Paeds1_Asthma -Sherine Dewlett
Speaker key
SD Sherine Dewlett
SD My name is Sherine Dewlett. I’m a consultant paediatrician with an allergy and respiratory interest at the Royal Free Hospital. And my talk today is about the essentials of asthma management in primary care. So a brief summary: it’s about the diagnosis of asthma, about the differential diagnosis and then about the management of asthma and when to refer on to secondary care.
IV How does a GP diagnose asthma?
SD Okay. Well, asthma’s very common and GPs tend to underdiagnose asthma in primary care. The symptoms of asthma are cough, wheeze, shortness of breath and chest tightness and a consideration of a diagnosis of asthma needs to be thought of when a child presents with these symptoms. It is a clinical diagnosis so there’s no gold standard test. So it’s based on taking the right history and asking the right question. And it’s about probability of it being asthma or not. So if a child presents with these symptoms and has other factors – so if these symptoms aren’t just with a virus but occur with exercise or with emotion or change of weather – that increases the probability of it being asthma.
Also asthma is on the allergic spectrum so if the child has atopy themselves, a personal history of atopy, or a family history of atopy, that increases the probability. So if there’s rhinitis, food allergies or eczema in the child or in the family, that would increase the probability of it being asthma. The other thing about asthma is that there’s a diurnal variation. So if there’s worsening symptoms at night-time or in the morning, that also increases the probability of it being asthma. So those would be the right questions to ask and, if any of them are positive, to consider a trial of asthma medication.
IV What tests are there in primary care to enable diagnosis?
SD So asthma is a clinical diagnosis. But in older children who can perform lung function tests, lung function can be helpful in the diagnosis. So there’s spirometry and a reduced FEV1 would be suggestive of asthma. The other tests they can do is a peak flow. Again, this is in older children, so over five that can comply with this. And a reduced peak flow would be suggestive of asthma, and particularly if there’s bronchodilator reversibility. So that’s peak flows pre and post a salbutamol inhaler. And if the peak flow increases by 12%, that’s suggestive of asthma.
IV What is the differential diagnosis? Are there any red flags?
SD So the differential diagnosis of asthma – one of the main differential diagnoses is probably viral induced wheeze which is wheeze that only occurs with viruses. But there are some other important conditions to think about. So the chronic suppurative conditions such as cystic fibrosis and primary ciliary dyskinesia, gastro-oesophageal reflux disease, anatomical problems in aspiration and, in older children, things like panic disorders and dysfunctional breathing, which can often coexist with asthma. So the red flag symptoms to consider is if a child has failure to thrive or if the onset is in the neonatal period or very early on, then you need to consider a differential diagnosis. And if vomiting is a main feature of the illness or if really there’s very little wheeze and it’s mainly just chronic wet cough, that would be suggestive of a suppurative condition. And another red flag is if there’s poor response to asthma medications; that would also alert to the possibility of a different diagnosis.
IV How does a GP treat asthma in primary care?
SD So asthma is an inflammatory condition and the mainstay of management is an inhaled corticosteroid. So a GP would treat asthma with an inhaled corticosteroid or a trial of a leukotriene antagonist in a younger child. And the way to treat asthma is to control the symptoms on the minimal dose of inhaled corticosteroid. And there’s a clear BTS guideline which is step one to five and to increase the dose according to the symptoms or to step down.
IV Are there any common pitfalls in treatment to try and avoid?
SD So when stepping up with medication, once asthma control has been assessed, instead of always just stepping up with the medication, the things that really need to be considered, so the pitfalls, would be to make sure that the patient understands what they’re doing, that they understand the difference between a preventer and a reliever and that they have an asthma action plan so they understand when to use the right medications. Inhaler technique is very important, so you need to show them inhaler technique regularly and make sure that they’re getting their medicines. Compliance is a very important issue and even though patients often say they’re taking their medication regularly every day, we know that that’s not really the case, and looking at electronic prescribing is useful in this case. And the other thing to think about is other triggers. So if there’s untreated rhinitis, that’s important to treat with a nasal corticosteroid. Or if there’s other triggers such as house dust mites or smoking, those are things to address as well.
IV How do you assess control?
SD Assessing control in asthma is very important, to know whether to step up or step down. The main questions to ask would be, do you have a cough at night or a cough with exercise. So that’s interval symptoms.
How often they’re needing their blue inhaler, their reliever medicine. And how often they’re missing school with their asthma. And then a general question about how they feel they are with their asthma. And also asking about how often they needed courses of steroids and how often they’ve attended A and E with their asthma.
IV When should a GP refer on?
SD So a GP should refer on if there’s any diagnostic uncertainty. If there is severity. So if the child has had two courses of oral steroids or if there’s multiple A&E attendances. If they’re reaching step two to three of the BTS guidelines or if the parents want a second opinion or are particularly concerned.
IV Where can GPs find out more?
SD So very useful resources are the BTS 2014 Guidelines which are available on the internet. The Global Initiative for Asthma also is very useful, has some pocket guides that can be downloaded. Other useful websites are www.asthma.org and Itchy Sneezy Wheezy and that has useful resources such as its asthma action plans and also videos on inhaler technique which can be quite useful to look at. And obviously there’s the BNF as well. So those are the places that a GP can find out more. So I’m happy to be contacted on .
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