Introduction
In the UK, over 5.4 million people receive treatment for asthma. Yet, despite advanced pharmacology, the UK continues to have one of the highest asthma mortality rates in Europe. This paradox is central to understanding the modern asthma management guidelines for the UKMLA.
The catalyst for the recent shift in guidelines was the National Review of Asthma Deaths (NRAD). This landmark report revealed a “fatal flaw” in historical management: patients were over-reliant on Short-Acting Beta-Agonists (SABA) like Salbutamol, while under-utilizing Inhaled Corticosteroids (ICS).
The Pathophysiology of “SABA Addiction”
Why is SABA-only treatment dangerous?
Beta-Receptor Downregulation: Regular use of Salbutamol causes the beta-2 receptors in the lungs to become less responsive (“tolerant”).
Unchecked Inflammation: SABAs treat the symptom (bronchoconstriction) but do nothing for the cause (airway inflammation).
The Result: The patient feels temporary relief, but the underlying inflammation worsens until a trigger causes a catastrophic, life-threatening attack that the desensitized lungs cannot respond to.
Current asthma management guidelines—specifically the BTS/SIGN British Guideline on the Management of Asthma—have moved aggressively towards Anti-Inflammatory Reliever (AIR) therapy, often referred to as MART (Maintenance and Reliever Therapy).
This guide will deconstruct the Joint Guidelines into a masterable 5-step protocol, ensuring you can safely manage both chronic and acute presentations in the UKMLA.
Key Takeaways
SABA Monotherapy is Dead: Relying solely on a blue inhaler is now discouraged. Most patients need an Inhaled Corticosteroid (ICS) from diagnosis to prevent mortality.
MART is the Gold Standard: For Step 3 onwards, combining the preventer and reliever in one inhaler (Maintenance and Reliever Therapy) significantly reduces severe exacerbations.
Diagnosis “Trap”: You must distinguish between NICE criteria (FeNO-led) and BTS criteria (Peak Flow variability-led) depending on the exam question context.
The “Normal pCO2” Warning: In an acute attack, a normal pCO2 is a sign of life-threatening respiratory failure, not stability.
Discharge Safety: Never discharge an asthma patient without checking inhaler technique, ensuring 24-hour stability, and issuing a Personalised Asthma Action Plan (PAAP).
Diagnosis: The “NICE vs BTS” Trap
Before treating, you must diagnose. This is a notorious area of confusion because two major bodies (NICE and BTS/SIGN) provide slightly different criteria. In clinical practice, these are merging, but for the exam, you must spot the specific criteria.
The Diagnostic Comparison Table
| Feature | NICE Guidelines (NG80) | BTS/SIGN Guidelines |
|---|---|---|
| Primary Focus | Objective Testing is mandatory for everyone aged 5+. | Clinical Probability based on history and simple tests. |
| FeNO (Nitric Oxide) | First-line test. Positive if ≥40 ppb (Adults) or ≥35 ppb (Children). |
Used only if diagnostic uncertainty remains after initial spirometry/peak flow. |
| Spirometry | Obstructive: FEV1/FVC < 70%. Reversibility: ≥12% AND ≥200ml improvement. |
Similar criteria, but emphasises “Clinical Judgement” over rigid numbers. |
| Peak Flow (PEF) | Used if spirometry is normal but symptoms persist. Look for >20% variability. | Key Criterion. Diurnal variability (morning vs evening) of >20% is diagnostic. |
UKMLA Exam Tip: If a Single Best Answer (SBA) question asks for the first-line investigation under NICE, choose FeNO. If the setting is a GP surgery with limited resources or follows BTS specifically, look for Peak Flow Diary.
The Stepped Care Ladder (Adults)
The core of asthma management guidelines is the Stepped Care Ladder. The goal is “Total Control”: no daytime symptoms, no night wakening, no limitations on activity.
Step 1: SABA Alone (The “Rescue” Step)
Drug: Salbutamol (Ventolin) or Terbutaline.
Indication: Only for patients with very mild, infrequent symptoms (e.g., <2 times a month) and no nocturnal symptoms.
The Shift: Guidelines now explicitly state that very few patients should remain on Step 1. If they use their inhaler >3 times a week, they need Step 2.
Step 2: Add Low-Dose ICS (The “Preventer” Step)
Action: Start a regular Inhaled Corticosteroid.
Drugs: Beclometasone, Budesonide, Fluticasone.
Mechanism: Reduces airway inflammation and bronchial hyper-responsiveness.
Patient Advice: “You must take this every day, even when you feel well. It works in the background to stop the fire burning.”
Step 3: Add LABA (The “Add-On” Step)
Indication: Asthma uncontrolled on SABA + Low-Dose ICS.
Action: Add a Long-Acting Beta-Agonist (LABA).
The Two Pathways:
MART (Preferred): Switch to a combined ICS/Formoterol inhaler (e.g., Fostair 100/6).
Fixed Dose: Keep the ICS and add a separate LABA (e.g., Salmeterol) or a fixed combination (e.g., Seretide).
Crucial Rule: Never prescribe a LABA without an ICS (monotherapy increases mortality risk).
Step 4: Medium-Dose ICS + LABA (+/- LTRA)
Action: Increase the ICS component to “Medium Dose” (e.g., Beclometasone 400mcg bd).
Add-On: Consider adding a Leukotriene Receptor Antagonist (LTRA) like Montelukast.
Note: NICE guidelines actually suggest trying Montelukast before LABA at Step 3, but BTS suggests LABA first. In practice and exams, LABA/MART is the standard escalation, with Montelukast added if rhinitis/exercise issues exist.
Step 5: High-Dose ICS / Specialist Referral
Action: Refer to respiratory medicine.
Therapies:
High-dose ICS (requires steroid card and monitoring for adrenal suppression – see Prescribing Safely).
LAMA (Long-Acting Muscarinic Antagonist): Tiotropium (Spiriva Respimat) is licensed for asthma.
Biologics: Monoclonal antibodies (e.g., Omalizumab for IgE-mediated, Mepolizumab for Eosinophilic) targeting specific inflammatory pathways.
Understanding MART (Maintenance and Reliever Therapy)
The modern asthma management guidelines rely heavily on MART. Understanding the pharmacology here is vital for the UKMLA.
Why Formoterol?
Not all LABAs are the same.
Salmeterol: Has a slow onset of action (30 mins). It cannot be used for relief.
Formoterol: Has a rapid onset (1–3 mins), similar to Salbutamol, but lasts for 12 hours.
The MART Regime
Instead of having a “Blue” (Reliever) and “Brown” (Preventer) inhaler, the patient has one inhaler (e.g., Fostair or Symbicort).
Maintenance: They take 1 puff morning and night.
Reliever: If they get symptoms, they take an extra puff of the same inhaler.
Why is this better? Every time the patient treats their symptoms (bronchoconstriction), they automatically receive a dose of steroid (anti-inflammatory). This titrates the steroid dose up during periods of illness/allergy, nipping exacerbations in the bud.
Acute Asthma Management (The “O SHIT ME” Protocol)
While chronic management is about the ladder, acute asthma is about immediate survival. You must be able to grade severity and treat instantly.
Grading the Severity
You must memorize the features of Acute Severe vs Life-Threatening asthma.
Moderate: PEF 50–75%. Speech normal. Respiration <25. Pulse <110.
Acute Severe: PEF 33–50%. Cannot complete sentences. Resp ≥25. Pulse ≥110.
Life-Threatening (Any ONE feature):
33: PEF <33%.
92: SpO2 <92%.
Silent Chest.
Cyanosis.
Poor Respiratory Effort.
Normal pCO2 (This is a trap! A tiring patient stops hyperventilating, so pCO2 rises from low to normal. This signals impending respiratory arrest).
The Management Protocol (Mnemonic: O SHIT ME)
O – Oxygen: High flow 15L non-rebreathe mask. Target 94-98% (unless known CO2 retainer, which is rare in pure asthma).
S – Salbutamol: 5mg Nebulised (driven by oxygen). Repeat back-to-back.
H – Hydrocortisone: 100mg IV (or Prednisolone 40-50mg Oral if can swallow). Steroids take 4-6 hours to work, so give them immediately.
I – Ipratropium Bromide: 500mcg Nebulised. (Anticholinergic bronchodilator – provides additive benefit to Salbutamol).
T – Theophylline / Aminophylline: IV infusion. (Consult senior/ITU). Requires cardiac monitoring due to arrhythmia risk.
M – Magnesium Sulfate: 1.2 – 2g IV infusion over 20 mins. (Smooth muscle relaxant). Highly effective in severe bronchospasm.
E – Escalate: Anaesthetics/ITU review for intubation if worsening or pCO2 rising.
For detailed documentation of these emergency encounters, refer to How to Document a Ward Round.
Discharge Criteria & Safety Netting
A critical part of asthma management guidelines often tested in the CPSA is the discharge process. You cannot send a patient home until they are safe.
Requirements for Discharge:
Stability: Stable on discharge medication (no nebulisers) for 12-24 hours.
Peak Flow: PEF >75% of best or predicted.
Inhaler Technique: Must be checked and corrected.
Steroids: Discharged with 5 days of Prednisolone (40-50mg OD). No tapering is needed if the course is <2 weeks.
Follow-up: GP appointment within 2 working days.
PAAP: Issue a Personalised Asthma Action Plan explaining when to seek help.
Paediatric Management Differences
Children follow a slightly different ladder in the asthma management guidelines.
Children Under 5
Diagnosis: “Suspected Asthma” (tests are unreliable).
Step 1: SABA.
Step 2: Very Low Dose ICS. (Start if using SABA >3/week).
Step 3: LTRA (Montelukast) is often the preferred first add-on (tablets/granules are easier than inhalers for some).
Step 4: Refer to specialist.
Children 5 – 12 Years
Step 1: SABA.
Step 2: Low Dose ICS (Paediatric dosing, e.g., Clenil 50mcg).
Step 3: Add LABA OR LTRA.
Note: BTS guidelines suggest LABA first. NICE suggests LTRA first. In practice, if a child has significant allergic rhinitis, Montelukast is a great “two birds, one stone” option.
Step 4: Increase ICS to Medium Dose / Refer.
Important: Always ensure asthmatic children are up to date with their UK Paediatric Immunisation Schedule 2026, especially the annual Flu vaccine, as influenza is a major trigger for hospitalisation.
Inhaler Technique & Devices
In the CPSA, “Teaching Inhaler Technique” is a common station.
1. Pressurized Metered Dose Inhaler (pMDI)
Examples: Ventolin, Clenil, Fostair.
Technique: “Shake, Exhale, Seal, Press, Slow & Steady Inhale, Hold 10s.”
The Spacer Rule: You should always prescribe a spacer (Volumatic/Aerochamber) for children and for ICS delivery in adults. It increases lung deposition and reduces oral thrush.
2. Dry Powder Inhaler (DPI)
Examples: Accuhaler, Turbohaler, Ellipta.
Technique: “Load dose, Exhale away, Seal, Quick & Deep Inhale, Hold 10s.”
Why different? The patient’s inspiratory force is what de-aggregates the powder. If they breathe slowly, they get no drug.
For comprehensive patient-facing videos and guides to share in your exam scenarios, rely on Asthma + Lung UK.
Clinical Scenarios: Putting it into Practice
Scenario 1: The “Salbutamol Overuser”
Patient: A 24-year-old male requests his 3rd Salbutamol inhaler in 2 months. He denies symptoms but admits to waking up coughing. Assessment: Uncontrolled asthma. Risk of beta-receptor downregulation. Management:
Explain Risk: “Using this blue inhaler too much is like putting a plaster on a infected wound. We need to treat the infection (inflammation).”
Step Up: Initiate Step 2 (ICS) or Step 3 (MART).
Review: See him in 4 weeks.
Scenario 2: The “Steroid Phobic” Parent
Patient: Parent refuses “brown inhaler” for 6-year-old due to growth concerns. Management:
Validate: Acknowledge the concern.
Evidence: Uncontrolled asthma (hypoxia, systemic inflammation, steroid bursts for attacks) causes more growth suppression than low-dose inhaled steroids.
Safety Net: Offer annual height checks. (See General Practice Essentials).
Practice Exercise: Test Your Knowledge
Question 1: A 35-year-old woman is on a Low-Dose ICS (Beclometasone) and SABA. She uses her SABA 4 times a week and has night symptoms. Adherence is good. What is the most appropriate next step?
A) Increase ICS to Medium Dose.
B) Add Montelukast.
C) Add a LABA (MART).
D) Refer to Respiratory Specialist.
E) Prescribe oral Prednisolone.
Correct Answer: C. Step 3 involves adding a LABA. The preferred method is switching to a MART regime (ICS/Formoterol). Increasing ICS (Option A) is Step 4.
Question 2: Which physiological sign indicates a “Life-Threatening” asthma attack?
A) Respiratory Rate 28.
B) Heart Rate 120.
C) Inability to complete sentences.
D) Normal pCO2 (e.g., 5.0 kPa).
E) PEF 40% predicted.
Correct Answer: D. A normal pCO2 in a tiring asthmatic indicates they can no longer hyperventilate to compensate. It is a sign of impending respiratory arrest. Options A, B, C, and E are features of “Acute Severe” asthma.
Frequently Asked Questions (FAQ) about Asthma Management Guidelines
Always ask about work history. If symptoms improve during weekends or holidays (“The Weekend Effect”), suspect occupational asthma (e.g., bakers, paint sprayers, laboratory workers). This requires referral to an occupational health specialist. The definitive treatment is removing the trigger (redeployment); simply increasing inhalers is ineffective and potentially dangerous as the sensitivity increases over time.
The golden rule is: It is safer for the baby to be on medication than for the mother to be hypoxic. Uncontrolled asthma causes fetal growth restriction, pre-eclampsia, and pre-term labour. Continue all usual asthma medications (including inhaled steroids and even oral steroids if necessary) during pregnancy. Never stop asthma medication upon confirming pregnancy.
Smoking reduces the efficacy of Inhaled Corticosteroids (ICS) by altering the inflammatory pathway (neutrophilic vs eosinophilic). Patients who smoke may require higher doses of ICS to achieve control. Furthermore, smoking increases the clearance of Theophylline, meaning smokers might need higher doses. Smoking cessation is the single most effective intervention you can offer.
While MART is flexible, there is a safety ceiling. For Fostair 100/6 (Beclometasone/Formoterol), the maximum total daily dose is usually 8 puffs (Maintenance + Reliever combined). If a patient is consistently needing more than this, they are effectively “uncontrolled” and require urgent medical review or a course of oral steroids.
Generally, No. Non-selective beta-blockers (e.g., Propranolol) can trigger severe bronchospasm and are contraindicated. Cardio-selective beta-blockers (e.g., Bisoprolol) may be used with extreme caution if there is a compelling cardiac indication (like heart failure), but this is usually a specialist decision.
Magnesium Sulfate is a smooth muscle relaxant. In severe asthma that isn’t responding to nebulisers, IV Magnesium helps to “relax” the bronchial smooth muscle, opening the airways. It is typically given as a 1.2g – 2g infusion over 20 minutes.
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Both are Short-Acting Beta-Agonists (SABAs). Salbutamol (Ventolin/Salamol) is far more common in the UK. Terbutaline (Bricanyl) is an alternative, often used if a patient has a specific sensitivity or prefers the Bricanyl Turbohaler device. Mechanistically, they are identical.
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FeNO is primarily a diagnostic tool in the NICE guidelines to confirm eosinophilic inflammation. However, it can also be used in management (Step 4/5) to guide whether increasing steroids will be beneficial. If FeNO is low, the asthma may be non-eosinophilic, and higher steroids might not help.
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Brittle Asthma describes asthma with variable, chaotic peak flows. Type 1 is persistent wide variability despite high treatment. Type 2 involves sudden, catastrophic drops in peak flow on a background of otherwise normal control. These patients often require syringe drivers or subcutaneous Terbutaline infusions and specialist care.
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Teenagers often dislike spacers due to size/stigma. Explain it as a “performance enhancer” for the drug. Without it, the spray hits the back of the throat and is swallowed (causing side effects). With the spacer, the drug hangs in the chamber, allowing them to breathe it deep into the lungs where it actually works.
Conclusion
Mastering the asthma management guidelines is a hallmark of a safe junior doctor. The shift away from SABA-monotherapy towards MART and Anti-Inflammatory Reliever (AIR) therapy represents the future of asthma care.
Your Checklist for Success:
Diagnosis: Distinguish FeNO (NICE) from Peak Flow (BTS).
Chronic: Use the ladder (Step 1 -> 2 -> 3 MART).
Acute: Recognize the “Normal pCO2” trap and use O SHIT ME.
Safety: Always check inhaler technique and provide a Personalised Asthma Action Plan (PAAP).
For further reading on patient safety and managing complex scenarios, ensure you review our guide on Professionalism and Patient Safety for CPSA.
