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Chapter 3: Obstructive lung disorders 111

Step 5: Continuous or frequent oral steroids
Daily oral steroids in lowest dose providing
adequate control whilst continuing maximal
inhaled steroids and use of other steroid
sparing agents. Refer patient for specialist care
Step 4: Persistent poor control
Consider trial of:
• Very high dose inhaled steroid
• Addition of a fourth drug e.g. leukotriene
receptor antagonist, slow release
theophylline or β agonist tablet
2
Step 3: Add-on therapy
1. Add inhaled long acting β agonist (LABA)
2
2. Assess control
• Good response – continue LABA
• Some benefit – continue LABA
and increase inhaled steroid dose
• No benefit – stop LABA increase
steroid inhaled to high dose
Step 2: Regular preventer
Add inhaled steroid (start at dose
appropriate to severity)
Step 1: Mild intermittent asthma
Inhaled short acting β agonist
2
as required
Figure 3.4 Stepwise long term management of asthma.

Acute management as dilation and destruction of the lung tissue distal to
This should follow the BTS/SIGN British Guidelines (see terminal bronchioles. The two frequently co-exist to
Figs. 3.5 and 3.6). varying degrees as chronic obstructive pulmonary dis-
ease (COPD).
Prognosis
Most children and teenagers with asthma improve as Prevalence
they get older, although asthma may recur in adult life. COPD has a prevalence of 12% aged 40–64 years. Em-
All patients should be advised not to smoke and to avoid physematous spaces are found in 50% of smokers aged
potential work allergens. Mortality is ∼2000 per year in over 60 at autopsy.
the United Kingdom and is reduced by inhaled steroid
therapy. Age
Incidence increases with age.
Chronic bronchitis and emphysema
Sex
Definition M > F
Chronicbronchitishasaclinicaldefinitionofcoughpro-
ductive of sputum on most days for at least 3 months of Geography
the year for more than 1 year. Emphysema is defined Follows patterns of smoking.