Diagnosis and assessment of severe asthma in paediatrics requires a careful, step-wise approach. It is important to initially confirm a diagnosis and assess for comorbidities, medication issues and triggers. Ongoing monitoring is necessary to assess for treatment side effects and determine whether additional add-on therapy will provide benefit.
The most important aspect of management for children with severe asthma is getting the basics right (Bush et al., Lancet, 2010)
Step 1, 2, 3 may be best organised during a planned admission with multi-disciplinary input. This should include asthma control, quality of life and lung function testing at beginning and end of admission.
Step 1 - Confirm Asthma Diagnosis and Rule out Alternative Diagnoses
Step 2 - Assess for Co-Morbidities
Step 3 - Assess Medication Dosing, Inhaler Technique and Adherence
Step 4 - Assess Trigger and Irritant Exposure
Step 5 - Monitor for Medication Side-Effects
Step 6 - Consider Home Visit by Nurse Specialist
Step 7 - Consider Addition of New or Alternative Treatment & Update Asthma Action Plan
Step 8 - Monitor Symptoms and Lung Function to Assess Response to Treatment
Step 1 - Confirm Asthma Diagnosis and Rule out Alternative Diagnoses
Review the evidence for asthma. If no objective evidence is available, obtain objective evidence such as bronchodilator responsiveness ≥12%, positive response to provocation with inhaled mannitol, exercise or an alternate asthma-relevant protocol. If there is no evidence of reversible, inducible or variable airflow obstruction, consider alternative diagnoses (although this does not completely exlude a diagnosis of “asthma”). For more information see Assessment in Paediatrics
Step 2 - Assess for Co-Morbidities
If asthma is confirmed, consider co-morbidities. Co-morbidities should be considered as either alternative diagnoses or exacerbating conditions. Co-morbidities can worsen asthma symptoms and/or impair asthma control.
Step 3 - Assess Medication Dosing, Inhaler Technique and Adherence
This should be part of EVERY asthma assessment
For recommended asthma medication dosing, see Treatments in Paediatrics.
- Assess ability to use inhaler and correct errors in technique. If competent, enquire about use at home (e.g. use of spacer)
- Explore adherence. Non-adherence with treatment may be due to lack of symptom perception. Hence, spirometry should be undertaken in all asthmatics periodically.
- Consider the use of a data logger to monitor adherence, which can be purchased for pMDIs and some DPIs (Morton et al. 2017). Devices can also be purchased that synchronise with both the patient’s phone and also the database of the treating medical service.
Example:
https://www.adherium.com/our-technology/
A very small minority of patients who are intentionally non-adherent for secondary gain will ensure monitoring is unsuccessful
- Non-adherent patients frequently report high levels of symptoms leading to the prescription of high dose of ICS, which remain ineffective as the primary cause of on-going problems (non-adherence) is not addressed
For ICS to be effective patients are required to take >80% of doses (i.e. >11 doses of a possible 14 per week for twice daily dosing).
The National Asthma Council website has useful videos demonstrating good inhaler technique with a range of inhalers techniques which can be found here
Assistance from Community Asthma Educators is available from Asthma Australia in WA and Victoria and Aiming for Asthma Improvement in NSW
www.asthmaaustralia.org.au/wa/education-and-training/i-am-a-health-professional/patient-education-referral-service
www.schn.health.nsw.gov.au/parents-and-carers/our-services/asthma-improvement
Step 4 - Assess Trigger and Irritant Exposure
Relevant triggers include tobacco smoke and allergens.
Perform allergy testing for inhalant allergens. Although there is limited evidence of any benefit from reducing house dust mite levels in the home of children with asthma, this should be considered for those with persistent asthma symptoms. For more information see Assessment in Paediatrics
Ask about tobacco smoke exposure in the home and support family members who are willing to quit smoking. For assessing young people smoking themselves see the Asthma in the Adolescent Population sub-section.
Step 5 - Monitor for Medication Side-Effects
Relevant medication side-effects include adrenal suppression, obesity and oral candidiasis.
- Encourage mouth rinsing after every dose of ICS
- For children on high-dose ICS or regular oral steroids, consider testing for adrenal suppression (e.g. 8-9 am cortisol or synacthen test).
- Consider other side-effects of steroids (e.g. reduced bone-mineral density, glucose intolerance, hypertension and obesity)
Step 6 - Consider Home Visit by Nurse Specialist
Areas to be addressed during a home visit:
- Medications: expiry dates, where are they kept, spacer device availability, spacer cleanliness
- Allergen exposure: Pets, dust mite, pollens
- Tobacco smoke exposure
- Psychosocial stresses within the family
Step 7 - Consider Addition of New or Alternative Treatment & Update Asthma Action Plan
Consider alternative treatments, following discussion with patient and their family, if necessary to improve adherence or inhaler technique, or reduce side-effects. Consider alternative options e.g. DPI which doesn’t need a spacer or longer-acting once-daily preventer (e.g. ciclesonide or fluticasone furoate/vilanterol) or montelukast (oral medication). Consider add-on therapy if uncontrolled symptoms persist. Additional information on therapies is available in the Medications in Paediatrics section.
All adults involved in care of the child should have access to an up-to-date asthma action plan. This includes both parents if separated, grandparents if child spends time with them, school, after-school care, daycare etc.
Step 8 - Monitor Symptoms and Lung Function to Assess Response to Treatment
Assessment of symptoms and response to treatment may include phone apps, questionnaires (e.g. Asthma Control Questionnaire, Quality of Life Questionnaire) and lung function testing.
Available resources include:
https://kissmyasthma.org.au/
http://www.qoltech.co.uk/index.htm
http://www.asthmacontroltest.com/
Ongoing Paediatric Asthma Management
- Regular review with physician to assess asthma control (not only during acute exacerbations)
- Ensure asthma action plan is up-to-date
- Assess compliance and technique at each visit
- Check for complications
- Assess for and treat co-morbidities
- Address exposure to allergens and irritants (e.g. tobacco smoke, pets)
- Annual flu vaccine is advised for all children with severe asthma requiring frequent hospital visits and the use of multiple medications
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