ChildandAdolescentAsthmaGuidelines
AsthmaandRespiratoryFoundationNZ2017
Acknowledgements• InnesAsher• CherylDavies• TeresaDemetriou• TerryFleming• MatireHarwood• LorraineHetaraka-Stevens• Tristram Ingham• JohnKristiansen• JimReid• DeniseRickard• DebbieRyan
• Consultedorganisations
Mainsources
• BTS/SIGNAsthmaGuideline2017• AustralianAsthmaHandbook2015• GINAguidelines• UKNationalReviewofAsthmaDeaths2015• HeMāramatanga Huangō:AsthmaHealthLiteracyforMāoriChildreninNewZealand2015
TheWhys
AsthmaMortality
• 65- 70deathsperyearinNZ• UKnationalreview2014suggestsmanypreventable– >80%deficienciesinacuteorchroniccare– 45%didnotseekhelp– Diagnosticprocessunclear
AsthmamortalitydisparitiesinNZ
Despitethistherearealsotreatmentdisparities
• MaoriandPacificchildrenmorelikelytoreceiveoralsteroidsandnebulisers
• ButlesslikelytoreceiveICS• Lesslikelytoreceiveasthmaeducation• Lesslikelytobegivenanactionplan
Crengle,Thesis2008Gillies,PrimCareResp J2013
Adherence(world-widedata)
• Only30- 50%ofasthmapatientsarewellcontrolled(adultsandchildren)
• CompliancewithICSpreventersonly20-30%• 34%ofpatientswithuncontrolledasthmauseapreventerlessthanonceperweek
• Adherencehasnotimprovedinthelast3decades
Rabe JACI2004Reddell MJA2015BenderJACI:InPractice2016
AsthmaHealthLiteracyforMaoriChildreninNZReport2015
Whanaureported:
• Nothavingadequateknowledge• <50%understoodwhatasthmais• 1/3notknowinghowtoseekurgenthelp• Notbeinglistenedto• Toomuchinformationatonce• Notbeingtaught“why”
“Theresponsibilityforhealthliteracyliesprimarilywithhealthprofessionals”
- AsthmaHealthLiteracyForMaoriChildrenReport2015
TheGuideline
Goalsfromtheguideline
• Allaspectsofthehealthsystemwillsupportbetterasthmacare,aimingtodecreaseinequitiesandimproveoutcomes
• Māorichildrenhaveasthmaoutcomesequaltonon-Māoriandnon-Pasifika children
• Pacificchildrenhaveasthmaoutcomesequaltonon-Pacific&non-Māorichildren
Top10wayshealthprofessionalscanhelp(apartfromprescribingmedicines)
• Relationships• Wellness• Smokeexposure• Housing• Income• Healthliteracy• Adherence• Actionplan,Access,Ambulance
Asthmamanagementasacontinuouscycleofmonitoringandreassessment• Requirementforfollowupandrepeatedreview
• Changefromepisodichealthcare• Useofrecallsystems
Goal:Allchildrenwhohaveasthmaarecorrectlydiagnosedpromptly
• Diagnosisinchildren– basedonhavingcharacteristicsymptomsinabsenceofanothercause
– ANDassessingresponsetotreatment
LikelihoodofAsthma
Incr Likelihood• Typicalepisodicwheeze/cough/SOB
• Typicaltriggers• Atopy• Familyhistory
Decr Likelihood• Lackofintervalsymptoms
• Isolatedcough• Moistcough• Dizzy/light-headed• Stridor• Signsofspecificdisease
RedFlags
• Dailyorconstantsymptoms– Infantwithwheezeeverydaysincebirth–Dailywetormoistcough
• Failuretothrive• Digitalclubbing
• Currentparadigm– <1year“bronchiolitis”– 1– 4year“pre-schoolwheeze”– >4yearasthma
Whatagedowediagnoseasthma?
Pre-SchoolWheeze
• Twodistinctgroups– Thosewhoonlywheezewithviruses(infrequent)– Thosewithfrequentwheeze– Patterndoesnotpredictlaterasthmaornot
• Onlyregularwheezers (incl thosewithfrequentviralexacerbations)benefitfrompreventersàtreatasasthma
• Canswapgroups– reviewandtrialoffmedseach3months
Goal:Allchildrenwithasthmaareassessedfortheirseverity,controlandfuturerisk
Goal:Therightstepofmedicineintherightdeviceisusedfortheageandsymptomsofthe
child• Maximizequalityoflife(reducesymptoms)• Reducerisk• Avoidadversetreatmenteffects• Utilising astep-wiseapproachtomanagement
Pre-schoolpreventermanagement
• Initiallyasneededsalbutamol• Severeflareupswithoutfrequentsymptoms
àMontelukast• Frequentflareupsorfrequentsymptomsbetweenflareupsà Inhaledcorticosteroid
• Stillpoorcontrol?– Addotheroption
• NeverforLABAs
Klok,ERJ,2014
Goal:ForallchildrenwithasthmaitshouldbeclearifICSshouldbeprescribed,andifso,aprescriptiongivenandthemedicinetaken
Assessingadherence
• Prescribingrecords– AtthePractice– Pharmacydatabase
• Selfreport– “Howoftendoyouforgettotakeyourinhalerinaweek?”
• Physicianjudgement• Electronicmonitoringdevices
Goal:Thecorrectinhalerdeviceisconsideredandageappropriate
• Spacerwithmask– <2years
• Spacernomask– transition2– 4years– Improvedlungdepositionby60%– Notwhensevereexacerbation
• Turbuhaler - from5- 7years
• MDIalone– never(possiblefrom8years)
NZchildren
• Only80%ofchildrenunder6useaspacer• Only30%ofchildrenover7useaspacer• Lessthan35%givenanactionplan
Crengle NZMJ2011Crengle Thesis2008
Assessinginhalertechnique:Checkeveryvisit
• Only7- 22%havehadtechniquetested• 20- 50%ofhealthprofessionalsincorrecttechnique!– upto85%fordrypowderinhalers
• Repeatededucationnecessary• Drypowderinhalerstake3sessions• Skillsdecayover2-6weeks
Goal:Identifyandaddresspersonal,whānau orenvironmentalfactorswhichmaybeunsettling
asthma• Smokeexposure• Housing• Allergenavoidance• Anxietyandpsycho-socialtriggers• Associatedconditions– Rhinitis
Goal:Achievingeffectiveself/familyeducationandmanagement
• Goodasthmaeducation– Enhanceshealth-literacy– Enhancesself-efficacy
Educationtakestimeandrepeatedeffort
• Educationateveryvisit(chunks)• Incorporateavarietyofmedia• Buildrapportbybuildingpartnership• Useasharedlanguageforbetterunderstanding– “Puffers”– “RelieversandPreventers”– “Flareups”
• Goalisimprovedself-management
Goal:Allchildrenwithasthmashouldbeprovidedwithanasthmaactionplan
AsthmaFoundationNZ
Goal:Allchildrenshouldbemanagedtoavoidlife-threateningasthmaordeath
SUMMARY:Inordertoreduceinequalityandimproveoutcomes
• Childrenwithasthmarequire– Time– Repeatedvisits
End
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