Primary care

Contents

1. Pre-school wheeze
2. National and international asthma guidelines
3. Making a diagnosis of asthma in children and young people
4. Pharmacological treatment for asthma in children and young people
5. Asthma reviews
6. Management of an asthma attack at a GP practice

Pre-school wheeze

Pre-school wheeze, often also known as viral induced wheeze in the under 5's can cause concern and vary in severity. The probability as to whether the child will continue with symptoms requiring a diagnosis of asthma requires several considerations.

Most children and young people with asthma are looked after in the community by their GP and Practice Nurse. Once a firm diagnosis of asthma is made, GP surgeries invite patients for an asthma review every year. If symptoms become severe and lead to an asthma attack requiring treatment by an Emergency Department or a hospital stay a GP or Practice Nurse review should take place approximately 48 hours after discharge.

There is information on pre-school wheeze in some of the national guidelines National Guidelines for the Under 5's with respiratory symptoms that may be asthma.

To access a flowchart providing guidance for pharmacological treatment of chronic asthma in children under 5 years visit Tools and resources - Asthma: diagnosis, monitoring and chronic asthma management and click on Algorithm D.

A short explanation of the flowchart:

• A child under 5 years presents with suspected asthma.
• For symptoms that indicate the need for maintenance therapy at presentation consider an 8-week trial of a paediatric moderate dose of ICS (inhaled corticosteroid) and give a SABA (short acting beta agonist).
• For symptoms that do not indicate the need for maintenance therapy at presentation offer a SABA alone. However, if asthma is uncontrolled in 4 - 8 weeks consider an 8-week trial of paediatric moderate dose ICS with a SABA.
• Stop ICS after 8 weeks and review response of which there are 3 options as follows:
• Option One - if symptoms resolved during the trial but recurred within 4 weeks of stopping ICS offer a paediatric low dose ICS with a SABA. If asthma continues to be uncontrolled in 4 to 8 weeks, consider paediatric low dose ICS plus a leukotriene receptor antagonists (LTRA) with a SABA. If asthma is uncontrolled after a further 4 to 8 weeks stop but continue with paediatric low dose ICS with a SABA and refer to a healthcare professional with expertise in asthma for further investigation and management.
• Option Two - if symptoms resolved during the trial but recurred beyond 4 weeks after stopping ICS, repeat 8-week trial of a paediatric moderate dose ICS.
• Option Three - if symptoms did not resolve during the trial, review whether an alternative diagnosis is likely.
• Tip - if the child responds to ICS after following the above consider reducing the dose if asthma has been controlled for at least 3 months.

The British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN) British Guideline on the Management of Asthma published in July 2019 also offers a diagnostic aid in the form of a flowchart which can be applied to patients presenting with suspected asthma at any age. However, in the case of children under 5 years and others unable to perform spirometry in whom there is a high or intermediate probability of asthma the options are monitored initiation of treatment or watchful waiting according to the assessed probability of asthma. Please use the following link, click on the full guideline and refer to table 3 on page 23 and figure 1 on page 27 of the document: British guideline on the management of asthma.

Here is a short explanation of the flowchart on page 27:

A patient presents with respiratory symptoms: wheeze, cough, breathlessness, chest tightness. During a structured clinical assessment (from history and examination of previous records) look for:

• Recurrent episodes of symptoms
• Symptom variability
• Absence of symptoms of alternative diagnosis
• Recorded observation of wheeze
• Personal history of atopy
• Historical record of variable PEF (peak expiratory flow) or FEV1 (forced expiratory volume in 1 second)

If you feel the patient has a high probability of asthma code as suspected asthma and initiate treatment. Assess the response objectively using lung function or a validated symptom score. If there is a good response diagnose with asthma, adjust maintenance dose, provide self-management advice, and arrange on-going review.

If there is a poor response, follow the route of intermediate probability of asthma and test for airway obstruction and bronchodilator reversibility. Optional investigations are testing for variability using reversibility, peak flow charting or challenge tests. Or testing for eosinophilic inflammation or atopy using FeNO, blood eosinophils, skin prick testing, total and specific immunoglobulin E (IGE). This is coded as suspected asthma and apply watchful waiting if asymptomatic or commence treatment and assess response objectively. If there is a good response diagnose with asthma. If there is a poor response investigate and treat for other more likely diagnosis.

If there is a low probability of asthma, then investigate/treat for other more likely diagnosis. Following this if another diagnosis is unlikely follow the previously mentioned route for an intermediate probability of asthma. Or if you find another diagnosis confirm this diagnosis.

Note below the chart: if a child under 5 years or is for any other reason unable to undertake spirometry in whom there is a high or intermediate probability of asthma, the options are monitored initiation of treatment or watchful waiting according to assessed probability of asthma.

For more information see The Pharmaceutical Journal webpage diagnosis and management of wheeze in pre-school children.

National and international asthma guidelines

There are currently four sets of guidelines available but for the purpose of this children and young people (CYP) Asthma Toolkit we will refer mainly to the first two:

• SIGN 158/BTS British guideline on the management of asthma – First published 2003, Revised edition published July 2019 (Scottish Intercollegiate Guidelines Network and British Thoracic Society)
• National Institute for Health and Care Excellence (NICE) – Asthma: diagnosis, monitoring and chronic asthma management – Published Nov 2017
• GINA strategy for asthma management and prevention – Updated 2022 (Global Initiative for Asthma)
• European Respiratory Society (ERS) – clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years
  • Clinical practice guidelines for the diagnosis of asthma in children aged 5 to 16 years
  • European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5–16 years
• Each guideline uses the same evidence base but different methodology to guide its recommendations. This has led to some differences in approach which can cause confusion, with healthcare professionals' unsure which guideline to follow.

Understanding why these differences are there can help professionals make sense of them and guide their decision making.

Here are some key points:

1. Objective tests should be used to support a diagnosis in children over the age of 6 years or thereabouts.
2. No single symptom or test is diagnostic.
3. Spirometry is pivotal in making an accurate diagnosis especially in older children or adults.
4. If diagnosis is suspected but not clear there should be an initiation of treatment with careful review
5. The process to reach an outcome must be recorded in the patients record.

For a more in depth at the differences between the guidelines please see British Medical Journal (BMJ) Journal guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE.

BTS/SIGN and NICE are currently working on a joint asthma guideline that should be published in 2024.

Making a diagnosis of asthma in children and young people

Making a diagnosis of asthma in children, young people and adults can be challenging and involves careful history taking, examination and the use of some objective testing such as spirometry, FeNO and/or peak flow variability. After completing as many of the above as possible it is then a case of looking at all the outcomes and piecing together in a similar way to a jigsaw puzzle.

Using national or local guidelines alongside clinical knowledge and experience is helpful.

Please refer to algorithm A on the NICE webpage: Tools and resources - Asthma: diagnosis, monitoring and chronic asthma management of the NICE: Asthma: diagnosis, monitoring and chronic asthma management. Published 29 November 2017, last updated 22 March 2021.

Here is an explanation of Algorithm A:

An adult, young person or child presents with symptoms of asthma. Take a structured clinical history. Specifically check for:

• Wheeze, cough, or breathlessness, and any daily or seasonal variation in these symptoms.
• Any triggers that make symptoms worse.
• A personal or family history of atopic disorders.

Do not use symptoms alone without an objective test to diagnose asthma and do not use a history of atopic disorders alone to diagnose asthma.

Examine people with expected asthma to identify expiratory polyphonic wheeze and signs of other causes of respiratory systems but be aware that even if examination results are normal the person may still have asthma.

If a person has acute symptoms at presentation:

• Treat immediately and perform objective tests if the equipment is available and testing will not compromise treatment.
• If objective tests cannot be done immediately, carry them out when acute symptoms have been controlled and advise patients to contact their healthcare professional immediately if they become unwell while waiting to have objective tests.
• Be aware that the results of spirometry and FeNO tests may be affected with inhaled corticosteroids.

For children under the age of 5 years treat symptoms based on observation and clinical judgement and review the child on a regular basis. If they still have symptoms when they are 5 years, see Algorithm B of the Tools and resources - Asthma: diagnosis, monitoring and chronic asthma management.

For children and young people between 5 to 15 years see Algorithm B of the Tools and resources - Asthma: diagnosis, monitoring and chronic asthma management.

Notes below:

Do not offer the following as diagnostic tests for asthma:

• Skin prick tests to aeroallergens
• Serum total and specific IgE
• Peripheral blood eosinophil count

Use skin prick tests to aeroallergens or specific IgE tests to identify triggers after a formal diagnosis of asthma has been made.

Alternatively, the BTS/SIGN British Guideline on the Management of Asthma published in July 2019 offers a diagnostic aid in the form of a flowchart which can be applied to patients presenting with suspected asthma at any age. Please use the following link, click on the full guideline and refer to page 27 of the document: British guideline on the management of asthma.

Here is a short explanation of the flowchart on page 27:

A patient presents with respiratory symptoms: wheeze, cough, breathlessness, chest tightness. During a structured clinical assessment (from history and examination of previous records) look for:

• Recurrent episodes of symptoms
• Symptom variability
• Absence of symptoms of alternative diagnosis
• Recorded observation of wheeze
• Personal history of atopy
• Historical record of variable PEF (peak expiratory flow) or FEV1 (forced expiratory volume in 1 second)

If you feel the patient has a high probability of asthma code as suspected asthma and initiate treatment. Assess the response objectively using lung function or a validated symptom score. If there is a good response diagnose with asthma, adjust maintenance dose, provide self-management advice, and arrange on-going review.

If there is a poor response, follow the route of intermediate probability of asthma and test for airway obstruction and bronchodilator reversibility. Optional investigations are testing for variability using reversibility, peak flow charting or challenge tests. Or testing for eosinophilic inflammation or atopy using FeNO, blood eosinophils, skin prick testing, total and specific IGE. This is coded as suspected asthma and apply watchful waiting if asymptomatic or commence treatment and assess response objectively. If there is a good response diagnose with asthma. If there is a poor response investigate and treat for other more likely diagnosis.

If there is a low probability of asthma, then investigate/treat for other more likely diagnosis. Following this if another diagnosis is unlikely follow the previously mentioned route for an intermediate probability of asthma. Or if you find another diagnosis confirm this diagnosis.

Note below the chart: If a child under 5 years or is for any other reason unable to undertake spirometry in whom there is a high or intermediate probability of asthma, the options are monitored initiation of treatment or watchful waiting according to assessed probability of asthma.

History and examination

There is not one single objective test that can confirm a diagnosis of asthma. A diagnosis consists of:

• A full history, including family and social history.
• Examination
• Peak flow variability or
• Spirometry and/or
• FeNO
• Trial of treatment

Taking a history and examination

What to ask in the history?

It is important to ask the child or young person if age and developmentally appropriate about:

• the nature, frequency and pattern of their chest symptoms (including coughing, wheezing, breathlessness and chest tightness) and specifically whether there is any diurnal or seasonal variation in these symptoms.
• whether there are any 'triggers' that make their symptoms worse such as pollens, pets, pollution, exercise, viruses and stress
• whether their symptoms are worse in a specific location such as when they are at home or at school.
• any personal or family history of atopic disorders (such as eczema and hayfever) and whether they have any symptoms that suggest an alternative diagnosis, but remember people can have more than one reason to have chest symptoms
• current or previous cigarette smoking in the over 12's or any other family members smoking in the household
• Whether there is any vaping inside or outside the household by the young person or family member that lives with the patient.

What to review in their records?

It is important to look for evidence of:

• a history of atopy
• recurrent or persistent chest symptoms, particularly if an associated wheeze was identified on clinical examination, as well as previous treatment (inhalers, oral steroids, antibiotics) for acute chest symptoms
• a raised blood eosinophil count which may indicate eosinophilic inflammation – if any previous blood tests have been done for other reasons

What to look for on examination?

• Is there evidence of widespread wheeze to support a diagnosis of asthma?
• Are there features suggestive of an alternative diagnosis such as finger clubbing, stridor, crackles in the chest or a monophonic wheeze?

Introduction to Objective Testing

Children aged 5 years and under are unlikely to be able to perform spirometry, FeNO or peak flow. However, FeNO and peak flow are slightly easier, and you can start to teach them how to do these tests from around age 4, 5 or 6 years depending on the child. They may not achieve recordable results, but you can offer a peak flow meter and an instruction leaflet or video to take home and practice with and then re-check their technique at their next review.

At least one objective test is useful, however, if symptoms are such that inhaled treatment is commenced whilst the patient is waiting for an appointment, or if the patient has not been exposed to a trigger at the time of the test; the results are likely to be normal.

NICE: Asthma: diagnosis, monitoring and chronic asthma management. Published 29 November 2017. Last updated 22 March 2021. Further information on objective testing in children aged 5 – 16 years with symptoms suggestive of asthma. Please refer to algorithm B on the webpage: Tools and resources - Asthma: diagnosis, monitoring and chronic asthma management.

Here is an explanation of algorithm B:

Order of tests:

• Perform spirometry in children and young people with symptoms of asthma.
• Consider bronchodilator reversibility if spirometry shows an obstruction.

If the child is unable to perform objective tests:

• Treat based on observation and clinical judgement and:
• Try doing the tests again every 6 to 12 months

If diagnostic uncertainty remains after spirometry and bronchodilator reversibility, consider FeNO.

If diagnostic uncertainty remains after FeNO, monitor peak flow variability for 2 to 4 weeks.

Interpretation of test results

If spirometry shows an obstruction and there is reversible airflow then diagnose with asthma.

If spirometry shows an obstruction and there is no reversible airflow obstruction offer a FeNO test. If FeNO levels are more than 35 ppb collect peak flow readings for 2-4 weeks and check for variability. If there is peak flow variability along with a positive FeNO diagnose with asthma.

If FeNO levels are less than 35 ppb refer for specialist assessment.

If there is a positive FeNO but no peak flow variability suspect asthma and review diagnosis after treatment.

If spirometry does not show an obstruction perform a FeNO test.

If the FeNO test shows 35 ppb or more collect peak flow readings for 2-4 weeks and check for variability. If there is variability diagnose with asthma. If there is no peak flow variability suspect asthma and review diagnosis after treatment.

If FeNO levels are less than 35 ppb collect peak flow readings for 2-4 weeks and check for variability. If there is peak flow variability suspect asthma and review diagnosis after treatment.

If FeNO levels are less than 35 ppb and there is no peak flow variability, consider alternative diagnoses and referral for specialist assessment.

Positive test thresholds:

• Obstructive spirometry: FEV1/FVC ratio less than 70% (or below lower limit of normal if available)
• FeNO: 35 ppb or more
• BDR: improvement in FEV1 of 12% or more
• Peak flow variability: variability over 20%

Spirometry and bronchodilator reversibility

Spirometry is the investigation of choice for identification of airflow obstruction. Training is required to obtain reliable recordings and to interpret the results, particularly in children.

The probability of asthma, differential diagnosis and approach to investigation is different in patients with and without airflow obstruction at the time baseline spirometry is undertaken. Confirmation of an asthma diagnosis hinges on demonstration of airflow variability over short periods of time. A normal spirogram obtained when the patient is asymptomatic does not, therefore, exclude the diagnosis of asthma.

Measuring lung function in children under five years of age is difficult and requires techniques which are not widely available. For developmentally mature children over five years of age conventional lung function testing is possible in most settings with an operator trained and experienced in undertaking paediatric spirometry. As in adults, normal results on testing, especially if performed when the child is asymptomatic, do not exclude a diagnosis of asthma.

The FEV1/forced vital capacity (FVC) ratio changes with age. In young children it can be as high as 90% so use of the commonly used fixed ratio of 70% will substantially underestimate airflow limitation. Accordingly, use of lower limits of normal is now recommended and is becoming easily available through software built into spirometers.

• British guideline on the management of asthma - page 12

Spirometry training

• For practitioners wishing to complete paediatric spirometry training working within primary care in Surrey please visit Surrey Training Hub
• When you have completed the course, if you would like to complete your Association of Respiratory Technology and Physiology (ARTP) competencies please visit Spirometry Certification - Association for Respiratory Technology and Physiology
• Spirometry Assessment, Certification and National Register FAQs - Primary Care Respiratory Society
• Spirometry Training - Association for Respiratory Technology and Physiology
• Respiratory Matters: Spirometry and preparation for entry onto the spirometry register (held by ARTP)
• Spirometry Package including ARTP assessment access - Education For Health
• Rotherham Respiratory LTD - Education in Long Term Conditions for Health Care Professionals

Infection control in spirometry and FeNO

All quality assurance measures, infection control protocols and calibration should be performed as highlighted during spirometry training.

Spirometry (Association for Respiratory Technology and Physiology) have published specific guidance (in 2021) and an update in December 2022 on risk minimisation in restarting spirometry services in the wake of the Covid-19 pandemic.

FeNO (Fractional exhaled Nitric Oxide)

Fractional exhaled Nitric Oxide (FeNO) is a test for measuring the amount of Nitric Oxide in the exhaled breath. The result shows the level of inflammation in the airways and this information can contribute to the making of an asthma diagnosis.

NICE guidelines Tools and resources - Asthma: diagnosis, monitoring and chronic asthma management do not recommend FeNO for everyone over 5 years of age. In children aged 5 to16 years FeNO is only needed if spirometry or reversibility is normal. In patients aged 16 or over NICE suggests both FeNO and spirometry tests if asthma is being considered.

What training do I need to use FeNO in my practice?

This is a relatively quick and easy test to perform. Please see the link to access the correct page on elearning for healthcare to sign up for the training.

Please also ensure that you receive appropriate training from the manufacturer of the machine that you choose. You will need to know how to use, maintain, calibrate and service the machine.

FeNO results

FeNO levels and assessment of airway inflammation, from the American Thoracic society (ATS) guidelines:

What does a high FeNO mean?

This suggests that there is untreated eosinophilic inflammation present and increases the likelihood of an asthma diagnosis and suggests that the patient will respond to corticosteroid medication. However, a high FeNO reading should not be used in isolation but in conjunction with a detailed clinical history, examination, and other tests such as spirometry.

What does a normal or low FeNO mean?

This suggests that there is currently no untreated eosinophilic inflammation present. This could be because the patient is already on treatment that suppresses inflammation, that they have the type of asthma that does not involve eosinophilic inflammation or that they have asthma, but the inflammation is currently in remission.

Some external factors may influence FeNO results. Ideally it should be performed before spirometry if doing both tests on the same day. People should refrain from eating (especially nitrate-rich food), drinking, smoking and exercising one to two hours before a FeNO test.

Please see the link below for the work of Wessex Academic Health and Science Network to support the spread of FeNO testing and to improve the pathways for people with suspected and confirmed asthma. Following this link will also take you to further information, training links and to resources in several languages for patients .

Peak flow variability

• Peak expiratory flow monitoring Peak expiratory flow (PEF) should be recorded as the best of three forced expiratory blows from total lung capacity with a maximum pause of two seconds before blowing.
• The patient can be standing or sitting. Further blows should be done if the largest two PEF are not within 40 L/min.

• Peak expiratory flow is best used to provide an estimate of variability of airflow from multiple measurements made over at least two weeks. Increased variability may be evident from twice-daily readings. More frequent readings will result in a better estimate, but the improved precision is likely to be achieved at the expense of reduced patient compliance.
• Use of electronic meters and diaries with time and date stamps can overcome problems of compliance and accuracy when recording peak flows in paper diaries.
• Peak expiratory flow variability is usually calculated as the difference between the highest and lowest PEF expressed as a percentage of the average PEF, although one study showed that three or more days a week with significant variability was more sensitive and specific than calculating mean differences.
• The upper limit of the normal range for variability is around 20% using four or more PEF readings per day but may be lower using twice-daily readings.
• Studies have shown sensitivities of between 3% and 46% for identifying physician diagnosed asthma.
• One limitation of these epidemiological studies is that it is not always clear whether the participants were symptomatic at the time of the monitoring. Peak expiratory flow charting when asthma is 'inactive' is unlikely to confirm variability; one study showed that significant PEF variability was associated with respiratory symptoms in the previous week.

In children, serial measures of peak-flow variability and FEV1 show poor concordance with disease activity and do not reliably rule the diagnosis of asthma in or out.

See page 13 of the British guideline on the management of asthma on the British Thoracic Society website.

Objective diagnostic summary

Chart showing objective tests for asthma and what is interpreted as a positive result.

Diagnostic summary is available to view on section 1.4 of the NICE website recommendations - Asthma: diagnosis, monitoring and chronic asthma management.

Differential diagnosis

Clinical clues to alternative diagnoses in wheezy children.

Perinatal and family history

Symptoms and signs

Investigations

Source - British guideline on the management of asthma - page 24 of the full guideline.

Useful links

• National bundle of care for children and young people with asthma - NHS England
• Asthma (Children and young people) - elearning for healthcare
• Asthma learning webinar - 1 hour long webinar Dr Kian Lee Consultant Paediatrician, Frimley Park Hospital.
• How clinicians can approach health inequalities in asthma conversations with patients – Dr Ian Sinha, Consultant Respiratory Paediatrician, Alder Hey Childrens' Hospital (video)
• Getting your child diagnosed - Asthma + Lung UK
• Childhood asthma symptoms and treatment - elearning for healthcare (ELF)
• Diagnosis of asthma in children: the contribution of a detailed history and test results - European Respiratory Society
• Asthma – state of child health - Royal College of Paediatrics and Child Health

Pharmacological treatment for asthma in children and young people over 5 years old

Please note that the BTS/SIGN guidelines and the NICE guidelines have different information as to what constitutes a very low dose, a low dose and a medium dose of inhaled corticosteroid as described by BTS/SIGN or a paediatric low dose, paediatric moderate dose or paediatric high dose as described by NICE. There are also some slight differences in the steps suggested for treatment. Please choose one guideline and the corresponding ICS doses chart to support your clinical decision.

BTS, SIGN and NICE are working together to produce a joint national guideline that updates the current BTS/SIGN and NICE guidelines for asthma. This is expected to be published in 2024.

It can be helpful to emphasise to families that there is not yet a cure for asthma. Asthma is a chronic inflammatory condition of the small airways. Discussion can take place with children, young people and families about scientists and researchers working on different things all the time but for now there are medicines that can prevent flare-ups and control symptoms. Therefore, in most cases, people will need this medication for life and the reason for an annual asthma review is to ensure the lowest dose necessary of preventer medication is being used to keep a person well.

Complete control of asthma is defined as:

• No daytime symptoms
• No night-time awakening due to asthma
• No need for rescue medication
• No asthma attacks
• No limitations on activity including exercise
• Minimal side effects from medication

Inhaled corticosteroids should be prescribed for children of whom have a firm diagnosis of asthma or those who are on a trial of treatment.

Note regarding the under-5's: A referral should be made to secondary care where an inhaled corticosteroid may be considered by a consultant paediatrician for under 5's with preschool (viral-induced) wheeze that becomes severe and difficult to manage when they have a common cold or other respiratory infection.

The aim of asthma treatment is to:

• Optimise symptom control
• Prevent acute attacks
• Minimise permanent airflow limitation
• Minimise side effects
• Promote self-management

When starting a pharmacological treatment, use a dose that will quickly abolish symptoms. When control is achieved maintain the child on the lowest possible dose whilst still achieving control. Be sure to correct any modifiable factors such as inhaler technique and adherence at every consultation.

For a summary of management in children in the BTS/SIGN Asthma guidelines 2019 please visit: British guideline on the management of asthma, open the full guideline and go to page 81 for a stepwise approach to the treatment of asthma in children.

The chart starts with a section at the top that says asthma suspected and advises assessment and diagnosis and considering an initiation of monitored treatment with a very low dose inhaled corticosteroid (ICS).

The next section says paediatric asthma – diagnosed. Step One is a regular inhaled corticosteroid at a very low paediatric dose or a leukotriene receptor antagonist (LTRA) in those aged 5 years or under. If a short acting beta agonist (SABA) is required three or more times a week, consider moving to step two.

Step two is an initial add-on therapy suggesting the child remains on the very low dose ICS plus adding a long acting beta agonist (LABA) for children over 5 years or a LTRA. For children under 5 years add a LTRA.

Prescribe ICS and LABA as a combination inhaler to ensure LABA not taken without ICS and to improve adherence.

If a short acting beta agonist (SABA) is required three or more times a week, consider moving to step three. Consider increasing the ICS to a paediatric low dose or for children over 5 years add a LTRA or LABA. If no response to LABA consider stopping LABA.

If control has not been reached at step 3 then refer to a specialist.

Evaluation at each step should include assessing symptoms, measuring lung function (if required and/or available), checking inhaler technique and ensuring the child or young person has the correct spacer if using a pressurised metered dose inhaler (pMDI). A spacer is recommended with a pMDI for all ages including adults. Check adherence by asking the child if age appropriate. If moving up or down a step always provide an updated asthma action plan.

Useful links:

• Your child's asthma action plan - Asthma + Lung UK
• Chronic management - Beat Asthma

To view the chart in the BTS/SIGN Asthma guideline 2019 highlighting the various inhaled corticosteroids available categorised into very low dose, low dose and medium dose visit British guideline on the management of asthma, open the guideline, and go to page 69.

For information given by NICE on the pharmacological treatment of asthma in children aged 5 – 16 years visit Tools and resources - Asthma: diagnosis, monitoring and chronic asthma management and then click on the link for Algorithm E.

This flowchart has a slightly different approach to the information offered by BTS/SIGN.

It starts with the presentation of a child or young person aged between 5 and 16 years with a new diagnosis of asthma. The first suggestion is for those with symptoms that indicate the need for maintenance therapy to be offered a paediatric low dose ICS with a SABA. If asthma is not controlled in 4 to 8 weeks to consider a paediatric low dose ICS plus a LTRA along with a SABA. If asthma continues to be uncontrolled in another 4 to 8 weeks to consider a paediatric low dose ICS plus a LABA and a SABA, and to stop the LTRA.

Prescribe ICS and LABA as a combination inhaler to ensure LABA not taken without ICS and to improve adherence.

If asthma is still uncontrolled in a further 4 to 8 weeks to consider a paediatric low dose ICS plus a LABA within a maintenance and reliever therapy (MART) regime.

If asthma is uncontrolled in another 4 to 8 weeks consider a paediatric moderate dose ICS plus a LABA either with a MART regimen or as a fixed dose with a SABA.

If asthma remains uncontrolled after a further 4 to 8 weeks consider seeking advice from a healthcare professional with expertise in asthma and consider a paediatric high dose ICS plus a LABA as a fixed dose with a SABA or consider continuing a paediatric moderate dose ICS regimen with a trial of an additional drug such as theophylline.

The second scenario in this flowchart is for those with infrequent, short lived wheeze and normal lung function to consider a SABA alone. If asthma in uncontrolled in 4 to 8 weeks to follow the same path as above.

The flowchart also has a note along the side which suggests considering decreasing maintenance therapy when asthma has been controlled with current maintenance therapy for at least 3 months.

Again, evaluation at each step should include assessing symptoms, measuring lung function (if required and/or available), checking inhaler technique and ensuring the child or young person has the correct spacer if using a pressurised metered dose inhaler (pMDI). A spacer is recommended with a pMDI for all ages including adults. Check adherence by asking the child if age appropriate. If moving up or down a step always provide an updated asthma action plan.

Useful links:

• Your child's asthma action plan - Asthma + Lung UK
• Chronic management - Beat Asthma

For the NICE paediatric inhaler dosing recommendations visit Tools and resources - Asthma: diagnosis, monitoring and chronic asthma management and then go to the box that says Education and then click the link that says inhaled corticosteroid doses.

Maintenance and reliever therapy (MART)

MART is a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required. MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol). Therefore, the young person only has one inhaler to allow for maintenance and relief.

This is licenced for children and young people aged 12 years and over.

MART should be considered for those:

• Who have a confirmed diagnosis or a highly suspected asthma diagnosis
• Who regularly forget their preventer inhaler
• Who overuse or are reliant on salbutamol
• Who can recognise symptoms and act on them
• Who are not achieving control using their current preventer

It may not be suitable for those:

• Who do not recognise symptoms
• Who do not have capacity to use it when needed and would require someone else to make the decision that they are symptomatic
• Who have a barrier to understanding the plan such as language or disability
• Who do not have a confirmed or highly suspected diagnosis of asthma.

GINA strategy for asthma management and prevention - this guideline recommends the use of MART (ICS plus formoterol combination inhaler) as a potential first step for the over 12 year olds and adults.

For more information see Asthma + Lung UK maintenance and Reliever Therapy (MART).

The dangers of overusing SABAs

It is now more widely known and understood that the overuse of short acting beta 2 agonists (SABAs) (relievers) is linked to poor clinical outcomes such as an increased risk of asthma attacks and deaths. SABA's do not treat the underlying inflammation in the small airways caused by asthma. The airway inflammation is kept at bay by regular use of an inhaled corticosteroid (ICS) (preventer) and for an asthma attack a short course of oral steroids are required.

• Why asthma still kills - Royal College of Physicians (RCP) London
• Prevalence of overuse of short-acting beta-2 agonists (SABA) and associated factors among patients with asthma in Germany - Respiratory Research
• "Tossing a coin:" defining the excessive use of short-acting beta2-agonists in asthma - the views of general practitioners and asthma experts in primary and secondary care - npj Primary Care Respiratory Medicine

The following document (page 26) National bundle of care for children and young people with asthma recommends that all patients prescribed with 3 or more SABAs in the previous 12 months should be invited for urgent review of their asthma control. Good practice includes a review of SABA's prescribed in the last year at each annual asthma review.

Based on the evidence of which a sample is in the links above the London Asthma Leadership and Implementation Group for CYP Asthma (LALIG) published a document regarding the use of salbutamol weaning plans post hospital discharge. Hospitals in Surrey are working hard to follow the recommendation to not use standardised prescriptive salbutamol weaning plans as part of a post asthma attack.

For more information on the process used for removing the salbutamol weaning plans from the discharge process please email syheartlandsicb.childrensasthma@nhs.net to contact one of the nurses in the children and young people's asthma team.

Inhaler devices and technique for children and young people

All younger children require a pressurised metered dose inhaler (pMDI) plus a suitable spacer for both their prevented and reliever inhalers. Very young children (< 4 years old) need a spacer with a mask. A child should use a mouthpiece type spacer without a mask as soon as they are able to effectively use a mouthpiece (usually from age 4). Older primary school age children may be able to use a dry powder inhaler. Inhaler technique should always be taught and checked when any change is made.

Practical Points - children that attend a childminder, nursery, school or often visit relatives outside of the home may require more than one set of inhalers and spacers. Advise the family that the child should rinse their mouth out after using an ICS (inhaled corticosteroid/ preventer inhaler). If used with a spacer and mask remind the family to also wash the child's face after using the ICS. To help improve adherence encourage the ICS to be taken just before brushing their teeth in the morning and again at night as the two things can then be remembered together. Children and young people of all ages must be supervised when taking their preventer inhaler to ensure that it is taken as prescribed.

Encourage families to dispose of their old, used inhalers by returning them to a community pharmacy for incineration.

Home Nebulisers - Use of a nebuliser purchased independently of medical advice for use in the home to deliver nebulised asthma rescue medications to children can mask a deterioration in the underlying disease and may increase the risk of potentially fatal delays in seeking medical attention if asthma deteriorates. If home use of a nebuliser for the acute treatment of asthma in children under 18 years of age is considered necessary, this should be initiated and managed by an appropriate specialist.

Further information is available on GOV.UK: Nebulised asthma rescue therapy in children: home use of nebulisers in paediatric asthma should be initiated and managed only by specialists

Some inhaled medication made in the form of a dry powder inhaler (DPI) are available for children to use from the age of 6 years depending on the child's ability to learn the technique. Often, from secondary school age some young people may prefer a DPI (dry powder inhaler ) especially as they do not require a spacer. Select an inhaler device with the young person based on their preference and their ability to use the device. Always ensure that inhaler technique has been checked and is correct, and that the young person likes the device before making a change. Young people often have an interest in the environmental impact of the different types of inhalers and knowing that DPI's are better for the environment than pMDIs could help them decide which inhaler suits them.

Tools and resources - Asthma: diagnosis, monitoring and chronic asthma management go to decision aids and click the link Asthma Inhalers and climate change (patient decision aid) link for more information.

Here are some dry powder inhaler devices that may appeal to young people:

Asthma reviews

Children and young people with asthma, aged 6 years and over, who have had prescribed asthma treatment in the last year should receive a routine annual asthma review. If the child or young person has had an asthma attack requiring a visit to the Emergency Department or an inpatient stay they should receive a review in primary care 48 hours from discharge. This must be completed by a clinician with training in the care of children and young people with asthma.

Components of an asthma review, including useful suggestions:

Assess current symptom control

Check use of short acting bronchodilator (SABA/reliever) – ask the child if age appropriate about their inhalers, they usually know them best by the colour of the device. Ask the child when and why they take their reliever, usually a blue device. Ask the parent/carer if they agree with the child's answer and agree a conclusion. Check to see how many reliever inhalers have been prescribed in the last year and see if that number matches with the use of the inhaler.

If the child is using two or more cannisters of their reliever in a year it could be that their asthma is not well controlled. Take into consideration that children should have a separate inhaler and spacer (if using a pressurised metered dose inhaler pMDI) for school and may also have another set with relatives or a childminder etc. Also, briefly ask about inhaler technique; it may be that many prescriptions have been ordered and dispensed due to poor inhaler technique and therefore not receiving the medication properly. You can do a thorough review of inhaler technique or come back to it later in the consultation. Run a check via your computer system of the number of salbutamol inhalers prescribed in the last year and how many preventer inhalers were prescribed. The current recommendation is that there should be no more than 3 SABA's per year prescribed. Read more about the overuse of SABAs.

Use a validated symptom score – visit the Chronic management webpage Beat Asthma website and then scroll to the section Asthma Annual Review and then you the links underneath for the Asthma Control Tests for children aged 4-11 years or the Asthma Control Test for young people 12 years and older.

Time off school due to asthma – ask whether time at school has been missed due to asthma symptoms. This may also be a good time to ask the child whether they feel the school they attend supports them when they have symptoms and need an inhaler. A discussion could also take place as to whether there is a process in place at the school to replace inhalers when they are empty or expired and spacer care. When children are switching from primary to secondary school is also a very good time to discuss arrangements for asthma care in the new school and find out whether the child or family have concerns.

Assess future risk of attacks

Past history of asthma attacks - ask the child if they can remember seeing the doctor or nurse either at the surgery or the hospital because they had symptoms of asthma and were using their reliever inhaler more frequently. Adapt your language to the age of the child. For example, talk about symptoms using words and phrases such as 'wheezy or whistly breathing', coughing a lot and ask whether it was in the daytime or night time and whether it woke them up, a 'funny tight feeling in their chest/tummy' as some young children describe a tight chest as being in their tummy. Ask the child whether they had to sleepover at the hospital. Following this conversation with the child ask the parent/carer of they agree and whether they have anything to add.

There is a greatly increased risk of asthma attacks for those with a previous history of asthma attacks and those with persistent asthma symptoms. Children and Young people who have needed a Paediatric Intensive Care Unit stay should be followed up in secondary or tertiary care.

Check how many courses of oral corticosteroids have been required in the last year. Two or more short courses indicate poor control, and the child may need referral to secondary care.

Exposure to tobacco smoke - If the young person is of secondary school age ask them if they had tried cigarette smoking or vaping and what their experience was. They may not want to say if they had tried cigarette smoking in front of a parent/carer. However, as they get older, it can be useful to ask the young person and family whether the young person could spend a few minutes in the consultation without a parent/carer to practice for when they transition to adult services. You can ask the child who else lives at home with them and they usually enjoy telling you this especially if you ask about pets too. You can then ask if anybody smokes indoors or outdoors. If there is a parent/carer or relative who smokes indoors or outside the house, it's a good time to ask whether they have considered stopping and highlight the support services in the area.

Useful links:

• Stop smoking support
• Health professionals
• National Centre for Smoking Cessation and Training (NCSCT)

Management

Inhaler technique: It's a good idea to have a range of the common inhaler placebos and spacers available or some photos of them. Ask the child what their inhaler looks like and whether they have a spacer, and which one is it. For younger children it can be helpful to have a doll and ask them to give the doll some puffs of the inhaler through a spacer and then see if they can show you how they do it. If they usually take their inhaler and spacer with a parent/carer they can show you on the doll together. You can then make any adjustments to the inhaler technique if needed.

Common issues are:

1. Having a spacer available but not using it, therefore puffing a metered dose inhaler directly into the mouth.
2. Having a spacer with a mask when the child is of an age to use a mouthpiece. This is possible in some children from the age of 3 years but usually around 5-6 years.
3. Not being supervised when taking their twice daily preventer. A parent/carer should witness the inhaler doses being taken. This also includes young people in their teens. This then ensures that both the child or young person and parent/carer are responsible for remembering to take it.

Many children of primary school age will not be able to inspire adequately to use a dry powder device. Always ensure that children or young people who would like to try this type of device have their inhaler technique checked with it before prescribing.

Adherence

It is estimated that between a third and a half of all medicines prescribed for long-term conditions are not taken as recommended. Evidence in people with asthma confirms that there is widespread non-adherence to regular preventer medication that increases over time. Poor adherence should always be considered when there is a failure to control asthma symptoms. Read more about monitoring adherence in children with asthma.

It can be difficult for busy families to remember to support their child or young person use their inhaler in the mornings, especially during term-time, and in the evening when it's very busy due to mealtimes, bath times and other activities.

Top tips:

Advice should be given that the child or young person should rinse their mouth out with water after using a preventer (steroid) inhaler to reduce the risk of the side effect of oral candidiasis (thrush). If they are using a spacer with a mask, the face should also be washed after using a preventer inhaler. Ask the child whether they brush their teeth in the morning and evening. If they say yes, suggest they put a sticker on the toothpaste to remind them to use their inhaler first. If they say no, remind of how important it is to brush their teeth twice daily, and suggest popping a reminder sticker on the toothpaste.

For younger children who are reluctant to use their inhaler in the morning or the evening, a sticker chart can be helpful, potentially with a reward at the end of a certain period if all doses were taken.

Visit the Asthma + Lung UK webpage how to get the best from your child's asthma review - Asthma + Lung UK for more information.

Tests / investigations

Measuring height and weight and plotting on a centile chart can be helpful to assure families the child is growing especially if there are concerns around the use of inhaled steroids. If there is a dip in the child's height or weight it can facilitate any further investigations that may be required.

If there is any diagnostic uncertainty spirometry and/or FeNO can be considered if available. Alternatively, a request could be made for the child and family to keep a peak flow diary for a period of time to assess diurnal variability.

Visit the objective testing for more information.

Trigger avoidance

Please visit the following sections:

• Triggers and prevention
• Training

Weight reduction in obese children

There is consistent evidence that being overweight or obese increases the risk of a subsequent physician diagnosis by up to 50% in children and adults of both sexes.

See children's healthy weight for more information.

Supported self-management

Education aimed at the child or young person about what is asthma, triggers, symptoms, what each inhaler is for and what to do if having an asthma attack is crucial. A personalised asthma action plan should be given toward the end of the review and going through the plan with the family is the ideal time to deliver some education. Models or drawings of the airways are helpful too to provide the visual picture. See the section on pharmacological treatment for if any changes to treatment are required.

Here is a short video showing an example of explaining asthma to a young person:

Useful links:

• Your child's asthma action plan - Asthma + Lung UK
• Chronic management - Beat Asthma
• Secondary healthcare professionals - Beat Asthma

Management of an asthma attack at a GP practice

Some surgeries have local guidance on what to do if a child or young person presents with an acute asthma attack.

For a flow chart on managing an asthma attack in a child at a GP surgery setting please visit the British guideline on the management of asthma on the British Thoracic Society website for the full guideline and go to page 167.

Before receiving appropriate treatment for an acute asthma attack in any setting, it is essential to accurately assess the severity of their symptoms. The following clinical signs should be recorded:

Pulse rate – tachycardia generally denotes worsening asthma, however, do check and see whether the child has already had puffs of salbutamol, how many and when, as this can increase the heart rate. A fall in heart rate in life threatening asthma is a preterminal event.

Respiratory rate and degree of breathlessness – is the child too breathless to complete sentences or to feed.

Use of accessory muscles of respiration – ask the child or parent/carer to pull up the child's top and expose the chest and belly, look at the work of breathing for hard and fast sucking in.

Look for a tracheal tug, head bobbing, grunting and/or nasal flaring. Note any colour changes to the skin.

Check for wheezing which may be audible with or without auscultation.

Check for degree of agitation and level of consciousness. Some children with acute severe asthma do not appear distressed and may be quieter than is usual for them.

Check oxygen saturations if the correct size probe is available. Using an adult, finger-clip type probe on a baby or a small child will give an inaccurate reading.

Ask for a peak flow reading if age appropriate and if the child is not too breathless to do one.

Following assessment record and treat as to whether the asthma attack is moderate, severe or life threatening as per flowchart.

As well as treating with bronchodilators as per flowchart it is also wise to give the appropriate dose of oral steroid if there is a supply available.

If there is a good response to treatment, the child appears clinically better and the child has not required any further bronchodilation within at least four hours, ensure a total of 3-5 days of oral corticosteroids are prescribed and send home with a clear personal asthma action plan. If the child is already on an inhaled corticosteroid their inhaler technique should be checked and they should continue with this whilst taking oral corticosteroids. Arrange follow-up in 48 hours and give clear advice on what to do if symptoms worsen again. However, consider admission if the attack is late afternoon or early evening, if the child has had a recent hospital admission with an asthma attack or if there is any concern over social circumstances and the ability to cope at home.

If there is a poor response to treatment stay with the patient until an ambulance arrives and send some written notes with the patient. If there is a delay with the ambulance treat with oxygen driven nebulised bronchodilators (if available), nebulised bronchodilators with a compressor type machine or using an inhaler give doses of 10 puffs via a spacer, one puff at a time for a count of 5-10 breaths depending on the ability of the child to breathe the medicine in.