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

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

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: 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- 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