Paediatric Asthma 2: Improving the
Management of Children with asthma - Dr
Jonathan Cohen
Speaker Key
JC
IV
Jonathan Cohen
Interviewer
JC
My name is Jonathan Cohen. I’m a consultant paediatrician at University
College London Hospitals. My talk today was about how to improve outcomes for
children with asthma by focusing on their annual review and their written asthma
management plan.
IV
What does good asthma control look like?
JC
I think, far too many children, young people and families don’t realise that
living with asthma, as a chronic illness doesn’t mean living with chronic ill health. It
doesn’t mean having symptoms and it’s possible, if the asthma’s well controlled, to
have excellent school attendance, fantastic exercise tolerance, to sleep well at night, to
live life to the fullest and not need to keep reaching for reliever medication or rushing
to the emergency department because things aren’t going well. That’s what good
asthma control can look like.
IV
How do you achieve good asthma control?
JC
I think, the two key elements in how to achieve good asthma control are
having a meaningful structured review, ideally, at least on an annual basis, of the
patient and their asthma and using that to inform a written management plan that the
patient and family understand themselves and can use, to help them self-manage their
condition until they’re next reviewed.
IV
What should take place during an asthma review?
JC
I think, there are several things to cover during an asthma review and ideally,
they’d be done differently for younger children and young people. What I mean by
that is, over the age of 12, I think, there should be some discussion between the health
professional and the young person without their parents’ presence. It’s really
important to use this as an opportunity to empower them towards caring for
themselves. It provides opportunities to ask them about smoking without a parent
present, to really understand, if they’re not, why they’re not taking their medication as
they’re supposed to. It helps them take responsibility for the future and, I think, that’s
one key thing that I would have in my mind when planning any annual review.
So the first part of an annual review, like any consultation, involves discussion; it
involves information sharing. The second part of the consultation for the asthma
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review is focused on decision making. And, I think, there are five points to think
about in the discussion stage and five points in the decision stage. I’ll just allude to
these as headlines. Much more information about this is available through Asthma
UK and within the BTS Guidelines.
The first key thing, in terms of discussion with a family is about asthma control and
it’s really important to ask very specific tight questions around a tight time period,
such as how much has asthma impacted on school attendance, home life and work life
in the last four weeks? How much reliever medication has been needed in the last four
weeks? How much has it affected sleep in the last four weeks? Overall, how do you
rate your asthma control in the last four weeks? You’ll get much more meaningful
answers with tight questions like that than you will with vaguer questions. Also, just
have a quick reassessment of what’s gone on over the past year and further before
that: Have they been in hospital? Have they had several courses of oral steroids? All
of that will help you assess their control.
Don’t forget also to think about the overall impact on their life. Families know what
their school attendance rate is; it goes on the school report every term. If it’s less than
95%, could it be down to their asthma? Is this a sign of something worrying? Is their
asthma affecting their growth? Is it impacting on other aspects of their life? So they’re
the first two things: control and impact. Then think about the environment, in which
the child’s living: what exposures are they having that could affecting this? Is there
cigarette smoke going on? Do parents smoke? Siblings, other family members, peers
at school? If they’re 11 or 12 upwards, you have to ask the patients themselves, if they
smoke and, as I’ve mentioned, best to do it without the parent there if you want to get
an honest answer about it. And then if the time’s right, signpost them towards
smoking cessation advice.
Think about the allergens they’re exposed to as well and what can be done to reduce
those. It may be their main problem is actually all in the upper airway and they’ve got
allergic rhinitis. It may be they’ve got allergic rhinitis as well as asthma. It may be
there are things that can be done to the environment to help improve their symptoms.
Someone with asthma may have other health issues as well: comorbidities, and this is
the fourth thing to think about during the review. Do they have obesity? If you’re
obese it makes your asthma worse and you can’t exercise as well, which impacts on
your asthma. You have to deal with both together if you’re going to get either of them
to improve.
And the last, and possibly most important, part of the asthma review, is to think about
the medication the patient’s taking or not taking. Ask them; ask their family. Does
that reconcile with the prescribing record? Are they overusing inhalers to relieve
symptoms? Are they underusing their preventers? All of these will give you clues and
help you understand what’s going on. Most of the time, improving asthma is really
simple but the only way to do that is by understanding really what’s going on and
what the blocks and the beliefs and the issues are with that particular family. With all
of that information then the decision making can be a lot easier.
IV
What are the key decisions to make during an asthma review?
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JC
I think, the most important first decision to make is, is this asthma? It’s an
opportunity to reflect: maybe we’ve got the diagnosis wrong. But assuming that is the
diagnosis, the next step is, what else is there beyond asthma that needs decision
making? Do I need to deal with their obesity? What’s my plan for helping the child or
family with that? What’s my plan for helping their allergic rhinitis? Do they have
food allergy as well as asthma and need to carry an EpiPen to treat anaphylaxis? With
all of that out the way, it’s then possible to focus more specifically on the decisions
around the asthma management. If their control isn’t good, they need to step up their
preventer therapy according to the British Thoracic Society guidelines. For many
patients, this might mean going from reliever therapy only onto a regular inhaled
steroid.
For those already on a regular inhaled steroid, the next step up for them would be the
addition of a long-acting beta agonist as part of a combination inhaler if they’re aged
five and above or for younger children, adding in the oral drug, montelukast. For
those children already on these therapies where control is poor, then you would like
to, ideally, avoid putting them on higher-dose steroids and that’s why this is probably
the right time to refer to a hospital asthma clinic, secondary care, where a whole MDT
approach can be taken. And it may well be that some of the issues you’ve started to
identify in the earlier part of the discussion can be addressed in more detail but if
necessary, more potent therapies can be introduced if required.
The last step, I think, of the decision making in the annual asthma review is making a
written asthma plan and if, what I’ve alluded to earlier, in terms of discussion and
decision making has taken place, then putting this into a written plan is very, very
easy. Asthma UK have downloadable guides that you can use for this for adults and
older teenagers and for younger children. And these act as a guide for families to help
them recognise what their triggers are, how to manage their asthma on a daily basis
and what to do if things are getting worse or if they have an asthma attack. The key
thing is that families are educated, they understand the disease and they’re
empowered and aware of what to do if things are getting worse and they don’t just
wait for the disaster of a severe attack that puts them in hospital. Asthma attacks are
preventable. Asthma deaths are preventable and you can play a part in achieving that
with a structured review and providing families with a written plan.
IV
Who should be referred to secondary care?
JC
I think, there are three groups of children and young people who should be
referred to secondary care. The first of those are patients who’ve had two attacks or
significant exacerbations of their asthma in the past year, because that’s a warning
sign. It’s a herald they’re at risk of having them in the future and that their current
management plan isn’t sufficient to prevent them happening. That could be two
hospital attendances to the emergency department or even two courses of oral
steroids.
A second group of children, who, I think, warrant referral, are those where they’re not
stable on step three of the British Thoracic Society guidelines. They may not have had
any specific attacks or exacerbations but they’ve got grumbling frequent or daily
symptoms, despite a good level of care and everything that’s achievable, from a
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preventative sense, in primary care. And they can benefit from the multidisciplinary
approach that can be offered in a hospital setting.
The final group of patients who would benefit from hospital referral are where
diagnosis is uncertain or there are difficult comorbidities going on, particularly, I
think, of younger children under the age of five, where it can be difficult to
differentiate, is this asthma/is this multi-trigger wheeze? What’s the best way to try
and prevent it? Or can we prevent it? And in secondary care, we’re always happy to
see children with these problems. In Camden there are clinics for children and young
people with asthma and wheezing difficulties, both at UCL hospitals and also at the
Royal Free Hospital. Paediatricians at both of these hospitals are also very happy to
take direct questions or be contacted for any queries that you have.
IV
Is there a Camden management pathway for primary care?
JC
A lot of exciting work’s been taking place over the past year towards
improving the integration of care for children and young people with a range of
conditions, but particularly with asthma for Camden. And there are a lot of new
initiatives taking place. If you’re not already part of the primary care asthma pilots, I
would strongly draw your attention to those and more information is available on the
Camden CCG website. There’s going to be further movement towards more
integrated care pathways for Camden, which you’ll hear about in due course.
IV
Where can GPs find out more?
JC
There’s a wealth of information and resources available on the Asthma UK
website. There’s information on it that’s accessible for children, for young people, for
parents, and for health professionals as well; and I’d strongly recommend you and
family spend time looking at that, though if you do have any queries or questions, I’m
very happy to be contacted. My email address is jonathan.cohen@uclh.nhs.uk. Please
feel free to discuss any patients or any other queries that you’ve got.
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