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Asthma in the Adolescent Population

Home Paediatrics & Adolescents Asthma in the Adolescent Population
woman and and a young adult discussing asthma and adolesence

Special consideration should be given to assessing and managing asthma in adolescents aged 12-25 years (adolescents & young adults) due to:

  • Increased risk of death from asthma in this age group (Fitzgerald et al. 2015)
  • Clinically significant anxiety and depression, which often develop over this period
  • Rapid physical, emotional, cognitive, and social change occurs, which can impact on asthma assessment and management:
    • Under-recognition and denial of disease severity
    • Misdiagnosis & overtreatment
    • Poor adherence with medication
    • Risk-taking behaviour
    • Emerging psychosocial factors
  • Management of asthma requires a holistic view of the physical and mental changes that these individuals are going through and how this may impact on their asthma
  • Transition from paediatric to adult care, where patients may fall through gaps in services
  • Adolescents are expected to take more responsibility for their health and medications, which they may not be prepared for

Patient Example

During medical history taking, an adolescent patient admits smoking marijuana.

(A) A condition-driven approach would find that the patient has taken up marijuana smoking and forgotten to take their asthma preventers

(B) A patient-driven approach may discover that the same patient has recently broken up with their boyfriend/girlfriend, precipitating depression and this has caused the patient to turn to marijuana and neglect their asthma medications

A management plan emphasising smoking cessation and adherence to asthma treatment will be poorly received, whereas a management plan emphasising an understanding of the circumstance and advocating for self-care and the role of a counsellor or psychologist is more likely to improve adherence and symptom control

Assessment and Management in Adolescence

Adolescents more than any other patient group require a developmentally focused adaptable approach (Wilson 2017).

Adolescent patients want their treating doctor to build rapport and trust which necessitates the patient to be seen by themselves for at least part of the consultation, providing privacy and confidentiality, as appropriate. Young people with chronic disease frequently emphasise the need for person-centred care, rather than condition-centred care. Engaging the young person around the impacts of asthma on their life allows the physician to guide them through the cycle of change towards engagement with their medical condition.

Key Points for Asthma Management in Adolescence

  • Engage and listen through an integrated, interactive approach
  • Ensure confidentiality and privacy
  • Explore patient goals, fears and barriers
  • Normalise and integrate treatment into life routine, minimising impact on developmental tasks of adolescence and quality of life
  • Educate regarding medications, inhaler technique, side effects
  • Explain need for asthma management plan with shared decision-making; how to use it with early recognition of symptoms & appropriate responses

Consider the Following

Exercise
Obesity
Sleep
Menarche and Menstrual-associated Symptoms
Psychosocial factors
Adherence
Assess psychosocial factors
Assess impact on school/ education
Acknowledge health beliefs
Assess smoking behaviour
Illicit drug taking
Ensure appropriate transition to adult care
Exercise

Assess activity and exercise levels. Is asthma restricting participation? Cardiopulmonary exercise testing may be helpful to clarify diagnosis and inform management.

Obesity

Assess BMI, onset of obesity and associated issues which can impact on asthma such as early menarche, restricted exercise and disordered sleep. Severe asthma can lead to sedentary lifestyle, and thus weight gain. Adipose tissue is also pro-inflammatory and associated with more severe asthma.

Sleep

Nocturnal asthma symptoms can affect sleep. Atopy and allergic rhinitis may also be associated with snoring and obstructive sleep symptoms. Sleep disturbance can affect mood and concentration.

Menarche and Menstrual-associated Symptoms

Asthma control may be worse when oestrogen levels are lowest and progesterone highest, with exacerbations in the pre-menstrual period. Premenstrual asthma can be relieved by oral contraceptive pill (OCP) through suppression of large hormonal fluctuations. Early menarche is associated with obesity and increased asthma prevalence.

Psychosocial factors

Screen for anxiety and depression. These can present in adolescence and exacerbate asthma symptoms

Adherence
  • Can be dynamic and should be reviewed at every assessment. Better adherence is associated with fewer severe exacerbations (Engelkes et al. 2015). Barriers to adherence during adolescence and early adulthood include:
    • Negative perceptions of treatments /clinicians
    • Cognitive difficulties following advice
    • Psychosocial barriers e.g. lack of family support
    • Denial/underestimation of symptoms
    • Health beliefs, self-regulation, organisational skills, fear of side effects

Encourage and teach self-management to improve adherence to medication & monitor progress

Adherence assessment tools include:

  • Medication Possession Ratio (MPR) i.e. number of days medication is supplied, over number of days between first and last refills
  • Canister weighing
  • Smart inhalers and other connected devices
  • Reminder apps (e.g. KissMyAsthma)
  • Asthma control questionnaire (ACQ) to monitor symptoms
Assess psychosocial factors

Consider using the HEADSSS Screen (Goldenring JM 2004 – assessment guide available here). HEEADSSS Assessment learning videos are available here. The HEADSSS Screen assesses the following elements:

  • Home environment
  • Education & employment
  • Eating & exercise
  • Activities
  • Drugs
  • Sexuality
  • Suicide/depression
  • Safety from injury

Assess impact on school/ education

Consider liaising with the school. Provision of interactive, comprehensive education program improves asthma control e.g. Triple A program in NSW (NSW Health), Aiming for Asthma Improvement (Sydney Children’s Hospital, Randwick NSW initiative)

Acknowledge health beliefs

Acknowledge health beliefs and cultural perspectives with potential impact on young person and family

Assess smoking behaviour

Assess smoking behaviour including household smoking, adolescent smoking and e-cigarettes

Illicit drug taking

Screen for illicit drug use e.g. with CRAFFT Clinician Interview screening tool. An increase in risk-taking behaviour can also be related to mood.

Encourage cessation. This link following links may be useful:
www.Kidsquit.org.au
teen.smokefree.gov

Ensure appropriate transition to adult care

This can require planning but improves long-term outcomes. GPs play an important role in continuity of care. Available resources include:

Differential Diagnoses to Consider in Adolescence

These disorders should be considered in adolescents/young adults with asthma that is not responding to conventional treatments, as they may be worsening asthma control or may be alternative differential diagnoses.

Predominantly Exercise-Induced Symptoms (Exercise-Induced Dyspnoea)
Predominantly Dyspnoea (+/- Wheeze)
Predominantly Cough Symptoms
Predominantly Exercise-Induced Symptoms (Exercise-Induced Dyspnoea)

Alternative diagnoses include:

  1. Exercise-induced bronchoconstriction (Asthma)
    • Usually after 6-7 minutes of exercise. Expiratory noise present.
  2. Exercise-induced laryngomalacia (EILM)
    • May occur very early in exercise. Inspiratory noise present.
  3. Exercise avoidance
    • No objective evidence of problem. Symptoms may vary from pain to breathlessness to cough.

A cardiopulmonary exercise test may help differentiate these diagnoses.

Predominantly Dyspnoea (+/- Wheeze)
  1. Vocal Cord Dysfunction (VCD)
    • Overlap with exercise-induced laryngeal obstruction.
    • Often misdiagnosed as asthma, with shortness of breath, chest, throat tightness, wheeze and voice change.
    • Present with social stressors and in overachievers
    • Mimics exercise-induced bronchoconstriction
    • Up to 50% overlap with asthma.
    • Aids to Diagnosis: flattened inspiratory flow volume loop and direct visualisation of vocal cord movement (laryngoscopy)
  2. Anxiety / Panic Disorder
    • May mimic or trigger acute ‘asthma’. However, symptoms are usually associated with normal spirometry, oximetry and rapid improvement.
    • Underlying anxiety may also worsen an acute asthma exacerbation.
Predominantly Cough Symptoms
  • Rule out other causes of chronic cough
  • Consider somatic cough syndrome (psychogenic cough) and tic cough (habit cough) (Vertigan et al. 2015)
    • Often misdiagnosed as asthma, but will not respond to asthma medications
    • Absent when child is sleeping. May be absent when distracted, even for prolonged periods
    • Reassurance may help with management
    • Psychology assessment is advised and often helpful with cognitive strategies / breathing techniques (Bryon et al. 2003)
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