1. Essentials of Asthma in Children In Primary care
Dr Sherine Dewlett
Consultant-Royal Free, London

2. What this talk contains..
Diagnosis of asthma
Management and monitoring
When to refer to secondary care
Asthma 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

3. 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!

4. 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"

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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

11. 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

12. Step wise management under 5 (BTS 2014)
Step 1: Mild intermittent asthma:
As needed SABA via spacer
Step2: Regular preventor:
Low dose ICS ( mcg)or LTRA, plus as needed SABA
Step3: Add on therapy
In those taking ICS ( mcg) consider add on LTRA-
if age< 2 consider step 4.
Step 4: Persistent poor control:
Refer to respiratory paediatrician- consider earlier if<2

13. Step wise management- age 5-12 (BTS 2014)
Step 1: Intermittent mild asthma-
as needed SABA +spacer
Step 2: Regular preventor
ICS 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

14. 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

15. 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:
Royal Free Wheeze Plan/Whittington asthma plan attached

16. Assessing control When: Assessing control- Step up or Down
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-

17. 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

18. 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

19. 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

20. 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
sneezy wheezy.com
NRAD report
Appendix ( attached documents): UCLP asthma guidelines, RF wheeze action plan, Whittington annual review sheet, Patient education sheet

21. 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?