Essentials of Asthma in Children In Primary care

Dr Sherine DewlettConsultant-Royal Free, London

Sherine.Dewlett@nhs.net

What this talk contains..

Diagnosis of asthmaManagement and monitoringWhen to refer to secondary careAsthma Networks and Useful resources– In slides: BTS step wise management/acute

management – Outside remit: Difficult asthma, asthma in adolescents,

Severe asthma management, Evidence base, Quality standards, New therapies

Importance

• Most common chronic disease of childhood• Treatable illness but undertreated in primary

care• National review of asthma deaths ( NRAD

2014): preventable deaths from asthma: 1-2 children dying a month in the UK

• Many shortfalls in management across the spectrum

• UK worst asthma mortality in Europe!

Asthma Definition (GINA)

• “A chronic inflammatory disorder of the airways associated with airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing particularly at night or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction within the lung that is often reversible either spontaneously or with treatment"

Diagnosis- is it asthma?

• Diagnosis in childhood can be challenging as cough and wheeze common with viral infections

• Pre-school children unable to perform lung function tests to guide diagnosis

• Clinical diagnosis (probability)• Symptoms ( consider if one or more of):– Wheeze ( high pitched musical noise)– Cough– SOB – Chest tightness

Is it Asthma?

• Multi-trigger- not just virus but also : exercise, smoke, allergens eg HDM, pollen, emotion, stress, weather change

• Family or personal history of atopy/asthma • Diurnal Symptoms: worse at night or early morning• Recurrent or severe symptoms> 3 episodes a year or

symptoms last for >10 days with URTI• Interval symptoms- cough at night and during exercise • Widespread wheeze on ausculation• Reversible airways obstruction, reduced PEF, diurnal

variation and bronchodilator reversibility ( reserved for patients who can comply >5)

Alternative diagnoses• CF, PCD, GORD, Aspiration, Anatomical abnormality, cardiac conditions, panic

disorder, dysfunctional breathing• Any of the following suggest alternative diagnosis and need for further inv and

referral:– FTT– Neonatal/Early onset– Continuous/Focal wheezing or no wheeze– Finger clubbing– Persistent wet cough, little wheeze/SOB– Excessive vomiting– Hypoxaemia outside viral illness– Stridor/Hoarse voice– Poor response to asthma medications ( consider education/compliance/triggers)– Tingling/dizziness– Normal Lung function or persistently abnormal– Abnormal X ray

Viral induced wheeze

• Common in pre-school• Wheeze occurs with viruses only• No interval symptoms• Post viral wheeze- post RSV can occur for 2 years• consider asthma if.. Multi-trigger, atopy, interval

symptoms, frequent and severe- trial of asthma tx• Treat with salbutamol, Trial of intermittent

montelukast at onset of viral illness-can reduce severity in some with right genotype, warn about sleep disturbance

Initial management of suspected asthma

• If high probability of asthma trial of low dose ICS- 2-3 month trial via MDI +spacer

• If intermediate- watch and wait, PEF and BDR or trial of treatment

• Follow up scheduled• If effective step up if needed to achieve control

at minimum dose• If not effective stop- consider alternative

diagnosis/inv and referral

Asthma management

• Goal is to achieve symptom control at minimum dose (minimise SE) and reduce risk of flare ups

• Education: brief explanation of asthma- Inflammation in the airways-Regular preventer/reliever medication-as needed

• Training in correct inhaler technique• Importance of adherance to preventor therapy• Written asthma action plan- managing flare ups/

triggers/when to seek medical advice

Asthma Medications

• SABA: salbutamol( ventolin)/Terbutaline ( relievers)• Antichinergic:Ipatropium ( relievers)• ICS: Beclamethasone, Fluticasone,Budesonide,

fluticasone, mometasone, ciclesonide• LTRA: Montelukast• LABA: Salmeterol or Formeterol• Combination: Seretide/Symbicort• Cromoglycates/Nedocromil• Theophyllines

Step wise management under 5(BTS 2014)

• Step 1: Mild intermittent asthma: – As needed SABA via spacer

• Step2: Regular preventor: – Low dose ICS (200-400 mcg)or LTRA, plus as needed

SABA• Step3: Add on therapy – In those taking ICS (200-400 mcg) consider add on LTRA-– if age< 2 consider step 4.

• Step 4: Persistent poor control:– Refer to respiratory paediatrician- consider earlier if<2

Step wise management- age 5-12(BTS 2014)

• Step 1: Intermittent mild asthma- – as needed SABA +spacer

• Step 2: Regular preventor– ICS 200-400 mcg

• Step 3: Add on therapy– LABA (preferably in combination-seretide/symbicort)– LTRA – (oral theophilline)

• Step 4:– Peristent poor control Increase steroid to 800 mcg/day ( 500 mcg of

fluticasone)• Step 5:oral steroids/refer to respiratory paediatrician

Asthma inhaler devices

• Children under 12 should use a spacer• Ensure training in inhaler technique-given to

parents/child- demonstration and regular review• Ensure the right inhaler prescribed for right

spacer• Children <5 should use a spacer with a mask• When can control breath use with a mouthpeice• Breath activated devices useful at school• www.asthma.org www.itchysneezywheezy.com

Written asthma action plans

• Guides Patient self management• How to recognise worsening symptoms, can use PEF• Preventor medicine• Triggers- eg viruses/exercise/pollen• What to do when symptom worsen- use of SABA- dose and

freqency 2-10 puffs every 4 hours, if requiring more often to seek medical help

• When to seek medical help• Plans: www.asthma.org www.itchysneezywheezy.com• Royal Free Wheeze Plan/Whittington asthma plan attached

Assessing control

• When: – When they come in to GP surgery with symptoms– 2 days after ED attendance– Annual review ( at least)

• Assessing control- Step up or Down – Do you have nocturnal/early morning symptoms or symptoms

with exercise?– Have you missed school with asthma?– How many courses of steroid in a year?– ED attendances?– How often do you use your blue inhaler(reliever)?– Overall how is your asthma? ACT- www.asthma.org

If Poor Control consider

• Adherance • Ask- how often do you forget to take preventer/did you take

it this morning? Also look at prescription uptake- ? Too much reliever? Non enough preventor. Electronic prescribing

• Psychosocial issues- Mental health/Social concerns

• Inhaler technique• Education ( do they have a written asthma plan?)• Triggers- Rhinitis/Smoking/HDM/Pets- identify and tx

(can refer)• Alternative diagnosis

When to refer:

• Diagnostic uncertainty• > 2 courses of prednisolone/year• Consider if recurrent ED attendances • Poor control/High medication dose: Step 2-3

of step wise plan (see previous)• If parents want second opinion/concerned

Acute exacerbations • Assess severity- RR, sats, HR, accessory muscles, ability to talk in

sentences, PEF>5• Severe/life threatneing: sats<92%, unable to speak in sentences, use of

accessory muscles, RR>40, reduced conciousness/agitation, PEF<50%• If severe features give nebuliser, oxygen and call an ambulance• Salbutamol 2-10 puffs via spacer and assess response• Oral prednisolone 2mg/kg• If good response home with 3 days prednisolone and weaning plan• Refer to hospital if severe/life threatening, poor response to inhaler/not

lasting 4hours between inhalers• Lower threshold for referral if late PM/Night, recent admission or

previous severe attack/social concerns• Annex 5- BTS guidline 2014

Networks and Useful Resources

• UCLP network/ Strategic Children’s Networks-producing diagnostic templates/action plans/guidelines/training

• BTS 2014 asthma guidelines• GINA guidelines-pocket guides• British National formulary• www.Asthma.org• www.Itchy sneezy wheezy.com• NRAD report• Appendix ( attached documents): UCLP asthma guidelines,

RF wheeze action plan, Whittington annual review sheet, Patient education sheet

Summary• Important and treatable condition- Treat inflammation• Consider asthma in children presenting with cough wheeze and

SOB and trial of inhaled steroid if indicated• Consider alternative diagnosis• Regular monitoring and review-step up and down• Patient Education, adherance factors, identification of triggers and

prevention, written asthma plans and inhaler technique essential !• Refer if in doubt

Any Questions or Comments?Sherine.dewlett@nhs.net