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ChildandAdolescentAsthmaGuidelines

AsthmaandRespiratoryFoundationNZ2017

Acknowledgements• InnesAsher• CherylDavies• TeresaDemetriou• TerryFleming• MatireHarwood• LorraineHetaraka-Stevens• Tristram Ingham• JohnKristiansen• JimReid• DeniseRickard• DebbieRyan

• Consultedorganisations

Mainsources

• BTS/SIGNAsthmaGuideline2017• AustralianAsthmaHandbook2015• GINAguidelines• UKNationalReviewofAsthmaDeaths2015• HeMāramatanga Huangō:AsthmaHealthLiteracyforMāoriChildreninNewZealand2015

TheWhys

AsthmaMortality

• 65- 70deathsperyearinNZ• UKnationalreview2014suggestsmanypreventable– >80%deficienciesinacuteorchroniccare– 45%didnotseekhelp– Diagnosticprocessunclear

AsthmamortalitydisparitiesinNZ

Despitethistherearealsotreatmentdisparities

• MaoriandPacificchildrenmorelikelytoreceiveoralsteroidsandnebulisers

• ButlesslikelytoreceiveICS• Lesslikelytoreceiveasthmaeducation• Lesslikelytobegivenanactionplan

Crengle,Thesis2008Gillies,PrimCareResp J2013

Adherence(world-widedata)

• Only30- 50%ofasthmapatientsarewellcontrolled(adultsandchildren)

• CompliancewithICSpreventersonly20-30%• 34%ofpatientswithuncontrolledasthmauseapreventerlessthanonceperweek

• Adherencehasnotimprovedinthelast3decades

Rabe JACI2004Reddell MJA2015BenderJACI:InPractice2016

AsthmaHealthLiteracyforMaoriChildreninNZReport2015

Whanaureported:

• Nothavingadequateknowledge• <50%understoodwhatasthmais• 1/3notknowinghowtoseekurgenthelp• Notbeinglistenedto• Toomuchinformationatonce• Notbeingtaught“why”

“Theresponsibilityforhealthliteracyliesprimarilywithhealthprofessionals”

- AsthmaHealthLiteracyForMaoriChildrenReport2015

TheGuideline

Goalsfromtheguideline

• Allaspectsofthehealthsystemwillsupportbetterasthmacare,aimingtodecreaseinequitiesandimproveoutcomes

• Māorichildrenhaveasthmaoutcomesequaltonon-Māoriandnon-Pasifika children

• Pacificchildrenhaveasthmaoutcomesequaltonon-Pacific&non-Māorichildren

Top10wayshealthprofessionalscanhelp(apartfromprescribingmedicines)

• Relationships• Wellness• Smokeexposure• Housing• Income• Healthliteracy• Adherence• Actionplan,Access,Ambulance

Asthmamanagementasacontinuouscycleofmonitoringandreassessment• Requirementforfollowupandrepeatedreview

• Changefromepisodichealthcare• Useofrecallsystems

Goal:Allchildrenwhohaveasthmaarecorrectlydiagnosedpromptly

• Diagnosisinchildren– basedonhavingcharacteristicsymptomsinabsenceofanothercause

– ANDassessingresponsetotreatment

LikelihoodofAsthma

Incr Likelihood• Typicalepisodicwheeze/cough/SOB

• Typicaltriggers• Atopy• Familyhistory

Decr Likelihood• Lackofintervalsymptoms

• Isolatedcough• Moistcough• Dizzy/light-headed• Stridor• Signsofspecificdisease

RedFlags

• Dailyorconstantsymptoms– Infantwithwheezeeverydaysincebirth–Dailywetormoistcough

• Failuretothrive• Digitalclubbing

• Currentparadigm– <1year“bronchiolitis”– 1– 4year“pre-schoolwheeze”– >4yearasthma

Whatagedowediagnoseasthma?

Pre-SchoolWheeze

• Twodistinctgroups– Thosewhoonlywheezewithviruses(infrequent)– Thosewithfrequentwheeze– Patterndoesnotpredictlaterasthmaornot

• Onlyregularwheezers (incl thosewithfrequentviralexacerbations)benefitfrompreventersàtreatasasthma

• Canswapgroups– reviewandtrialoffmedseach3months

Goal:Allchildrenwithasthmaareassessedfortheirseverity,controlandfuturerisk

Goal:Therightstepofmedicineintherightdeviceisusedfortheageandsymptomsofthe

child• Maximizequalityoflife(reducesymptoms)• Reducerisk• Avoidadversetreatmenteffects• Utilising astep-wiseapproachtomanagement

Pre-schoolpreventermanagement

• Initiallyasneededsalbutamol• Severeflareupswithoutfrequentsymptoms

àMontelukast• Frequentflareupsorfrequentsymptomsbetweenflareupsà Inhaledcorticosteroid

• Stillpoorcontrol?– Addotheroption

• NeverforLABAs

Klok,ERJ,2014

Goal:ForallchildrenwithasthmaitshouldbeclearifICSshouldbeprescribed,andifso,aprescriptiongivenandthemedicinetaken

Assessingadherence

• Prescribingrecords– AtthePractice– Pharmacydatabase

• Selfreport– “Howoftendoyouforgettotakeyourinhalerinaweek?”

• Physicianjudgement• Electronicmonitoringdevices

Goal:Thecorrectinhalerdeviceisconsideredandageappropriate

• Spacerwithmask– <2years

• Spacernomask– transition2– 4years– Improvedlungdepositionby60%– Notwhensevereexacerbation

• Turbuhaler - from5- 7years

• MDIalone– never(possiblefrom8years)

NZchildren

• Only80%ofchildrenunder6useaspacer• Only30%ofchildrenover7useaspacer• Lessthan35%givenanactionplan

Crengle NZMJ2011Crengle Thesis2008

Assessinginhalertechnique:Checkeveryvisit

• Only7- 22%havehadtechniquetested• 20- 50%ofhealthprofessionalsincorrecttechnique!– upto85%fordrypowderinhalers

• Repeatededucationnecessary• Drypowderinhalerstake3sessions• Skillsdecayover2-6weeks

Goal:Identifyandaddresspersonal,whānau orenvironmentalfactorswhichmaybeunsettling

asthma• Smokeexposure• Housing• Allergenavoidance• Anxietyandpsycho-socialtriggers• Associatedconditions– Rhinitis

Goal:Achievingeffectiveself/familyeducationandmanagement

• Goodasthmaeducation– Enhanceshealth-literacy– Enhancesself-efficacy

Educationtakestimeandrepeatedeffort

• Educationateveryvisit(chunks)• Incorporateavarietyofmedia• Buildrapportbybuildingpartnership• Useasharedlanguageforbetterunderstanding– “Puffers”– “RelieversandPreventers”– “Flareups”

• Goalisimprovedself-management

Goal:Allchildrenwithasthmashouldbeprovidedwithanasthmaactionplan

AsthmaFoundationNZ

Goal:Allchildrenshouldbemanagedtoavoidlife-threateningasthmaordeath

SUMMARY:Inordertoreduceinequalityandimproveoutcomes

• Childrenwithasthmarequire– Time– Repeatedvisits

End