Asthma Management Handbook

Planning and conducting routine asthma review for children

Recommendations

As a general guide, review each child’s asthma:

  • every 3–6 months when asthma is stable and well controlled
  • 4 weeks after increasing the dose or number of medicines to regain control of partially or poorly controlled asthma
  • 4–6 weeks after reducing dose of preventer or stepping down treatment
  • within 4 weeks after a visit to the emergency department or a hospital stay due to acute asthma (in addition to early post-acute reassessment within 3 days of discharge).

Table. Definition of levels of recent asthma symptom control in children (regardless of current treatment regimen)

Good control Partial control Poor control

All of:

  • Daytime symptoms ≤2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • No limitation of activities
  • No symptoms§ during night or when wakes up
  • Need for SABA reliever# ≤2 days per week

Any of:

  • Daytime symptoms >2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • Any limitation of activities*
  • Any symptoms during night or when wakes up††
  • Need for SABA reliever# >2 days per week

Either of:

  • Daytime symptoms >2 days per week (lasting from minutes to hours or recurring, and partially or fully relieved by SABA reliever)
  • ≥3 features of partial control within the same week

SABA: short-acting beta2 agonist

† e.g. wheezing or breathing problems

‡ child is fully active; runs and plays without symptoms

§ including no coughing during sleep

# not including doses taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

​* e.g. wheeze or breathlessness during exercise, vigorous play or laughing

†† e.g. waking with symptoms of wheezing or breathing problems

Notes:

Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future asthma outcomes should also be assessed and taken into account in management.

Validated questionnaires can be used for assessing recent symptom control:
Test for Respiratory and Asthma Control in Kids (TRACK) for children < 5 years
Childhood Asthma Control Test (C-ACT) for children aged 4–11 years

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

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Arrange more frequent follow-up for children with any of the following risk factors:

  • confirmed food allergy
  • poor asthma control
  • admission to hospital in preceding 12 months
  • a history of intubation for acute asthma
  • over-use of short-acting beta2 agonist reliever
  • frequent failure to attend consultations
  • abnormal spirometry findings
  • reversible expiratory airflow limitation on spirometry despite treatment
  • poor adherence to preventer
  • poor inhaler technique for preventer
  • poor adherence to asthma action plan
  • significant parental psychological or socioeconomic problems
  • carer unequipped to manage asthma emergency
  • exposure to clinically relevant allergens
  • exposure to tobacco smoke
  • obesity.
  •  food allergy is risk factor for life-threatening asthma flare-ups

Notes:
Normal spirometry includes FEV1/FVC greater than lower limit of normal for age and FEV1 % predicted ≥80%.
Reversible expiratory airflow limitation in children is defined as an increase in FEV1 ≥12% from baseline 10–15 minutes after administration of bronchodilator.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • NSW Child Death Review Team 20171
  • Consultative Council on Obstetric and Paediatric Mortality and Morbidity2
  • GINA 20183
  • Quezada et al. 20164

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At each asthma review, assess:

  • recent asthma symptom control based on reported symptoms, limitation of daily activity and need for reliever medicine
  • whether the child has any risk factors for poor asthma outcomes in future (e.g. persistent symptoms, over-use of short-acting beta2 agonist reliever, severe asthma, poor adherence, exposure to tobacco smoke, obesity, severe allergies such as food allergies or history of anaphylaxis, previous severe life-threatening acute asthma or hospital admission for asthma, history of sudden severe unpredictable asthma flare-ups, or significant psychosocial factors including socioeconomic deprivation)
  • lung function using spirometry (for children old enough to perform the test)
  • adherence to treatment
  • inhaler technique
  • whether the written asthma action plan is up to date
  • modifiable environmental factors including exposure to tobacco smoke or significant airborne allergens
  • whether parents or child have any concerns about the treatment (e.g. cost, potential side effects).

Notes:
Assessments can be made by asking the same questions at each visit, or using validated questionnaires.
If children are referred to a lung function laboratory for spirometry for the purpose of monitoring asthma treatment, they should keep taking their preventer as usual. Inhaled corticosteroid–long-acting beta2 agonist preventers should not be withheld before the test. (If referred for diagnostic spirometry, preventer should be withheld to ensure the test is accurate.)

Table. Definition of levels of recent asthma symptom control in children (regardless of current treatment regimen)

Good control Partial control Poor control

All of:

  • Daytime symptoms ≤2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • No limitation of activities
  • No symptoms§ during night or when wakes up
  • Need for SABA reliever# ≤2 days per week

Any of:

  • Daytime symptoms >2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • Any limitation of activities*
  • Any symptoms during night or when wakes up††
  • Need for SABA reliever# >2 days per week

Either of:

  • Daytime symptoms >2 days per week (lasting from minutes to hours or recurring, and partially or fully relieved by SABA reliever)
  • ≥3 features of partial control within the same week

SABA: short-acting beta2 agonist

† e.g. wheezing or breathing problems

‡ child is fully active; runs and plays without symptoms

§ including no coughing during sleep

# not including doses taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

​* e.g. wheeze or breathlessness during exercise, vigorous play or laughing

†† e.g. waking with symptoms of wheezing or breathing problems

Notes:

Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future asthma outcomes should also be assessed and taken into account in management.

Validated questionnaires can be used for assessing recent symptom control:
Test for Respiratory and Asthma Control in Kids (TRACK) for children < 5 years
Childhood Asthma Control Test (C-ACT) for children aged 4–11 years

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Table. Sample questions for reviewing asthma in children

Recent symptom control

How often does child wheeze or become short of breath?

Does child wake during the night due to wheezing or shortness of breath? (How many times per month?)

How often does child need to take reliever inhaler? (How many days per week? How many times per day? How many puffs?)*

How many weeks does child’s reliever inhaler last?

Has child missed time from childcare, school and or sport due to asthma?

Validated questionnaires are available for assessing recent symptom control:

Adherence to preventer treatment (if prescribed)

Does child take a preventer inhaler? (What dose is on the label? How many puffs per day have you been told to use?)

Many children miss some doses. In the last four weeks:

  • how many days a week would your child have taken the preventer medication? None at all? One? Two? (etc).
  • ​how many times a day would your child take it? Morning only? Evening only? Morning and evening? (or other)
  • each time, how many puffs would they take? One? Two? (etc).

Do you find it easier to remember to give it in the mornings or evenings?

How often does child need new script for preventer medicine? (Note: number of doses per unit varies between brands)

Flare-ups

Has child had a flare-up since last visit?

What triggered it? (e.g. cold symptoms, allergies, stopping preventer)

How was the flare-up treated?

Has child since last visit/ever needed to take oral corticosteroids? (How often and how much?)

Has child ever been hospitalised for asthma or a wheezing episode?

When was the child’s last flare-up (and last flare-up before that one)? How were these flare-ups treated?

How many times has child visited GP/hospital emergency room for asthma symptoms in the last [specify time period, e.g. year/month/2 weeks]?

Allergies

Does child have allergic rhinitis (hay fever)?

Is child using other medicines for respiratory symptoms (e.g. oral or intranasal antihistamines, intranasal corticosteroids)?

Does the child have allergies (e.g. to foods or insect bites) or need an adrenaline injector (e.g. Epipen) for emergencies?

Does the child get skin rashes caused by allergies?

Inhaler technique

Can you show me how you use the inhaler?

When did you last wash the spacer? (How do you wash it?)

*Note: The use of more than 3 canisters per year (equivalent to use every day) is associated with doubling of the risk of severe flare-ups.1

1: Stanford RH, Shah MB, D'Souza AO et al. Short-acting beta-agonist use and its ability to predict future asthma-related outcomes. Ann Allergy Asthma Immunol 2012; 109: 403-7. (Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/23176877).

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

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Validated checklists or questionnaires can be used to assess recent asthma symptom control at each visit, e.g:

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

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Pharmacists should record the number of times a non-prescription short-acting beta2 agonist is dispensed for a child and ask parents how long puffer usually lasts, so that over-use can be identified and addressed (e.g. by counselling parents about risk of over-use of relievers, assessing asthma control and advising parents to visit their GP if poor control is identified, or alerting the child’s GP).

  • Dispensing of 3 or more canisters in a year (average 1.6 puffs per day) is associated with increased risk of exacerbations. Dispensing 12 or more canisters in a year (average 6.6 puffs per day) is associated with increased risk of asthma death.

Notes:
Recent asthma symptom control can be assessed using validated checklists or questionnaires.
Recording short-acting beta2 reliever dispensing is a regulatory requirement in some states.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Stanford et al. 20125
  • Suissa et al. 20006

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For children taking inhaled corticosteroids long term, monitor linear growth. At least annually, measure height and weight, accurately measured and plotted on a percentile chart.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 20107

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If treatment with high-dose inhaled corticosteroids is needed for 6 months or longer to control asthma or wheezing symptoms, or frequent courses of oral corticosteroids are needed:

  • refer to a paediatric specialist (e.g. paediatric respiratory physician or paediatrician) for assessment, including screening for adrenal suppression
  • provide specific written advice (steroid alert card) for other health professionals such as emergency services (e.g. that if child shows reduced consciousness, consider the possibility of adrenal insufficiency, check serum biochemistry, blood glucose level and serum cortisol urgently, and consider whether intramuscular hydrocortisone is indicated)
  • warn parents that adrenal suppression is a possible side effect and advise them what to do if the child develops symptoms consistent with adrenal insufficiency, such as lethargy, vomiting, abdominal pain or seizures (e.g. go to the emergency department without delay, tell staff that the child is using regular high-dose medicine for asthma, and hand them the child’s steroid alert card)
  • advise parents to consider having the child wear a medical alert bracelet.

Note:
Morning cortisol level is the standard screening test for adrenal suppression. If abnormal, it is followed up with a low-dose adrenocorticotropic hormone stimulation test. Referral to an endocrinologist is indicated if adrenal suppression is suspected or detected.

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (microg)

Low

High

Beclometasone dipropionate

100–200

>200 (maximum 400)

Budesonide

200–400

>400 (maximum 800)

Ciclesonide

80–160

>160 (maximum 320)

Fluticasone propionate

100–200

>200 (maximum 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: 
http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Issa-El-Khoury et al. 20158
  • van Asperen et al 20107
  • Zöllner et al. 20129
  • Schwartz et al. 201210
  • Ahmet et al. 201111
  • Priftis et al. 200912
  • Macdessi et al. 200313

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More information

Inhaled corticosteroids for children: adverse effects

Local adverse effects

Hoarseness and pharyngeal candidiasis are not commonly reported among preschool children or school-aged children talking inhaled corticosteroids. 14, 7, 15

Topical effects can be reduced by use of spacer devices (which reduce oropharyngeal deposition), and by mouth-rinsing and spitting after use.7 Immediate quick mouth-rinsing removes more residual medicine in the mouth than delayed rinsing.16

There is limited evidence that inhaled asthma medication can affect dental health.7, 17 Mouth rinsing might reduce this risk.

Systemic adverse effects

Systemic effects of inhaled corticosteroids in children depend on the dose, but clinically significant adverse effects are uncommon.7

The use of spacers and mouth rinsing will not reduce systemic effects, but the use of a spacer may increase efficacy so that a lower dose is required.

Growth

Short-term suppression of linear growth has been demonstrated in children taking inhaled corticosteroids.18,19 The effect seems to be maximal during the first year of therapy and only one study has reported an effect in subsequent years of treatment.19 A Cochrane systematic review concluded that regular use of inhaled corticosteroid at low or medium daily doses is associated with a mean reduction of 0.48 cm per year in linear growth velocity and 0.61 cm less gain in height during 1 year of treatment in children with mild to moderate persistent asthma.19

One study of patients who participated in a clinical trial of inhaled corticosteroids as children, reported a reduction in adult height of approximately 1 cm,18, 20, 21, 22 whereas several studies have reported that children taking inhaled corticosteroids attained normal adult height.23, 24, 25

The effect is dose-dependent21,22 and may be more likely in children who begin inhaled corticosteroid treatment before age 10.20

Other factors affect growth in children with asthma. Uncontrolled asthma itself reduces growth and final adult height.24 One study found that inhaled corticosteroid equivalent to budesonide 400 microg/day affected growth less than low socioeconomic status.25

Bone density

Inhaled corticosteroids have not been associated with effects on bone density or fractures in children. 7 However, data from a recent study in Australia suggested asthma itself is associated with increased incidence of fractures in children, independent of medication.26

Given that the total dose of corticosteroids (both inhaled corticosteroids and oral corticosteroids) influences bone health, the aim of asthma management is to maintain symptom control using the lowest inhaled corticosteroid dose required, and to avoid repeated courses of oral corticosteroids.

Adrenal suppression

Biochemical testing in a research setting suggests that hypothalamic–pituitary–adrenal axis suppression may occur in up to two-thirds of children treated with inhaled corticosteroids, and may occur at even low doses.9 The risk is higher among children receiving concomitant intranasal steroids and those with lower body mass index,9 and is influenced by genetics.27

Clinical adrenal insufficiency in children taking inhaled corticosteroids is rare but has been reported, 11, 12, 28 including cases in Australia.28 Most cases have involved children given more than 500 microg per day fluticasone propionate.11

Adrenal suppression is associated with hypoglycaemia, hypotension, weakness, failure to grow, and is potentially fatal. Hypothalamic–pituitary–adrenal axis suppression may not be detected until adrenal crisis is precipitated by physical stress.29

Written information (e.g. a steroid alert card) can be prepared for children receiving long-term high-dose inhaled corticosteroids. Parents/carers can be instructed to present the card if the child ever needs to go to the emergency department (for any reason) or be admitted to hospital. A steroid alert card should state that child has asthma and the inhaled corticosteroid dose. A medical alert bracelet could also be considered.

There are no nationally accepted protocols for routine assessment of adrenal function in primary care because it has not yet been possible to identify precisely which children should be tested, to interpret test results reliably, to identify the appropriate interval for retesting, and because a clinical benefit has not been clearly demonstrated.

Regular monitoring of height might help detect adrenal suppression, based on the findings of a study in which a reduction in linear growth velocity occurred before adrenal suppression.30

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (microg)

Low

High

Beclometasone dipropionate

100–200

>200 (maximum 400)

Budesonide

200–400

>400 (maximum 800)

Ciclesonide

80–160

>160 (maximum 320)

Fluticasone propionate

100–200

>200 (maximum 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: 
http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

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Approaches to assessment and monitoring of asthma control in children

Assessment of asthma control in children is based mainly on:

  • recent asthma symptom control (assessed by the frequency and severity of symptoms between flare-ups 
  • the degree to which asthma symptoms affect daily activities such as interference with physical activity or missed school days)
  • the frequency of flare-ups
  • spirometry in children who are able to perform the test reliably.

Standardised questionnaires

Questionnaire-based instruments have been validated for assessing asthma control in children:

Lung function tests

Frequent spirometry to guide asthma treatment in children has not been shown to achieve superior outcomes to symptom-based treatment.35 Current evidence does not support use of home spirometers to guide asthma treatment in children.36 However, low FEV1 predicts clinically significant flare-ups, so spirometry should be performed at asthma reviews for children who are old enough to do the test.
The quality and utility of spirometry depends on the skill, clinical expertise and experience of the person doing and interpreting spirometry.

The results of one study in children aged 6–16 years with moderate atopic asthma suggest that asthma treatment guided by airway hyperresponsiveness (measured by bronchial provocation testing) may have a benefit over symptom-guided treatment in improving lung, but this effect was lost after 3–7 years of usual care.3738 Repeated bronchial provocation testing is not feasible in clinical practice.

Measures of airway inflammation

Measures of airway inflammation (e.g. sputum eosinophil count, exhaled nitric oxide measurement) are not recommended in primary care to guide treatment decisions, but are increasingly used in specialist clinics.

Asthma treatment guided by sputum eosinophil count has been shown to reduce the frequency of flare-ups in adults with asthma, but there is insufficient evidence to ascertain its value for children.39

Exhaled nitric oxide measurement may be useful in guiding asthma management in some children. In children not taking inhaled corticosteroid, a high nitric oxide level probably predicts a good short-term response to inhaled corticosteroid treatment,40 but it does not distinguish between asthma and eosinophilic bronchitis and is often high in children with atopy. There is insufficient evidence to ascertain whether a low exhaled nitric oxide level predicts successful withdrawal from inhaled corticosteroids without asthma relapse,40 or safety of treating asthma without inhaled corticosteroids.

A Cochrane review41 found that exhaled nitric oxide-guided management was significantly better than other approaches to adjusting medicines for reducing the number of children with flare-ups and the number of children who needed oral corticosteroids, but did not reduce the frequency of flare-ups or the rate of flare-ups requiring hospitalisation, improve lung function or symptoms scores, or reduce inhaled corticosteroid doses. The authors concluded that it could not be recommended for all children but may be beneficial for a subset not yet defined.41

Towards personalised asthma care

Emerging understanding of asthma phenotypes and of genetic factors that predict therapeutic response to preventer options is leading to the possibility of personalised, genomics-based treatment for asthma in children.42 In the near future, individual tailored therapy is may replace the standardised step model based on population data.

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Asthma triggers in children: respiratory tract infections

Viral respiratory infections, such as the common cold, are a frequent cause of wheezing and asthma flare-ups in children, especially in preschool children.

The findings of observational cohort studies and limited randomised controlled trials show that influenza vaccination reduces the number, frequency and duration of asthma flare-ups in children, and lower the rate of emergency department visits and hospitalisation for asthma.43

Although bacterial respiratory infections may also trigger wheezing, antibiotics are not routinely indicated for asthma flare-ups or wheezing, and should only be given if they would otherwise be indicated.

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Asthma triggers in children: environmental allergens

There is insufficient evidence on which to base recommendations for the reduction of exposure to environmental allergens in the treatment of wheezing in preschool children.14

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Asthma triggers in children: tobacco smoke

There is consistent, high-quality evidence that exposure to environmental tobacco smoke can both cause and worsen wheezing in preschool children.1444

The Introduction of environmental tobacco controls has led to significant reduction in asthma hospitalisations among children.

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Written asthma action plans for children

Every child with asthma should have their own written asthma action plan.

A systematic review found that the use of written asthma action plans significantly reduces the rate of visits to acute care facilities, the number of school days missed and night-time waking, and improves symptoms.45 

For children and adolescents, written asthma action plans that are based on symptoms appear to be more effective than action plans based on peak expiratory flow monitoring.45

A written asthma action plan should include all the following:

  • a list of the child’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
  • clear instructions on what to do in all the following situations:
    • when asthma is getting worse (e.g. when needing more reliever than usual, waking up with asthma, more symptoms than usual, asthma is interfering with usual activities)
    • when asthma symptoms get substantially worse (e.g. when needing reliever again within 3 hours, experiencing increasing difficulty breathing, waking often at night with asthma symptoms)
    • during an asthma emergency.
  • instructions on when and how to get medical care (including contact telephone numbers)
  • the name and contact details of the child’s emergency contact person (e.g. parent)
  • the name of the person writing the action plan, and the date it was issued.

Table. Checklist for reviewing a written asthma action plan

  • Ask if the person (or parent) knows where their written asthma action plan is.
  • Ask if they have used their written asthma action plan because of worsening asthma.
  • Ask if the person (or parent) has had any problems using their written asthma action plan, or has any comments about whether they find it suitable and effective.
  • Check that the medication recommendations are appropriate to the person’s current treatment.
  • Check that all action points are appropriate to the person’s level of recent asthma symptom control.
  • Check that the person (or parent) understands and is satisfied with the action points.
  • If the written asthma action plan has been used because of worsening asthma more than once in the past 12 months: review the person's usual asthma treatment, adherence, inhaler technique, and exposure to avoidable trigger factors.
  • Check that the contact details for medical care and acute care are up to date.

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Templates for written asthma action plans

Templates are available from National Asthma Council Australia:

  • National Asthma Council Australia colour-coded plan, available as a printed handout that folds to wallet size and as the Asthma Buddy mobile site
  • Asthma Cycle of Care asthma action plan
  • A plan designed for patients using budesonide/formoterol combination as maintenance and reliever therapy
  • Remote Indigenous Australian Asthma Action Plan
  • Every Day Asthma Action Plan (designed for remote Indigenous Australians who do not use written English – may also be useful for others for whom written English is inappropriate)
  • Children’s written asthma action plans.

Some written asthma action plans are available in community languages.

Software for developing electronic pictorial asthma action plans4647 is available online.

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Asthma education programs for parents/carers and children

Asthma education for children and/or caregivers reduces the risk of emergency department visit for asthma, compared with usual care.48

However, the most effective components of education have not been clearly identified.4849 There have been relatively few Australian controlled trials assessing education programs.49

There is not enough evidence to tell whether asthma education programs in the child’s home are more effective in helping control asthma than asthma education provided somewhere else or standard care,49 or to identify which types of education is more effective.

All age groups

A systematic review50 found that asthma education programs were associated with moderate improvement in lung function and with a small reduction in school absence, restriction of physical activity, and emergency department visits. The greatest effects were in children with more severe asthma.50

Another systematic review found that educational programmes for the self-management of asthma in children and adolescents improved lung function, reduced the number of school days missed and the number of days with restricted activity, reduced the rate of visits to an emergency department, and possibly reduced the number of disturbed nights.51

0-5 years

There is little evidence about the effects of education for parents of preschool-aged children with asthma or wheezing. Most studies have investigated the effects of asthma management education for older children and their parents.14 Limited evidence suggests that:

  • education for parents of preschool children (e.g. written information and review by a health professional, small-group teaching by nurses or education in the family’s home) may help improve asthma control14
  • education programs are more likely to be effective if they involve multiple sessions, each longer than 20 minutes’ duration.14

Opportunistic asthma education

In addition to the types of structured or formal asthma education evaluated in research trials, all health professionals who work with children with asthma and their parents/carers can provide asthma education whenever the opportunity occurs.

Table. Childhood asthma education checklist Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/30

Resources

Education resources are available from the National Asthma Council Australia, Asthma Australia, and the Asthma Foundation in your state or territory.

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Correct use of inhaler devices

Checking and correcting inhaler technique is essential to effective asthma management.

Most patients with asthma or COPD do not use their inhalers properly,52, 53,5454, 55 and most have not had their technique checked or corrected by a health professional.

Incorrect inhaler technique when using maintenance treatments increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD.52, 53, 56, 57, 58, 59

Poor asthma symptom control is often due to incorrect inhaler technique.60, 61

Incorrect inhaler technique when using inhaled corticosteroids increases the risk of local side effects like dysphonia and oral thrush.

The steps for using an inhaler device correctly differ between brands. Checklists of correct steps for each inhaler type and how-to videos are available from the National Asthma Council website.

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Common reasons for poor response to preventer treatment

Apparent lack of response to asthma treatment is commonly due to one or more of the following:62

  • poor adherence (which may be due to lack of perceived need for the medication, concern about potential or actual side-effects, cost of medicines, a busy lifestyle, misunderstanding of the purpose and effects of asthma medicines, or inability to follow the medical instructions)
  • poor inhaler technique
  • mishandling devices (e.g. failure to clean spacer, allowing mouthpiece of dry-powder inhalers to become blocked)
  • incorrect dose or frequency
  • empty inhaler
  • expired medicines
  • continued exposure to smoke or allergen triggers.

Failure to identify these causes before adjusting medicines could result in over-medication with preventers.

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References

  1. NSW Child Death Review Team,. NSW Child Death Review Team annual report 2016–17. NSW Ombudsman, Sydney, 2017.
  2. The Consultative Council on Obstetric and Paediatric Mortality and Morbidity,. Victoria’s mothers, babies and children 2014 and 2015. Victoria State Government Health and Human Services, Melbourne, 2017.
  3. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2018. Available from: https://ginasthma.org/
  4. Quezada, W., Kwak, E. S., Reibman, J., et al. Predictors of asthma exacerbation among patients with poorly controlled asthma despite inhaled corticosteroid treatment. Ann Allergy Asthma Immunol. 2016; 116: 112-7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/26712474/
  5. Stanford, R. H., Shah, M. B., D'Souza, A. O., et al. Short-acting beta-agonist use and its ability to predict future asthma-related outcomes. Ann Allergy Asthma Immunol. 2012; 109: 403-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23176877
  6. Suissa, S, Ernst, P, Benayoun, S, et al. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000; 343: 332-336.
  7. van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: https://www.thoracic.org.au/journal-publishing/command/download_file/id/25/filename/The_role_of_corticosteroids_in_the_management_of_childhood_asthma_-_2010.pdf
  8. Issa-El-Khoury K, Kim H, Chan ES, et al. CSACI position statement: systemic effect of inhaled corticosteroids on adrenal suppression in the management of pediatric asthma. Allergy Asthma Clin Immunol. 2015; 11: 9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25802532/
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