NEW ZEALAND CHILD ASTHMA GUIDELINES...New Zealand, with the aim of improving outcomes and achieving health equity. The intended users are health The intended users are health professionals

NEW ZEALAND CHILD ASTHMA GUIDELINESU P D A T E D J U N E 2 0 2 0

NEW ZEALAND CHILD ASTHMA GUIDELINES

2 www.nzrespiratoryguidelines.co.nz

Asthma And Respiratory Foundation NZ

New Zealand Child Asthma Guidelines:

a quick reference guide David McNamara, Innes Asher, Cheryl Davies, Teresa Demetriou,

Theresa Fleming, Matire Harwood, Lorraine Hetaraka, Tristram Ingham, John Kristiansen, Jim Reid, Debbie Rickard, Debbie Ryan, Joanna Turner

Author information:David McNamara, Respiratory Service, Starship Children’s Health, Auckland District Health Board, Auckland

Innes Asher, Paediatrics: Child and Youth Health, University of Auckland, Auckland; Cheryl Davies, Tu Kotahi Maori Trust, Lower Hutt, Wellington; Teresa Demetriou, (previously) Asthma and Respiratory Foundation NZ, Wellington;

Theresa Fleming, Paediatrics: Child and Youth Health & Psychological Medicine, University of Auckland, Auckland; Matire Harwood, Te Kupenga Hauora Maori, Faculty of Medical and Health Sciences, Auckland; Lorraine Hetaraka, Te Arawa Whanau Ora, Rotorua;

Tristram Ingham, Medicine, University of Otago, Wellington; John Kristiansen, Auckland Regional Public Health Service, Auckland; Jim Reid, Dept of the Dean, Dunedin School of Medicine, Dunedin; Debbie Rickard, Capital and Coast District Health Board, Wellington;

Debbie Ryan, Pacific Perspectives Limited, Wellington; Joanna Turner, Asthma and Respiratory Foundation NZ, Wellington.

Corresponding author: Dr David McNamara, Respiratory Service, Starship Children’s Health

Private Bag 92024, Auckland 1142 Email: [email protected]

ABSTRACTThe purpose of the New Zealand Child Asthma Guidelines: a quick reference guide is to provide simple, practical,

evidence-based recommendations for the diagnosis, assessment and management of asthma in children in New Zealand, with the aim of improving outcomes and achieving health equity. The intended users are health

professionals responsible for delivering asthma care in the community and hospital emergency department settings, and those responsible for the training of such health professionals.

Key words: assessment, asthma, child, diagnosis, guideline, inequities, health equity, management.Short title: New Zealand Child Asthma Guidelines

Abbreviations:

FEV1 Forced expiratory volume in one secondICS Inhaled corticosteroidLABA Long-acting beta-agonistpMDI Pressurised metered dose inhalerPEF PeakexpiratoryflowSABA Short-acting beta-agonistSpO2 Oxygen saturation

https://www.asthmafoundation.org.nz

https://www.nzrespiratoryguidelines.co.nz

mailto:[email protected]



1. Introduction

1.1 Inequities in Child Health in New ZealandAllchildreninNewZealand(NZ)havetherighttoachieve the highest standard of not just asthma treatmentbutalsooutcomes.InNewZealand,alargenumber of children have poor outcomes, especially due to disadvantages that arise from inadequate income to meetthebasicneedsforwell-being.Unhealthyindoorenvironments(homeswhicharecrowded,cold,damp,mouldy1,smoke-exposedorwithunfluedgasheating2)alsocontribute.MāoriandPacificchildrenwithasthmaare more likely to have severe asthma symptoms and be hospitalised but are less likely to be prescribed an inhaledcorticosteroid(ICS),haveanactionplan,orreceiveadequateasthmaeducation(see4.5,4.6). Othergroupswhoexperienceinequitiesincluderefugees,peoplelivinginremoteruralareas,andpeoplewithlowEnglishlanguageproficiency.Allhealthprofessionalshave a role in improving health outcomes and achieving health equity, and these guidelines specify the actions required regarding asthma.

1.2 New reports to inform usThreeimportantreportswerereleasedbytheAsthmaandRespiratoryFoundationofNZin2015andcontributedtothe2017versionofthisguideline: The Impact of Respiratory Disease in New Zealand: 2014 Update3, He Māramatanga Huangō: Asthma Health Literacy for Māori Children in New Zealand4, and Te Hā Ora: The National Respiratory Strategy5.In2018,The Impact of Respiratory Disease in New Zealand report wasupdated. These reports describe the growingimpactofasthmainNZ,especiallyamongchildren,theinequitiessufferedbyMāori,Pacificpeoplesandlow-incomefamilies,andtheintersectoraland holistic approaches needed to tackle the issues.

1.3 Other guidelines consultedThisversionisarevisionofthe2017guidelines.Revisionwasperformedbyasmallcommitteeformedfromtheoriginalauthors;however,thisworkislargelythatoftheoriginalteamwhoarecreditedastheauthorsofthisdocument.Therevisionfollowedsomenewliteratureclarifyingmanagementofpreschoolwheeze.Thefollowingguidelineswerereviewedinthepreparationoftheoriginaldocument:theNationalAsthmaCouncilofAustralia2015Australian Asthma Handbook version 1.1, including the companion Quick Reference Guide6,theGlobalInitiativeforAsthma2020Asthma Management and Prevention, including the companion Pocket Guide7,theSIGN2016British Guidelines on the Management of Asthma, including the

Quick Reference Guide8, and the Asthma and RespiratoryFoundationNZ Adolescent and Adult Asthma Guidelines 2020: A Quick Reference Guide9. Forthe2020revision,majorchangesarefoundin therevisionofthemanagementofpreschoolwheezeand the transfer of the adolescent section to the adult guideline.Asystematicreviewwasnotperformed,althoughrelevantreferenceswerereviewedasrequiredtoformulate this guideline version, and to clarify differencesinrecommendationsmadebetweenguidelines. Readers are referred to the above published guidelines and handbooks for the more comprehensive detail and references that they provide. Additional analysesandreviewsontheassessmentandmanagementofpreschoolwheezingwereconsulted10-12.

1.4 GradingNo levels of evidence grades are provided due to the format of the Child Asthma Guidelines: A Quick Reference Guide. Readers are referred to the above published guidelines and handbooks for the level of evidencefortherecommendationsonwhichtheChild Asthma Guidelines: A Quick Reference Guide are based.

1.5 AgeAdolescentsTheseguidelinesapplytochildren11yearsandbelow.The soon to be published Adolescent and Adult Asthma Guidelines 2020: A Quick Reference Guide, is intended for those 12 years and over. Special care is needed in ensuring that the adolescent transitions in adevelopmentallyappropriatewayastheybecomemoreindependent,maketheirowndecisionsandemerge as adults.

Aged under 5 yearsThere are special considerations in young children (1-4years)whowheeze,asmanyofthemdonotgoontodevelopasthma.SeeDiagnosis(2.2).

1.6 Guideline developmentThe Guideline Development Group included representatives from a range of professions, disciplines and backgrounds relevant to the scope of the guidelines. A Draft for Consultationofthisreportwaspeer-reviewedbyawiderangeofrespiratoryhealthexpertsandkeyprofessionalorganisations(seeAppendixC).The guidelines are primarily presented through lists, tablesandfiguresinanelectronicformat,whichcanbe used in clinical practice. Key references are provided





wherenecessarytosupportrecommendationsthatmay differ from previous or other guidelines, or standard clinical practice.

1.7 Dissemination planTheguidelineswillbetranslatedintotoolsforpracticaluse by health professionals and used to update existing consumerresources.TheywillbepublishedontheAsthmaandRespiratoryFoundationNZwebsite: www.nzasthmaguidelines.co.nzanddisseminatedwidelyvia a range of publications, training opportunities and other communication channels, to health professionals, nursing and medical schools, primary health organisations and district health boards.

1.8 ImplementationThe implementation of the Child Asthma Guidelines: A Quick Reference Guidebyorganisationswillrequirecommunication, education and training strategies.

1.9 Expiry dateTheexpirydateoftheguideis2025.

1.10 Top 10 ways health professionals can help childhood asthma (apart from prescribing medicines)1. Relationships

Encouragecontinuityofcarewithdoctors,nurses,asthma nurse educators and pharmacists in primary and secondary care. Easy access to a trusted nurse andtelephonefollow-upisrecommended.

2. Smoke exposure Ask about smoke exposure including vaping. Encourage reducing tobacco smoke exposure in the child’senvironment(homeandcar)andrecommendsmoking cessation. If appropriate, give advice and refer to a local smoking cessation service, or Quitline(0800778778).ProvideHealthSponsorshipCouncil’s pamphlet A Guide to Making Your Home and Car Smokefree www.healthed.govt.nz/.

3. Housing NewZealandersoftenliveinunhealthyhousing,andconditionsareworseinprivaterentalhousing.Some families are homeless. Ask about housing and unhealthyfeatures(crowding,cold,damp,mouldy,unfluedgasheater).Providethefamilyand whānauwithinformationabouthavinga healthyhome(“Tipsforhealthyliving” www.asthmafoundation.org.nz/your-health/healthy-living).Referforhealthyhousingassessment if available in your region.

4. Income Assumethatmostfamiliesstrugglewithincomeand ask about it. Inquire about the ability to access the doctor, a pharmacy, and pay prescription costs. Does the child have partly or uncontrolled persistent asthma and meet criteria for Child Disability Allowance13? www.workandincome.govt.nz. Encourageallfamilyandwhānaumembersto use the same pharmacy to reduce prescription co-payments www.health.govt.nz/your-health/conditions-and-treatments/treatments-and-surgery/medications/prescription-charges

5. Health literacy Assume little health literacy, and use steps described in He Māramatanga Huangō: Asthma Health Literacy for Māori Children in New Zealand. Specificallyaskthechildandwhānauwhattheyunderstand,whattheywanttoknow,andusesimple language to explain about asthma, for example usetheterm‘asthmaflare-up’ratherthan‘asthmaexacerbation’.Usetheterm‘puffer’insteadof‘inhaler’.Workwithfamiliestoattainandmaintainwellness,andnotacceptsicknessasthenorm.

6. Adherence Firstly, assume inhaler device technique is poor, and check it. Secondly, assume adherence is imperfect, and don’t judge. Ask questions in an openway,suchas,“Manypeopletakelesspreventerthanthedoctorprescribes–abouthowmanytimesaweekdoyoutakeyourasthmapreventer?”14-16

7. Asthma action plan Developanappropriateasthmaactionplanwiththechild,familyandwhānauandchecktheplanoneach visit. Plans should be made available to schoolsandchildcarefacilitieswhereappropriate.See:www.nzasthmaguidelines.co.nz/resources

8. Access Helpthefamilyandwhānautounderstandhowtoaccess care appropriate to asthma severity and identify any barriers they have. Consider referral to asthma educator, nurse practitioner, public health nurse,Māoriprovidersorpaediatricianwhereavailable and appropriate.

9. Ambulance Ensurethefamilyandwhānauknowwhenandhowtocallanambulance.Insomeregionsthisservice may incur a charge so ensure families have ambulance membership to avoid charges.

10. Influenza vaccine Ensurechildrenwithasthmaorrecurrentwheezereceivetheinfluenzavaccineeveryyearfrom 6monthsofage.



https://www.nzasthmaguidelines.co.nz

http://www.healthed.govt.nz/

https://www.asthmafoundation.org.nz/your-health/healthy-living

https://www.asthmafoundation.org.nz/your-health/healthy-living

https://www.workandincome.govt.nz/

http://www.health.govt.nz/your-health/conditions-and-treatments/treatments-and-surgery/medications/prescription-charges



https://www.nzasthmaguidelines.co.nz/resources



2. Diagnosis Goal: All children who have asthma are correctly diagnosed promptly

2.1 Approach to diagnosis● Asthmainchildrenisdefinedonthebasisof

characteristic symptoms and signs occurring in a typicalpattern(Table1)andtheresponsetotreatment,in the absence of an alternative explanation.

● The key to making the diagnosis of asthma is to take acarefulclinicalhistoryandassessclinical+/-spirometryresponsetoinhaledbronchodilatorand/orICS treatment. There is no reliable single ‘gold standard’ diagnostic test.

● Inchildrenwithahighprobabilityofasthma,startatrialoftreatment(seeFigures3and4)andassessthe response to therapy.

● Spirometryshowingatleasta12%responsetobronchodilatoror10%decreasewithexercisemaybehelpfulbutshouldbeconductedbyqualifiedstaff and according to spirometry guidelines criteria. Better results are obtained if staff have experienceworkingwithchildren.Thecut-offcriteria used depend on the protocol employed.

● Initial diagnosis is probability-based and should alwaysbereconsideredifthepatientfailstorespondto therapy or has atypical symptoms or signs.

● The diagnosis and monitoring of asthma requires frequentandrepeatedreview.Thismayrequiretheuseofrecallorfollow-upsystems(Figure2).

● Continuity of care should be encouraged for follow-upfordiagnosisandongoingmanagement.

● Algorithms are provided to guide the diagnosis in 1to4-yearolds(Figure1A)and5to11-yearolds(Figure1B).

Practice points● During a trial of therapy, give the patient a label of

‘suspected asthma’ or ‘suspected preschool asthma’ as ameansofcommunicatingwithotherhealthprofessionals.

● Thenexthealthprofessionalseeingachildwithalabel of ‘suspected asthma’ or ‘suspected preschool asthma’ should determine the response to therapy and change the diagnostic label.

● In most children, observing a symptomatic response totreatmentmayhelptoconfirmthediagnosis,buta limited response to bronchodilator or ICS does not rule out asthma.

● Inchildrenwithalowprobabilityofasthma,performfurtherinvestigations,suchaschestX-rayand/orspecialist referral prior to initiating preventer therapy.

● Spirometrymaybehelpfulinolderchildren(6yearsandaboveifpaediatric-trainedtechnician).

● Cough or night cough alone in the absence of signs ofwheezeandshortnessofbreathhasalowlikelihoodofasthma,althoughwheezemayonlybedetected on auscultation and not by parents.

● InNewZealand,bronchiectasisshouldbeconsideredinallchildrenwithrespiratorysymptoms.Sometimesbronchiectasisco-existswithasthmaandcanbemissedonachestX-ray.Chronicwetcoughisakeymarker.

2.2 Children 1 - 4 years of ageYoungchildrenunder5yearsareaspecialgroup,asabouthalfofthosewhowheezedonothaveasthmaatschool age, and later. Previously described patterns of multi-triggerandepisodicpreschoolviralwheezedonotremain constant and are not helpful in predicting risk17. Preschoolerswithwheezearemanagedaccordingtothe frequency and severity of symptoms and future risk offlare-ups7 and labelled accordingly to assist making decisions about prescribing ICS.

Infrequent preschool wheeze Thesepreschoolershavemildwheezewithviralillnessesandnotatothertimesandhavealowriskofsevereflare-up.Analternativetermsometimesusedis‘infrequentepisodic(viral)wheeze’.ICSarenotindicated.

Preschool asthma Forthefollowingpreschoolersconsiderthemashaving‘suspected preschool asthma’:●Frequentepisodesofwheeze(morethanevery6-8weeks).●Severeepisodesofwheeze(definedasneedingtoseekmedicalattentionforasevereflare-up).

●Symptomstypicalforasthmaintheintervalbetweenviral illnesses.

●Regularnightwakingwithsymptomsofcoughorwheeze.18

GiveatrialofICSforaminimumof8weeks.Ifthereisa positive response, these children should then be labelled as ‘preschool asthma’. An alternative term sometimes used is ‘frequent episodic (viral) wheeze’. Thislabeldoesnotmeanthechildwillgoontohaveasthmaatschoolageorasanadult,whichmaybereassuring for many families. If the treatment above is not effective, the treatment should be stopped, after checking adherence and inhaler technique.

Practice points● Preschoolerswithwheezearemorelikelytogoon

to have childhood or adult asthma if there is a personalhistoryofeczema,aparentalhistoryofasthma, or if the child has elevated blood eosinophils or is sensitised to aeroallergens or food.19

● Inallchildrenover1yearofagewithrecurrentwheeze,abronchodilatorshouldbeprescribedasforasthma,accordingtoclinicalseverity(seeFigure3).





2.3 Wheezing in children under 1 yearInchildrenunder1year,bronchiolitisisthemostcommoncauseofwheezing,andthePREDICTAustralasianBronchiolitis Clinical Practice Guideline20shouldbefollowed.Iftheillnessdoesnotseemtobebronchiolitis, then refer to Table 1, Figure 1A and section 2.2 for guidance.

Table 1: Clinical features that increase or decrease the probability of asthma in children

A. Asthma more likely

• More than one of the following: ° Wheeze (most sensitive and specific symptom of asthma) ° Breathlessness ° Chest tightness ° Cough • Particularly if: ° Typically, worse at night or in the early morning ° Provoked by exercise, cold air, allergen exposure, irritants, viral infections, stress and aspirin ° Recurrent or seasonal • Personal history of atopic disorder or family history of asthma • Widespread wheeze heard on chest auscultation • Otherwise unexplained expiratory airflow obstruction on spirometry • Otherwise unexplained blood eosinophilia or raised exhaled nitric oxide • Bronchial hyper-responsiveness on challenge testing at appropriate age • Positive response to bronchodilator (clinical or lung function).

B. Asthma less likely

• Isolated cough in absence of wheeze or difficulty breathing • History of wet, moist or productive cough • No wheeze or repeatedly normal physical examination when symptomatic • Normal spirometry or peak flow (PEF) when symptomatic • No response to trial of asthma treatment • Features that point to an alternative diagnosis (see C below).

C. Red flags suggesting alternate diagnoses*

• Daily symptoms from birth • Frequent or daily wet, moist-sounding or productive cough • Digital clubbing • Chest wall deformity • Failure to thrive • Heart murmur • Spilling, vomiting or choking • Asymmetrical chest findings • Stridor as well as wheeze • Persistent ear, nose or sinus infection • Family history of unusual chest disease

• Symptoms much worse than objective signs or spirometry.

* Consider aspiration, bronchiectasis, ciliary dyskinesia, cystic fibrosis, developmental airway anomaly, foreign body aspiration, heart disease, hyperventilation, immunodeficiency, tuberculosis, vocal cord dysfunction





Figure 1A: Diagnostic pathway for asthma and wheeze in children 1 - 4 years6,8

Child with respiratory symptomsAre the symptoms typical for asthma?

(See Table 1)

Typical

No

Yes

Not typical

Reliever as neededICS not indicatedReconsider trials

of therapy if symptoms frequent

or severe

Consider other diagnoses. Refer and investigate

as appropriate. A trial of asthma therapy

may be helpful

Frequency and pattern of

symptoms

“Infrequent preschool wheeze”

Infrequent symptoms with

viral illnesses only (< every 6 – 8 weeks)No severe flare-ups

Trial of asthma therapy

Responds to preventer?

“Preschool asthma”Treat as asthma

Evaluate response and reconsider diagnosis

after 3 months

Frequent (> every 6 – 8 weeks)

or severe flare-ups with viral illnesses

Frequent typical symptoms between viral

illnesses or flare-ups

“Suspected preschool asthma”





Figure 1B: Diagnostic pathway for asthma and wheeze in children 5 - 11 years

Typical

Yes No

Asthma reasonably likely

Asthma not likely

Asthma not likely

Asthma likely

Not typical

Refer, investigate and treat

as appropriate for other disorder

Child with respiratory symptomsAre the symptoms typical for asthma?

(See Table 1)

“Suspected asthma” Consider other diagnoses

Trial of asthma therapy

Further investigation e.g. spirometry and

reversibility test A trial of asthma

therapy may be helpful

Responds to asthma therapy?

Diagnose and treat as asthma

Evaluate response and

reconsider diagnosis

after 3 months

Reconsider diagnosis

Further investigation

e.g. spirometry and reversibility

test





3. Assessing asthma severity, control and future risk

Goal: All children with asthma are assessed for their severity, control and future risk

3.1 Evaluation of asthma control and severity● Evaluation of asthma severity, the level of control

and the risk of future events are important componentsoftheassessmentofchildrenwithasthma.

● Asthmacontrolisdefinedbythefrequencyofsymptoms,thedegreetowhichsymptomsaffectsleep and activity, and the need for reliever medication.

● Poorasthmacontrolisdefinedasregularsymptomsoccurringinausualweekthataffectthepatient’s

quality of life, or according to the asthma symptom controlmeasuresbelow.

● Poorcontrolshouldtriggerareviewofadherence,inhaler technique and preventer therapy.

● If poor control persists, then reconsider the diagnosis.● If poor control persists despite above, then consider

increasing the asthma treatment step. ● The level of asthma control should be assessed

regularly. Twomethodsforassessingasthmasymptomcontrolare:● Child-AsthmaControlTest(4to11years):

www.asthmacontrol.co.nz● GINA assessment of control questions.

Table 2 GINA assessment of asthma symptom control in children 5 - 11 years (See Table 3)1

(GINA recommends assessment of risk factors as an essential part of the assessment of asthma control)

A. Asthma symptom control Level of asthma symptom control

In the past 4 weeks, has the patient had: • Daytime asthma symptoms more than twice/week? Yes No

• Any night waking due to asthma? Yes No

• Reliever needed for symptoms* more than twice/week? Yes No

• Any activity limitation due to asthma? Yes No

Well controlled

None of these

Partly controlled

1-2 of these

Uncontrolled

3-4 of these

(Modified with permission of GINA)

Practice points – severity and future risk:● Assessment of asthma also involves assessing risk of

adverseoutcomes,includingsevereflare-ups,deathandtreatment-relatedadverseeffects(Table3).

● Severityofasthmaisdefinedbythetreatmentstep(Figures3and4)neededtomaintaingoodcontrol.Workwithpatient/parenttodeterminewhatgoodcontrol looks like.6

● For symptomatic children, asthma severity can be determined only after a therapeutic trial of ICS for atleast8weeks(Figures3and4).Startthetherapeutictrialandbookthefollow-upappointmentfor8weekslater.

● Thebestpredictoroffutureasthmaflare-upsisthenumberofflare-upsinthelast12months.

● Growth(heightandweight)shouldbemeasuredatleastannuallyinchildrenwithasthmaandplottedon a percentile chart. Fall-off on percentiles suggests poor asthma control; other causes include

malnutrition, frequent oral corticosteroids or after initiation of higher dose ICS.

● Increaseinweightmayreflectinappropriatedietand steroid dose.

● Monitorhealthcareuse.Childrenwithhighhealthcareuse(suchashospitaladmissions,emergency department visits, emergency doctor visits,andunplanneddoctorvisits)areathighriskfor severe or life-threatening asthma.

● Monitormedicineuse.Childrenwithhighmedicationrequirementsorusage(suchascoursesof oral steroids, frequency of beta-agonist prescriptions, and more prescriptions for beta-agoniststhanICS)areathighriskforsevereorlife-threatening asthma.

● Each time the child is seen, and control is assessed, considersteppinguporsteppingdowntherapy,asperFigure3and4.



http://www.asthmacontrol.co.nz/



Table 3: Features associated with increased risk of severe asthma flare-ups and/or death from asthma21

A. Asthma

• Poor asthma control.• Hospitalisation or emergency department visit for asthma in the last year.• Extreme inhaled bronchodilator use (>1 canister per month).• History of sudden asthma attacks.• Intensive care admission or intubation (ever).• Requirement for long-term oral steroids.

B. Comorbidity

• Major psychosocial problems.• Alcohol and drug abuse in family.• Severe food allergy and anaphylaxis.

C. Other factors

• Poor inhaler technique.• Underuse or poor adherence to ICS treatment. • Tobacco smoke exposure.• Discontinuous medical care.• Socioeconomic disadvantage.• Financial hardship.• Unhealthy housing.• Maori and Pacific ethnicity. • Child protection issues (consider Vulnerable Children Act 2014). www.legislation.govt.nz/act/public/2014/0040/latest/DLM5501618.html

4.Managementapproaches

4.1 Identifying management goals with the child and whanau

Goal: The child, family and whānau participate in goal setting

● Managingasthmarequiresapartnershipbetweenthechild,theirparents,theirwhānau,andtheirhealthcareteam.Thiswillchangeanddevelopaschildrenageandinvolvespatientwillingnessandunderstanding, agreeing on management goals.

● Management and partnership are based on a cycle of repeated assessment, adjustment of treatment andreviewofresponses,asoutlinedinFigure2.

4.2 Non-pharmacological measures

Goal: Personal, whānau or environmental factors which may be unsettling asthma are identified and addressed (also see 1.10)

● To improve asthma outcomes, avoid exposure to knowntriggerswhichprecipitateaflare-up,andexposure to smoking or vaping.

● Exercise and physical activity should be encouraged, as exercise induced asthma can be managed. Chlorinatedswimmingpoolsmaybeatriggerforsome children.

● Psychosocial stressors are potent triggers of asthma symptoms.Identificationofthesetriggersandtheintroductionofverysimplestrategies,suchasslow,relaxedbreathingwhenstressed,mayhelpthepatientandwhānauinmanagingsymptoms.



http://www.legislation.govt.nz/act/public/2014/0040/latest/DLM5501618.html



● If anxiety or panic play a part, involve the family andwhānautosupportthepatientandconsiderreferral for psychological counselling.

● Dysfunctional breathing or a breathing pattern disorder can be a contributing factor in the severity of symptoms. A physiotherapist can advise on breathingawarenessandexercisestohelprelaxation and improve effectiveness of breathing.

● Keepingthenoseclearwillhelpasthmacontrol,asitfilters,warmsandhumidifiestheairtothelungs.Salinedropsasneededtoclearthenose(maximumfourtimesperday)andfrequentblowingareusually adequate.

● Asthma control may be improved by better

insulation and avoiding cold, damp, mouldy, or crowdedhousing.

● Unfluedgasheatersmaymakeasthmasymptomsworsewww.health.govt.nz/your-health/healthy-living/environmental-health/household-items-and-electronics/unflued-gas-heaters.

● Housedustmite(HDM)avoidancemeasuresareonlyeffectiveinchildrenwhoareconfirmedtobesensitisedtoHDMandrequireimpermeablebedencasingstowork.33

● Modificationstodiet,suchaseliminatingfoods, are unlikely to improve asthma control unless confirmedfoodallergy.

Figure 2: Asthma management as a continuous cycle of monitoring and reassessment, adapted from GINA (1)

*

*

* (patient or parent)

4.3 Self-management

Goal: Effective self/family/whānau education and management is achieved● Asthma education and improving health literacy

andself-efficacyarefundamentalinasthmamanagement and are the responsibility of all health professionals.

● Allpatientswithasthmaandtheircaregiversshouldbeofferedmanagementeducation,whichshouldincludeawrittenpersonalisedasthmaactionplan(See4.4).Askthepatient/parenthowbest to achieve this.36,37

● The prescriber must ensure that education is given, an action plan is provided, and inhaler technique is checked. Providing a prescription

withoutaddressingtheseisineffective.● Refer to community asthma nurse or nurse

educatorifthefamilyorwhānauhavedifficultywithself-management,orafteranyhospitaladmissionwithasthma.

● Adherence to treatment should be routinely assessed and encouragement provided as part of the self-management education. The health professionalshouldgainanunderstandingofwhythepatient/parentischoosingnottofollowadvice,astheremaybespecificcircumstanceswhichcanbe addressed. 7,8

● Ensurecaregiversandwhānauunderstandtheimportance of not running out of inhalers and prescribedmedication.Checkthattheyknowtheprocess for obtaining repeat prescriptions.



http://www.health.govt.nz/your-health/healthy-living/environmental-health/household-items-and-electronics/unflued-gas-heaters





● Ensure enough medications are prescribed and reinforce the need for appropriate regular clinical assessment.

● Asthma management should be addressed in all areaswherethechildspendssignificanttime,including multiple homes, childcare and school.

Practice points – enhancing self-management:● Asthmaeducationshouldincreasehealthknowledge

about asthma, general health literacy and self-efficacy,andshouldbereinforcedateveryvisit.

● Teachfamiliestorecognisewhenasthmaispoorlycontrolled,andknowwhenandhowtocallemergency services.

● Asthma education should utilise a variety of media, includingprintedmaterialsaswellasverbalexplanations,andprintedmaterialsinthefirstlanguageifpossible,e.g.www.pamp.co.nz,awebsitewhichproducessimple,individualisedpictorialasthmamedicationplansinTeReoMāori,Samoan, Tongan, Tuvaluan and Chinese24.

● Education should be delivered in chunks and delivered across multiple visits instead of all at once.

● Education should be developmentally appropriate. As children mature, offer further information, and coach to take increasing responsibility for their care.

● Askchildrenandfamilieswhattheyalreadyknow,thenaddtotheirknowledgeby‘scaffolding’newinformation in manageable steps.

● Inhaler technique should be routinely assessed whereverpossibleandtrainingprovidedaspartofself-management education.

4.4 Asthma action plans

Goal: All children with asthma are provided with an asthma action plan● To assist in self-management of childhood asthma,

consider all of the child’s regular caregivers and environments in preparing and distributing the action plan.

● Asthma action plans that are symptom-based, rather than PEF-based, are preferred in children, although someolderchildrenmaywantaPEF-basedplan.

● Child asthma action plans from the Asthma and RespiratoryFoundationNZcanbedownloadedfrom:www.nzasthmaguidelines.co.nz/resources

● The Child Asthma Action Planshouldbewrittenandreviewedwiththecaregiversandwhānau.Itmustbe individualised for the child and culturally appropriate(seeAppendixA).

● A Child Asthma Symptom Diary may be used to clarify the pattern of symptoms and response to treatment,toguidetheActionPlan(seeAppendixB).

● The My Asthma App may be helpful in developing theactionplanandcanbedownloadedfrom:Android:bit.ly/AsthmaAppAndroid or Apple:bit.ly/AsthmaAppApple

Practice points – asthma action plans: ● Alwaysinvolvethechildbyusingdevelopmentally

appropriate language.● Ensurethechild(inanageappropriatemanner)

andthecaregiversandwhānauunderstandtheplan.● Keep a record of the plan and provide copies of the

Child Asthma Action Plan for all caregivers – including multiple homes, childcare or school.

● Reviewtheplanatleastannuallywiththechild,familyandwhānau.Thefrequencyofreviewswilldependonthewhānau’sconfidenceandcompetencewithasthmamanagement.

● Highlighttheneedtotake2puffsofrelieverpriorto exercise if the child has exercise related symptoms.

● The instructions on the Child Asthma Action Plan shouldbespecificenoughthatre-interpretationorre-prescription by another health professional is notnecessarywhenperformingeducation.

4.5 Maori – getting it right for Maori children with asthma

Goal: Māori children have asthma outcomes equal to non-Māori and non-Pacific childrenMāorirightsinregardstohealth,recognisedin Te Tiriti O Waitangi and other national and internationaldeclarations,promotebothMāoriparticipationinhealth-relateddecisionmaking,aswellasequityofhealthoutcomesforallNewZealanders.Currently,Māoriwithasthmaaremorelikelytobehospitalisedordieduetoasthma.Despitethis,MāoriwithasthmaarelesslikelytobeprescribedICS,havean asthma action plan, or receive adequate education. MajorbarrierstogoodasthmamanagementforMāorimay include access to care, discontinuity and poor-quality care, and poor health literacy. Māoriwhānauhavegreaterexposuretoenvironmentaltriggers for asthma, such as smoking, vaping and poor housing 9,25 The aim should be equitable outcomes, not just equitable treatment. The evidence of the health literacy demands, barriers, facilitators, and steps to delivering excellentasthmamanagementwithMāoriaredescribedinHeMāramatangaHuangō:AsthmaHealthLiteracyforMāoriChildreninNewZealand.ItisrecommendedthatforMāoriwithasthma:● Māorileadershipisrequiredinthedevelopmentof

asthma management programmes that improve



http://www.pamp.co.nz/

https://www.nzasthmaguidelines.co.nz/resources

http://bit.ly/AsthmaAppAndroid

http://bit.ly/AsthmaAppApple



accesstoasthmacareandfacilitate‘wrap-around’servicestoaddressthewiderdeterminants(suchashousingorfinancialfactors)forMāoriwithasthma.

● A systematic approach to health literacy and asthmaeducationforMāoriwhānauisrequired.

● Asthma healthcare providers should support staff to develop cultural competency skills for engaging Māoriwithasthmaandtheirwhānau,inlinewithprofessional requirements.

● Asthma providers should undertake clinical audit or other similar quality-improvement activities to monitor and improve asthma care and outcomes forMāori.26

Practice points – Māori at every review:

● EnsureallMāorichildrenwithwheezeandasthmareceive appropriate preventer therapy.

● EnsureallMāorichildrenwithwheezeandasthmahave an action plan.

● EnsureallMāorichildrenwithwheezeandasthmaandtheirwhānaureceiveasthmaeducationandthatthisrepeatedinappropriate-sizedchunks.

● ConsiderareferraltoalocalMāorihealthproviderif available.

4.6 Pacific peoples – getting it right for Pacific children with asthma

Goal: Pacific children have asthma outcomes equal to non-Pacific & non-Māori childrenThePacificpopulationisdiverseandgrowingfast,withPacificchildrennumberingoneinfourbabiesborninAuckland.Pacificchildrenhavegreatdisparitiesandunequalaccesstohealthcarecomparedwithother NewZealandchildren. 27-32 Changeswillcomefromhealthworkersunderstandingthe drivers for poor health in minority groups, and action at multiple levels of the health and social systems.CentralactiontoimprovethehealthofPacificchildrenwillbeacommitmenttoworkwiththestrengthsofthePacificcommunities.Thefollowingrecommendationsforactionneededforgood levels of health services and practitioners are basedontheoryandlessonsfromgoodpractice:● UnderstandthePacificpopulationprofile,withthe

majority living in urban areas. Perform an audit on theclinicalactivitiesandunderstandwhoisregisteredwiththeservice,andwhoisregisteredbut do not attend.

● Withover60%ofPacificchildrenlivinginfamilieswithhardshipand30%inseverehardship,materialinsecuritieswillaffectcaregiverandwhānau

engagementwithhealthproviders.Practitionersshould explore these insecurities and set up effectivepathwaystoaddressthese.

● Researchshowscommunicationdifficultiesareabarrier for healthcare. Assess the level of English languageproficiency,anduseinterpretersifnecessary.Useasthmaself-managementresourceswritteninthefirstlanguagewheneverpossible.

Practice points – Pacific children at every review:

● EnsureallPacificchildrenwithwheezeandasthma receive appropriate preventer therapy.

● EnsureallPacificchildrenwithwheezeandasthma have an action plan.

● EnsureallPacificchildrenwithwheezeandasthma and their family and aiga receive asthma education and that this repeated in appropriate-sizedchunks.

● ConsiderareferraltoalocalPacifichealthprovider if available.

4.7 Health systems approaches

Goal: All aspects of the health system will support better asthma care, aiming to achieve equity and improve outcomesGood asthma management requires a system approach incorporating information systems to improve quality and service delivery. Thefollowingarerecommended:● Computerised decision-support systems, such as

web-basedsystemsforself-management.Theseshould incorporate simple tools for the assessment and monitoring of asthma control.

● School-based asthma interventions, such as education programmes and Asthma Friendly Schools.

● Pharmacy-based interventions, such as inhaler techniqueeducationandtheidentificationofasthma medicine uptake from dispensing history e.g. infrequent preventer dispensing history.





5.Medicines

5.1 Inhaler devices at different ages

Goal: The correct inhaler device is considered and age appropriate● Prescribe an inhaler device that is appropriate for

the development of the child and ensure that the childand/orcaregiverisabletodemonstratetheycanuseitcorrectly(Table4).

● Healthprofessionalswhoteachpatientsshouldensure they have correct inhaler technique themselves.

● When teaching inhaler technique, have the child or caregiverdemonstratehowtheyusethedevice. Usechecklistsandreminderliststoidentifyandcorrect errors.

● Inhaler technique needs to be taught repeatedly. Check inhaler technique and adherence at every visit by asking the child or caregiver to demonstrate howtheyusethedevice.

● Advise not to share inhalers.● Consider alternative inhaler devices if the patient

haspersistentdifficultywithtechnique.

Table 4: Inhaler devices recommended by age group

Inhaler device < 2 years 2-4 years 5-7 years 8-11 years

pMDI, small volume spacer & mask

Yes May transition to no mask

pMDI & spacer No mask Possible Yes Yes

pMDI (alone)* Possible, but use with a spacer is preferable

Dry powder device Possible Yes

Breath-activated device Possible Yes

*A spacer should be used with the pMDI for the regular administration of ICS, and for the administration of SABA in the setting of an acute attack.

5.2 Stepwise approach to long-term asthma treatment

Goal: The right step of medicine in the right device is used for the age and symptoms of the child ● Inthestepwiseapproachtomanagement,children

step-upanddowntherapyasrequiredtoachieveand maintain control of their symptoms and reduce theriskofasthmaflare-ups.6,8,34

● Achieving good control requires frequent and repeated assessments. This may require the use of recallorfollow-upsystems.

● At each step, check inhaler technique, adherence to treatment, understanding of a self-management plan, and barriers to self-care. 6,8,31-33,36-38

● Mostchildrenwhoarecompliantandhavegoodinhalertechniquewillbewellcontrolledonstandard preventer therapy - if they are not, then reconsider the diagnosis.

● Alternative therapies, such as tiotropium, may be considered in some children on specialist advice.Tiotropium, a long-acting muscarinic receptor antagonist(LAMA),iscurrentlylicensedforusebutnotfundedforasthmaindicationsinNewZealand22 and the role of LAMAs in paediatric asthma is not yet clear.

● AtStep5,oralsteroids,oraltheophylline,andmonoclonal antibody therapy, may be considered as an add-on treatment, if directed by a paediatrician.



https://en.wikipedia.org/wiki/Muscarinic_receptor

https://en.wikipedia.org/wiki/Receptor_antagonist



Figure 3: Stepwise approach to treatment of children with wheeze 1 - 4 years

STEP 1Infrequent or non-steroid responsive preschool

wheezeNo

maintenance therapy required

STEP 4Preschool

asthmaPoor Control

Same as

Step 3 plus referral to

Paediatrician

STEP 3Preschool

asthma

Maintenance Low dose ICS

and

Montelukast

STEP 2Preschool

asthma


if frequent or severe

symptoms

STEP UP to achieve control and reduce risk of exacerbationCheck adherence and inhaler technique before stepping up

SABA reliever 1 – 2 puffs as needed

STEP DOWN if stable for 3 months step down in incremental fashionIf relapses, resume previous level of therapy





Figure 4: Stepwise approach to treatment of children with asthma 5 - 11 years

Practice points – stepwise management:● Step–upandStep-downaredeterminedbyasthma

control(see3.1AsthmaControlTestandTable2).Step-upmayberequiredwhenasthmaispartiallycontrolled or uncontrolled. Once asthma has been well-controlledforatleast8weeks,considerStep-down,andreassesscontrolafteratleast12weeks.

● Manychildrenhaveintermittentasthma(Step1)anddonotneedanasthmapreventer;however,childrenwithaflare-upinthelast12monthsareatincreased risk and a preventer considered.

● RecommendeddosesofICSarelowerinchildrenthanadults(SeeTable5).Theusualmaximumdailydoseinchildrenisalsolowerthanadults,andequivalenttobeclomethasone800micrograms,orfluticasonepropionate500micrograms.Boththese

doses are at the top of the dose response curve. Ifthisdoseisexceededthereisnotherapeuticbenefit,and there is an increase in adverse medication effects.

● When issuing repeat prescriptions for reliever inhalers, ensure that preventer medication is being used.

● Whenwritingprescriptionsforinhalers,ensurethatdirectionsarewrittensothepharmacistmaydispense the number of inhalers required by the patientasallowedwithinthe3-monthsupplylimit.Additional inhalers may be required for children livingacrosstwohouseholdsorneedingextrainhalers for school.

● Influenzavaccinationshouldbeencouragedforallchildrenandpreschoolersatfutureriskofaflare-up.

● Remember non-pharmacological approaches to managementaswellasmedicines(see1.10and4.2).

STEP 1No

maintenance therapy required

STEP 4

Poor control on low dose

ICS/LABA

Maintenance Standard dose

ICS/LABA

Add montelukast if poor control

Refer to Paediatrician if

poor control

STEP 5

Frequent or continuous

systemic steroids

Standard dose ICS/LABA

Plus montelukast

Consider high dose ICS/LABA

Definite Referral to

Paediatrician

Consider biologics

STEP 3Maintenance

Low dose ICS/LABA STEP 2


STEP UP to achieve control and reduce risk of exacerbationCheck adherence and inhaler technique before stepping up

SABA reliever 1 - 2 puffs (unless on SMART therapy)

STEP DOWN if stable for 3 months step down in incremental fashionIf relapses, resume previous level of therapy





5.3 Initial treatment choices (when to add ICS)

Goal: For children with asthma, ICS are prescribed and taken when indicated● Atinitialdiagnosis,allchildrenwithasthmashould

beprovidedwithaSABAtotakeasrequiredforrelief of symptoms.

● It is recommended that ICS therapy is introduced if childrenhavesymptoms>2timesperweek,usetheirreliever>2timesperweek,haveregularnightwakinginthepastmonth,orhaveaflare-uprequiring oral steroids in the previous year. 8

● ICS therapy should also be introduced if there is

excessive pickup or purchase of reliever inhalers (3ormoreperyear).

● Diagnosisisoftenmadeatatimewhenpreventertherapy should be introduced.

● Ifthechildislikelytohaveanasthmaflare-upinaparticular season or time of the year, then they should be prescribed ICS therapy during that time.

● In preschoolers, intermittent ICS therapy may be used as an alternative to regular therapy. ThisisinitiatedatthefirstsignofanURTIat“standard”dose(Table5).23 Regular rather than intermittenttherapyispreferredforthosewithfrequent symptoms.

Table 5: The recommended low and standard daily dose of ICS in children with asthma. “High” doses are double the standard doses (see Tables 4 and 5)

Low dose Standard dose

Beclomethasone dipropionate 200 mcg/day Beclomethasone dipropionate 400-500 mcg/day

Beclomethasone dipropionate ultrafine 100 mcg/day Beclomethasone dipropionate ultrafine 200 mcg/day

Budesonide 200 mcg/day Budesonide 400mcg/day

Fluticasone propionate 100 mcg/day Fluticasone propionate 200-250mcg/day

Practice points on ICS:● ThedailydosesofICSinchildren,whichachieve

80-90%ofmaximumefficacy,arethelowdosesshowninTable5.Thedoseslabelled‘standard’dosesarethesamemicrogram/day‘standard’dosesin the Adolescent and Adult Asthma Guidelines.

● ICSshouldbeadministeredfromapMDIwithspacer,orfromadry-powderinhaler.Thechild’sability to use the inhaler should be checked. 6,7,42,43

5.4 When to add LABA therapy in children 11 years and under

Goal: LABAs should never be prescribed without ICS● CombinationICS/LABAcombinedsingleinhaler

treatmentshouldbeprescribedatafixedmaintenancedose and patients also prescribed a SABA as a reliever therapy. LABA monotherapy is unsafe.

● LABAsshouldnotbeusedinchildren<4years of age. Montelukast should be used instead as add-on therapy.

● LABAs(withICS)shouldnotbeinitiatedwhenthechild is clinically unstable. They should be stopped iftheyareineffectiveorworsenasthmastability.

● The LABA should be stopped if the child deteriorates after starting it.

● The LABA should be stopped after 3 months if ineffective.

5.5 SMART TherapySMARTtherapy(‘SinglecombinationICS/LABAinhalerMaintenanceAndRelieverTherapy’)istheuseofacombinationICS/fastonsetLABAinhalerasbothmaintenance and reliever therapy in children. ThereisonepreviousstudyofcombinedICS/LABAmaintenanceandrelievershowingamarkedreduction inexacerbations,comparedtofixeddosesofICS/LABA or ICS plus SABA.44 ICS and SABA combinations are also under study.45 Atthemoment,thereisinsufficientevidencetorecommendSMARTtherapyasfirstlinetherapyinchildren 11 years and under, but it may be considered onspecialistadviceinselectchildrenwhoarepoorlycontrolledonSteps3-5:● The child should be able to use the inhaler device

effectivelyevenwhenshortofbreath.● Thechildand/orcarershouldunderstandthe





upperlimitonrelieverdosesperdayallowedintheaction plan, before seeking medical assistance.

● Along-actingbeta-agonistwithrapidonsetofactionmustbeused,andtheonlyproductlicensedinNewZealandforthisapproachisSymbicortviaturbuhaler.

● Prescriptionshouldbeforonepufftwicedailyofthe100/6microgramturbuhalerastheregularscheduled maintenance dose.

● Onepuffisgivenasneededasreliever.Upto4reliever puffs per day may be used. After this, the child and caregiver should seek medical attention foraflare-up.

● When presenting to primary or secondary care for aflare-up,aSABAmaybegivenasusual.

5.6 Montelukast● In preschoolers, montelukast should be trialled as

add-ontherapyforchildrenwhoremainpoorlycontrolled on ICS.

● In school age children, montelukast may be trialled in children poorly controlled on combined ICS/LABAtherapy.

● As montelukast is not effective in all patients, the trial should be stopped if not successful or if there are adverse effects.

● Montelukast may also be considered as an alternative to ICS at Step 2 in preschool and school-age children, but ICS are generally more effective. 46

● Thedoseofmontelukastis4mgoncedailyinchildrenunder5yearsand5mginschool-agechildren. The different doses are different formulations, so the effective dose is quite different betweenthem.

● Montelukastisgenerallysafewithasimilarrateof

adverse events as placebo in trials.47,48However,due to neuropsychiatric side-effects, the medication should not be used for mild symptoms, and parents shouldbewarnedtostopthemedicationifthereisincreased suicidal ideation in older children, or sleep and behavioural disturbance.

5.7 Specialist referral and step 5 therapyChildren requiring frequent or continuous doses of systemicsteroids(morethan14daysina12-monthperiod),orwhoarepoorlycontrolledatStep4,orwhoareonStep5shouldbereferredtoaspecialistpaediatricianforreview.● Lack of response to preventer therapy suggests the

child may not have asthma and the diagnosis should be reviewed,whichmayrequirespecialistinvestigation.

● Aprolongedcourse(>7days)ofdailyoralternateday oral corticosteroid may be required in some cases to gain symptomatic control, and this may best be prescribed under specialist supervision and withobjectivemonitoringofbenefit.

● Children are at greater risk of adverse events to systemic steroids than adults and should be monitored,andanyaffectsongrowthassessed by a specialist if they receive frequent steroids.

● Injectablebiologicanti-inflammatoryagents (e.g.omalizumabandmepolizumab),whichpreventflare-upsandreducetheneedforsystemiccorticosteroids,arenowavailable.Theserequirespecialistreviewforfundingandneedtobeinitiated in a secondary care setting. These agents aresafeandeffectiveandwhereappropriatetheiruse is encouraged, but outside the scope of these guidelines.

6.Treatmentofacutesevereasthma(primarycare,after-hours careorED)Goal: All children should be managed to avoid life-threatening asthma or deathAcuteasthmamanagementisbasedon:● Objective measurement of severity.● Assessment of the need for referral to hospital

and/orhospitaladmission(Table5).● Administering treatment appropriate for the

degree of severity.

● Repeatedly reassessing the response to treatment.● Monitor pulse rate, respiratory rate, accessory

muscleuseandabilitytospeak(words/breath).● Keyprioritiesincludeidentificationofalife-

threatening attack requiring urgent admission to intensive care, and a severe asthma attack requiringhospitaladmission(Table6andFigure5).





Table 6: Criteria for acute referral to hospital and/or hospital admission in children

• Child with any feature of life-threatening asthma.

• Child with any feature of an acute severe attack persisting after initial treatment.

• Child in whom other considerations suggest that admission may be appropriate: - Still have significant symptoms after initial treatment - Psychosocial problems in child or parent/caregiver - Physical disability or learning difficulties - Previous near-fatal or brittle asthma - Flare-up despite adequate dose of oral steroids pre-presentation - Presentation at night - Remote location or without transportation/communication

Nebulisation, spirometry and peak expiratory flow monitoring are aerosol generating procedures and their use should be minimised while COVID-19 is a risk.

Practice points – acute severe asthma:● A lack of response to initial bronchodilator

treatmentand/orarequirementforrepeatdoses2-hourly or more often indicates the need for referraltohospitaland/oradmission.

● Formostchildren,initialtreatmentwithbeta-agonistviaaspacerandoralsteroidsislikelytobesufficient.Reservenebulisedbeta-agonistsforthosewithsevereasthmawhorequirecontinuousoxygen.49

● If the child does not respond to initial therapy via spacer, carefully observe spacer technique, and if inhalation is ineffective use a nebuliser.

● The standard regimen for a course of prednisone in thesituationofsevereasthmais1-2milligrams/kg(toamaximumof40milligrams)dailyfor3-5days.

● Steroids, such as oral prednisone are not likely to be effectiveinchildren<5years.Inthisagegroup,they should be reserved for children admitted to hospital(orwhoareenroute)andwhoareonoxygen.

● In ambulance or hospital consider IV magnesium sulphate according to local protocol if the patient is life-threateningorapatientwithsevereasthmaisdeteriorating. Salbutamol and sometimes aminophylline may also be used depending on local protocols.

● Non-invasive ventilation in life-threatening asthma is not recommended outside of an intensive care setting.

● Forchildrenwithacutesevereasthmawhoaretreated in primary care or discharged from the after-hours clinic or ED, long-term management shouldbereviewedandfollow-upappointmentwithintheweekwiththeirprimaryhealthcareteamshould be arranged.

● Allchildren≥5yearswhohavepresentedwithacutesevereasthma,andwhoarenottakingICS,should be prescribed ICS before going home.8

● Avoid prescribing antibiotics, unless clear evidence ofabacterialinfection.Asthmaflare-upsareusually caused by viruses.





Figure 5: Algorithm for community management of moderate, severe and life-threatening acute asthma in children 4 – 11 years.

Arrange urgent transfer to hospital

via ambulanceAll patients will require

hospital admission

MildAble to talk

SpO₂ ≥ 92%

(PEF ≥ 50% best or predicted)

No incr Resp Rate

Mild expir wheeze and/or mild dyspnoea

Give 2 x 100 mcg Salbutamol via MDI & Spacer

Prednisone not requiredDischarge with advice

UnstableSigns of moderate or

severe asthma or PEF < 70

Refer to hospitalContinue management

according to figure

DISCHARGEOnce pre-discharge

conditions met

Continue Prednisone 3 - 5 days

Follow up

Life-threateningSpO₂ < 92%Plus any of:

• Exhaustion, agitation or altered consciousness

• Cyanosis or silent chest• (PEF < 30% best or predicted)

Oxygen as requiredGive continuous Salbutamol 2.5 mg nebulised with oxygen

Ipratropium bromide 0.25 mg nebulised

Hydrocortisone IV 4mg/kg (max 100 mg)

Oxygen as required

Give Salbutamol 2.5 mg nebulised with oxygen, frequency determined by response up to continuously

Ipratropium bromide 0.25 mg nebulised 4 hrly till improved

Consider IV MgSO4, Salbutamol, Aminophylline as per local protocol

Refer Resus/ HDU/ICU

ModerateAble to talk

SpO₂ ≥ 92%

(PEF ≥ 50% best or predicted)

Incr Resp Rate

More than mild expir wheeze or mild dyspnoea

Give 6 x 100 mcg Salbutamol via MDI & Spacer

Age ≥ 5y, give Prednisone 1mg/kg (max 40 mg)

Remains moderateRepeat 6 x 100 mcg

Salbutamol via MDI & Spacer

Age ≥ 5y, give Prednisone 1mg/kg (max 40 mg)

if not given above

REASSESS (1 - 2 h)

ASSESS SEVERITY

SevereToo breathless to talk

Obvious accessory muscle useSpO₂ < 92%

(PEF 30 - 50% best or predicted)

Oxygen as requiredGive 6 x 100 mcg Salbutamol

via MDI & Spacer or Salbutamol 2.5 mg

nebulised with oxygenGive Prednisone 1mg/kg

(max 40 mg)

REASSESS (15 – 60 mins)

Good responseConsider ICS and oral

prednisone if not given above

DISCHARGEOnce pre-discharge conditions met

Continue Prednisone 3 - 5 days

Follow up within one week

Follow upWean reliever to as needed

Ensure ICS commenced

Check risk factors, compliance, education and action plan

StableNo signs of moderate

or severe asthma

SevereOxygen as required

Give 6 x 100 mcg Salbutamol via MDI & Spacer or Salbutamol 2.5 mg nebulised with oxygen up to 3 times

per hour over 1st hour

Ipratropium bromide 4 x 20 mcg via MDI & Spacer

or 250 mcg nebulised

Use life-threatening pathway if any life-

threatening features





Table 7: Pre-discharge considerations in children

1. Most children presenting with acute flare-ups of asthma should have a course of oral prednisone, 1 - 2 milligrams/kg (to a maximum of 40 milligrams) daily for 3 - 5 days.

2. All children admitted to hospital for asthma should have a structured review assessing control, inhaler technique, asthma education, an action plan and follow-up by a specialist.

3. It is recommended that children have prednisone and ICS dispensed prior to discharge to ensure there are no barriers to taking medication.

4. Before sending a child home, ensure that the child with caregiver:

• Understands treatment prescribed and the signs of worsening asthma.

• Can demonstrate inhaler use correctly and has a supply of the medication.

• Understands how to contact emergency services/seek further advice if symptoms deteriorate (i.e. has an action plan).

• Has access to phone and transportation.

• Arranges an early follow-up appointment with their primary healthcare team for review (within a week).

5. Consider:

• Referral to asthma educator.

• Housing and social implications, e.g. social worker involvement.

• Encourage notification of hospital admission to school or childcare centre.

Checks at follow-up visit after admission

1. Clinical assessment – resolution of symptoms and signs would be expected.

2. Consider spirometry in older children.

3. Child and/or carer understand treatment prescribed and the signs of worsening asthma.

4. Child and/or carer can demonstrate inhaler use correctly and has a supply of the medication.

5. Carer understands how to contact emergency services/seek further advice if symptoms deteriorate.

6. Check written action plan.

7. Check housing and social implications.

8. Check vaccinations and other preventive measures.





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36. HoltSetal.Theuseoftheself-managementplansystemofcareinadultasthma.PrimCareRespJ2004;13:19-27.

37. GibsonPG,PowellH.Writtenactionplansforasthma:anevidence-basedreviewofthekeycomponents.Thorax2004;59:94-9.

38. RobsonB,HarrisR.Hauora:MāoriStandardsofHealthIV.Astudyoftheyears2000–2005.2007. TatauKahukura:MāoriHealthChartBook2015,3rdedition.Accessed www.health.govt.nz/publication/tatau-kahukura-maori-health-chart-book-2015-3rd-edition

39. D’SouzaWetal.Asthmamorbidity6yrsafteraneffectiveasthmaself-managementprogrammeinaMāoricommunity.EurRespirJ2000;15:464-9.

40. PilcherJetal.Combinationbudesonide/formoterolinhalerasmaintenanceandrelievertherapyinMāoriwithasthma.Respirology2014;19:842-51.

41. AsthmaandRespiratoryFoundationofNewZealand2015.TeHāOra(TheBreathofLife):NationalRespiratoryStrategy.Wellington:TheAsthmaFoundation.

42. PowellH,GibsonP.Highdoseversuslowdoseinhaledcorticosteroidsasinitialstartingdoseforasthmainadultsandchildren.TheCochraneCollaboration.TheCochraneLibrary2008,Issue4.

43. HoltSetal.Dose-responserelationofinhaledfluticasonepropionateinadolescentsandadultswithasthma: meta-analysis.BMJ2001;323:253-6.

44. BisgaardHetal.Budesonide/formoterolmaintenanceplusrelievertherapy:anewstrategyinpediatricasthma.Chest.2006Dec;130(6):1733-43.

45. Martinezetal.Useofbeclomethasonedipropionateasrescuetreatmentforchildrenwithmildpersistentasthma(TREXA):arandomised,double-blind,placebo-controlledtrial.Lancet.2011Feb19;377(9766):650-7.

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http://www.health.govt.nz/publication/equity-health-care-maori-framework

http://hdl.handle.net/10523/6747



http://www.health.govt.nz/publication/tatau-kahukura-maori-health-chart-book-2015-3rd-edition



Appendix A

Dat

e Pr

epar

ed:

____

____

____

____

___

Doc

tor/

Nur

se S

igna

ture

: ___

____

____

____

____

____

____

____

__ P

lan

to b

e re

view

ed w

hen

trea

tmen

t cha

nged

Wel

l W

hen

I’m w

ell:

•

I hav

e no

cou

gh

• I p

lay

just

like

oth

er c

hild

ren

• I u

se m

y re

lieve

r puff

er le

ss th

an 2

tim

es a

wee

k

Wor

seW

hen

my

asth

ma

is g

etti

ng w

orse

:

• I c

ough

or w

heez

e an

d it

’s ha

rd to

br

eath

e, o

r •

I’m w

akin

g at

nig

ht b

ecau

se o

f my

asth

ma,

or

• I c

ough

or w

heez

e w

hen

I pla

y, o

r•

I nee

d m

y re

lieve

r inh

aler

to c

ontr

ol m

y as

thm

a m

ore

than

2 ti

mes

per

wee

k

If m

y as

thm

a ge

ts w

orse

I sh

ould

:

Keep

taki

ng m

y pr

even

ter e

very

day

as

norm

al a

nd ta

ke _

____

_ pu

ffs o

f my

relie

ver e

very

4 h

ours

If I’m

not

get

ting

bett

er d

oing

this

I sh

ould

see

my

doct

or to

day

Cont

act:

My

puff

ers

are:

Prev

ente

r: I

take

this

eve

ry d

ay e

ven

whe

n I’m

wel

l.

Th

e na

me

of m

y pr

even

ter i

s __

____

____

____

____

____

____

_

The

colo

ur is

I t

ake

____

__ p

uffs

in th

e m

orni

ng a

nd _

____

_ pu

ffs a

t nig

ht th

roug

h a

spac

er.

Relie

ver:

I ta

ke th

is o

nly

whe

n I n

eed

it

Th

e na

me

of m

y re

lieve

r is

____

____

____

____

____

____

___

Th

e co

lour

is

I tak

e __

____

puff

s th

roug

h a

spac

er w

hen

I whe

eze,

cou

gh o

r whe

n it

’s ha

rd to

bre

athe

.

If I fi

nd it

har

d to

bre

athe

whe

n I e

xerc

ise

I sho

uld:

Tak

e __

____

puff

s of

my

relie

ver

Wor

ried

My

asth

ma

is a

wor

ry w

hen:

•

My

relie

ver i

sn’t

help

ing,

or

•

I’m fi

ndin

g it

hard

to b

reat

he, o

r

•

I’m b

reat

hing

har

d an

d fa

st, o

r

•

I’m s

ucki

ng in

aro

und

my

ribs/

thro

at,

try

look

ing

unde

r my

shir

t•

I’m lo

okin

g pa

le o

r blu

e

• Si

t me

dow

n an

d tr

y to

sta

y ca

lm•

Giv

e m

e 6

puffs

of r

elie

ver t

hrou

gh a

spa

cer,

ta

king

6 b

reat

hs fo

r eac

h pu

ff

• If

I do

n’t s

tart

to im

pro

ve I

need

hel

p n

ow

Emer

genc

yD

IAL

111

and

ask

for a

n am

bul

ance

WH

ILE

YOU

’RE

WA

ITIN

G:

• Tr

y to

sta

y ca

lm a

nd k

eep

me

sitt

ing

uprig

ht

•

Giv

e 6

puffs

of r

elie

ver t

hrou

gh a

spa

cer e

very

6

min

utes

with

6 b

reat

hs fo

r eac

h pu

ff u

ntil

help

arr

ives





Appendix B

Ast

hma

Emer

genc

yW

ell

Wor

seW

orri

ed

If yo

u ha

ve ti

cked

any

of t

he

red

boxe

s, yo

u ne

ed to

dia

l 111

an

d as

k fo

r an

ambu

lanc

e.

If yo

u ha

ve ti

cked

any

of t

he

yello

w b

oxes

, incr

ease

you

r tre

atm

ent i

n lin

e w

ith y

our

actio

n pl

an. If

you

’re n

ot g

ettin

g be

tter s

ee y

our d

octo

r tod

ay.

If yo

u ha

ve ti

cked

onl

y th

e gr

een

boxe

s, th

ings

are

goi

ng

real

ly w

ell.

If yo

u ha

ve ti

cked

any

of t

he

oran

ge b

oxes

, see

a d

octo

r to

day.

Doc

tor:

____

____

____

____

____

____

____

___

Pre

vent

er: _

____

____

____

____

____

____

____

__ R

elie

ver:

____

____

____

____

____

____

____

___

Refe

r to

the

sym

ptom

s key

to h

elp

you

fill i

n th

e sy

mpt

om d

iary

cha

rt b

elow

. U

se th

is S

ympt

om D

iary

alo

ng si

de y

our A

sthm

a Ac

tion

Plan

.

Dat

eD

id y

ou c

ough

toda

y?D

id y

ou w

heez

e to

day?

Did

you

r ast

hma

affec

t you

r nor

mal

ac

tivi

ty?

Did

you

r ast

hma

wak

e yo

u up

in th

e ni

ght?

How

man

y do

ses o

f re

lieve

r did

you

take

to

day?

Com

men

ts

If yo

u ar

e fr

ight

ened

at

any

stag

e ca

ll 11

1.





Appendix C

List of organisations and individuals consulted for feedback:

AllDHBs

AllPHOs

AsthmaNZ

Australasian College of Emergency Medicine

AuthorsofAsthmaandRespiratoryFoundationNZ, NZAdolescentandAdultAsthmaGuidelines

Breathingworks

CanterburyHealth

Conference delegates

Departments of General Practice for Medical Schools

GeneralPracticeNZ

HealthInformaticsNZ

HealthInformationStandardsOrganisation

IanTown

InternalMedicineSocietyofAustraliaandNZ

JulianCrane

KidzFirst

MaternalandChildHealthMid-CentralDistrictHealth

Medtech

MedicalResearchInstituteofNewZealand

Ministry of Education

MinistryofHealthNGO

NationalHealthITBoard

Nicola Corna

NgāKaitiakioTePunaoRongoāoAotearoa, MāoriPharmacists’Association

NPNZ

NZMedicalAssociation

NZResuscitationCouncil

NZSpeechTherapistsAssociation

NZNO&NZNOCollegeofRespiratoryNurses

Paediatric Society

Paediatrics’ Otago Medical School

PasifikaGPNetwork

PasifikaMedicalAssociation

PHARMACPharmaceuticalManagementAgency

PharmaceuticalSocietyofNZ

PharmacyGuildofNZ

PhilippaHowden-Chapman

POITeamPublicHealthSouth

ProCare Clinical Advisory Committee

RespiratoryandSleepMedicineAucklandUniversity

Royal Australasian College of Physicians

RoyalNZCollegeofGPs

Special Education

StJohnsAmbulance

StarshipChildren’sHealth

TeOra:MāoriMedicalPractitioners

Teresa Chalecki

TeRūngangaoAotearoa(NZNOMāori)

ThoracicSocietyofAustraliaandNZ–NZBranch

TSANZNursesspecialinterestgroup

Wellington Free Ambulance

Competing interests:

DrHarwoodreportspersonalfeesfromAstraZenecaLimitedoutsidethesubmittedwork;

DrReidreportsaffiliationwithContractResearchoutsidethesubmittedwork;

DrAsherreportsonegrantfromBoehringerIngelheimNewZealandoutsidethesubmittedwork;

DrInghamreportspersonalfeesfromTeHāOra:TheAsthma&RespiratoryFoundationofNewZealand, grantsfromJanssenResearch&Development,non-financialsupportfromAstraZeneca,outsidethesubmittedwork;

TeresaDemetrioureportsgrantsfromREXMedicaloutsidethesubmittedwork.



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NEW ZEALAND CHILD ASTHMA GUIDELINES...New Zealand, with the aim of improving outcomes and achieving health equity. The intended users are health The intended users are health professionals