Diagnosis And Management Of Chronic Asthma

Version v3.0 From: Jan 22 – To: Jan 24 Author(s): Wynne Smith (ST8) and Katy Pike (Consultant in Paediatric Respiratory Medicine)

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SETTING Trust-wide

FOR STAFF Paediatric medical staff and allied healthcare professionals

PATIENTS Children under the age of 16 years with asthma

_____________________________________________________________________________

This guideline complements the Management of Acute Asthma Guideline (http://nww.avon.nhs.uk/dms/download.aspx?did=11537) and is intended to aid in diagnosis and management of chronic asthma across the trust. It includes: Information on the local implementation of national guidelines; useful links to aid care delivery; information on when to refer; details of how to access appropriate advice.

CONTENTS

QUICK LINKS ...................................................................................................................................................................... 2

KEY RECOMMENDATIONS .............................................................................................................................................. 2

DIAGNOSIS ......................................................................................................................................................................... 3

DIFFERENTIAL DIAGNOSIS ............................................................................................................................................. 4

PROBABILITY OF ASTHMA ............................................................................................................................................. 5

ASTHMA MANAGEMENT .................................................................................................................................................. 7

MEDICAL MANAGEMENT ................................................................................................................................................. 7

PREVENTER TREATMENT ........................................................................................................................................................... 7 RELIEVER TREATMENT .............................................................................................................................................................. 7 INITIAL ADD ON THERAPY ........................................................................................................................................................... 8 ADDITIONAL CONTROLLER THERAPIES ...................................................................................................................................... 8 COMBINATION INHALER FOR MAINTENANCE AND RELIEVER THERAPY (MART) ..................................................................... 8 SPECIALISED THERAPIES ........................................................................................................................................................... 8 MANAGEMENT OF COMORBIDITIES .......................................................................................................................................... 11

SUPPORTED SELF-MANAGEMENT ............................................................................................................................. 11

PERSONALISED ASTHMA PLAN (PAAP) .................................................................................................................................. 11 MINIMISING IMPACT OF TRIGGERS ........................................................................................................................................... 11

MONITORING DISEASE CONTROL AND RISK OF ATTACK .................................................................................... 12

MONITORING ASTHMA CONTROL ............................................................................................................................................. 12 INHALER AND SPACER TECHNIQUE .......................................................................................................................................... 12 MEDICATION CONCORDANCE .................................................................................................................................................. 13 RISK OF ATTACK ...................................................................................................................................................................... 13 RISK REDUCTION ..................................................................................................................................................................... 14

PROBLEMATIC SEVERE ASTHMA ............................................................................................................................... 14

TRANSITION OF CARE TO ADULT SERVICES ........................................................................................................... 15

APPENDIX 1 – CATEGORISATION OF INHALED CORTICOSTEROIDS BY DOSE ............................................... 17

APPENDIX 2 – PEAK EXPIRATORY FLOW CHART ................................................................................................... 19

Clinical Guideline

DIAGNOSIS & MANAGEMENT OF CHRONIC ASTHMA IN CHILDREN

http://nww.avon.nhs.uk/dms/download.aspx?did=11537


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Quick Links

USEFUL / RELEVANT RESOURCES DETAILS

Management of Acute Wheeze / Asthma Management Guideline: http://nww.avon.nhs.uk/dms/download.aspx?did=11537

Trust guideline detailing local implementation of national guidelines for the management of acute asthma attacks

Advice and guidance: login via e-RS nww.ebs.ncrs.nhs.uk

Single point of entry for primary care to discuss a patient

BTS / SIGN asthma guidelines: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/

Comprehensive acute and national asthma management guidelines

NICE guideline Asthma: diagnosis, monitoring and chronic asthma management: https://www.nice.org.uk/guidance/ng80

Comprehensive national chronic management guideline

Global Initiative for Asthma (GINA) main report: https://ginasthma.org/gina-reports/ And pocket guide: https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/

Comprehensive international report and short pocket guideline

http://www.rightbreathe.com Inhaler identification tool Please be aware that ALL licensed inhalers are listed including some we would not recommend such as serevent

Asthma UK inhaler videos: inhaler technique www.asthma.org.uk/advice/inhaler-videos/ and spacers https://www.asthma.org.uk/advice/inhalers-medicines-treatments/inhalers-and-spacers/spacers/

Inhaler technique videos for different devices Spacer use and care information

Asthma control tests (ACT) for ≥12 years and 4-11 years: https://www.asthmacontroltest.com/en-gb/welcome/

Validated asthma control tools

Personal asthma plan asthma UK my-asthma-plan-2021-v5-multi-media-live.pdf

Asthma UK: variety of plans for patients of all ages

Connecting care https://connectingcare.swcsu.nhs.uk/concerto/Login.htm

Link to GP prescribing data for SABA use and prescription uptake check

Key recommendations

• We follow the comprehensive BTS / SIGN 2019 guideline

• Asthma control and risk of asthma attack should be assessed at each contact

• Salbutamol is not recommended as monotherapy except for infrequent, short-lived wheeze


https://nww.ebs.ncrs.nhs.uk/

https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/


https://www.nice.org.uk/guidance/ng80

https://ginasthma.org/gina-reports/

https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/


http://www.rightbreathe.com/

http://www.asthma.org.uk/advice/inhaler-videos/

https://www.asthma.org.uk/advice/inhalers-medicines-treatments/inhalers-and-spacers/spacers/

https://www.asthma.org.uk/advice/inhalers-medicines-treatments/inhalers-and-spacers/spacers/

https://www.asthmacontroltest.com/en-gb/welcome/


https://www.asthma.org.uk/e75bf921/globalassets/health-advice/resources/children/my-asthma-plan-2021-v5-multi-media-live.pdf

https://www.asthma.org.uk/e75bf921/globalassets/health-advice/resources/children/my-asthma-plan-2021-v5-multi-media-live.pdf

https://connectingcare.swcsu.nhs.uk/concerto/Login.htm



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• Treatment decisions are made in partnership with patients / families following the steps below:

1. Diagnosis

• Asthma is a clinical diagnosis (episodic cough/wheeze/breathlessness/chest tightness)

• Isolated cough/wet cough/throat tightness and lightheadedness should prompt reconsideration

• A 6-8 week therapeutic trial of a preventer containing inhaled corticosteroids (ICS) might help

• If diagnosis unclear consider contacting the general paediatric or paediatric respiratory team

2. Consideration of inhaler technique, concordance, triggers and comorbidity

Before starting a new treatment the following should be checked:

• Inhaler technique

• Medication concordance

• Asthma triggers and possible means to minimise exposure

• Comorbidities, in particular consider treatment for allergic rhinitis

3. Initiating or changing treatment in response to control or risk of attack

Inhaled corticosteroids should be considered for all children using inhaled β₂ agonists x 3 a week or more; symptomatic x 3 a week or more; or waking one night a week. In addition, ICS should be considered in children aged 5–16 who have had an attack requiring oral steroids in the last 2 years.

Medications can be stepped down if symptoms are controlled for the last 3 months

The following factors should be monitored and recorded at each contact:

• Asthma control

• Peak expiratory flow rate (PEFR), in children able to do this reliably (usually ≥ 5 years)

• Frequency of asthma attacks, oral corticosteroid use and time off school

• Growth, height and weight according to centiles

• Presence of factors known to be associated with risk of attacks, including smoke exposure

• Possession and use of a personal asthma action plan (PAAP)

4. Supported self-management

All children with asthma and all adult carers should receive self-management education including:

• A written personalised asthma action plan

• Inhaler technique check

• Advice about triggers and avoidance of tobacco smoke and other indoor and outdoor pollutants

5. Ongoing medical management / referral

• After acute admission education and a PAAP should be given before discharge (this can be arranged with the ward nurses or asthma champions). Follow up should be arranged for 6 weeks in secondary care asthma clinic or respiratory paediatrics if already under follow up.

• Children with severe asthma should be referred to the problematic severe asthma service.

Diagnosis


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The diagnosis of asthma in children and young people is based on recognising characteristic episodic respiratory symptoms and signs in the absence of an alternative explanation (Table 1).

Table 1 Features that increase or decrease the probability of asthma

FEATURES THAT INCREASE THE PROBABILITY OF ASTHMA

FEATURES THAT DECREASE THE PROBABILITY OF ASTHMA

More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness, particularly if these symptoms: - are frequent and recurrent - are worse at night and early morning - occur in response to, or are worse after

exercise and other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter

- occur apart from colds Personal history of atopic disorder Family history of atopic disorder and / or asthma Widespread wheeze heard on auscultation History of improvement in symptoms or lung function in response to adequate therapy

Symptoms with colds only, and no interval symptoms Isolated cough in the absence of wheeze History of wet cough Prominent dizziness, light headedness, peripheral tingling Repeatedly normal physical examination of chest when symptomatic Normal PEFR or spirometry when symptomatic No response to trial of asthma therapy Clinical features pointing to alternative diagnosis

Differential diagnosis

Features that are not commonly found in asthma may suggest alternative diagnoses (Table 2).

Specialist discussion or referral is indicated if there are features of any significant alternative diagnosis, or if there is uncertainty about diagnosis, failure to respond to conventional low dose ICS treatment trial, or parental anxiety or need for reassurance about the diagnosis.

Table 2 Features suggestive of alternative diagnosis

PERINATAL AND FAMILY HISTORY POSSIBLE DIAGNOSIS

• Symptoms present from birth or perinatal lung problem

• Family history of unusual chest disease

• Severe upper respiratory tract disease

Cystic fibrosis; chronic lung disease of prematurity; ciliary dyskinesia; developmental lung anomaly

Cystic fibrosis; neuromuscular disorder

Defect of host defence; ciliary dyskinesia

SYMPTOMS AND SIGNS


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• Persistent wet or productive cough

• Excessive vomiting or posetting

• Dysphagia

• Breathlessness with light headedness and peripheral tingling

• Inspiratory stridor

• Abnormal voice or cry

• Focal signs in chest

• Finger Clubbing

• Nasal polyps

• Failure to thrive

Cystic fibrosis; bronchiectasis; protracted bacterial bronchitis; recurrent aspiration; host defence disorder; ciliary dyskinesia

Gastro-oesophageal reflux (± aspiration)

Swallowing problems (± aspiration)

Hyperventilation / panic attacks / dysfunctional breathing

Tracheal or laryngeal disorder

Laryngeal problem

Developmental anomaly; post-infective syndrome; bronchiectasis; tuberculosis; foreign body

Cystic fibrosis; bronchiectasis

Cystic fibrosis; allergy

Cystic fibrosis, host defence disorder; gastro-oesophageal reflux

INVESTIGATIONS

• Focal or persistent radiological changes Developmental lung anomaly; cystic fibrosis; post-infective disorder; recurrent aspiration; inhaled foreign body; bronchiectasis; tuberculosis

Probability of asthma

With a thorough history and examination, a child can usually be classed into one of three groups (see Figure 1):

• High probability of asthma

• Intermediate probability of asthma – diagnosis uncertain

• Low probability of asthma – diagnosis more likely to be something other than asthma


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Figure 1 Diagnostic algorithm from BTS/SIGN158 British guideline on the management of asthma (revised 2019)

For children with intermediate probability of asthma, further investigations such as peak flow variability; spirometry (if able) and bronchodilator reversibility; or fractional exhaled nitric oxide (FeNO) may help establish a diagnosis. Looking for evidence of atopy using either skin prick testing for specific suspected allergens can be helpful in selected patients, as might blood tests for total and specific IgE, and eosinophil counts.

A 6-8 week trial of therapy for patients with intermediate or high probability of asthma is recommended. BTS/SIGN advises starting at the most appropriate therapy for the severity of symptoms. For children < 5 years NICE suggests 100 mcg beclomethasone 2 puffs twice daily.

It is important to assess response to therapy or a therapeutic trial using objective measures where possible. The asthma control test can be used before and after starting treatment in addition to PEFR variability, spirometry and FeNO.



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Asthma management

Asthma management is multifaceted and comprised of:

• Medical management (including management of comorbidities)

• Supported self-management

• Monitoring of disease control and risk reduction (including review of inhaler technique, and medication concordance and adverse effects)

Medical management

The NHS has committed to net zero directly controllable carbon emissions by 2040 and has identified that this might be achieved by increased prescribing of dry powder inhalers (DPIs) and increased prescribing smaller volume HFA134a inhalers (e.g. Salamol) rather than larger volume or HFA227ea-containing inhalers (e.g. Ventolin). Inhalers should only be changed where clinically appropriate and not purely to meet guidance. However, healthcare professionals should be prepared to answer patients’ questions on this topic. Patients and providers may also want to consider the whole life cycle impact of inhalers which does not favour DPIs so clearly. Preventer treatment Treatment should be started at the level most appropriate to initial severity. Aim to achieve early control and then maintain control by increasing treatment when necessary and decreasing treatment no more than 25-50% of therapy every three months when control is good. ICS are the first line recommended preventer for children aged 5–12 years. Inhaled corticosteroids (ICS) should be considered for those with any of the following asthma features:

• Using inhaled β₂ agonists three times a week or more

• Symptomatic three times a week or more

• Waking one night a week

• Asthma attack requiring oral corticosteroids in the last two years

ICS should also be considered for children under the age of five who have frequent or symptoms (as above) or a history of frequent or severe attacks. Categorisation of ICS by dose for children and adolescents / adults is shown in Appendix 1. The lowest dose of inhaled corticosteroids compatible with maintaining asthma control should be used and growth should be monitored (height and weight centile) on an annual basis at least. Adrenal insufficiency is a possibility in any child maintained on ICS presenting with shock or a decreased level of consciousness. For children treated with medium- or high-dose ICS specific written advice about steroid replacement in the event of a severe intercurrent illness or surgery should be given and the child should be under the care of a specialist paediatrician. For younger children especially, and if there is doubt about need for inhaled steroid treatment, a respiratory opinion would be appropriate. Reliever treatment An inhaled rapid acting β₂ agonist should be prescribed as short-term reliever therapy for all patients with symptomatic asthma. The BTS recommendation is for an inhaled short acting β₂ agonist (SABA), such as salbutamol or terbutaline. SABA alone is no longer considered as a step in treating children with confirmed asthma only for infrequent short-lived wheeze.


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Of note the Global Initiative for Asthma (GINA) 2021 report prefers combined ICS and long acting rapid β₂ agonist (LABA) in place of SABA as a reliever because of evidence which suggests this strategy is associated with a reduced risk of severe exacerbation but comparable asthma control and lung function. For children we use Symbicort as it is currently the only paediatric option for combined ICS/LABA. When prescribing separate preventers and relievers consideration should be given to whether non-adherence to ICS preventer treatment would place a patient at risk of inadvertent SABA only treatment. Excessive SABA use is linked with increased risk of asthma attack. Patients using > 6 short-acting bronchodilator device per year need urgent assessment and should be identified and have their asthma assessed urgently and measures taken to improve asthma control if this is poor. Referral to general paediatrics or respiratory would be appropriate if high SABA usage. Initial add on therapy If control is not optimal, add on therapy should be considered after reviewing the diagnosis, checking adherence to current medications, checking inhaler technique and minimising triggers where possible (see Figure 2).

In children ≥ 5years initial add on therapy options are: inhaled long-acting β₂ agonist (LABA); or, a leukotriene receptor antagonist (LTRA) (montelukast). If < 5years, LTRA should be used.

When considering LABA, please note that giving LABA without ICS is not recommended. LABA should only be prescribed in combination inhalers. This is due to concerns about increased adverse events when LABA is given without ICS.

Additional controller therapies If control is not optimal, additional controller therapy should only be considered after reviewing the diagnosis, checking adherence to current medications, checking inhaler technique and eliminating triggers Additional controller therapies for children ≥ 5yrs and adolescents are outlined in Figure 2.

Combination Inhaler for Maintenance and Reliever Therapy (MART) For young people aged 12 years and over Symbicort 100/6 or 200/6 DPI are licensed to be prescribed as maintenance 2 puffs daily in 1–2 divided doses, (200/6 can be increased if necessary to 2 puffs twice daily) with 1 puff as required for relief of symptoms, increased if necessary up to 6 puffs as required, max. 8 puffs per day. Up to 12 puffs daily can be used for a limited time but medical assessment is recommended. For Symbicort and 100/3 metered dose inhaler (MDI) recommended dosing is maintenance 4 inhalations daily in 1–2 divided doses, increased if necessary up to 4 inhalations twice daily; 2 inhalations as required for relief of symptoms, increased if necessary up to 12 inhalations as required, usual max. 16 inhalations per day; up to 24 inhalations daily can be used for a limited time but medical assessment is recommended. Specialised therapies Specialised treatments may be initiated by the Paediatric Respiratory Medicine Severe Asthma service. These are briefly included for completeness / information. Tiotropium - for adults there is evidence that adding tiotropium to ICS / LABA in patients with uncontrolled asthma is associated with reduced attacks and some improvement in lung function but paediatric data is conflicting.


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Theophyllines - may improve lung function and symptoms, but are associated with an increase in adverse events. Monitoring is required in line with BNF guidelines. Frequent or continuous oral corticosteroids – (these should be avoided where possible). Children receiving these treatments should be under the care of a tertiary specialist asthma service and carry steroid cards provided by pharmacy. They should undergo blood pressure, urine or blood sugar, cholesterol and bone mineral density monitoring. Cataracts and glaucoma may be screened for through community optometric services. Biologics - three biologic monoclonal treatments are currently licensed to treat paediatric asthma. These are anti IgE, omalizumab, anti IL5, mepolizumab, and dupilumab an anti IL 4 receptor antagonist (affecting IL4 and IL 13 pathways) each is licensed from 6 years. These should be prescribed in line with the relevant NICE guidance. Overview | Omalizumab for treating severe persistent allergic asthma | Guidance | NICE Overview | Mepolizumab for treating severe eosinophilic asthma | Guidance | NICE https://www.nice.org.uk/guidance/ta751/chapter/1-Recommendations Patients being considered for monoclonal antibody treatment should be assessed to confirm the diagnosis of asthma, that uncontrolled asthma is the cause of their ongoing symptoms, and that they are adherent with current treatment. An asthma specialist with expertise in monoclonal antibody treatment should assess patients prior to undergoing treatment, and treatment should take place in a specialist centre with appropriate resources and training, including intensive care. Immunotherapy - asthma is not a licensed indication for immunotherapy although there are EAACI immunotherapy guidelines for house dust mite driven asthma. Uncontrolled asthma is a contraindication for immunotherapy.

https://bnfc.nice.org.uk/drug/theophylline.html#monitoringRequirements

https://www.nice.org.uk/guidance/ta278

https://www.nice.org.uk/guidance/TA671

https://www.nice.org.uk/guidance/ta751/chapter/1-Recommendations

https://www.eaaci.org/images/Agache_et_al-2019-Allergy_1.pdf


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Management of comorbidities Obesity - Obese and overweight children should be offered weight-loss programmes to promote general health and to reduce the risk of respiratory symptoms suggestive of asthma. School nurse, health visitor and Surestart advice can be used to support this. Patients can also be referred to the Care of Childhood Obesity (COCO) clinic if they meet referral criteria. Pattern disorders (dysfunctional breathing) online resources can be offered to children with asthma as an adjuvant to pharmacological treatment to improve quality of life and reduce symptoms. These are particularly helpful where a breathing pattern disorder is suspected. Breathing pattern disorders are suspected based on the following Signs mouth breathing, short, shallow breaths, quick and erratic, noisy, raised shoulders, movement at the top of the chest or Symptoms breathlessness, persistent coughing, excessive yawning or sighing, a feeling of not being able to take a deep breath, dizziness, poor concentration, pins and needles, bloating, fatigue, and lethargy.

Useful questionnaires include the Nijmegen questionnaire and the Brompton breathing pattern assessment tool.

Anxiety and depression Brief screening questionnaires for anxiety and depression suitable for use in adolescents are available and may help identify those with significant anxiety and depression. Revised anxiety and depression scale (RCADS).

Allergic rhinitis Patients with asthma often have rhinitis. The most effective therapy for rhinitis is intranasal steroids. LTRAs can also be helpful. Whilst RCT evidence suggest treating rhinitis improves asthma control is currently lacking, rhinitis significantly impairs quality of life and should be aggressively treated. Further information on rhinitis treatment can be found in the BSACI guideline.

Gastro-oeophageal reflux should be treated if causing GORD but there is no evidence that GORD treatment improves asthma symptoms.

Supported self-management

Self-management refers to the tasks that individuals must undertake to live with chronic conditions including, recognising and acting on symptoms and signs of deterioration as well as the broader challenges of living with asthma.

Personalised asthma plan (PAAP) All people with asthma (and each of their parents or carers) should be offered self-management education which should include a written PAAP at diagnosis. This should be supported by regular professional review. Every asthma-related hospital / GP contact should include revisiting and discussing self-management and a PAAP, particularly, after an acute asthma attack. Hospital admissions represent a critical moment for asthma education. Prior to discharge, inpatients should receive written personalised asthma action plans, given by ward nurses with expertise in providing asthma education. The asthma CNS team oversee asthma education for children admitted to HDU / PICU, where possible, before discharge and can arrange education post discharge. Refer via careflow to BRHC Asthma and Allergy CNS. They can also be contacted via [email protected]

Minimising impact of triggers

https://www.physiotherapyforbpd.org.uk/self-help/

https://www.physio-pedia.com/Nijmegen_Questionnaire#:~:text=The%20Nijmegen%20Questionnaire%20%28NQ%29%20gives%20a%20broad%20view,could%20benefit%20from%20breathing%20regulation%20through%20capnographic%20feedback.

https://www.corc.uk.net/media/1225/rcads-childreported_8-18.pdf

https://www.bsaci.org/wp-content/uploads/2020/01/Scadding_et_al-2017-Clinical_amp_Experimental_Allergy.pdf

https://www.bsaci.org/wp-content/uploads/2020/01/Scadding_et_al-2017-Clinical_amp_Experimental_Allergy.pdf

mailto:[email protected]


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Tobacco smoke exposure - People with asthma and parents/carers of children with asthma should be advised about the dangers of smoking and second-hand tobacco smoke exposure, including increased wheezing in infancy and increased risk of persistent asthma and should be offered appropriate support to stop smoking. Primary care and pharmacies might be able to support this. The local smoking cessation service is Everyone Health Bristol Targeted Stop Smoking Service: Email [email protected] or telephone 0333 005 0095.

Air pollution - Poor air quality may provoke acute asthma attacks or aggravate existing chronic asthma. NICE offers guidance about the effects of both poor outdoor and indoor air quality. Information on current levels of air pollution, recommended actions and health advice is available from The Daily Air Quality Index. Aeroallergen avoidance guidance is available from Asthma UK for house dust mite and pollens. Physical activity - physical training improves indices of cardiopulmonary efficiency and should contribute to a general approach of improving lifestyle and rehabilitation in people with asthma. There is increased risk of exercise induced bronchoconstriction in uncontrolled asthma. In patients who experience symptoms triggered by exercise, we advise taking their reliever before exercise and avoiding exercise in cold or poor air quality conditions. Young children should not be encouraged to take their inhaler before each break and lunch time.

Monitoring disease control and risk of attack

Monitoring asthma control Routine clinical review of asthma should be done at least annually, though in practice we see children at least twice per year. Closer review should be considered for those with severe asthma or attacks within the last year. This review should explore symptom control with the child as well as the parent / carer; objectively assessing current asthma control and reviewing reliever use.

The 'Royal College of Physicians (RCP) 3 questions' is simple to use in every day clinical practice, but has not been validated in children. Answering 'no' to all three questions is consistent with controlled asthma. The three questions are:

• Have you had difficulty sleeping because of your asthma symptoms?

• Have you had your usual asthma symptoms during the day?

• Has your asthma interfered with your usual activities? Validated but more time consuming control tests include the asthma control test. Spirometry or peak flow variability should be measured at every review and consideration given to whether FeNO might usefully provide information about concordance or untreated eosinophilic inflammation.

Inhaler and spacer technique There are many inhalers available and identifying what a patient uses can sometimes pose a challenge. The rightbreathe website (see quick links) has an identification tool to help. Appendix 1 shares tables from BTS/SIGN guidelines showing the equivalence of different devices for both children and adolescents / adults. All children with aerosol inhalers should take these via a spacer, and be shown how to take their medication. Spacer care and inhaler technique should be reviewed regularly (see asthmaUK website). Spacers should be replaced at least annually and washed according to manufacturers




https://uk-air.defra.gov.uk/air-pollution/daqi

https://www.asthma.org.uk/advice/triggers/dust-mites/

https://www.asthma.org.uk/advice/triggers/pollen/


https://www.asthma.org.uk/advice/inhalers-medicines-treatments/using-inhalers/

https://www.asthma.org.uk/advice/inhalers-medicines-treatments/using-inhalers/


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instructions (air drying is necessary unless using an anti-static device). Most children will be able to switch from a facemask to mouthpiece at 3 years, but this should be checked. Children and carers should be supported until they are able to demonstrate effective technique.

Medication concordance This can be assessed by asking specific questions about medication use in addition to review of prescription uptake data. Attitudes to medications and practical barriers to concordance should be explored in an open and non-judgemental way.

Useful questions include:

“How do you think that the inhaler is helping you control your asthma?”

“Are there times when you find that you don’t need your inhaler?”

“How much bother do you have from side effects?”

“Some people worry about taking regular medication… what do you think?”

“People sometimes find it difficult to remember to take regular treatment…”

“How often did you use your preventer inhaler last week?”

Patients can be asked to rate from 1 to 5 their response to the following questions prefaced by: “Many people find a way of using their medicines which suits them. This may differ from the instructions on the label or from what their doctor had said. Here are some ways in which people have said they use their medicines. For each statement, which best applies to you? 5=never, 4=rarely, 3=sometimes, 2=often, 1=always”

I take less than instructed

I stop taking it for a while

I miss out a dose

I alter the dose

I forget to take it

Primary care medication prescription collection can be reviewed via connecting care https://connectingcare.swcsu.nhs.uk/concerto/Login.htm. It is important to check how many devices are dispensed with each prescription and to consider whether there are alternative sources of prescribing eg after ward admission or outpatient appointment. Reliever use can be estimated from prescribing data although it is important to remember that relievers are often dispensed on repeat alongside a preventer, regardless of actual usage.

Risk of attack Risk of attack is known to be associated with a number of factors the most strongly predictive being previous asthma attacks (see



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Table 3). Factors associated with asthma attacks in school aged children are listed below. Factors associated with future attacks in preschool children are atopy, younger age, low socioeconomic status, male sex, overweight, raised eosinophils, sensitisation to aeroallergens and need for a preventer medication (likely related to severity). Factors associated with attacks in those with severe asthma are previous attacks, greater SABA use, lower PEF or FEV1/FVC and raised FeNO.

Table 3 Factors associated with increased risk of future asthma attacks in school-aged children

Level of increased risk Factor

Greatly increased risk History of previous asthma attacks Persistent asthma symptoms

Moderately increased risk High ratio of reliever to preventer medication (controller <0.5 total asthma prescriptions) Comorbid atopic/allergic disease Low income family Vitamin D deficiency

Slightly increased risk Younger age Exposure to environmental tobacco smoke Obesity Low parental education

No increased risk Gender Urban residence

Evidence equivocal Reduced lung function Raised FeNO at routine reviews Positive skin prick tests History of allergen exposure

Risk reduction Healthcare professionals can help support children and young people with asthma by identifying goals around secondary prevention measures, including stopping smoking and preventing secondary smoke exposure; weight loss for overweight / obese patients; breathing exercise programmes shown to improve quality of life and reduce symptoms.

Problematic severe asthma


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A minority of children and young people have asthma symptoms which remain uncontrolled despite being prescribed high doses of conventional therapy. These children and young people are considered to have problematic severe asthma and need specialist evaluation and treatment by a multi-disciplinary team. Difficult asthma Often there are reasons for asthma being difficult to control. These reasons might relate to other medical conditions being confused with asthma or making asthma symptoms worse, or problems with the medication prescribed, for example it is complicated or time consuming to take. Severe therapy resistant asthma Children and young people who have on-going poor control despite attention to the basics of asthma management have severe asthma and might benefit from specialised investigation and targeted specialist therapy. Children likely to benefit from referral to the Problematic Severe Asthma clinic include those:

1. Prescribed maintenance or frequent courses of oral steroids 2. Under consideration for biological agents or immunosuppressive treatment 3. With on-going poor control evidenced by:

• Persistent chronic symptoms: most days for >3 months or Asthma Control Test score <20

• Prescription of ≥12 salbutamol inhalers per year • Persistent airflow obstruction (FEV1 <80% post bronchodilator) • ≥ 2 attacks in the past year requiring hospital admission or oral steroids for at least

3 days • PICU admission within the past year

Despite treatment with: high dose inhaled corticosteroids (budesonide >800µg/day or fluticasone >500µg/day) plus a long acting β2 agonist plus montelukast (or previous failed trial) or trial of other add on therapy such as theophylline.

All patients with difficult asthma should have diagnosis confirmed, assessment of therapeutic adherence and identification of the mechanism of persisting symptoms. This should be performed by the severe asthma team at Bristol Royal Hospital for Children, led by Dr Katy Pike. This assessment includes confirmation of diagnosis and comorbid or exacerbating factors as well as a detailed assessment of adherence, psychosocial factors, consideration of dysfunctional breathing contribution and careful monitoring of airway inflammation and response to treatment.

Transition of care to adult services

As young people grow older and become independent, they will need to transfer to an adult team. The transition process aims to:

• Support teenagers to develop skills which allow them to manage their health more

independently

• Support parents in helping their teenager to achieve this to the best of their ability

• Prepare young people and their families for transfer from child-centred healthcare

to adult healthcare

Transition should be seen as a process and not just the event of transfer to adult services. It usually begins from 14 years although the medical team may have a plan before this. It should be planned, involve the young person, and be both age and developmentally appropriate. Young people should be given the opportunity to be seen without their parents/carers. Transition



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services must be multidisciplinary and multiagency. There should be an identified co-ordinator who supports the young person until he or she is settled within the adult system. Generally, this will be a member of the Asthma CNS team.

Young people with well controlled asthma can be cared for in primary care. The asthma CNS team run a Monday afternoon transition clinic for all children with asthma aged 14 and over. We use the ready, steady, go documentation.

Problematic severe asthma is cared for across a network of centres in the South West including Plymouth, Exeter, Taunton and Bristol (BRI and Southmead) with outreach to local hospitals. Criteria for referral to an adult severe asthma service are:

Patients fulfilling the ERS/ATS definition of severe asthma (asthma which requires treatment with high-dose inhaled corticosteroids plus a second controller (and/or systemic corticosteroids) to prevent it from becoming ‘uncontrolled’ or which remains uncontrolled despite this therapy) and one of the following:

• An event of acute severe asthma which is life threatening, requiring invasive ventilation with elevated inflation pressures within the last 10 years.

• Continuous or frequent treatment with oral corticosteroids (defined as 2 or more courses in the previous year).

• Fixed airflow obstruction, with a post bronchodilator forced expiratory volume in 1 second (FEV1) less than 70% of predicted normal.

• Referred as an adolescent transition patient from a paediatric severe asthma service

REFERENCES BTS/SIGN asthma guidelines: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ NICE guideline Asthma: diagnosis, monitoring and chronic asthma management: https://www.nice.org.uk/guidance/ng80 Global Initiative for Asthma (GINA) main report: https://ginasthma.org/gina-reports/ and pocket guide: https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/

RELATED DOCUMENTS AND PAGES

Management of Acute Wheeze/Asthma Management Guideline: http://nww.avon.nhs.uk/dms/download.aspx?did=11537 Connecting care https://connectingcare.swcsu.nhs.uk/concerto/Login.htm

AUTHORISING BODY

Paeds respiratory governance Group

SAFETY No issues

QUERIES AND CONTACT

BRHC clinical asthma nurse specialists: Myriam Kanchanatheera, Kathryn Hogarth and Esme Welch can be contacted by professionals only on 0117 342 8248 or on the CNS mobile: 07775 816 975 Email: [email protected] Advice and guidance links in quick links section.












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Appendix 1 – Categorisation of inhaled corticosteroids by dose

These tables are from the BTS / SIGN guideline 2019. Check doses / age ranges against the up-to-date BNF or BNFc. Adult tables are included as adolescent doses are often equivalent.

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Appendix 2 – Peak expiratory flow chart

Diagnosis And Management Of Chronic Asthma

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