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Childhood asthma:

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EUSTACE KARO

on 4 December 2013

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Transcript of Childhood asthma:

Childhood asthma:
diagnosis and treatment

Key points :
Diagnosis,Management,Clinical tips.

Key points
: Diagnosis

Childhood asthma
is characterised by chronic or recurrent cough or wheeze.

The diagnosis can be confirmed with
peak flow measurements and spirometry

in children old enough to perform these measurements.

A therapeutic trial of medications also may be helpful.
Childhood asthma:
what is it?, who gets it, diagnosis,
history, exam., & treatment.
What is it?

Childhood asthma is characterised by

chronic or recurrent cough or wheeze.

The diagnosis can be confirmed with
peak flow measures and spirometry
in children old enough to perform these measurements.
Childhood asthma:

diagnosis and treatment.
Drug measures

The British Thoracic Society
recommends a stepwise approach to drug treatment.


Control of asthma is assessed against these standards.

Minimal symptoms during day and night

Minimal need for reliever drugs

No exacerbations

No limitation of physical activity

Normal lung function

(in practical terms, forced expiratory volume in one second or peak expiratory flow >80% predicted or best, or both)
Symptom relief.
Inhaled short acting beta2 agonists.

Benefits

Inhaled short acting beta2 agonists
are the most effective drugs for relieving acute bronchospasm.

They are the drug of choice for step 1
&
just before exercise to prevent exercise induced wheeze.
Prophylaxis.
Inhaled corticosteroids.

Benefits

Inhaled corticosteroids are the best treatment for single agent prophylaxis.

Prophylactic inhaled steroids improve symptoms and lung function
in children with asthma.

The British Thoracic Society
recommends that inhaled steroids be used at step 2.
This module provides
the essential facts on the diagnosis and management
of asthma in childhood.


It is based on the best available evidence.

After reading the module,
you can test your knowledge with
our "best of many questions" quiz.
Learning outcomes

After completing this module you should be able to:

1. Consider which inhaler device is most suitable for a child with asthma

2. Use steroids more judiciously in children with viral episodic wheezing

3. Use high doses of steroids to gain initial control in a child with asthma but step down the dose to reduce the risk of complications

4. Refer children who are taking high dose inhaled steroids to a specialist to consider the implications for their long term growth.
About the author.

Alexander Williams
is a GP at St Thomas Health Centre in Exeter.

He was formerly a registrar in general and respiratory medicine at Torbay Hospital
&,
until recently, was hospital practitioner in
respiratory medicine at Wonford Hospital, Exeter.
Why I wrote this module

"
I wrote this module so that I could better understand the diagnosis and treatment of childhood asthma.

I learnt that childhood asthma can be categorised into:

1) classic childhood asthma
(often associated with atopy)
&
2) viral episodic wheezing
(often triggered by viral infections).

The two forms are treated differently.
"
Key points:
Management

The British Thoracic Society
recommends
a stepwise approach to the treatment of asthma.

Children aged 5-12 years.

Step 1: mild intermittent asthma

Start the child on an INHALED SHORT ACTING
beta2 agonist as needed.
Key points:
Management

The British Thoracic Society
recommends a stepwise approach to the treatment of asthma.

Children aged 5-12 years.

Step 2: regular preventer therapy

Add in an inhaled steroid at 200-400 µg/day
(beclometasone or equivalent).

Use a starting dose of inhaled steroid
appropriate for the severity of disease:

the usual starting dose is 200 µg/day.
Key points:
Management

The British Thoracic Society
recommends a stepwise approach to the treatment of asthma.

Children aged 5-12 years.

Step 3: add on therapy

You should add inhaled long acting beta2 agonists
&
then assess control of the asthma:

If the patient has a good response
to the long acting beta2 agonist,
continue the drug.
Key points:
Management

The British Thoracic Society
recommends a stepwise approach to the treatment of asthma.

Children aged 5-12 years.

Step 4: persistent poor control

Increase inhaled steroid up to 800 µg/day.
Key points:
Management

The British Thoracic Society
recommends a stepwise approach to the treatment of asthma.

Children aged 5-12 years.

Step 5: continuous or frequent use of oral steroids

Start daily steroid tablets
at the lowest dose possible for adequate control
&
maintain high dose inhaled steroid (800 µg/day).

Refer to a respiratory paediatrician.
Key points.

Management.

The British Thoracic Society recommends
a stepwise approach to the treatment of asthma.

Children aged <5 years


Step 1: mild intermittent asthma

Start an inhaled short acting beta2 agonist as needed.
Key points.
Management.

The British Thoracic Society
recommends a stepwise approach to the treatment of asthma.

Children aged <5 years.

Step 2: regular preventer therapy

Add in an inhaled steroid at a dose of 200-400 µg/day (beclometasone or equivalent)
or
a leukotriene receptor antagonist
if an inhaled steroid cannot be used.

Start at a dose of inhaled steroid appropriate for the severity of disease.
Key points.

Management.

The British Thoracic Society
recommends a stepwise approach to the treatment of asthma.

Children aged <5 years.

Step 3: add on therapy

In children aged 2-5 years,
try a leukotriene receptor antagonist.

In children aged <2 years, consider moving to step 4.
Key points.

Management.

The British Thoracic Society
recommends a stepwise approach to the treatment of asthma.

Children aged <5 years.

Step 4: persistent poor control

Refer to a respiratory paediatrician.
Clinical tips

You should refer children to a respiratory paediatrician in the case of :

Diagnostic uncertainty

Symptoms present from birth

Excessive vomiting or posseting

Severe upper respiratory tract infection

Persistent wet cough
Clinical tips

You should refer children to
a respiratory paediatrician in the case of.

Growth faltering

Family history of unusual chest disease

Unexpected clinical findings
(for example, focal chest signs or dysphagia)

Failure to respond to conventional treatment
(for example, if a child needs to take inhaled steroids equivalent to
>400 µg/day beclometasone or makes frequent use of steroid tablets)

Parental anxiety.
Who gets it?

Many children wheeze,

but this often gets better on its own

(especially if no personal or family history of atopy is present)
Who gets it?

Asthma
is more common in children with a personal
or
family history of atopy.


The highest incidence is in boys aged <5 years ;

the incidence then falls with increasing age.
Who gets it?

The number of children with asthma has rocketed in recent years.


About one in every eight (1 in 8) children in the UK has asthma,
compared with about one in 50 in the late 1970s.


Why more children are getting asthma today
than 20 years ago is not clear.
Who gets it?

People used to blame an increase in air pollution.


But this seems unlikely because
it has been found that many of the most polluted countries in the world,
such as China and Eastern European countries,
have low rates of asthma,
whereas
countries with the best air quality,
such as New Zealand, have high rates of asthma.
Who gets it?

One of the most popular explanations
at the moment is the "hygiene hypothesis."

This blames increasing asthma rates
on cleaner homes,
which have meant that children get
fewer infections than they used to.
Who gets it?
Asthma attacks usually result from:


Infection
House dust mites
Pets
Anxiety
Tobacco smoke.
Who gets it?


Some scientists think that childhood infections
help to build up the immune system,
&
because children are getting fewer infections,
they have less protection against asthma.
How do I diagnose it?

Childhood asthma is diagnosed by the presence of reversible episodes of airflow obstruction

in the absence of alternative diagnoses.
How do I diagnose it?

The differential diagnosis of asthma in infants and children is as follows.

Vocal chord dysfunction

Obstruction involving small airways

Viral bronchiolitis or obliterative bronchiolitis

Cystic fibrosis.
How do I diagnose it?

The differential diagnosis of asthma in infants and children is as follows.

Upper airway diseases

Allergic rhinitis and sinusitis

Transient non-specific wheeze associated with viral infections

Obstruction involving large airways

Foreign body in trachea or bronchus
History

Asthma is diagnosed from the patient's history.

You should note the type and frequency of symptoms,
whether there is a family history and whether there are any particular triggers.

Symptoms of asthma can be one or more of the following:

Cough
Wheeze
Breathlessness
Feeling of tightness in the chest.

The diagnosis can be confirmed with peak flow measurements and spirometry in children old enough to do these.

Spirometry can be undertaken in children from the age of 5 upwards.
History

Asthma is diagnosed from the patient's history.

You should note the type and frequency of symptoms,
whether there is a family history and whether there are any particular triggers.

Other points to remember in the diagnosis include:

1) Sleep may be disturbed by nocturnal dry cough

2) Cough may be present in the absence of wheeze

3) A therapeutic trial of drugs may be helpful

4) Question the diagnosis if the treatment is not working.

The diagnosis can be confirmed with peak flow measurements & spirometry
in children old enough to do these.
Spirometry can be undertaken in children from the age of 5 upwards.
Examination

Most children with asthma look completely normal.

Children with severe asthma may have hyperinflation
&
chest deformity
(for example, pigeon chest).

Wheeze may be audible when you listen to the chest.
Examination.

Unilateral chest signs should raise the suspicion of chronic lung disease
(such as cystic fibrosis)
or, rarely,

obstruction from a foreign body

(such as a peanut).

If the child is failing to thrive,
suspect chronic lung disease.
Investigations.

Older children may be able to measure


their peak expiratory flow rate
&
record the values in a peak flow diary.
Investigations

In patients with asthma,

peak flow is often variable
&
gets worse at night.
Investigations.

A chest x ray

may be warranted if you suspect
suppurative lung disease.
How is it treated?

Non-drug measures
Avoidance of other exacerbating factors.

No evidence confirms that removing pets from the house helps
children with asthma who have a pet allergy,
but
many experts still recommend this approach.

If there is no pet then it might be a good idea to advise against
getting one.

Cessation of smoking by parents can reduce the severity of their
children's asthma.
How is it treated?

Non-drug measures
Avoiding house dust mites.

Evidence
No good evidence supports the theory that allergen avoidance may help reduce disease severity.

One review found that methods to reduce levels of house dust mites did not help patients with asthma
&
sensitivity to dust mites
How is it treated?

Non-drug measures
Avoiding house dust mites.

Side effects

No ill effects result from reducing levels
of house dust mites;

however,
attempts to reduce levels can cause upheaval in the home.
How is it treated?

Non-drug measures
Avoiding house dust mites.

Benefits

Methods to reduce levels of house dust mites
have not been proved to reduce symptoms of asthma.
How is it treated?

Non-drug measures

Other measures.

In the other study,
there was an improvement in overall clinical assessment

&
number of functionally impaired days

in the patients receiving family therapy.
How is it treated?

Non-drug measures

Other measures.
A Cochrane review found that family therapy

(which is organised through child and adolescent services to address the needs of families under stress)

may be a useful adjunct to drugs
in difficult childhood asthma.
How is it treated?

Non-drug measures

Other measures.

Two trials with a total of 55 children were included.

It was not possible to combine the findings of these two studies because of differences in outcome measures used.

In one study,
gas volume, peak expiratory flow rate, & daytime wheeze
showed improvement in family therapy patients compared to controls.
Drug measures
The British Thoracic Society
recommends a stepwise approach to drug treatment.

A stepwise approach aims to:

1) Abolish symptoms as soon as possible

2) Optimise peak flow by starting treatment at the level most likely to achieve this.
Drug measures
The British Thoracic Society
recommends a stepwise approach to drug treatment.

A stepwise approach aims to:

1) Patients should start treatment at the step most appropriate for the initial severity of their asthma.

2) The aim is to achieve early control & then to maintain control by

stepping up treatment as necessary & stepping down when control is good.
Drug measures.

The British Thoracic Society
recommends a stepwise approach to drug treatment.

Children aged 5-12 years

Step 1: mild intermittent asthma

Start the child on an inhaled short acting beta2 agonist as needed.

Step 2: regular preventer therapy

Add in inhaled steroid at 200-400 µg/day (beclometasone or equivalent).

Use a starting dose of inhaled steroid appropriate for the severity of disease: the usual starting dose is 200 µg/day.

Use other preventer drugs if inhaled steroids cannot be used.
Drug measures

The British Thoracic Society
recommends a stepwise approach to drug treatment.

Children aged 5-12 years

Step 3: add on therapy

You should add inhaled long acting beta2 agonists & then assess control of the asthma:

If the patient has a good response to the long acting beta2 agonist, continue the drug

If the patient has benefit from long acting beta2 agonist, but control is still inadequate, continue the drug and increase the dose of inhaled steroid to 400 µg/day
(if they are not already taking this dose)

If the patient has no response to long acting beta2 agonist, stop it & increase the inhaled steroid dose to 400 µg/day.

If control is still inadequate, try other treatments: for example, leukotriene receptor antagonists or slow release theophylline.
Drug measures

The British Thoracic Society
recommends a stepwise approach to drug treatment.

Children aged 5-12 years

Step 4: persistent poor control

Increase inhaled steroid up to 800 µg/day.
Drug measures

The British Thoracic Society
recommends a stepwise approach to drug treatment.

Children aged 5-12 years

Step 5: continuous or frequent use of oral steroids

Start daily steroid tablets at the lowest dose possible for adequate control & maintain high dose inhaled steroid (800 µg/day).

Refer to a respiratory paediatrician.
Drug measures

The British Thoracic Society
recommends a stepwise approach to drug treatment.

Children aged <5 years

Step 1: mild intermittent asthma

Start an inhaled short acting beta2 agonist as needed.
Drug measures

The British Thoracic Society recommends
a stepwise approach to drug treatment.

Children aged <5 years

Step 2: regular preventer therapy

Add in an inhaled steroid at a dose of 200-400 µg/day (beclometasone or equivalent)
or
a leukotriene receptor antagonist if an inhaled steroid cannot be used.

Start at a dose of inhaled steroid appropriate for the severity of disease.
Drug measures

The British Thoracic Society
recommends a stepwise approach to drug treatment.

Children aged <5 years

Step 3: add on therapy

In children aged 2-5 years, try a leukotriene receptor antagonist.

In children aged <2 years, consider moving to step 4.
Drug measures

The British Thoracic Society
recommends a stepwise approach to drug treatment.

Children aged <5 years

Step 4: persistent poor control

Refer to a respiratory paediatrician.
Inhaled short acting beta2 agonists

Side effects

Common side effects in children
include
tachycardia
&
hyperactivity.

Hypokalaemia
can occur with excessive doses.
Inhaled short acting beta2 agonists

Evidence

One systematic review
showed that regular use of short acting beta2 agonists did not prevent exacerbations of asthma,
&
that patients who used their inhaler as needed
had better symptom control than those who used it continuously.
Inhaled short acting beta2 agonists

Dose

Use the minimum dose necessary on an as required basis.
Inhaled short acting beta2 agonists

Evidence

It is unethical to run trials that measure the effects of
short acting beta2 agonists on symptom control.

More recently,
research has focused on whether
short acting beta2 agonists
have a role in the prophylaxis of asthma.
Inhaled corticosteroids.

Side effects

Two systematic reviews of studies with long term follow up found no evidence of growth retardation in children treated with low dose inhaled corticosteroids.

Short term studies, however,
found that growth velocity was reduced and that high doses of
inhaled steroids particularly can restrict growth.
Inhaled corticosteroids.

Side effects

Oropharyngeal side effects of inhaled corticosteroids
(sore throat, hoarse voice, and candidiasis)
are
uncommon at low doses
, especially if a spacer is used and if the mouth is rinsed after inhalation.

At higher doses, systemic absorption can occur.

Systemic absorption is more likely to occur with beclometasone than
the other steroids.
Inhaled corticosteroids.

Side effects.

Two observational studies found no evidence that inhaled steroids affect bone metabolism in children.

Two cross sectional studies found no evidence that they cause
cataracts
in children.
Inhaled corticosteroids

Evidence

One systematic review compared inhaled steroids with placebo.

This showed

1) improved symptom scores,
2) reduced use of beta2 agonists,
3) reduced use of oral corticosteroids, &
4) improved peak flow rates

in those who took inhaled corticosteroids.
Inhaled corticosteroids

Evidence

Inhaled corticosteroids were better at improving

symptoms & lung function
than
1) inhaled long acting beta2 agonists,
2) oral leukotriene receptor antagonists,
3) sodium cromoglycate, &
4) nedocromil.
Inhaled corticosteroids

Dose

Beclometasone
is a commonly used inhaled steroid that may be started at 200 µg/day.

Fluticasone
is about twice as potent per microgram as budesonide and beclometasone:
100 µg fluticasone is equivalent to 200 µg budesonide or beclometasone.

If asthma is poorly controlled on low dose inhaled corticosteroids,
common practice is to increase the dose.
Inhaled corticosteroids

Dose

One randomised controlled trial,
however,
found that increasing the dose
did not improve symptom scores or lung function.

The increased dose was more likely
to cause growth retardation.
Inhaled corticosteroids

Dose.

A variety of CFC free inhalers are now licensed in children
(Clenil Modulite, Asmabec Clickhaler, and Pulmicort Turbohaler)
.

Flixotide Evohaler is only available for the over 4s
&
Budesonide Easihaler only for those over 6.

Seretide (fluticasone & serevent) is only for use in over 4s
&
Symbicort (budesonide & formoterol) only for the over 6s.
Inhaled corticosteroids.

Mast cell stabilisers

Benefits

Prophylactic inhaled nedocromil improves symptoms & lung function
in children with asthma;
however,
inhaled nedocromil is less effective than inhaled steroids.


It is not specifically included
in the British Thoracic Society stepwise approach.

It is rarely used nowadays.
Inhaled corticosteroids.

Mast cell stabilisers

Side effects

Reported side effects include

an unpleasant taste, nausea, vomiting, & abdominal pain.
Inhaled corticosteroids

Mast cell stabilisers

Evidence

One randomised controlled trial

(1041 children)

compared nedocromil, budesonide, & placebo in children with mild to moderate asthma.

Nedocromil
reduced the number of urgent care visits & courses of prednisolone compared with placebo,

but children who took inhaled budesonide had better control of symptoms & needed fewer hospital stays.
Inhaled corticosteroids.

Mast cell stabilisers

Evidence

Two randomised controlled trials in children aged 6-12 years found that,
compared with placebo, inhaled nedocromil reduces
1) asthma symptom scores,
2) asthma severity, &
3) bronchodilator use, &
4) improves lung function.
Inhaled corticosteroids.

Mast cell stabilisers

Dose

A dose of 4 mg nedocromil
may be given four times daily;
when control is achieved, it may be possible to
reduce the frequency to twice daily.
Theophyllines

Benefits

Prophylactic oral theophylline improves
symptoms & lung function
in children with asthma.

The British Thoracic Society
recommends that theophylline
is tried at step 3 in children aged 5-12 years
who are symptomatic despite taking 400 µg/day of inhaled steroid &
a long acting beta2 agonist
(the latter should be stopped before theophylline is started).
Theophyllines

Side effects

Patients who take theophylline need to be monitored for potential but serious side effects,
including
arrhythmias & convulsions.

Oral theophylline
is associated with a higher frequency of
1) headache,
2) gastric irritation, &
3) tremor
than inhaled beclometasone.
Theophyllines.

Evidence

One randomised controlled trial compared
oral theophylline with inhaled corticosteroids.

Both treatments provided good symptom control,
but
children who took corticosteroids
needed fewer additional drugs
than those on theophylline.
Theophyllines

Dose

In a child aged >6 years,
theophylline 125 mg
may be given every 12 hours.
Oral leukotriene receptor antagonists

Benefits

Oral leukotriene receptor antagonists improve some symptoms of asthma in children.

In children with asthma that is poorly controlled
with inhaled steroids alone,
introduction of a leukotriene antagonist
can improve lung function & reduce exacerbations.
Oral leukotriene receptor antagonists

Benefits

In children aged <5 years,
oral leukotriene antagonists can be started at step 2
if inhaled steroids cannot be tolerated.

Oral leukotriene receptor antagonists
should be used at step 3 in children aged 5-12 years
who are still symptomatic despite taking 400 µg/day of inhaled steroid
&
a long acting beta2 agonist
(the latter should be stopped before leukotriene receptor antagonists are started).
Long acting beta2 agonists

Evidence

Two randomised controlled trials compared treatment with

inhaled long acting beta2 agonists
with treatment with
inhaled corticosteroids
(beclometasone versus salmeterol)
in 308 children.

The first smaller study found that beclometasone
was more effective than salmeterol
at improving lung function & the need for short acting beta2 agonists.
Long acting beta2 agonists

Benefits

Prophylactic long acting beta2 agonists
improve symptoms & lung function in children
with asthma compared with placebo.

The British Thoracic Society guidelines
advise that long acting beta2 agonists be used at step 3 in children aged 5-12 years.
Long acting beta2 agonists

Evidence

Children treated with the corticosteroid had fewer exacerbations.


Both treatments improved symptom scores.

In the second study, 241 children were randomised to receive
1) beclometasone,
2) salmeterol, or
3) placebo.

Both salmeterol and beclometasone
improved lung function,
but
the corticosteroid was more effective as it reduced exacerbations
&
the need for bronchodilator while salmeterol did not.
Long acting beta2 agonists

Side effects

Side effects of long acting beta2 agonists
include :--

1) tachycardia,
2) tremor, &
3) hypokalaemia.
Long acting beta2 agonists

Dose

The dose of salmeterol is 50 µg twice a day.
Choice of inhaler.
Selecting an appropriate device is fundamental
to the success of asthma management.

You may prescribe a dose of medication,
but the amount that reaches the target site in
the airways depends on:

1) The device used (suitability)
2) How it is used (technique)
3) The ease with which it is used (convenience & adherence)
4) Disease severity
Patient choice is crucial, and the device should be appropriate for the age of the patient.

Patients should be carefully instructed
on how to use their inhaler device;

1) a demonstration,
2) observation of technique, &
3) subsequent reinforcement

should all be part of ongoing asthma management.
Large volume spacers
(for example, Volumatic or Nebuhaler)
are most efficient when used properly.

But smaller volume spacers
(for example, Aerochamber)
may be easier to carry, & this may help with compliance.

In young children it is appropriate to use a spacer
with a silicone mask & a small volume chamber
that requires little inspiratory effort to open.
The stainless steel Nebuchamber
may be more efficient than plastic models,
but it is not generic.

The Aerochamber,
on the other hand, fits most metered dose inhalers.
Spacers
should be used when high doses of medication
are needed,
&

to deliver bronchodilators in exacerbations.
Viral episodic wheezing

Usually only acute wheezy episodes need to be treated.


The best evidence supports the use of
short acting inhaled beta2 agonists
via
a metered dose inhaler and spacer.
When should I refer my patient?
The British Thoracic Society
recommends
referral to a respiratory paediatrician for :

1) Diagnostic uncertainty
2) Symptoms present from birth
3) Excessive vomiting or posseting
4) Severe upper respiratory tract infection
5) Persistent wet cough
The British Thoracic Society

recommends
referral to a respiratory paediatrician for :

1) Failure to thrive
2) Family history of unusual chest disease
3) Unexpected clinical findings
(for example, focal chest signs or dysphagia)
4) Failure to respond to conventional treatment(for example,
if a child needs to take inhaled steroids
equivalent to >400 µg/day beclometasone or
makes frequent use of steroid tablets)
5) Parental anxiety
Follow up

Frequency of follow up
depends on the severity of the presenting attack
or
the frequency of exacerbations.

Children who rarely wheeze,
or
who wheeze only with viral infections,
can be managed symptomatically.
What's the outlook?

In one study,
children aged <12 years with asthma
were followed up for 20 years :

1) 28%
became asymptomatic
2) 24%

had occasional mild symptoms
3) 27%

had gone into remission for three years or more but had relapsed as adults.
4) 21%

had not experienced remission for any period exceeding three months.
What's the outlook?
Factors associated with persistence include :

1) Family history of atopy
(a risk factor for recurring wheeze throughout childhood)

2) Coexisting atopic illness
(a risk factor for persistence of asthma through childhood)

3) Sex

(male sex is a risk factor for asthma in prepubertal children but female sex is a risk factor for persistence of asthma in the transition from childhood to adulthood)

4) Viral episodic wheeze in infancy

(often this is followed by wheeze in early childhood but most children outgrow this tendency to wheeze)
What's the outlook?
Factors associated with persistence include :

1) Age at presentation

(the earlier the onset of wheeze, the better the prognosis.
A "break point" is seen at two years:
most children who present before this age are asymptomatic by age 6-11 years)
2) Increased frequency and severity of episodes
(associated with recurrent wheeze in adulthood)
3) Exercise related symptoms in pre-school children
4) Poor lung function

(correlates with persistence into adulthood).
What do patients and parents want to know?

1).
Patients and their parents will want to know how serious the asthma is and what can be done about it.
2).
They will also want to know about the side effects of drugs.
3).
Further information for patients and doctors can be found at the end of this module.
Getting the right start:
national service framework for children

1).
The national service framework provides guidelines for the design and delivery of hospital services around the needs of children and their families.

2).
It focuses on the safety of children while they are in hospital, the quality of hospital services for children, and the suitability of hospital settings for the care children receive.
Getting the right start:
national service framework for children.

The framework includes guidance on long term and life threatening diseases such as asthma:

it states that specialist paediatric clinics such as asthma clinics should have ready access to a mental health liaison service if this is required
(for example, if the asthma is causing great psychosocial difficulty).
Getting the right start:
national service framework for children.

No specific national service framework currently exists for asthma, however, there is a children’s NSF Asthma exemplar and this gives some detail to the journey of a patient from diagnosis aged 4, through adolescence, to the start of adult life, with reference to children’s NSF themes and the appropriate evidence.
Getting the right start:
national service framework for children.
1)
Swimming is often recommended as a sport as it has many health benefits.
2)
It is also recommended in asthmatic children as a sport with a lower potential for prompting exercise induced asthma.
3)
However, there is growing interest in the potentially harmful effects of repeated respiratory tract exposure to chlorinated products.
4)
The problem of possible swimming-related health hazards is gaining importance at international level.
5)
Available data on the effects of low chronic exposure in recreational swimmers are more uncertain: there is a need for longitudinal studies to clarify any role of chlorinated swimming pool attendance in the development of asthma in recreational swimmers
General medical services contract for GPs .

The new GMS contract allows practices to earn for performing certain actions that relate to asthma.

This has been defined in the Quality and Outcomes Framework (QOF)
Records
Practices can receive up to four points by achieving ASTHMA 1


(that is producing a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma related drugs in the last 12 months).
Initial management

Practices can receive up to 15 points by achieving ASTHMA 8

(that is having a diagnosis confirmed by spirometry or peak flow measurement in 40-80% of patients aged ≥8 years diagnosed as having asthma from 1 April 2008).
Ongoing management

Practices can receive up to six points by achieving ASTHMA 3

(that is having a record of smoking status in the previous 15 months in 40-80% of patients with asthma aged 14-19 years).

Practices can receive up to 20 points by achieving ASTHMA 6

(that is if up to 70% of patients with asthma have had an asthma review in the previous 15 months).
Ongoing management.

All these targets are relatively easy to achieve with good organisation.

You can carry out an annual asthma review
either
in a structured asthma clinic
or opportunistically
when the patient attends the surgery for another problem.
Ongoing management

The author’s practice has identified patients
who have not used an inhaler for more than two years,

&
reclassified them as having a history of asthma
so that
they are excluded from the prevalence data.
Ongoing management

Because the population with asthma is around 10% of a GP's list size,
it may be difficult to recall all patients to clinics.

So you should give priority to patients with troublesome symptoms
or
poor control
(for example, recent admission, use of steroids or nebulisers, & polypharmacy)
&
those on regular prophylactic treatment.

Childhood asthma: diagnosis and treatment

A 10 year old boy attends your clinic with his mother.
He has asthma and is taking a short acting beta2 agonist as needed and beclometasone 400 µg/day. His asthma symptoms, however, are still not under control.
What should you do?
Your answer Correct answer
a.
Add a long acting beta2 agonist

b.
Add prednisolone 20 mg daily
c.
Increase the dose of beclometasone to 800 µg/day

a :
Add a long acting beta2 agonist

The boy's treatment is at step 3,
so the most appropriate next step is to add a long acting beta2 agonist.

b :
Add prednisolone 20 mg daily

Oral steroids should not be used until step 5.

c :
Increase the dose of beclometasone to 800 µg/day

Increasing the dose of beclometasone to 800 µg/day should not be done until step 4.
QUESTIONS & ANSWERS
A 4 year old boy comes to your clinic with his mother. He has asthma and is taking an inhaled beta2 agonist as required and beclometasone 400 µg/day and montelukast 4 mg daily.

He is still wheezy. What should you do?
a.
Add inhaled nedocromil
b.
Refer to a respiratory paediatrician
c.
Advise his mother about avoiding house dust mites
Childhood asthma: diagnosis and treatment

A 4 year old boy comes to your clinic with his mother. He has asthma and is taking an inhaled beta2 agonist as required and beclometasone 400 µg/day and montelukast 4 mg daily.
He is still wheezy. What should you do?
Your answer Correct answer
a.
Add inhaled nedocromil
b.
Refer to a respiratory paediatrician

c.
Advise his mother about avoiding house dust mites

a :
Add inhaled nedocromil

Inhaled nedocromil is less effective than inhaled steroids and is unlikely to be of help.
b :
Refer to a respiratory paediatrician

The boy is at step 4 (persistent poor control), so you should refer him to a respiratory paediatrician. It is important to check both inhaler technique and concordance with therapy when considering difficult to treat asthma.

c :
Advise his mother about avoiding house dust mites

No good evidence supports avoidance of house dust mites, which is unlikely to help this boy with severe asthma.

Childhood asthma: diagnosis and treatment

A 10 year old girl attends your clinic with nausea and vomiting. She has a history of severe asthma.
Examination reveals marked tachycardia and tremor; however, good air entry is present throughout her chest.
Midway through the examination she has a seizure.
What diagnosis should you make?

a)
Prednisolone overdose
b)
Theophylline overdose
Temazepam overdose

Childhood asthma: diagnosis and treatment

A 10 year old girl attends your clinic with nausea and vomiting. She has a history of severe asthma. Examination reveals marked tachycardia and tremor; however, good air entry is present throughout her chest. Midway through the examination she has a seizure. What diagnosis should you make?
Your answer Correct answer
a.
Prednisolone overdose
b.
Theophylline overdose

c.
Temazepam overdose
a : Prednisolone overdose

This clinical picture strongly suggests a theophylline overdose.

b : Theophylline overdose

Nausea, vomiting, tremor, tachycardia, and seizures in a girl with asthma strongly suggest theophylline overdose.

c : Temazepam overdose

This clinical picture strongly suggests a theophylline overdose.
A 10 year old boy with asthma attends your review clinic. His mother is worried about the future and asks you whether he will grow out of it. What percentage of children younger than 12 years undergo complete remission and become fully asymptomatic?
Around 10%
Around 30%
Around 60%
Around 90%
Childhood asthma: diagnosis and treatment

A 10 year old boy with asthma attends your review clinic. His mother is worried about the future and asks you whether he will grow out of it. What percentage of children younger than 12 years undergo complete remission and become fully asymptomatic?
Your answer Correct answer
a.
Around 10%
b.
Around 30%

c.
Around 60%
d.
Around 90%
a : Around 10%

Nearly 30% of children will become completely asymptomatic.

b : Around 30%

Nearly 30% of children will become completely asymptomatic.

c : Around 60%

Nearly 30% of children will become completely asymptomatic.

d : Around 90%

Nearly 30% of children will become completely asymptomatic.
Childhood asthma: diagnosis and treatment

What proportion of children in the UK currently has asthma?
1 in 4
1 in 8
1 in 50
Childhood asthma: diagnosis and treatment

What proportion of children in the UK currently has asthma?
Your answer Correct answer
a.
1 in 4
b.
1 in 8

c.
1 in 50
a : 1 in 4

About one in every eight children in the UK has asthma.

b : 1 in 8

The number of children with asthma has increased in recent years. About one in every eight children in the UK has asthma, compared with about one in 50 in the late 1970s.

c : 1 in 50

About one in every eight children in the UK has asthma
Childhood asthma: diagnosis and treatment

Which of the following factors suggests that a child with asthma will grow out of it in adulthood?
Severe asthma
First episode of wheezing at the age of 1
Poor lung function tests
Family history of asthma

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Childhood asthma: diagnosis and treatment

Which of the following factors suggests that a child with asthma will grow out of it in adulthood?
Your answer Correct answer
a.
Severe asthma
b.
First episode of wheezing at the age of 1

c.
Poor lung function tests
d.
Family history of asthma
a : Severe asthma

Severe asthma suggests that the asthma will persist.

b : First episode of wheezing at the age of 1

The earlier the age of onset the better the prognosis. A "break point" is seen at 2 years: most children who present before this age are asymptomatic by age 6-11 years.

c : Poor lung function tests

Poor lung function tests suggest that the asthma will persist.

d : Family history of asthma

A positive family history of asthma suggests that the asthma will persist.
Childhood asthma: diagnosis and treatment

You diagnose a 4 year old boy with asthma. He has trouble using the salbutamol inhaler. What would you advise first?
Give the salbutamol via a nebuliser
Give it via a metered dose inhaler plus a spacer
Childhood asthma: diagnosis and treatment

You diagnose a 4 year old boy with asthma. He has trouble using the salbutamol inhaler. What would you advise first?
Your answer Correct answer
a.
Give the salbutamol via a nebuliser
b.
Give it via a metered dose inhaler plus a spacer

a : Give the salbutamol via a nebuliser

You should first of all advise that he tries to use a metered dose inhaler plus a spacer.

b : Give it via a metered dose inhaler plus a spacer

You should first of all advise that he tries to use a metered dose inhaler plus a spacer.
Childhood asthma: diagnosis and treatment

A 16 year old boy comes to your surgery with a rash. He has a past history of asthma and allergic rhinitis. He says his shortness of breath has worsened recently. On examination the rash appears to be vasculitic. You arrange a chest x ray: this shows a pulmonary infiltrate. Full blood count reveals marked peripheral eosinophilia. What is the most likely diagnosis?
Allergic bronchopulmonary aspergillosis
Goodpasture's syndrome
Churg-Strauss syndrome

Childhood asthma: diagnosis and treatment

A 16 year old boy comes to your surgery with a rash. He has a past history of asthma and allergic rhinitis. He says his shortness of breath has worsened recently. On examination the rash appears to be vasculitic. You arrange a chest x ray: this shows a pulmonary infiltrate. Full blood count reveals marked peripheral eosinophilia. What is the most likely diagnosis?
Your answer Correct answer
a.
Allergic bronchopulmonary aspergillosis
b.
Goodpasture's syndrome
c.
Churg-Strauss syndrome

a : Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis is possible but the vasculitic rash points away from this diagnosis.

b : Goodpasture's syndrome

Goodpasture's syndrome is characterised by

Alveolar haemorrhage and
A rapidly progressive glomerulonephritis.
c : Churg-Strauss syndrome

Churg-Strauss syndrome is the most likely diagnosis as there is:

A history of asthma and rhinitis
Worsening pulmonary symptoms
Peripheral eosinophilia
Pulmonary infiltrate
Vasculitic rash.
You should ask him whether he is taking a leukotriene receptor antagonist. You should also ask about whether he has recently stopped or reduced oral or inhaled steroids as this may unmask the disease.
Childhood asthma: diagnosis and treatment

A 5 year old girl returns to your surgery.
She has recurrent chest infections and also gets wheezy from time to time.
She is also short for her age. A CXR shows peribronchial cuffing.
Pilocarpine iontophoresis reveals elevated sodium and
chloride levels on two separate occasions.
But there is no family history of cystic fibrosis.
What is the most likely diagnosis?
Severe asthma
Bronchiolitis obliterans
Cystic fibrosis
Childhood asthma: diagnosis and treatment

A 5 year old girl returns to your surgery. She has recurrent chest infections and also gets wheezy from time to time. She is also short for her age. A CXR shows peribronchial cuffing. Pilocarpine iontophoresis reveals elevated sodium and chloride levels on two separate occasions. But there is no family history of cystic fibrosis. What is the most likely diagnosis?
Your answer Correct answer
a.
Severe asthma
b.
Bronchiolitis obliterans
c.
Cystic fibrosis

a : Severe asthma

Cystic fibrosis is the most likely diagnosis.

b : Bronchiolitis obliterans

Cystic fibrosis is the most likely diagnosis.

c : Cystic fibrosis

Cystic fibrosis is the most likely diagnosis. She has recurrent chest infections, failure to thrive, an abnormal chest x ray and a positive sweat test. Cystic fibrosis is an autosomal recessive condition so it is not unusual for there to be no family history.
Childhood asthma: diagnosis and treatment

Which of the following drugs is
LEAST likely to cause hypokalaemia?
Ipatropium bromide
Predisolone
Salbutamol
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Childhood asthma: diagnosis and treatment

Which of the following drugs is LEAST likely to cause hypokalaemia?
Your answer Correct answer
a.
Ipatropium bromide

b.
Predisolone
c.
Salbutamol
a : Ipatropium bromide

Ipatropium does not cause hypokalaemia.

b : Predisolone

Steroids can cause hypokalaemia.

c : Salbutamol

Beta2 agonists can cause hypokalaemia.

Which of the following is LEAST likely to cause paradoxical bronchospasm?
Your answer Correct answer
a.
Inhaled salmeterol
b.
Prednisolone

c.
Inhaled budesonide
a : Inhaled salmeterol

Long acting beta2 agonists can cause paradoxical bronchospasm.

b : Prednisolone

Predisolone is least likely to cause paradoxical bronchospasm.

c : Inhaled budesonide

Inhaled steroids can cause paradoxical bronchospasm.
Childhood asthma: diagnosis and treatment

Which of the following drugs is contraindicated
in patients with hepatic impairment?
Salbutamol
Salmeterol
Budesonide
Zafirlukast
Childhood asthma: diagnosis and treatment

Which of the following drugs is contraindicated in patients with hepatic impairment?
Your answer Correct answer
a.
Salbutamol
b.
Salmeterol
c.
Budesonide
d.
Zafirlukast

a : Salbutamol

Salbutamol may be used in patients with hepatic impairment.

b : Salmeterol

Salmeterol may be used in patients with hepatic impairment.

c : Budesonide

Budesonide may be used in patients with hepatic impairment.

d : Zafirlukast

Zafirlukast is contraindicated in patients with hepatic impairment
Key points:
Management

The British Thoracic Society
recommends a stepwise approach to the treatment of asthma.

Children aged 5-12 years.

Step 3: add on therapy
If the patient has benefit from long acting beta2 agonist,
but control is still inadequate, continue the drug
&
increase the dose of inhaled steroid to 400 µg/day
(if they are not already taking this dose).
Key points:
Management

The British Thoracic Society
recommends a stepwise approach to the treatment of asthma.

Children aged 5-12 years.

Step 3: add on therapy

If the patient has no response to long acting beta2 agonist,
stop it
&
increase the inhaled steroid dose to 400 µg/day.

If control is still inadequate, try other treatments:
for example,
leukotriene receptor antagonists or
slow release theophylline
Evidence
on whether
addition of inhaled ipratropium bromide

is of benefit is conflicting.

Evidence
that oral steroids are helpful for treating
acute wheeze in infants is conflicting.
Evidence

is weak & conflicting on whether
inhaled steroids
are valuable as prophylaxis
against recurrent infant wheezing.
Follow up.


Regular review of patients
as treatment is stepped up
or
down is important.
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