 408 416 423 430 437 443 450 455 461 466 471 476
50 389 396 404 411 418 425 431 437 442 448 453 458 463
Female
55 376 383 391 398 404 411 417 422 428 433 438 443 448
60 362 369 376 383 389 395 401 407 412 417 422 427 431
65 347 354 361 368 374 379 385 390 395 400 405 409 414
70 332 339 346 352 358 363 368 374 378 383 387 392 396
75 317 324 330 336 341 347 352 357 361 366 370 374 378
80 302 308 314 320 325 330 335 340 344 348 352 358 360
Normal values for ‘EU-scale’ peak flows in Litres per Minute BTPS derived from modified Nunn and Gregg values (MR Miller – Airways J 2004; 2(2):80-2.).
From Sept 2004 the EU scale must be used on peak flow meters.
27
Normal ‘EU scale’ values for peak

expiratory flow in young people
FEMALE LITRES PER HEIGHT MALE LITRES PER

MINUTE (BTPS) (CM) MINUTE (BTPS)
65 100 66
119 110 121
173 120 176
226 130 231
280 140 286
333 150 341
387 160 395
441 170 450
494 180 505
548 190 560
Normal values for ‘EU-scale’ peak flows in litres per minute BTPS
derived from modified Godfrey equations (Godfrey S, Kamburoff PL,
Naim JL. Spirometry, lung volumes and airway resistance in normal
children ages 5 to 18. Br J Dis Chest 1970; 64: 15-24.) From Sept
2004 the EU scale must be used on peak flow meters.
Read codes
Diagnosis codes
A
Acidosis – respiratory C3621.
Alkalosis – respiratory C3631.
Allergic rhinitis (hayfever) H172.
Anxiety state Eu411
Anxiety with depression Eu412
Asbestosis with pleural plaque disease H410.
Asbestosis H41..
Asperger’s syndrome Eu845
Asthma – acute attack H333.
Asthma – extrinsic H330.
Asthma – intrinsic H331
Asthma H33..
B
Bronchiectasis H34..
Bronchiolitis – RSV positive H0615
Bronchiolitis H061.
Bronchitis – acute H060.
Bronchopneumonia H25..
C
Chronic obstructive pulmonary disease (COPD) Mild H36..
Chronic obstructive pulmonary disease (COPD) Moderate H37..
Chronic obstructive pulmonary disease (COPD) Severe H38..
Cushing’s syndrome C150.
D
Depression – with anxiety Eu412
Depression Eu32.
E
Eczema – infantile M112.
Eczema M111.
Extrinsic allergic alveolitis H35z0
M
Manic depression (bipolar affective disorder) Eu31.
Mesothelioma BBPX.
P
Pertussis (whooping cough) (bordetella) A33..
Pleural plaque disease (see also asbestosis) H410.

Pneumonia – atypical H28..
Pneumonia – basal H261.
Pneumonia – congenital Q310.
Pneumonia – lobar H260.
Pneumonia – viral H20..
Pneumonia H2…
Pneumothorax H52..
Polyp – nasal H11..
R
Reflux – gastro-oesophageal (GOR) J10y4
Respiratory acidosis C3621
Respiratory alkalosis C3631
Respiratory distress syndrome (RDS) Q30..
S
Sinusitis – acute H01..
Sinusitis – chronic H13..
Sinusitis – recurrent H135.
U
Upper respiratory tract infection (URTI) – recurrent H054.
Upper respiratory tract infection (URTI) H05z.
W
Whooping cough (Bordetella pertussis) A33..
Read codes
Monitoring codes
GENERAL MONITORING
Height 229..
Weight 22A..
Body mass index 22K..
Smoking status codes
Cigarette smoker 137P.
Cigar smoker 137J.
Pipe smoker 137H.
Passive smoker 137I.
Rolls own 137M
Ex-smoker, cigarettes 137S.
Ex-smoker, cigars 137O.
Ex-smoker, pipe 137N.
Smoking cessation advice 8CAL
Health Education 8CA4
Smoking 6791.
Diet 6799.
Exercise 6798.
Alcohol 6792.
ASTHMA
Symptoms
Cough 171..
Night cough present 1717.
Night cough absent 1718.
Wheezing 1737.
Nocturnal cough/wheeze 173B.
Asthma limiting activities 663P.
Asthma not limiting activities 663Q.
Asthma disturbing sleep 663N.
Asthma not disturbing sleep 663O.
Exercise induced asthma 173A.
Indicators
Peak flow 3395.
Peak flow (PEFR) using EN13826 device 339o.
Predicted peak flow 339H.
Best peak flow 339D.
Spirometry 5882.
Spirometry reversibility negative 33G0.
Spirometry reversibility positive 33G1.
FEV1 3397.
FEV1/FVC 339M.
Treatment
Asthma prophylaxis used 663W.
Inhaled steroid use 663g.
Oral steroids started 663F.
Steroid dose inhaled daily 663Y.
Bronchodilators used a maximum once daily 663M.
Bronchodilators used more than once daily 663L.
Nebuliser therapy 8674.
Oral steroids started 663F.
Spacer device in use 663I.
Monitoring
Asthma monitoring 663..
Initial asthma assessment 6631.
Follow-up asthma assessment 6632.
Asthma monitoring by nurse 66YQ.
Asthma monitoring by doctor 66YR.
Asthma annual review 66YJ.
Asthma – currently dormant 663h.
Asthma – currently active 663j.
Asthma resolved 21262
Asthma monitoring refused 9OJ2.
Respiratory disease treatment started 663C.
Respiratory disease treatment changed 663B.
Respiratory disease treatment stopped 663D.
Inhaler technique good 663H.
Inhaler technique poor 663I.
Inhaler technique observed 6637.
Inhaler technique shown 6636.
Asthma leaflet given 8CE2.
Asthma management plan given 663U.
Other Useful Codes

Family history of asthma 12D2.
Referral to chest physician 8H4C.
Referral to paediatrician 8H42.
Emergency admission, asthma 8H2P.
Acute exacerbation of asthma H333.
MENTAL HEALTH
History and Examination
Symptoms 1B1..
Anxiousness 1B13.
Agitated 1B16.
Depressed 1B17.
Inadequate 1B18.
Suicidal 1B19.
Memory loss – amnesia 1B1A.
Cannot sleep – insomnia 1B1B.
Hallucinations 1B1E.
Rambling 1B1F.
Excess crying 1B1I.
Emotional problems 1B1J.

Frightened 1B1H.
Lonely 1B1K.
Stress related problems 1B1L.
Poor self esteem 1B1N.
Harmful thoughts 1BD..
Flight of ideas 1BG..
Delusions 1BH..
Mood swings 1BO..
Blunted affect 1BI..
Social History
Housing
Housing Lack 13D..
Inadequate housing 13E..
Housing dependency scale 13F..
Employment
Occupation 0….
Early retirement 13J4.
Medically retired 13J6.
Unemployed 13J7.
Unfit for work 13JJ.
Mental state examination 28…
O/E – disorientated 284..
Neurotic condition – insight 285..
Neurotic condition – no insight 286..
Confabulation 28D..
Cognitive decline 28E..
Forgetful 28G..
Easily distractible 28B..
Management and Monitoring

Psychotherapy
Behavioural psychology 8G10.
Cognitive psychotherapy 8G11.
Psychodynamic psychotherapy 8G12.
Family therapy 8G21.
Group psychotherapy 8G51.
Antiphobic psychotherapy 8G52.
Anxiety management 8G94.
Child guidance 8GD..
PROCEDURE CODES
Bronchoscopy 744B.
Lung transplant 7450.
Nasal polypectomy 74060.
Seen in chest clinic 9N1b.

Seen in paediatric clinic 9N1v.
Read codes
Exception Codes
Nicotine replacement therapy refused 8I39
ALLERGY OR ADVERSE REACTION

Aspirin allergy 14LK
Influenza vaccine allergy 14LJ
Pneumococcal vaccine allergy 14LR
Adverse reaction to Beta blockers TJC6
Adverse reaction to Salicylates TJ53
Spirometry testing declined 8I3b
Influenza vaccination declined 9OX5
MEDICATION CONTRA-INDICATED
Aspirin prophylaxis contra-indicated 8I24
Beta blocker contraindicated 8I26
Influenza vaccination contraindicated 8I2F
Pneumococcal vaccination contraindicated 8I2E

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Emergency Asthma Care

Access to Emergency Asthma Care

Asthma Treatment Pathways

Discharge and follow-up

Access to emergency asthma care 4

Asthma treatment pathways 13

Discharge and follow-up after an 18

Further resource materials are contained within this pack – including an

It is shocking that 1 in 6 people with asthma who have received treatment

Professor Martyn Partridge MD FRCP

• guidance on evidence-based standards of emergency asthma care, no

• templates to adapt to your own setting – eg assessment form, discharge

• Emergency Asthma Care CD-Rom – including presentation on

• Emergency Asthma Care Checklist poster.

Your clinical team should have a current asthma training programme,

All staff should be aware that if a person with asthma is complaining of

Process of emergency asthma care

It is important to treat each asthma consultation as you would for severe

asthma, until it is shown to be otherwise.

2. Inform appropriate healthcare professional

3. Prioritise patients needing urgent attention

4. Transfer to emergency care, maintaining condition

8. Arrange follow-up (GP/asthma nurse or secondary

Risk factors for fatal or near fatal asthma attacks

Adverse behavioural or psychosocial features recognised by one or more of:

• psychosis, depression, other psychiatric illness or deliberate self-harm

• indicate which areas of assessment are commonly missed

See tables 2, 3 and 4 for levels of severity of asthma attacks.

Patient name: Anne Smith

9. Inhaler device(s) Large volume spacer and pMDI

12. In the last week or month:

asthma symptoms at night Awakes twice nightly – coughing

13. Smoker (current, ex, passive) Non smoker

Smoking pack years

Hayfever (self/in family) No

19. Other significant factors eg pregnant, a carer, away from home

Owns two cats

Near fatal asthma Raised PaCO2 and/or requiring mechanical

Life-threatening Any one of the following in a patient with

Severe asthma Any one of:

Moderate asthma Increasing symptoms

Brittle asthma • Type 1: wide peak flow variability (>40%

Life-threatening • silent chest

Severe asthma • unable to complete sentences in one

Moderate asthma • able to talk

< 130 in children aged 2–5 years

Severe asthma • SpO2 < 92%

Moderate asthma • SpO2 > 92%

Access to emergency asthma care

These pathways can be adapted for other settings in which asthma

How to develop your own treatment pathway

• Use evidence-based information such as the BTS/SIGN British Guideline

The following section features examples of pathways developed in discussion

It also includes a sample pathway that might be used in a community pharmacy

‘Using the skills of all our staff

SADIE CLAYTON, PAEDIATRIC RESPIRATORY

Assess and record: • Peak flow

Moderate asthma Severe asthma Life-threatening asthma

Treat in pharmacy Call Dr _______________ Dial 999

Asthma treatment pathways

Mild/Moderate Severe Life-threatening

• Normal vital signs • Too breathless to talk/feed • Cyanosis/pallor

Immediate medical assessment,