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Sample Topic: Asthma

Asthma : Last revised in December 2013


Managing children with suspected asthma

How should I manage children with a low probability of asthma?

Consider an alternative diagnosis, or refer to secondary care for further investigations.

Basis for recommendation
This recommendation is based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011].

How should I manage children with a high probability of asthma?

  • Start a trial of asthma treatment for 2–3 months. The choice of treatment depends on the severity and frequency of symptoms. For more information, see the section titled ‘How should I start treatment for asthma?‘ below.
  • If response is good, continue treatment.
  • If response is poor:
    • Assess compliance and inhaler technique.
    • Consider checking airway reversibility, or refer to secondary care for additional tests.

Basis for recommendation
This recommendation is based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011].

How should I manage children with an intermediate probability of asthma who cannot perform airway obstruction tests?

The following options may be tried depending on the frequency and severity of symptoms:

  • Watchful waiting — review the child after a time interval agreed with the parents or carers. In children with mild, intermittent wheeze and other respiratory symptoms which occur only with viral upper respiratory tract infections, it is reasonable to give no specific treatment and then review the child.
  • Start a trial of asthma treatment for 2–3 months. The choice of treatment depends upon the severity and frequency of symptoms:
    • If response is good, continue treatment.
    • If response is poor, assess compliance and inhaler technique, and consider referral for Additional tests in secondary care.
    • If it is unclear whether a child has improved, careful observation during a trial of treatment withdrawal may clarify whether they have responded to asthma treatment.

Basis for recommendation
This recommendation is based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011]:

  • Measuring lung function in young children is difficult and not usually possible in children younger than 5 years of age.
  • Although a trial of treatment with inhaled or oral steroids is often used to make a diagnosis there is little objective evidence to support this approach in children who present with a history of recurrent wheeze.

How should I manage children with an intermediate probability of asthma who can perform airway obstruction tests?

  • Check for airway obstruction using spirometry:
    • Spirometry should be done by a trained healthcare professional; if this is not possible, seek advice.
    • Normal spirometry results obtained when the child is asymptomatic do not exclude a diagnosis of asthma. Repeated measurements of lung function may be more helpful to interpret than a single measurement.
  • If there is no evidence of airway obstruction, consider referring for Additional tests in secondary care.
  • If there is evidence of airway obstruction, assess for reversibility to either bronchodilator therapy (for example salbutamol 400 micrograms via metered-dose inhaler and spacer) and/or to a trial of asthma treatment for 2–3 months:
    • If there is significant reversibility (greater than 12% increase in forced expiratory volume in 1 second [FEV1]), or if there is a significant increase in peak expiratory flow rate after a bronchodilator, a diagnosis of asthma is probable. Continue to treat as asthma. The choice of asthma treatment (for example inhaled short-acting beta2-agonist or inhaled corticosteroid) depends on the severity and frequency of symptoms. For more information, see Starting asthma treatment.
    • If there is no significant reversibility (less than 12% increase in FEV1), and a trial of treatment is not beneficial, refer to secondary care for additional tests.
    • If it is unclear whether a child has improved on a trial of asthma treatment, careful observation during a trial of treatment withdrawal may clarify whether they have responded to asthma treatment.

Basis for recommendation
This recommendation is based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011]:

  • In children, tests of airway obstruction (spirometry or measuring peak expiratory flow) may provide support for a diagnosis of asthma.
  • Spirographs require calibration to allow accurate interpretation of the results (for example Rosenthal normal values based on the child’s sex and height). Healthcare professionals require training on how to calibrate and interpret the results from a spirogram. Prodigy recommend that advice should be sought regarding carrying out spirometry in children and interpreting the results, unless the healthcare professional has received appropriate training.
  • Although a trial of treatment with inhaled or oral steroids is often used to make a diagnosis there is little objective evidence to support this approach in children who present with a history of recurrent wheeze.

How should I start treatment for asthma?

  • Explain that lifestyle changes and medication are meant to control asthma symptoms and prevent an exacerbation.
  • Explain the difference between reliever and preventive therapy, and demonstrate how to use inhalers and spacer devices.
  • Prescribe an effective delivery device on the basis of convenience, cost, and suitability.
  • Prescribe a short-acting beta2-agonist for use as required to treat daytime symptoms (twice weekly or less often) of short duration (lasting only a few hours).
  • Prescribe a regular inhaled corticosteroid with the short-acting beta2-agonist if symptoms are at least three times weekly, or waking the person one night weekly.
  • Prescribe a peak flow meter and record the person’s best peak expiratory flow rate reading. Advise monitoring during an exacerbation, worsening symptoms, or a medication change. Regular monitoring of peak expiratory flow is no longer advised as it does not provide additional benefit when added to a symptom based management strategy.
  • Provide education about asthma, such as how to monitor symptoms and recognize an exacerbation.

Additional information
Demonstrate how to use inhalers and spacer devices. Ask the person to repeat the technique back to you. For more information on how to use inhalers (with demonstrations), see www.asthma.org.uk or www.ginasthma.org.

  • Encourage monitoring of asthma control on the basis of symptoms [SIGN and BTS, 2011]:
    • Symptoms that worsen at night, or exercise-induced asthma, may suggest poor asthma control. The frequency of short-acting beta2-agonist use is a useful guide to asthma control. Ideally, people should not be using reliever medication in controlled asthma.
    • Do not recommend routine monitoring of peak expiratory flow rate (PEFR) unless the person has severe asthma or a poor perception of bronchoconstriction [SIGN and BTS, 2011]. However, encourage measuring PEFR as part of a self management programme: loss of asthma control may be assessed by symptoms or by measuring PEFR or both [SIGN and BTS, 2011].
    • Ideally, record PEFR annually in children whilst they are still growing [Pinnock and Shah, 2007].
  • A short-acting beta2-agonist should be started on an as required basis for mild, intermittent symptoms. People should have normal lung function and no nocturnal awakening. When symptoms are more frequent or are worsening, people require treatment at a level based on the severity of symptoms.

Basis for recommendation
This recommendation is based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011]:

  • Measuring peak expiratory flow rate (PEFR): The guideline development group for the British guideline on the management of asthma: a national clinical guideline commented that studies in children have shown that routine serial measurements of PEFR do not provide additional useful information when added to a symptom based management strategy [SIGN and BTS, 2011].
  • Short-acting bronchodilators: inhaled short-acting beta2-agonists are the preferred treatment for rapid symptom relief. The evidence suggests that short-acting beta2-agonists have a quicker onset of action and fewer adverse effects than other reliever drugs (inhaled anticholinergics, short-acting oral beta2-agonists, and short-acting theophylline). An as required regimen is at least as effective as regular use in people with asthma [GINA, 2006].