Information and resources for professionals

The asthmatic airway is inflamed.  This improves with inhaled corticosteroids.   If the patient comes into contact with a trigger, smooth muscles around the airway tighten and cause constriction, which can be treated with a bronchodilator such as salbutamol.  Common triggers include exposure to viruses, mold, pollen, exhaled tobacco smoke, emotion, weather changes, pets and exercise. Triggers can be different for everyone. 

Use the ‘airway model’ above to discuss key principles with your patients. 

• Bronchodilators (such as salbutamol) only treat the muscles on the outside to give emergency relief – they do nothing for the underlying inflammation, which needs an inhaled steroid
• Using a bronchodilator for symptomatic relief only is no longer recommended¹. Children should also be using a preventer (steroid) inhaler)
• Recognising and managing exposure to triggers can reduce the risk of attacks and improve control.

Traditional pathway

An inhaled corticosteroid is taken regularly to treat and prevent airway inflammation.  If symptoms occur, a bronchodilator is used to open up the airways.   However, many patients have poor adherence to inhaled steroids, and tend to use their short acting beta agonist only (SABA, usually salbutamol), and this is associated with increased risk of attacks and asthma related deaths. 

‘SABA’ free pathway

From 12 years of age, an alternative approach is to combine the inhaled corticosteroid with a bronchodilator in a single inhaler, used as both preventer and reliever.  As the need for reliever increases, the dose of preventer is increased.  Licensed medications in this age group include budesonide with formoterol.  This is recommended in the draft NICE/BTS asthma management guideline², due to be published in November 2024. 

Children & parents must be able to understand the regimen and use the inhaler effectively.  This can sometimes be a challenge due to the higher inspiratory flow required for dry powder devices compared to using a pMDI via a spacer.

Further information on these pathways will be provided once the NICE/BTS guidance² is approved.

References

1. 2023 GINA Main Report - Global Initiative for Asthma - GINA (ginasthma.org)
2. Asthma: diagnosis, monitoring and chronic asthma management (nice.org.uk)

Step 1: Take a thorough history 

• Are there recurrent episodic symptoms, generally including wheeze PLUS one of cough, chest tightness, breathlessness?
• Are episodes diurnal (ie worse at night or in the morning)?
• What are the triggers for these episodes? Common triggers include exercise, cold weather, smoke exposure, pollution, allergens, emotion and viral infection.
• Does the child have atopy (hayfever, eczema, allergies)?
• Is there a family history of asthma or atopy?
• Are there pets, damp or mould in the house? Or does the child live on a very busy/polluted road? This can help to identify triggers if having episodes mainly when at/near home.

Step 2: Review the child's miedical records

• Has the child ever presented with an acute wheeze episode?  How severe was this?
• Has reliever treatment ever been tried during an episode (e.g. beta-agonist) and did this improve symptoms?  Bronchodilator responsiveness is the hallmark of asthma
• Is there a previous finding of raised eosinophil count when well?  A value of 0.3 or greater increases the likelihood of airway eosinophilia and an asthma diagnosis.

Step 3: Examine the child

• Is the child well?  Is there clubbing, wet cough, failure to thrive etc?
• Auscultate the chest.  This should be normal if asymptomatic, which is why examining at the time of an exacerbation and documentation of wheeze by a health professional is key to aid diagnosis. Parental reports of wheeze may actually be stridor, ‘rattily’ chest, upper airway noises or snoring.
• Check weight and height as this will be useful in future for calculating predicted peak flow and it is important to monitor growth for children on inhaled cortico-steroids.

• Refer if there are RED FLAGS for an alternative diagnosis 

• Failure to thrive
• Symptoms present from birth or perinatal lung problem
• History of recurrent severe respiratory tract infections
• Persistent wet or productive cough
• Stridor or abnormal voice/cry
• Nasal polyps
• Family history of unusual chest disease
• Acute episodes with paraesthesia/ dizziness with normal examination, suggestive of breathing dysfunction/ panic attacks

Step 4: Perform baseline investigations

• For children aged 6 years and above, teach the child to perform peak flow & record a baseline diary - two weeks of readings.  . 
• Perform baseline spirometry and FeNO if available
• In the absence of spirometry/ FeNO, the BTS pragmatic approach is recommended
  • If high probability of asthma - trial of treatment and review
  • If intermediate probability of asthma – use clinical judgement on whether to initiate a trial of treatment or refer to secondary care.  Seek advice from your local asthma service
  • If low probability – refer

Step 5: Trial of treatment

• At baseline
  • Get the basics right – educate, check inhaler technique, provide an asthma action plan
  • Peak flow monitoring if able - best of three blows, twice a day for two weeks
  • Measure ACT/ cACT score
  • Then start inhaled corticosteroids (see medication section)
• Review response in 6-8 weeks
  • Repeat peak flow diary and ACT/cACT score
• If objective improvement, and parents agree that the child is better, then a diagnosis of asthma can be made.  If there is uncertainty/ poor response - stop tre

Coding and QOF

• QOF applies to children aged 6 years and over
• For diagnosis (AST011) the requirements are for the following to be performed from three months before, to six months after diagnosis/ newly registered patient
  • Quality-assured spirometry PLUS
  • Bronchodilator reversibility OR FeNO OR Peak flow diary
• However there is currently no routine pathway in primary or secondary care for these investigations (24/25) in North West London.  A personalised care adjustment (exemption) stating ‘service not available’ can be entered into the electronic record and the child exempted from that QOF point.

For many years, doctors have been told not to diagnose asthma in under 5s who are often labelled as ‘viral induced wheeze’ or ‘recurrent wheeze’

However, it is important that cases of preschool asthma are not missed.  A child under 5 years with significant recurrent wheeze episodes, particularly when severe enough to require hospital management, should trigger clinicians to consider a diagnosis of preschool asthma, and managing the child accordingly

Children who have had three or more admissions to hospital for preschool wheeze should be referred to your local asthma service.

GPs may have a lower threshold to refer to paediatrics due to the diagnostic uncertainty in this age group. 

Diagnosis in this age group is often about trialling treatment and monitoring response, as younger children do not have the ability to perform diagnostic testing

The following approach may be helpful.

Peak flow

• From age 6-8 years.  Requires coaching face to face on how to perform
  • Prescribe a peak flow meter (low range 30-400L/min or standard range 60-850L/min)
  • Download & print a peak flow chart for the patient from Asthma and Lung UK
  • https://www.asthmaandlung.org.uk/symptoms-tests-treatments/tests/peak-flow
• Instructions for patient
  • Record the best of three readings, twice daily for two weeks
  • Standing or sitting but be consistent
  • Ask them to also record symptoms and inhaler use on the chart
  • Link to video demonstrating technique from Asthma and Lung UK

 https://www.youtube.com/watch?v=UQa74XtQXf8

• Interpretation
  • % variability = (highest PEF – lowest PEF)/mean PEF x 100
  • Variability ≥ 12% (ERS), >13% (GINA), ≥20% (NICE+BTS) is considered significant
  • If accurate peak flows recorded on a chart are a flat line, or very little variability DESPITE ongoing symptoms, it is hard to attribute this to asthma

• • Link to calculation video

Watch this short video for help calculating PEFR variability

Spirometry

• From age 6-8years.  Must be supervised by an ARTP Spirometry trained professional
• Instructions for patient
  • Take inhalers/ spacers to the test
  • Stop SABA 4-6 hours before
  • Stop LABA 36 hours before
• Interpretation
  • Obstruction = abnormally low FEV1, with FEV1/FVC <70% (NICE+BTS) or FEV1 Z score < -1.64
  • Bronchodilator response = FEV1 increase of ≥ 12% (GINA+NICE+BTS+ERS) 20mins after 4 puffs of salbutamol

FENO

• From age 4 years. 
  • Levels are increased in active allergic rhinitis, and rhinovirus infection. 
  • Levels are lower in cigarette smokers and when individuals are taking inhaled or oral steroids.
• Interpretation
  • <20ppb = normal
  • >25 ppb=raised (ERS), >35ppb = raised (NICE+BTS)
• Useful resources
  • FeNO patient leaflet (england.nhs.uk)

“Show me how you use your inhaler” - the ONLY way to find out what is happening!

Inhaler technique must be checked face to face or by video call - it CANNOT be done by telephone.

Teach until the patient is an expert

For new medications, consider utilising your community pharmacists by requesting a ‘New Medication Review’

• Age: under three years - pMDI with spacer and mask:

How to use a spacer with mask

• Age: three years plus - pMDI via spacer + mouthpiece

How to use a spacer without a mask

• Age: 10 years onwards – consider a dry powder device

These devices have a lower carbon footprint than pMDIs BUT they need a higher inspiratory flow to be effective and some patients find this difficult. 

It is essential to train and check technique face to face – use these videos to support training. 

• pMDI/ Spacers:  Wipe the pMDI mouthpiece monthly with a dry cloth. They should be washed in detergent and allowed to dry in air. The mouthpiece should be wiped clean of detergent before use. Replace annually, or when opaque.  Remind patients to rinse their mouth after using ICS.
• Dry powder inhalers:  Wipe mouthpiece weekly with a dry cloth.  Never use water on a DPI.  only change after discussion and agreement with patients.  Remind patients to rinse their mouth after using ICS. 

All children and young people with asthma need a personalised asthma action plan.  These provide a traffic-light approach on how to manage asthma.  You must explain this when agreeing the plan. 

Green  - Routine care when well     

Orange - What to when there are symptoms     

Red - How to recognise and manage an emergency

It’s important to give clear treatment limits on reliever use at home

• Traditional pathway - six puffs of SABA should resolve symptoms and last four hours – if needing more puffs or more often, seek medical review.  Symptoms should be getting better within 48 hours.
• SABA free pathway – Maximum 8 puffs per day; up to 12 puffs daily can be used for a limited time but medical assessment is recommended (BNFc recommendation)

Editable asthma action plans are available online with options for standard and MART plans.

• Childrens_Asthma_Plan_A4_trifold_DIGITAL.pdf (shopify.com)
• MART_action_plan_editable_full_colour_V4.pdf (shopify.com) 
          

1. Smoking, passive smoking and vapes

• Exposure to tobacco smoke decreases the effectiveness of ICS 
• The British Paediatric Respiratory Society strongly condemns the use of vaping – see here
• Refer to your local smoking cessation service
• Train yourself on how to deliver ‘very brief advice’ on smoking cessation using this link: NCSCT Very Brief Advice training module

     2. Air pollution

• Outdoor
  • Give advice to avoid busy roads and vigorous outdoor exercise on high pollutions days
• Indoor
  • Electricity is cleanest home energy source
  • Burning wood, candles and incense adversely affect asthma.
  • ‘Chemical free’ or ‘allergy friendly’ household and personal products may limit asthma triggers
• Patient resources
  • Clean Air Information Hub
  • Daily Air Quality Index - Defra, UK
  • Air pollution and your lungs

      3. Damp and mould

• There is good evidence that exposure to damp and mould is harmful for all children, and particularly those with asthma.  It can be a driver of poor asthma control and should be taken seriously
• Practical guidance with fact sheet for families is available here MECC Link
• This includes the following resources, plus template letters for landlord’s/ housing authorities
  • Can damp and mould affect my health? - NHS (www.nhs.uk)
  • Damp and mould problems - Shelter England
  • Repairs - damp - Citizens Advice
  • Understanding and addressing the health risks of damp and mould in the home - GOV.UK (www.gov.uk)

• Inhaler emissions account for approximately 3% of the NHS carbon footprint.
• The propellant used in metered dose inhalers is responsible for most of these emissions
• Alternative options with a lower carbon footprint exist, such as dry powder inhalers
• Supporting patients to consider using lower carbon inhalers creates an opportunity to improve patient outcomes while reducing harmful carbon emissions
  • Other potential advantages are ease-of-use and convenience
  • It may be an opportunity to switch to a SABA free pathway

BUT

• Dry powder inhalers require a high minimum inspiratory flow rate (approximately 30l/min)
• This is much higher than a pMDI via spacer and can be challenging for younger children, especially in exacerbations
  • You must teach and check the patient has effective technique
  • Use a training devices such as the In-Check DIAL G16 and/or placebo inhalers

**Well controlled asthma has the lowest carbon footprint**

Ask patients to return all used inhalers to pharmacies for safe disposal, as plastics from inhalers cannot be recycled using domestic recycling schemes

Resources

• Greener Practice Asthma Care  - clinician led network
• Asthma inhalers and climate change: Patient decision aid, London: Top Tips for Respiratory Prescribing and Sustainability

All children with an acute asthma attack needing a course of oral corticosteroids should receive a GP review within two working days of their exacerbation or discharge from hospital

• If presenting to primary care, GPs should book the review before the child leaves the consulting room
• If presenting to urgent care/ hospital, parents will be informed to contact their GP practice and book a review within 2 working days of discharge
• It is worth ensuring the terms ’48-hour review’ or ‘2 working day review’ are universally recognised within the GP surgery, for ease of access to an urgent appointment

During the review

• Is the child better?
• Consider using the objective assessment tool on EMIS/SystemOne
• If not better, extend the course of oral prednisolone and consider a referral back to secondary care
  • Check ‘the basics’ (inhaler technique/ asthma action plan/ understanding)
  • Ensure adequate inhaler/ medication supply (school and home including spacer)
  • Reinforce safety net advice according to their asthma plan
  • Look at the background issues, adherence, medication use, diagnosis and book for a more detailed asthma review within four weeks
  • If the child has had two or more acute attacks within the last 12 months they should be referred to an asthma clinic for review  

The post-attack assessment tool is available within EMIS and SystemOne templates for NW London

• How is the child now?
• How many days of steroids completed?
• Do they have an asthma action plan?
• Check inhaler technique

Recognition

• Uncontrolled symptoms with low symptom scores (cACT/ ACT <20)
• SABA overuse (≥3 used per year increases the risk of future attacks) (see table below)
• Asthma attacks needing oral steroids/ hospital attendance in the last 12 months
• Poor lung function (especially FEV1<60%)
• Use of home nebulisers (Link to MHRA alert)
  • These are associated with asthma deaths and should not be part of routine asthma care
  • If children are found to be using home nebulisers refer to your local asthma service for advice

Common causes and management

• Basics not right
  • Poor knowledge/ self-management skills
  • Poor adherence (commonest cause)
  • Poor inhaler technique
  • Comorbidities not managed (rhinitis/obesity/food allergy/anxiety/depression)
• Ongoing exposures
  • Seasonal pollens
  • Air pollution (indoor and outdoor)
  • Environmental tobacco smoke
  • Damp/ mould
• Safeguarding/ Psychosocial factors
  • Consider a referral to social care and/or your local asthma service for children who are not brought to their second offered appointment.  This is paramount for children with evidence of poorly controlled asthma and/or other risk factors for future attacks
• True severe asthma
  • A significant proportion, around 5%, have severe asthma due to steroid resistance and other factors.  These patients may continue to have asthma attacks despite the basics being right with good adherence.  They may benefit from new biologic medications.  Please refer to your local asthma service to assess further and consider referring to tertiary care.

Refer patients with poor control despite optimisation in primary care

• After any hospital admission for acute asthma (all patients admitted with acute asthma need hospital follow up – this should be booked by the hospital before discharge)
• Two or more attacks/ courses of oral steroids in the last year
• Ongoing low cACT/ ACT scores
• High SABA use
• PICU/ life-threatening episode of asthma (carries a lifetime risk of severe asthma episodes)

Other factors

• Diagnostic uncertainty/ red flags for other condition (refer to secondary care not community clinic)
• Two or more ‘was not brought’ ‘DNAd’ appointments with ongoing poor control

Community asthma services

Secondary care referrals