Asthma (chronic)

Diagnosis of asthma in children is clinical and based on the BTS/Sign guidelines 2019 which states that factors involved in a clinical assessment include:

Episodic symptoms

• More than one of the symptoms of wheeze, breathlessness, chest tightness and cough occurring in episodes with periods of no (or minimal) symptoms between episodes. Note that this excludes cough as an isolated symptom in children.
• For example:
• a documented history of acute attacks of wheeze, triggered by viral infection or allergen exposure with symptomatic and objective improvement with time and/or treatment
• recurrent intermittent episodes of symptoms triggered by allergen exposure as well as viral infections and exacerbated by exercise and cold air, and emotion or laughter in children.
• An historical record of significantly lower FEV₁ or PEF during symptomatic episodes compared with asymptomatic periods provides objective confirmation of the obstructive nature of the episodic symptoms.

Wheeze confirmed by a healthcare professional on auscultation

• It is important to distinguish wheezing from other respiratory noises, such as stridor or ‘rattly’ breathing.
• Repeatedly normal examination of chest when symptomatic reduces the probability of asthma.

Evidence of diurnal variability

• Symptoms which are worse at night or in the early morning.

Atopic history

• Personal history of an atopic disorder (ie eczema or allergic rhinitis) or a family history of asthma and/or atopic disorders, potentially corroborated by a previous record of raised allergen-specific IgE levels, positive skin-prick tests to aeroallergens or blood eosinophilia.

Absence of symptoms, signs or clinical history to suggest alternative diagnoses

Children with a high probability of asthma based on clinical assessment, should be commenced on a 6 week course of standard asthma treatment, which is usually an inhaled corticosteroid with salbutamol as a reliever.  There should be a review in place at 6-8 weeks which should assess response, using PEFR as an objective measure if the child is able and old enough.  If there is little, or no response, consider:

• The possibility of alternative diagnoses
• Medication technique and compliance
• Psychosocial factors
• Whether they need a paediatric opinion (see under ‘Referral Information’)

If there is a good response to initial treatment, please titrate inhaled corticosteroids to the lowest dose which controls symptoms, and ensure that good education has taken place.  This should include a written ‘Allergy Action Plan’, and a plan for regular medical review. Discuss avoidance of possible triggers such as domiciliary cigarette and other smoke.

Reviews

For children with an established diagnosis of asthma, who are undergoing community review it is important to consider:

Symptom Control

• What is the use of reliever (usually salbutamol) therapy? How frequently is it required?
• Are there interval symptoms – nocturnal cough or exercise induced cough/wheeze?
• Have they needed oral steroids for an acute attack, either in primary or secondary care?
• Have they needed emergency care (may not necessarily result in treatment with steroids)
• Has the child completed the ‘Asthma Control Test’ specific to their age group?  A link can be found in ‘Supporting Information’.
• What is their compliance with medication like (both self-reported and objectively from practice records)?

Objective measures

• What is their height and weight, as plotted on an appropriate age-specific centile chart?
• What is the PEFR and is this appropriate for age/height?
• How many prescriptions have been filled for preventers (usually salbutamol from the practice)?

Social issues

• Are there smokers in the family? Has smoking cessation advice been discussed?
• Are there pets at home – has the possibility of allergy been discussed?
• Is there a possible issue with house dust mite? Has reduction of dust mite exposure been broached?
• Is this seasonal – either related to Autumn/winter viruses or pollen in summer?
• Is this affecting education? What time have they had off school due to health?
• Consider compliance with medication/inhaler technique (see under management)
• Do the family know the advice for action in an acute attack – do they have a written ‘Asthma Action’ plan?

Every medical encounter is an opportunity to educate children and parents/carers about their asthma.  This should involve:

• Discussing emergency regimes/treatment, including when and how to seek urgent medical help
• Medication – compliance with prescribed medications and inhaler technique
• Providing or reviewing a written ‘asthma action’ plan
• Discussing any triggers or exacerbating factors
• Eliciting any psychosocial factors which may have an impact, including family support, mental health, any safeguarding concerns.