Abstract

The National Review of Asthma Deaths found that 43% of patients who died from asthma had had no primary care review in the previous 12 months. In children and young people there was a particular lack of adherence to medical advice and a lack of awareness about the risks of a poor outcome. Features of asthma deterioration in children that parents should be aware of include: difficulty talking or walking, unable to feed, little relief with salbutamol, a drop in peak flow, hard and fast breathing, and coughing and wheezing a lot. In some patients the signs and symptoms may be more subtle including persistent nocturnal cough, chest pain, reduced energy or appetite. Clinical signs sometimes correlate poorly with the degree of airway obstruction. In some cases of acute severe asthma, children may not appear distressed. The BTS/SIGN guideline specifies that the accurate measurement of oxygen saturation is essential in the assessment of all children with acute wheezing. It recommends that oxygen saturation probes and monitors should be available for use by all healthcare professionals assessing acute asthma in primary care. It is important to use the appropriate size paediatric probe to ensure accuracy. Teenagers with asthma, particularly those with perceived mild or moderate disease are at greater risk of acute, severe and life-threatening exacerbations. Any patient who presents to the GP practice with any features of a moderate exacerbation should be referred to an emergency department for further assessment and monitoring. Features of life-threatening asthma include: SpO2 < 92%, peak expiratory flow < 33% best or predicted, poor respiratory effort, silent chest, cyanosis, exhaustion, confusion, and hypotension.

Asthma is a common and potentially serious condition that still leads to avoidable deaths.¹ More than one million children in the UK are receiving treatment for asthma with the vast majority managed in primary care.²

Acute asthma can be rapidly fatal. The National Review of Asthma Deaths found that 43% of patients who died from asthma had had no primary care review in the previous 12 months.¹ In children and young people there was a particular lack of adherence to medical advice and a lack of awareness about the risks of a poor outcome. Fewer than one quarter of patients who died from asthma had a written asthma action plan.

Teenagers with asthma, particularly those with perceived mild or moderate disease are at greater risk of acute, severe and life-threatening exacerbations.^1,3

This article discusses the typical features of an acute exacerbation of asthma and recommends management in primary care based on national guidelines and other evidence.

Presentation

Viral upper respiratory tract infection is the most common cause of an asthma exacerbation. Other causes include allergen or pollutant exposure, cessation/reduction/non-compliance with medication or concomitant medication (e.g. non-selective beta blockers).⁴ Prematurity, low birthweight, personal and family history of atopy are risk factors for recurrent wheezing. Parents should be made aware that the features listed in table 1, below, indicate that their child's asthma is deteriorating.⁵

Typical features of moderate to life-threatening attacks as described in the BTS/SIGN guideline are outlined in table 2.⁶ In some patients the signs and symptoms may be more subtle including persistent nocturnal cough, chest pain, reduced energy or appetite.

Assessment

All children presenting with respiratory symptoms should have a clinical history and examination focusing on the features in table 1, and table 2, below. The history should also include enquiry about what rescue therapy the child has received and a review of their personalised asthma action plan. Severity of previous attacks, response to treatment during exacerbations and adherence to preventer treatment should be explored.^5,6
The BTS/SIGN guideline⁶ specifies that the accurate measurement of oxygen saturation is essential in the assessment of all children with acute wheezing (see figure 1).

It recommends that oxygen saturation probes and monitors should be available for use by all healthcare professionals assessing acute asthma in primary care.⁶ It is important to use the appropriate size paediatric probe to ensure accuracy.

The following clinical signs should be checked and recorded:
• Pulse rate
• Respiratory rate, degree of breathlessness, and oxygen saturation
• Use of accessory muscles of respiration
• Amount of wheezing
• Conscious level and degree of agitation

It is important to be aware that clinical signs sometimes correlate poorly with the degree of airway obstruction.⁵ In some cases of acute severe asthma, children may not appear distressed.⁷ It may be that the patient’s inhaler technique is at fault. Those who are unable to use their inhaler correctly are at increased risk of poor control and subsequent exacerbations.⁸

Treatment

Essential equipment for managing paediatric asthma emergencies in primary care is listed in box 1.

Children with acute asthma should receive prompt and appropriate management in the primary care setting, see table 3. Inhaled short-acting beta agonists such as salbutamol relax airway smooth muscle and relieve obstruction.⁶ In asthma, the early use of steroids has been proven to reduce the need for hospital admission and prevent a relapse in symptoms after initial presentation.⁹ The treatment course of oral prednisolone is usually three days with no need to taper the dose. It can be challenging to remember doses and vital sign parameters for different age groups and it can be helpful to consult the emergency assessment and treatment pages on the BTS/SIGN asthma guideline smart phone app
(see External weblinks).

The use of inhaled corticosteroids as an alternative or additional treatment to oral steroids is not recommended.⁶ Dexamethasone is now being used as an alternative steroid in some secondary care centres for mild to moderate acute asthma exacerbations although it is not yet recommended by BTS/SIGN. There is some evidence that it has a similar efficacy but lower cost than prednisolone. Another advantage is that a number of studies have demonstrated that only a single dose is required.¹⁰

Referral

Any patient who presents to the GP practice with any features of a moderate exacerbation should be referred to an emergency department for further assessment and monitoring.6 Have a lower threshold for referral if there are social concerns, recent hospital admissions or it is late afternoon/evening.

Improving outcomes

Childhood asthma remains a common and at times life-threatening condition. While the vast majority of patients are appropriately managed in primary care the National Review of Asthma Deaths did highlight that some deficiencies were found in almost 50% of fatal cases. Primary Care Respiratory Society UK has developed key recommendations as a strategic guide to try to improve outcomes in asthma, see below.¹
• All patients with asthma should have a personalised asthma action plan and be informed about how to respond in the event of deteriorating control (see figure 2, pp13-14).
• Patients who have experienced acute asthma episodes should be reviewed as soon as practically possible. Good communication with secondary care is essential to follow up patients promptly who have had recent hospital attendances or inpatient stays. These reviews should be conducted by clinicians trained in asthma care who should be particularly aware of the factors that place patients at higher risk of exacerbation and death
• Each primary care practice should have a named healthcare professional for asthma care standards and staff education
• In the event of acute asthma exacerbation, practices should ensure that their systems encourage and enable swift access to advice and clinical assessment
• Practices should consider developing a high risk register for those patients who have had previous serious/life-threatening exacerbations
• Local clinical commissioning groups should ensure that GPs, out of hours providers and walk-in centres are aware of, and follow, the BTS/SIGN guideline.