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Table 2. Additional investigations Investigation type

Serum immunoglobulins( IgG, IgA, IgM, IgE)

FBC

Allergic bronchopulmonary aspergillosis( ABPA) markers( specific IgE, Aspergillus fumigatus precipitins)

High-resolution CT chest

Rationale

Source: Global Initiative for Asthma 32

Seen in inborn errors of immunity Low IgG and high IgE associated with uncontrolled asthma IgE levels greater than 3000 with low IgG / IgA / IgM may be hyper IgE syndrome

Raised serum eosinophils can be seen in uncontrolled asthma Hypereosinophilia( greater than 1500 /µ L) may indicate other disorders( eg, eosinophilic granulomatosis with polyangiitis)

ABPA can occur in chronic lung diseases like asthma and bronchiectasis ABPA, while less common in children, can be an important cause of persistent wheezing in children with asthma

Indicated if asthma is uncertain, or presence of red flags for other disease( eg, digital clubbing, chronic productive cough) Should be limited to tertiary centres where reduced radiation exposure is possible

Table 3. Daily inhaled corticosteroid doses in children

Corticosteroid Low dose High dose

Patient Name

‘ TIME HACK’: THE 15 MINUTE ASTHMA VISIT

IN THE WAITING ROOM

Use this checklist to conduct an asthma review in 15 minutes.

This checklist takes health professionals through the recommended steps for a scheduled review, based on recommendations and resources from the Australian Asthma Handbook. 1

Date of Consult

When the patient arrives, they complete an asthma intake form including a validated patient questionnaire 1, 2

Asthma Score( Asthma Control Test) Primary care Asthma Control Screening( PACS) Asthma Control Questionnaire( ACQ)

The practice nurse checks lung function if that is required( every 1 – 2 years for most people) 1

Source: Asthma Australia. Available from asthma. org. au / review-checklist

professionals. Results are available within 15-20 minutes, allowing GPs and other health professionals the opportunity to discuss aeroallergen minimisation strategies with parents / carers. Unfortunately, skin prick testing is not available for everyone, either because of local unavailability or relative contraindications, for example, severe eczema, or oral antihistamine use at time of testing. In these cases, consider allergen-specific blood testing as an alternative. 26

BRONCHIAL PROVOCATION TESTING Bronchial provocation testing can be useful in children aged over eight where there is still a questionable diagnosis of asthma, or when spirometry and FeNO are inconclusive. The testing involves the controlled inhalation of mannitol to induce airway hyperresponsiveness. 29 A positive bronchial provocation test is a greater than 15 % drop in FEV1. 29 SABA, preventer therapy and antihistamines, if prescribed, are withheld for 24-72 hours before testing, as these may affect the validity of test results. 30, 31 Bronchial provocation testing can be facilitated by referral to a respiratory specialist.

Additional investigations

In children with severe or difficult to control asthma, additional investigations guided by respiratory specialists may be considered to identify other key drivers of chronic disease( see table 2).

MANAGEMENT

AT the core of asthma management is the focus on establishing effective asthma control and reducing the risk of morbidity and mortality.

Role of the GP

GPs play a critical role in managing asthma in children and young people. Taking an individualised approach that incorporates shared decision-making with the parent and / or child promotes effective asthma self-management and can improve a child’ s asthma control. 33 Parents / carers will often only seek GP review when their child is experiencing an acute asthma flare-up. However, regular GP review when the child is well plays an important role in maintaining asthma control; encouraging parents / carers to regularly attend with either the GP or practice nurse provides an opportunity for asthma management and action plan review, symptom enquiry, monitoring of medication adherence and assessment of delivery device techniques.

At each review, assess for signs of persistent asthma when well and consider early referral for lung function testing. Various online checklists are available, including from the National Asthma Council Australia and Asthma Australia( see figure 2). GPs are uniquely placed as most will be continuing to care for the child through adolescence and into adulthood. Asthma is not just a disease of childhood, and the management principles, support and education provided in childhood have a lifelong impact.

Pharmacological

The National Asthma Council Australia’ s Australian Asthma Handbook provides guidance on the management of asthma in Australin children. 7 A stepped‘ ladder approach’ split into relevant age groups( less than six, 6-11, and older than 12) is recommended.

STEPPED APPROACH TO ASTHMA CARE Under six Salbutamol as required when

ACTION PLAN

Figure 3. Stepped Approach to adjusting asthma medications in children aged 1-5. SABA = short-acting beta 2 agonist, ICS = inhaled corticosteroid.

unwell is first-line. A smaller percentage will require regular preventer treatment, particularly those who have recurrent or persistent symptoms between viral respiratory infections. In this group, low-dose ICS, for example, fluticasone propionate 50μg is recommended. 7 This is approved by streamlined PBS prescription for children under six and can be prescribed by GPs. Montelukast, a leukotriene antagonist, can be considered as an alternative firstline monotherapy to ICS; the former can be useful particularly if the child has difficulty with or refuses to use a preventer inhaler with a spacer / mask, or has significant concurrent allergic rhinitis

8 MINUTE REVIEW TREATMENT PLAN & EDUCATE

Figure 2. Asthma Australia asthma consultation checklist.

( see figure 3). 7 If montelukast is considered, counsel parents / carers regarding neuropsychiatric and behavioural side effects, although these do not occur in most children. 34 If these adverse side effects occur, they typically happen within the first two weeks after initiation and disappear within 72 hours of cessation. 34

If the asthma remains uncontrolled, children may be trialled on either high-dose ICS( see table 3) or a combination of low-dose ICS and montelukast. 7 Review and reassessment are key. Have a low threshold for specialist referral if children under six have symptoms of poorly controlled asthma at step 2, as evident in figure 3.

Adjust medications based on stepped approach

Review rescue and controller medications and device technique Give trigger advice and make an appointment for flu vaccination if due Check the person has an up-to-date written Asthma Action Plan and they know how to use it – ask the patient to repeat the plan back to you Set goals and plan the next follow-up visit

Source: Adapted from the Australian Asthma Handbook 7

Six to eleven Some children aged 6-11 may be managed on a SABA only. In those with frequent asthma symptoms, a low-dose ICS and SABA as required is recommended( see figure 4). If the child’ s asthma remains poorly controlled, and treatment adherence and technique have been optimised, prescribe either a high-dose ICS or a combination inhaler with ICS and LABA.

Combination inhalers are not routinely prescribed in children younger than five because of the association of LABAs with increased risk of exacerbations and asthma-related mortality. 35 Newer combination inhalers including budesonide / PAGE 30