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ROYAL FREE CHILDREN’SSERVICES

Rahul Chodhari , Consultant Paediatrician07711808012, R.Chodhari@nhs.net

Aims of the talk• Opportunities to improve asthma care in

Camden• Diagnosis in primary care• Preschool wheeze v asthma

– When to refer?

A belief that asthma could be cured bythe sound of a violin

Asthma, caricature from 'Album Comique de Pathologie Pittoresque', published in Paris, 1823

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NRAD and Children• 28 children died of asthma (CF registry 0%)• 80% died before reaching hospital• 42% who died were labelled as mild /

moderate asthma• “Asthma attack” kills rather than severe asthma

label• 80% had one or more avoidable Factors• 30% had an inhaler assessment in 10 care

Thx to Dr. James Paton, Clinical Audit Lead, RCPCH, NRAD – May 2014

are likely to have asthma.*75% of asthma admissions are preventable.

On average, 3 children in a classroom of 30

Asthma UK -2010*Epidemiology and Statistics Unit. Trends in Asthma Morbidity and Mortality. NYC: ALA, July 2006.

22%

24%

20%

14%

14%

23%

24%

31%

52%

11%

18%

5%

0

10

20

30

40

50

60

70

0 1 2 3 4 5 6 7 8 9 10 11 12 13

Totalmonthly

Paediatricasthma

attendances

Months

RFH Paediatric asthma admission rates (%) 2014

January February March April May June July August September October November December

1/3 of A&Eattendances arerepeat attendances

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Chimat atlas of Paediatric admissions

Camden 119

Barnet 55

Islington282

Haringey185

Brent 452RFH

http://www.chimat.org.uk/resource

Cases: Asthma, episodic wheeze ormulti trigger wheeze?

• 3 year old Gemma• 4 year old Jonny

Definitions• Preschool children

– Episodic viral wheeze – the child is only wheezing duringclinically diagnosed URTI

– Multiple trigger wheeze – URTI, smoke, allergens, exercise,food allergy and pollution

• Asthma is a chronic disease characterised bywheezing, breathlessness, night time or earlymorning coughing– Episodes are usually associated with airflow obstruction

within the lungs that is reversible with treatment

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Preschool wheeze clinical categoriesEpisodic viral wheeze

(EVW)Multiple trigger wheeze (MTW):

Viral URTI inducedwheeze

+++ +++

Interval symptoms None. Wheeze with triggers, such as exerciseand smoke and allergen exposure.

Treatment Symptomatic only forthe episode

Rx is ↑ or ↓depending on symptompattern and severity

Eosinophilicinflammation &remodelling

None Similar to asthma

Will it lead to asthma? Not in long runprovided there is noh/o of atopy.

More likely with higher number oftriggers.

European Respiratory Society Task Force classification

Case: Episodic Viral Wheeze (EVW)

• What are treatment options for EVW?• Would you prescribe Montelukast, inhaled

steroids or oral prednisolone?• Would you prescribe prophylactic

Montelukast or inhaled steroids?

Royal Free Out patientspictures.

Episodic Viral Wheeze (EVW)• PREEMT trial – Use of Montelukast resulted in fewer

visits to GP’s/ED & fewer days away from nursery– Start Rx at the first sign of a viral cold and discontinue it when

the child has recovered• No evidence that inhaled corticosteroids or oral

prednisolone helps in treatment or prevention of futureepisodes

• Some hospitalised children may need steroids• Long acting β2 agonists are not licensed for use in

preschool children

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Multiple Trigger Wheeze (MTW)• Treat acute episodes with Salbutamol or

anticholinergics• Pragmatic regimen for treatment (Prof Bush, 2014)

– Step 1: Trial of inhaled corticosteroids or Montelukast instandard dose for max eight weeks

– Step 2: Stop treatment; either there has been noimprovement, in which case further escalation is notvaluable, or symptoms have disappeared

– If there is no benefit and the symptoms are worse – refer.– Step 3: Restart treatment only if symptoms recur; then

reduce treatment to the lowest level that controlssymptoms.

Prevalence of asthma• It is the most common childhood chronic condition• Patient reported asthma symptoms (adults included)

• 1973 – 4.2%• 1988 – 9.1%• 2003 – 15.4%• 2010 – 17%

• Hospital admissions are falling• Risk of asthma rises with:

– positive family history atopy– maternal smoking in pregnancy– early sensitisation to aeroallergens

Burr Thorax 2006, Asthma UK, National statistics

British Thoracic Society (BTS) guideline Oct 2014

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Case: High v Low probability of asthma?• 5 year old Josh:

– 4 episodes of wheezingin the past, mostly withURTI

– Improvement insymptoms after startingRx

– Symptoms are worse atnight and in the earlymorning

– Widespread wheezeheard on auscultation

Royal Free OPD

High probability of asthma• More than one of the following symptoms:• Wheeze, cough, difficulty breathing, chest

tightness, particularly if these symptoms:• are frequent and recurrent• are worse at night and in the early morning• occur in response/worse after triggers, such as

exposure to pets, cold or damp air, or with emotions orlaughter

• occur apart from cold• personal/ Family history of atopy or asthma• wheeze heard on auscultation• improvement in symptoms or lung function in response

to adequate therapy

Case: High v Low probability ofasthma?

• 13 year old Jenny:– Isolated cough in the absence of

a wheeze or difficulty breathing– Dizziness, light-headedness and

peripheral tingling– Normal peak expiratory flow

when symptomatic– No response to a trial of asthma

therapy

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Low probability of asthma• Symptoms only with colds and with no interval symptoms• Isolated cough in the absence of a wheeze or difficulty

breathing• Prominent dizziness, light-headedness and peripheral tingling• Repeatedly normal physical examination of the chest when

symptomatic• Normal peak expiratory flow (PEF) or spirometry when

symptomatic• No response to a trial of asthma therapy• Clinical features pointing to alternative diagnosis

Clinical features pointing to alternativediagnosis

• Symptoms are present from birth or perinatallung problem

• Isolated upper respiratory tract disease– Stridor, chest deformity and asymmetric signs

• Persistent moist cough• Failure to thrive• Abnormal voice or cry

When should you refer?• Investigations - SPT, PEFR or spirometry

• Escalating dosages above BTS step 2/3• To establish and review definitive diagnosis

• Poor response +/- compliance• Trigger avoidance advice• Education & device technique• Risk assessment – severity and home visits• Management of co-morbidities• Communication with other agencies

• Involved people (doctor, child, family) areunhappy with outcomes

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Clinical Gems• Clarify what the family means by wheezing• Isolated dry cough in a community setting is

rarely due to asthma• Preschool wheeze - “episodic viral” or

“multiple trigger”• Pre school wheeze treatment is driven

solely by current symptoms• Prednisolone is not indicated in preschool

children with wheezing attacks• Focus clinical assessment of school wheeze

based on high or low probability of asthma