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Vasi V, Bourke T. Regular review pivotal in chronic asthma in children. Practitioner Nov 2017;261(1809):19-23

Regular review pivotal in chronic asthma in children

23 Nov 2017

AUTHORS

Dr Veena Vasi MB BAO, ST8 Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK

Dr Thomas Bourke MD MRCPCH, Clinical Lecturer in Paediatrics, Queens University Belfast, Belfast, UK

Competing interests: None

Article

Abstract

Asthma is a heterogeneous disease characterised clinically by recurrent episodes of wheeze, cough, and breathlessness. Physiologically it is defined by bronchospasm resulting in variable airflow obstruction. Patients typically present with more than one of wheeze, cough and breathlessness occurring episodically. At present asthma is a clinical diagnosis. The difficulty with this approach is that children may be overdiagnosed and then overtreated. It is likely that investigation-based approaches such as exhaled nitric oxide measurements and demonstrating reversibility will play a much greater role. These approaches are currently being reviewed by NICE and new guidelines are expected in the near future. BTS/SIGN advise that children with recurrent episodes, documented wheeze and atopy are considered to have a high probability of asthma. These children should receive a six-week trial of inhaled corticosteroids. A good response to treatment confirms the diagnosis. The aim of asthma treatment is complete control of symptoms as soon as possible while minimising side effects and inconvenience to the patient. Therapy should be escalated in children who are symptomatic more than three times a week, using their reliever inhaler more than three times per week or waking one night a week. All parents and older children should be offered a written action plan. This should include details of the patient’s regular medicines, how to recognise deterioration and what to do in the event of an attack. Children should be referred to secondary care if: the diagnosis is unclear; control remains poor despite monitored treatment; they have suffered a life-threatening attack or red flag featuresare present.


Asthma is a common heterogeneous disease characterised clinically by recurrent episodes of wheeze, cough, and breathlessness. Physiologically it is defined by bronchospasm resulting in variable airflow obstruction.1

It is a common cause of primary care attendance and hospital admissions. Asthma can be fatal with 14% of deaths in the UK occurring in children and young people under the age of 19.

Of those who died 80% had evidence of poor care and 60% had modifiable risk factors, the National Review of Asthma Deaths found.2

Clinical features

Patients typically present with more than one of wheeze, cough and breathlessness occurring episodically. Symptoms may be worse at night.

A strong personal or family history of eczema, rhinitis or other atopy is common.1,3

Parents use the word wheeze to describe a wide range of respiratory noises but this correlates poorly with objectively recorded findings.4,5 An open mind should be kept about the nature of the sound described unless a true polyphonic wheeze has been documented by a clinician. Isolated chronic cough is rarely if ever due to asthma.6

Distinguishing asthma from episodic viral wheeze can be difficult and we have discussed this previously in an earlier article in this journal.7

The red flag features which are suggestive of other diagnoses and warrant referral for further investigation are shown in table 1.3

Diagnosis

At present asthma is a clinical diagnosis.1,8 The difficulty with this approach is that children may be overdiagnosed and then overtreated.

It is likely that investigation-based approaches such as exhaled nitric oxide measurements and demonstrating reversibility will play a much greater role. These approaches are currently being reviewed by NICE and new guidelines are expected in the near future (Now published see external websites on the right). BTS/SIGN advise that children with recurrent episodes, documented wheeze and atopy are considered to have a high probability of asthma. Children with only some of these features have an intermittent probability and children with none have a low probability of asthma.3

Children considered to have a high probability should receive a six-week trial of inhaled corticosteroids (ICS).

A good response to treatment confirms the diagnosis.3

In younger children with an intermittent probability of asthma either a watch and wait approach to symptoms or a monitored trial of treatment could be adopted. In older children with an intermittent probability of asthma spirometry may be useful to check for bronchodilator reversibility. 

Evidence-based treatment

Non-pharmacological management

Exposure to environmental tobacco smoke increases wheezing in infancy, risk of persistent asthma, number of exacerbations and need for ICS. Parents should be strongly advised to stop smoking and offered appropriate support.

Interventions to promote weight loss in overweight children can be considered although evidence is limited. There is no evidence that strategies to reduce house dust mite exposure improve asthma control and these should not be recommended.9

A Cochrane review of air ionisers showed no benefit and one study actually showed an increase in cough.10 Two randomised controlled trials on fish oils during pregnancy showed no reduction in asthma or other allergies.3 There are no good quality studies on other supplements during pregnancy. There is no evidence to support the use of acupuncture, homoeopathy or other alternative treatments.3

Some retrospective studies suggest a modest association between paracetamol during pregnancy and childhood asthma.11 However, UK guidance has not changed and pregnant women are still advised to take paracetamol at the lowest effective dose for the shortest time.

Pharmacological management

The aim of asthma treatment is complete control of symptoms as soon as possible while minimising side effects and inconvenience to the patient.3,8

All patients should be prescribed a short-acting beta-2 agonist to be used as required as a reliever. In some patients with infrequent short-lived symptoms this will be adequate.

The BTS/SIGN guidelines advocate a stepwise approach to preventer therapy.3 Before stepping up treatment it is essential to:

• Reconsider if the diagnosis of asthma is correct

• Check concordance with existing therapy and technique 

Therapy should be escalated in children who are symptomatic more than three times a week, using their reliever inhaler more than three times per week or waking one night a week.3 ICS should be started twice daily at a very low dose. Details of ICS preparations and dosages are available from www.sign.ac.uk/assets/sign153_table10.pdf

The next step in children over five years is addition of a long-acting beta-2 agonist (LABA). In children under five years a leukotriene receptor antagonist (LTRA) should be added. If there is no response to the LABA it should be stopped and treatment increased to include low dose ICS. If there is a partial response to LABA therapy it should be continued and treatment increased to include low dose ICS. Addition of an LTRA should be considered if control is still inadequate.

Additional treatments that will be considered in secondary care include higher dose ICS, oral theophyllines or systemic steroids.

Children on low dose ICS are at low risk of side effects. We advise parents that those on medium and high dose ICS are at risk of poor growth and adrenal suppression. Those most at risk are likely to be attending secondary care where their growth is monitored regularly. If it falters their steroid dose will be reviewed. ICS dose should be reduced when control is achieved. However, there is no clear evidence on how best to do this.

Regular review and clinical judgment is required as patients can deteriorate at different rates. In principle, steroid doses should be decreased every few months. Some children have a clear seasonal pattern to their symptoms and it may be appropriate to taper doses over the summer months.

Devices

Studies have shown that in children under 12 years, metered dose inhalers (MDI) with an appropriate spacer are as effective as any other devices.3 There is no evidence to support the use of breath-actuated inhalers. In practice some patients continue to have difficulty with MDIs and some older children may prefer a dry powder inhaler.

A spacer with a face mask is required until the child can use a spacer with a mouthpiece, see figure 1.

The correct technique must be taught and reassessed at each visit.

Monitoring

The National Review of Asthma Deaths found that 43% of patients who died had had no primary care review in the previous 12 months.2 Other risk factors identified included:

• Healthcare professionals failing to adhere to asthma guidelines

• More than 12 reliever inhalers in 12 months

• Underprescription of ICS

• Inappropriate use of single component LABA

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.  These risk factors should all be addressed at every consultation and at least once yearly at the annual review, see table 2.

The National Review of Asthma Deaths also noted that fewer than one quarter of patients who died from asthma had a written action plan and recommended that all parents and young people should have one.2 An example produced by Asthma UK is shown in figure 2, and includes details of the patient’s regular medicines, how to recognise deterioration and what to do in the event of an attack.

Referral

Children should be referred to secondary care if:

• The diagnosis is unclear

• Control remains poor despite monitored treatment

• They have suffered a life-threatening attack

• Red flag features are present, see table 1.

Conclusion

Chronic asthma is a common disease of childhood and a significant burden on primary care and other health services. If diagnosed and managed correctly most patients can have a safe and symptom-free lifestyle.

BTS/SIGN advocate a stepwise approach to management to ensure adequate control while minimising potential side effects from ICS.

REFERENCES

1 Bush A, Fleming L. Diagnosis and management of asthma in children. BMJ 2015;350:h996

2 Royal College of Physicians. Why Asthma Still Kills: The National Review of Asthma Deaths (NRAD) Confidential Enquiry Report. RCP. London. 2014 www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf

3 British Thoracic Society, Scottish Intercollegiate Guidelines Network. SIGN 153. British guideline on the management of asthma. Updated 2016. www.sign.ac.uk/sign-153-british-guideline-on-the-management-of-asthma.html

4 Cane RS, Ranganathan SC, McKenzie SA. What do parents of wheezy children understand by “wheeze”? Arch Dis Child 2000;82:327-32

5 Cae RS, McKenzie SA. Parents’ interpretations of children’s respiratory symptoms on video. Arch Dis Child 2001;84:31-34

6 Jiang M, Guan WJ, Fang ZF et al. A critical review of the quality of cough clinical practice guidelines. Chest 2016;150(4):777-78

7 McVea S, Bourke T. Optimising the management of wheeze in preschool children. Practitioner 2016;260(1794):11-14

8 Turner S. The management of childhood asthma - what is new? Paed Child Health 2017;27(7):311-17

9 Gotzsche PC, Johansen HK. House dust mite control measures for asthma. Cochrane Database Syst Rev 2008:Apr 16;(2):CD001187

10 Blackhall K, Appleton S, Cates CJ. Ionisers for chronic asthma. Cochrane Database Syst Rev 2003;(3):CD002986

11 Magnus MC, Karlstad O, Håberg SE et al. Prenatal and infant paracetamol exposure and development of asthma: the Norwegian Mother and Child Cohort Study. Int J Epidemiol 2016;45(2);512-22

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Chronic asthma in children