Key learning points:
– The diagnosis of asthma should include objective testing wherever possible
– Management of asthma is more than just inhalers – it is important to address the basics such as adherence and proper use of medications before escalating treatment
– An asthma attack is an emergency, and its occurrence should prompt a full review of management
Asthma is a chronic respiratory disease that can affect people of all ages but often starts in childhood. Asthma is characterised by combinations of wheezing, coughing, and breathlessness, causing either or both of chronic symptoms and acute attacks. In older children and adults, there is underlying airway inflammation. Physiologically there is variable airflow obstruction over time and with treatment, as shown by peak flow recordings. The frequency and severity of asthma attacks can vary greatly between one child and another but what is clear is if left untreated they can be life threatening, but with appropriate treatment they are reversible.
The UK has one of the highest prevalence rates of asthma in the world. According to Asthma UK up to 5.4million1 people are receiving treatment for asthma in the UK. The national review of asthma deaths (NRAD) highlighted that during 2011-12 there was a total of 65,316 hospital admissions for asthma, broken down to 25,073 for 0-14 years old and 40,243 for those aged 15 and over.2 The number of reported asthma deaths in the UK remains among the highest in Europe. NRAD reported that between 1 February 2012 and 31 January 2013 there were 195 deaths due to asthma, of which 14% were aged 19 years and under.2
The diagnosis of asthma in children is based on recognising a characteristic pattern of episodic respiratory symptoms and signs (see Box 1) in the absence of an alternative explanation.3 Of note, the word wheeze is used to describe many different sounds by parents, and objective confirmation that the child is actually wheezing should always be sought.4 It can be difficult to confirm or disprove a diagnosis of asthma as there is currently no gold standard test.2 To establish a diagnosis the child should be seen over at least two separate consultations, initially performing an in-depth history and physical examination to exclude other causes of respiratory symptoms3 (see Box 2).
The National Institute for Health and Care Excellence (NICE) has published draft clinical guidelines which are out for consultation aiming to identify a clear diagnostic algorithm including objective testing for children aged between 5-16 years. The algorithm has suggested the use of spirometry, fractional exhaled nitric oxide (FeNO) and peak flow monitoring as adjuncts to a comprehensive history and physical examination.
There are a variety of physiological tests available to support the diagnosis and confirm variable airflow obstruction such as peak flow monitoring at home, acute bronchodilator-reversibility (BDR) to short-acting bronchodilator, and response to exercise.
This sort of peak flow monitoring should be available in every primary care facility. A diagnostic algorithm that uses peak flow monitoring as a support to the diagnosis of asthma can be used:5
· If peak flow is below the age appropriate limit but improves by 12% or more 20 minutes after administering a short acting beta-2 agonist this confirms variable airflow obstruction.
· If peak flow is normal, then a two week period of home monitoring may confirm the diagnosis. If the peak flow values remain static or the variability is within normal limits despite reported symptoms it would be difficult to attribute the symptoms to asthma.
· If peak flow is normal, the child can be asked to exercise vigorously, with peak flow measurements before and 20 minutes after the end of exercise; a 15% decline in peak flow rate supports the diagnosis of asthma.
· A peak flow variability of 15% or more is strongly suggestive of asthma but compliance with peak flow monitoring can often
· Other disease such as bronchiectasis may be characterised by peak flow variability, emphasising the need for a good history and thorough physical examination.
Asthma UK has developed a useful video to demonstrate appropriate peak flow technique; this can be found in the resources section.
FeNO is measured during a slow breath out at a fixed rate (conventionally 50 ml/sec), nitric oxide levels are raised if there is eosinophilic airway inflammation characteristic of asthma. It is elevated in school age children with asthma who are not using inhaled corticosteroids, but it is not specific for asthma, since elevations are seen in atopic non-asthmatics. A low level would be a pointer away from a diagnosis of asthma. This test is not widely available in primary care.
If asthma is likely, but cannot be confirmed, a ‘trial of treatment’ of inhaled corticosteroids (ICS) may be considered, but blind trials are a last resort.5
Management of asthma
The aim of asthma management is to take control of the disease. A stepwise approach should be used and control should be maintained by stepping up treatment as necessary and stepping down as appropriate when control has been achieved.3
In summary, the child is managed with short acting beta-2 agonists if these are needed less than two to three times per week. If they are used more than this, then preventive treatment with low dose inhaled steroids is instituted. For most children, doses above 100 mcg bd of fluticasone equivalent offers no benefit. If more therapy is needed, then a steroid long acting beta-2 agonist is trialled; occasionally a leukotriene receptorantagonist may be added. If at this level of treatment asthma is not controlled, and no obvious cause has been found (below) the child should be referred to secondary care for an evaluation.
Severe or problematic asthma?
Before escalating the treatment in any child it is important to understand why the asthma may be difficult to control. The child may not have asthma at all, it may be potentially mild but exacerbated by one or more comorbidities such as obesity or allergic rhinitis, or they may have difficulty treating asthma due to possibly reversible causes such as poor adherence to treatment, poor inhaler technique.
Finally it may be true, severe therapy resistant asthma which remains refractory to treatment even when the reversible factors are taken into account.6 Adherence can be a major obstacle to effective management of a patient and is the single biggest reason for treatment failure.7
Getting the basics right
Getting the basics correct is paramount in the control of asthma and differentiates which children have severe therapy resistant asthma from those with asthma that is poorly controlled due to remediable factors.
The role of the nurse in asthma management is to help children and their families keep control of asthma while on the minimum amount of treatment. Improved baseline control and the prevention of asthma attacks involve identifying an avoiding triggers, patient education and effective management plans, and ensuring
adequate adherence to medication. In addition a home visit carried out by a specialist nurse can be invaluable if resources are available. It can also help to identify which patients have severe therapy resistant asthma that will improve if remediable issues are identified and eliminated.7
Adherence:It is known to be poor even among children with apparently severe asthma. Adherence can be assessed by looking at the patients inhaler technique,8 prescription uptake, confirming the child is supervised when taking their medications, taking serum levels of prednisolone and cortisol blood serum. At least 50% of children have medication issues that contribute to poor asthma control. Poor adherence is one of the key determinants of sub-optimal asthma control. Correctly identifying children with poor adherence can avoid unnecessary escalation of treatment and enable a targeted adherence intervention.7
Exposure to Allergens:Exposure to indoor allergens such as house dust mites, or dog and cat dander can worsen asthma in sensitive individuals. Exposure can increase airway inflammation and bronchial hyper-responsiveness,9 thus increasing the potential for hospital admission. High allergen exposure in the home and allergic sensitisation is associated with acute exacerbation in children.10
Smoke exposure:Active cigarette smoking has a detrimental effect on the lungs and causes steroid resistance.11 It is likely that passive cigarette smoke exposure can have similar effects.
Psychosocial issues:There is a wide range of psychosocial morbidity in patients with asthma.12 The importance of acute and chronic stress as a trigger of asthma exacerbations is well recognised.13 Helpful tools include the asthma control test (ACT) and juniper questionnaire14 which can help gauge the impact asthma plays in daily activities such as exercise limitation, sleep quality and time off school and overall quality of life. A clinical psychologist should help interpret the results. The relationship between the nurse and the family is crucial in the success of uncovering any issues that may be contributing to poor asthma control. If psychosocial issues are likely contributors to the severity, often appropriate referrals can be made to a clinical psychologist and local mental health services.
Asthma treatment plans are under used and thought to be associated with poor outcomes.2 It is recommended following the NRAD review that all children with asthma should be provided with an individual asthma plan after every review.2 These should provide written information on prescribed regular medication and guidelines on how to recognise and treat exacerbations. A plan can also include other useful information about correct inhaler technique and the care of inhaler devices.
An asthma attack can be immediately fatal if not managed appropriately. The usual trigger is an upper respiratory viral infection, the effects of which are aggravated by allergic sensitisation to an allergen which is present in high concentration in the home.
The British guideline on the management of asthma3 has classified the severity of an asthma attack into three categories; life threatening asthma, acute severe asthma and moderate asthma exacerbation.3 Before commencing the appropriate level of treatment it is important to assess the severity of the patient’s symptoms.
Inhaled beta-2 agonists should be given as first line treatment and the patient must then be reassessed after two minutes;
this together with systemic corticosteroids is the bedrock of therapy. Depending on the response, treatment can be escalated or reduced.
Acute severe asthma is a medical emergency and can be classified as:
· Cannot complete sentences in one breath or too breathless to talk or feed.
· Peripheral capillary oxygen saturation below 92%.
· Peak expiratory flow 33-55% best or predicted.
· Pulse 140 and above in children aged two to five years.
· Pulse 125 and above in children aged five years and above.
· Respirations above 40 breaths/min aged two to five years.
· Respirations above 30 breaths/minute aged five years and above in children.
Detailed protocols for management can be found in the BTS/SIGN guidelines.3 After an asthma attack, the nurse should be involved in a prompt and focused response of all aspects of management, including reviewing the factors leading to the attack, whether the asthma plan was followed and whether it should be changed, and if lessons can be learned from the lead-up to the attack and its management to try and prevent a recurrence.
Asthma in children is common and most children can be well controlled with a low dose of inhaled steroids, however it is important to address the basics of asthma management at each consultation and particularly when considering escalating treatment.
Peak flow technique – www.youtube.com/watch?v=DxBDfqPmaZU
1. Asthma UK. Asthma Facts and FAQ.http://www.asthma.org.uk/asthma-facts-and-statistics (accessed 23 May 2015).
2. Royal College of Physicians. Why asthma still kills: the national review of asthma deaths. 2014. www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-repo... (accessed 3 Jun 2015).
3. British Thoracic Society Scottish Intercollegiate Guidelines Network. British Guideline on the management of Asthma, A national clinical guideline. https://www.brit-thoracic.org.uk/document-library/clinical-information/a... (accessed 23 May 2015).
4. Cane R, Ranganathan S, McKenzie S. What do parents of wheezy children understand by “wheeze”?. Archives of Disease in Childhood 2000;82:327–332.
5. Bush A, Fleming L. Diagnosis and management of asthma in children. BMJ 2015;350:h996doi: 10.1136/bmj.h996. (accessed 24 May 2015)
6. Bush A, Saglani S. Management of severe asthma in children. Lancet 2010;376(9743): 814–825.
7. Bracken M, Fleming L, Hall P, Van Stiphout N, Bossley C, Biggart E, Wilson N, Bush A. The importance of home visits in children with problematic asthma. Archives of Disease in Childhood 2009;94:780-4.
8. Aalderen W, Garcia-Marcos L, Gappa M, Lenney W, Pedersen S, Dekhuijzen R, Price D. How to match the optimal currently available inhaler device to an individual child with asthma or recurrent wheeze. Nature 2015; 25 (14088): 1-6. doi:10.1038/npjpcrm. (accessed 27 May 2015)
9. Fowler S, Langley S, Truman N, Simpson A, Woodcock A, Custovic A.Exposure to house dust mite allergen is associated with an increase in bronchial hyperresponsiveness over four years in asthma. Thorax 2006;(61):S29-30
10. Murray C, Polettiv G, Kebadze T, Morris J, Woodcock A, Johnston S, Custovic A. Study of modifiable risk factors for asthma exacerbations: virus infection and allergen exposure increase the risk of asthma hospital admissions in children. Thorax 2006; 61:376–382. doi: 10.1136/thx.2005.042523. (accessed 27 May 2015)
11. Chalmers W, Macleod K, Little S, Thompson A, McSharry C, Thomson N. Influence of cigarette smoking on inhaled corticosteroid treatment in mild asthma. Thorax 2002;57(3):226-230.
12. Richardson L, Lozano P, Russo J, Mc Cauley E, Bush T, Katon W. Asthma symptom burden: relationship to asthma severity and anxiety and depression symptoms. Paediatrics 2006;118(3):1042-1159
13. Sandberg S, Paton J, Ahola S , McCann D, McGuinness D, Hillary D, Clive R, Hannu O. The role of acute and chronic stress in asthma attacks in children. Lancet 2000;356(9234):982-987
14. Juniper E, Guyatt G, Feeny D, Ferrie P, Griffith L, Townsend M. Measuring quality of life in the parents of children with asthma. Quality of Life Research 1996;5:27-34.
You are currently leaving the Nursing in Practice site. Are you sure you want to proceed?