1. CHILDHOOD ASTHMA IN PRIMARY CARE Dr Naushin Hossain GPST1

2. Overview Cases Factors that put patients at risk of Life Threatening Asthma

3. Case One- Daniel 6 yr old boy 3/7 hx of coryzal symptoms Nocturnal cough Mum using 4 puffs of salbutamol tds Wanted NEBS

4. PMH – Wheezy episodes during winter. Treated as asthma Eczema DH- Salbutamol INH 2puffs prn

5. O/E Patient was alert and well Speaking in sentences No signs of respiratory distress T 36.9, P 94, Sat02 92 Lung fields- Good air entry bilaterally Occasional wheeze ENT exam NAD

6. Differentials

7. Exacerbation of asthma Possible triggers- URTI, cold air, exercise Exposure to allergens- pets, pollen (hx of atopy) Inhaler technique ( are they using mask and spacer?)

8. What would you do?

9. Management Treat the acute exacerbation Long term management

10. Management- Acute Reassure Not wheezy, so NEBS not indicated atm Taught how to use 10 puffs if deteriorated Started on oral steroids as was having to use reliever so often

11. Longer Term Plan Mostly exacerbations were during winter Exacerbations treated with oral prednisolone So, asked to step up treatment during winter only salbutamol prn+clenil two puffs bd Emphasised the role of clenil as preventer

12. Follow up Telephone consultation 2/7 later Was fine

13. Case Two- Sam 4y old SOB since mane Breathing fast and unable to complete sentences

14. PMH- episodes of wheeze Saw OOH and had NEBS at least 5X over the last 6 months DH- prn salbutamol, clenil 2 puffs bd

15. O/E T 37, P 181, RR 54, SatO2 95 Trachael tug subcostal recession Widespread wheeze

16. Diganosis?

17. Cause of Exacerbation Was on clenil Parents did not think he needed to use it, so not given

18. Management How would you treat him?

19. Acute Treatment NEBS- Salbutamol and IpBr Oral steroids After NEBS- Sat 95, using accessory muscles of respiration, tachycardic, no cyanosis Deemed safe to go home with safety netting OOH or AE if unwell over the weekend

20. Long Term Added inhaled steroids- two puffs bd Asthma r/v the following week.

21. Asthma may not be the parents main concern!

22. Case 3- Jane Six year old girl Brought in by mother with 2/52 hx of flu like symptoms Now 3/7hx of fever, given calpol Cough productive of yellow phlegm Vomiting Had a takeaway last night

23. o/e Well patient, alert Speaking in complete sentences Not in respiratory distress Wheeze bilaterally ++ ronchi in left lower lobe T 38.0, RR 24, Sat 02 94, HR 95

24. What do you think is happening?

25. Viral illness with secondary bacterial infection ??Wheeze

26. Further questioning Known asthmatic Coughs +++ in cold weather and after sports Having to use her reliever inhaler five times a day Not using spacer Prescribed 200mcg of clenil bd, 5mg montelukast od From records- Had an acute attack 2/12 Treated with a course of oral steroids and commenced on montelukast

27. Compliance Took montelukast only when asthma was bad Not had asthma r/v in a year

28. Management How would you manage her?

29. Managment Acute episode treated with antibiotics Use of spacer Extra spacer and inhaler prescribed for school Prophylactic use of 2 puffs of salbutamol before sports Parent education regarding use of montelukast and regular asthma r/v

30. Case 5- Tom 7year old asthmatic BIB father 7/7 hx of cough and diarrhoea Using his reliever inhalers 8x daily Ran out of blue inhaler Mother was giving him his brother's inhaler Not on any preventer medication

31. O/E Systemically well P 98, T 37.5, RR 30, SatO2 92 Bilateral wheeze but no focal signs ENT NAD

32. Management Acute episode managed, needed oral steroids Taught how to use 10 puffs Beclometasone 200mcg bd added 48 Hr r/v

35. In both Cases 3 and 4 Asthma was not was the parents' main concern Asthma control was poor Needed to be dealt with urgently Children continue to die from asthma in the UK Parents underestimate their severity

36. FACTORS WHICH INCREASE THE RISK OF LIFE THREATENING ASTHMA

37. Review of Asthma Deaths Royal College of Physicians 195 asthma- related deaths from 1 February 2012 to 31 January 2013 investigated Factors that put patients at high risk of developing life threatening asthma:

38. Patients at high risk of developing life threatening asthma Having to use short acting reliever inhaler more than once every four hour eg salbutamol Given a repeat prescription of short acting beta- agonist inhaler more then once every month over the last year (check inh issued over 3/12) Issued fewer than twelve prescription of preventer medication over the past year (either alone or a combination inhaler) Suffered from concurrent mental health problems

39. Recommendations 1. Arrange follow-up review within 2/7 working days of any patients who has needed A&E or OOH treatment for an acute asthma 2. Consider referral for any patient: i) Who needed two courses of systemic steroids in the past year. ii) Who has had two or more attendances at the emergency department for their asthma in the past year iii) Who are in Step 4 or 5 of the BTS or SIGN guidelines treatment ladder iv) Who have childhood asthma with concurrent food allergy

40. Asthma reviews should only be conducted by health professionals who have specialist training in asthma Every patient diagnosed with asthma should have a personal asthma plan although the level of detail can be tailored to the individual

41. Putting it to Practice Keep a list of all the acute asthmatics seen in clinic Aim to follow them up in two days' time They never attend 48 h asthma r/v, so GP has to keep chasing them Could book telephone consultation for yourself

42. What I try to do Be more alert when I am asked to prescribe inhalers- Patients should not be requesting more than one reliever a month or less one preventer Check compliance.

43. Consider before Referring May not need to be referred straightaway May need counselling first Inhaler technique is poor, or they are not taking preventer inhalers regularly, or clear trigger, eg Have parents who are smoking

44. Key Points Asthma is common, affects>10 % of school children BTS Guidelines Good management often has more to do with inhaler technique and patient education than which inhaler to prescribe Watch out for factors that increase the risk of life threatening asthma

45. Questions?