Paediatric Wheeze & Asthma

Paediatric Wheeze & Asthma Dr Naveen Rao 01/05/2013

Objectives • Approach to childhood wheeze • Diagnosing Asthma • Awareness of treatment guidelines • Patient centered approach • Emergency management

The wheezy child…. • 30% infants by 3rd birthday and 60% by 6th Birthday. • 60-70% who wheeze before 3rd birthday will be asymptomatic by 6-8 years of age. • May prompt parents to seek help and advice from multiple professionals. • Parental expectation may precipitate an early diagnosis of asthma • 50% children diagnosed with asthma will be asymptomatic adults!

The size o the problem • At least 6 million people in UK have Asthma. • 1 in 11 children are receiving treatment for Asthma. • Every 16 minutes a child is admitted in England, Wales or Scotland because of Asthma. • 33% of children with asthma (or their parents) say that asthma can result in being left out of sports activities at school. • An estimated 75% of Asthma admissions are avoidable. • More than 16 deaths in last year. • 90% of deaths from Asthma are preventable.

Asthma – The facts… • At least 6 million people in UK have Asthma. • 1 in 11 children are receiving treatment for Asthma. • Every 16 minutes a child is admitted in England, Wales or Scotland because of Asthma. • 33% of children with asthma (or their parents) say that asthma can result in being left out of sports activities at school. • An estimated 75% of Asthma admissions are avoidable. • More than 16 deaths in last year. • 90% of deaths from Asthma are preventable.

NRAD data notifications by age & sex (n=416)(February – July 2012) BTS Winter Meeting 2012

Relevance • The north west accounts for 20% of UK asthma emergency admissions (1.6 times national average). • Children in North west 75% more likely to have and emergency asthma admission that children in London. • Higher than average hospital admission stay. • Potential for significant cost savings.

Avoiding Hospital Admissions and Emergency Admissions • Patients with good control are 5X less likely to present with an Asthma exacerbation. • Most Asthma exacerbation requiring admission build up slowly over 6 hours or more.

Avoiding Hospital Admissions and Emergency Admissions • Patients with good control are 5X less likely to present with an Asthma exacerbation. - So Diagnosis and control is key • Most Asthma exacerbation requiring admission build up slowly over 6 hours or more. - Self management could avoid hospitalisation

BTS/SIGN Asthma guidance - accepted treatment framework Diagnosis Treatment Prevention

Diagnosis of Asthma • A clinical one. • Focus initial assessment of suspected asthma on: • presence of key features in history and examination • careful consideration of alternative diagnoses. Bristish guidelines on management of asthma BTS/SIGN 2008

Clinical features that increase the probability of asthma • More than one of the following symptoms: wheeze, cough, difficulty breathing, chesttightness, particularly if these symptoms: - are worse at night and in the early morning. - occur in response to, or are worse after,exerciseor other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter • occur apart from colds • Personal history of atopic disorder. • Family history of atopic disorder and/or asthma. • Widespread wheeze heard on auscultation • History of improvement in symptoms or lung function in response to adequate therapy BTS/SIGN 101 British guidelines on management of asthma

Clinical features that lower the probability of asthma • Symptoms with colds only, with no interval symptoms. • Isolated cough in the absence of wheeze or difficulty breathing. • History of moist cough. • Prominent dizziness, light-headedness, peripheral tingling. • Repeatedly normal physical examination of chest when symptomatic. • Normal peak expiratory flow (PEF) or spirometry when symptomatic. • No response to a trial of asthma therapy. • Clinical features pointing to alternative diagnosis. British guidelines for management of Asthma BTS/SIGN 2008

Assessing the probability of a diagnosis of asthma • High probability – diagnosis of asthma likely • Low probability – diagnosis other than asthma likely • Intermediate probability – diagnosis uncertain British guidelines for management of Asthma BTS/SIGN 2008

Assessing the probability of a diagnosis of asthma • High probability – diagnosis of asthma likely • Low probability – diagnosis other than asthma likely • Intermediate probability – diagnosis uncertain Refer for specialist assessment

Intermediate probability of Asthma- Suggested approach • Watchful waiting with review. • Trial of treatment with review. • If treatment beneficial treat as asthma. • Stop treatment if no benefit. • Spirometry with reversibility testing. British guidelines for management of Asthma BTS/SIGN 2008

Wheezing Phenotypes Tuscon cohort

RSV Bronchiolitis • a seasonal viral illness characterised by fever, nasal discharge and dry, wheezy cough. • Characterised by fine inspiratory crackles and/or high pitched expiratory wheeze. • mainly affects infants under two years of age. • Following acute bronchiolitis, cilial damage persists for 13-17 weeks. • 39% symptomatic after 14days, 18% after 21 days and 9% after 28 days!

Transient early wheeze • Lower lung function than normal at birth, continues into adulthood. • No personal or family history of atopy. • Associated with maternal smoking in pregnancy. • Associated with daycare attendance or other siblings at home. • Resolves by 3 to 6 years of age. • May not respond to treatment.

Non Atopic Wheeze • Usually virus induced. • No history of atopy. • Will outgrow. • Respond to bronchodilators. • Benefit of ICS equivocal.

Indications for specialist referral in children • Diagnosis unclear or in doubt, Symptoms present from birth or perinatal lung problem • Excessive vomiting or posseting • Severe upper respiratory tract infection • Persistent wet or productive cough • Family history of unusual chest disease • Failure to thrive • Nasal polyps, inspiratory stridor • Unexpected clinical findings e.g. focal signs, abnormal voice or cry, dysphagia, • Failure to respond to conventional treatment (particularly inhaled corticosteroids above 400 mcg/day or frequent use of steroid tablets) • Parental anxiety or need for reassurance British guidelines for management of Asthma BTS/SIGN 2008

Asthma likely • Record basis on which diagnosis suspected. • Move straight to a trial of treatment. • Reserve further testing for those with a poor response. British guidelines for management of Asthma BTS/SIGN 2008

The Goal Of Asthma Management Achieving current control • Symptoms • Reliever use • Activity • Lung Function Reducing future risk • Instability/ Worsening • Exacerbations • Loss of Lung function • Medication adverse effects.

At any stage, step down therapy once asthma is controlled

Stepwise management of asthma in children <5 yrs BTS/SIGN British Guideline on the Management of Asthma, May 2008

Stepwise management of asthma in children < 5yrsBTS/SIGN British Guideline on the Management of Asthma, May 2008

Stepwise management of asthma in children <5yrsBTS/SIGN British Guideline on the Management of Asthma, May 2008

Stepwise management of asthma in children 5-12BTS/SIGN British Guideline on the Management of Asthma, May 2008

Asthma medications • Relievers • Preventers • Additional therapies

Steroids – Key pointsShould be given twice daily

Key practice points • Inhaled steroids are the recommended preventer drug. • In children >5 years, add inhaled long acting ß2 agonists rather than increasing the dose of inhaled steroids above 400mcg/day • pMDI + spacer is preferred delivery method in children aged0-5 years, and as effective as other delivery methods for other age groups • Multiple puffs(up to 10) of a short-acting ß2 agonist via a spacer device is as effective as nebulised • Children(and adults) with mild and moderate exacerbation of asthma should be treated by bronchodilator given from a pMDI + spacer with doses titrated according to clinical response • Choice of inhaler should be based on patient preference and ability to use

Key practice points • Dose equivalence of corticosteroids • CFC free corticosteroid inhalers • Accurate medication history • Do not initiate inhaled steroid treatment in preference to oral steroids in acute asthma exacerbation. • Doubling dose of inhaled steroids during an acute exacerbation is of unproven value.

Monitoring in Primary Care • Symptom score • Exacerbations, oral corticosteroid use, time off school/nursery. • Inhaler technique • Adherence • Possession of and use of self management plans • Exposure to tobacco smoke. • Growth. British guidelines for management of Asthma BTS/SIGN 2008

James • Has returned for a review aged 6 years. Not been very well last few weeks, needing reliever 2-3 times a day. Also up most nights with cough. Unable to participate in PE at school. Has had 3 courses of steroids in last 6 months. • You note he is quite breathless and wheezy. Looks pale and has increased work of breathing. Struggling to speak in sentences. Has been like this for 2 days but Mum thought she would wait as she was seeing you soon anyway! • On examination his RR 32/min, Sats 92%in air, and wheezy all over the chest.

Key issues? • Management of acute exacerbation. • Ensuring long term control. • Education regarding early recognition of exacerbation.

Management of acute asthma inchildren aged >2 years in general practice

Steroid therapy for acuteasthma in children aged >2 years

Education regarding recognition

Assessing control- Practice points • Current control is best predictor of future exacerbation. • Ask closed questions. • Provide written management plans • Monitor growth annually.

What are the reasons for poor control? • Poor compliance. • Poor inhaler technique. • Inadequate or incorrect therapy. • Rhinitis. • Smoking. • Other phenotypes. • Incorrect diagnosis.

Addressing poor compliance • Simple regimes • Oral therapy • Simplified treatment • Written Self Management plans • SMART therapy • Education - Specific beliefs vs necessity vs concerns

Paediatric Wheeze & Asthma