HNY Policy and Pathway Repository - Humber

Management of Childhood Asthma 5-16 years

A Guide for Health Care Providers

What is Asthma?

1. Patients must have at least 2 of the following symptoms:

• Wheeze (recorded by a health professional)
• Breathlessness
• Chest tightness
• Cough

2. Symptoms vary in time and intensity; worsening with triggers, at night or on wakening

3. Evidence of variable airflow obstruction

• FEV₁ is low -> FEV₁/ FVC ratio is reduced.
• Bronchodilator reversibility; FEV₁ increases more than 12% of the base line value.

A personal or family history of atopy also increases the likelihood of asthma but should not be used in the diagnostic criteria.

STEP-WISE APPROACH

SABA as required                            

Use in patients who fit the following profile:

• Normal PEFR or FEV1
• Rarely symptomatic
• No nocturnal symptoms
• No exacerbations for over 1y

STEP 1 - Regular preventer

Very low (paediatric) dose ICS or LTRA <5 years)

STEP 2 - initial add-on preventer

Very low (paediatric) dose ICS plus

• Children > 5 years of age - add inhaled LABA
• Children <5 years of age - add LTRA

STEP 3 - Additional add-on therapies

If no response to LABA - stop LABA, consider increased dose of ICS to low dose

If benefit from LABA but control still inadequate - continue LABA and ICS and consider trial of other therapy - LTRA         

STEP4 - High dose therapies

Consider trials of:

• Increasing ICS upto medium dose
• Addition of a 4th drug, SR Theophylline

Refer to respiratory pediatrician

STEP 5 - Under respiratory paediatrician only

Low dose daily oral steroid, maintaining medium dose ICS

Anti-IgE (SC omalizumab) in severe allergic asthma >6y

Anti-IL5 (SC mepolizumab, SC benralizumab) >12y with severe eosinophilic asthma

Stepping up

If poor control despite 2-3 months of current treatment. CHECK:

• Is it the correct diagnosis?
• Check inhaler technique
• Check compliance
• Modifiable risk factors are adjusted where possible
• Co-morbid conditions are screened for and treated

Stepping down

If well controlled for 3 months + low risk for exacerbations

Complete control is defined by SIGN as:

• No exacerbations
• No need for rescue medication
• No nocturnal wakening due to asthma
• No day time symptoms
• No limitation of activity (including exercise)
• PEFR >80% best or predicted

Reduce ICS dose by 25-50% at 2-3 monthly intervals

Provide written asthma plan - Book a follow-up visit

Categorization of inhaled corticosteroids

Updated HERPC guidance: February 2019

 

Diagnostic Criteria 

1. History of Variable Respiratory Symptoms

• Wheeze, cough, breathless, chest tightness
• Asthmatics usually have more than 1 symptom
• Variable over time, worse with triggers, at night or early morning

2. Evidence of Variable Expiratory Airflow Limitation supported by evidence of airway inflammation

• Ideally spirometry and Fractional exhaled Nitric Oxide (FeNO) should be used in the diagnosis of asthma.
• There should be at least 12% rise in FEV₁ following bronchodilator inhalation to diagnose asthma.
• PEFR measurement can be used where spirometry is not available. NICE suggests that variability of 20% in PEFR is suggestive of asthma. However, studies have shown that PEFR measurements in children are not reliably reproducible and therefore its results cannot exclude or confirm a diagnosis of asthma. Recordings at different times of the day, when symptomatic and asymptomatic, before and after salbutamol use may be of more value.
• Suggest that patients make a diary of recordings at least twice daily for 2-4 weeks
  • The more times variation in airflow is recorded, the more convincing the diagnosis of asthma.
  • Lack of reversibility on initial testing does not exclude asthma. Repeat when symptomatic, early morning and withholding bronchodilator medications. Well controlled asthmatics may not show any variability.
• Reversibility may not be seen during inter-current infections or severe exacerbations.
• FeNO can be normal where there is no eosinophilic inflammation. Likely to be poor corticosteroids response when there is no eosinophilic inflammation (i.e. normal FeNO).

Triggers

• Viral infections
• Allergens e.g. house dust mite, pollens
• Tobacco smoke
• Exercise
• Stress, laughter
• Cold air
• Medications e.g. beta-blockers, NSAIDs, aspirin

PROBABILITY OF ASTHMA

High Probability

Patients should be considered to have a high probability of having asthma if they have:

• A history of recurrent episodes of wheeze recorded by a health professional
• History of variable airflow obstruction
• A positive history of atopy
• No features to suggest an alternative diagnosis

Low Probability

In patients who do not have typical symptoms, or an alternative diagnosis is likely, then either investigate/ treat as the more likely alternative diagnosis or arrange further investigations to test for asthma.

Intermediate Probability

Patients have an intermediate probability of asthma if:

• Some, but not all, typical features are present, or
• Patients who do not respond well to a 6-8 weeks trial of ICS (ensure compliance and inhaler technique first).

In children who are old enough to perform PEFR, ask them to record a symptom and PEFR diary over 2-4 weeks and review with results.

Management options for children with an intermediate probability who are unable to perform PEFR:

• Start initiation of ICS and review in 6-8 weeks
• If asymptomatic then adopt a “watchful waiting” approach.

Modifiable Risk Factors - Non-Pharmacological Therapy

 Obesity

Offer weight-loss programmes where available. Encourage physical activity

 Smoking, including parental smoking

Refer to smoking cessation services

 Anxiety

Breathing exercise programmes may improve quality of life and reduce symptoms in some with asthma

 Confirmed food allergy

Avoid NSAIDs if there is a clear history of exacerbation associated with its use

Note that the use of physical and chemical methods of reducing house dust mite burden in the house are not effective and should not be endorsed

Pharmacological Management - Stepwise approach

Asthma Review Appointments

• 1-3 months after starting treatment
• Then every 3-12 months depending on level of control, response to treatment and skills at self-management
• Within 1 week following an exacerbation
• Check inhaler technique at every opportunity
• Smoking cessation advice (if applicable)

• Check compliance

  • At least 50% of patients do not take their controller medications as prescribed
  • Check with patient how many days a week they miss a dose
  • Check dispensing records
  • Explore attitudes and beliefs about asthma and the treatment

Written Asthma Action Plans

Personalised action plans have been shown to improve outcomes for asthmatics. They should be given to all patient’s carers so they know how to recognize worsening asthma and respond appropriately. At each review appointment, or following an acute exacerbation, the plan should be reviewed.

Action plan resources can be downloaded: www.asthma.org.uk/control

Alternative Diagnoses

Many alternative diagnoses have features which may overlap with asthma. Consideration should be given to other possibilities such as; recurrent viral infections, gastro-oesophageal reflux, post-nasal drip, vocal cord dysfunction, amongst others.

Referral to specialist care should be done in children with the following features

• Step four of Asthma management
• Failure to thrive
• Abnormal clinical findings (such as stridor, focal chest signs, dysphagia)
• Symptoms present from birth
• Excessive vomiting
• Nasal polyps
• Severe respiratory infection(s)
• Persistent productive cough
• Family history of unusual respiratory disease
• Significant care-giver anxiety
• Severe or life-threatening exacerbation

Astma pathway Jan 2019 v2 approved

Additional Information

Pathway references

Abbreviations

• PEFR - Peak Expiratory flow rate, a person's maximum speed of expiration, as measured with a peak flow meter
• FEV1 – Forced Expiratory Volume, is the maximal amount of air you can forcefully exhale in one second
• FVC – Forced vital capacity measurement,  shows the amount of air a person can forcefully and quickly exhale after taking a deep breath
• The FEV1/FVC ratio, also called Tiffeneau-Pinelli index, is a calculated ratio used in the diagnosis of obstructive and restrictive lung disease.
• ICS – Inhaled Cortico Steriods
• LRTA - Leukotriene Receptor Antagonists
• SABA - Short-acting beta agonist
• LABA - Long-acting beta2 agonist
• LAMA - long acting muscarinic antagonist

A