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PAGE 27 formoterol with a rapid-acting
LABA are gaining trac-
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Box 4. Asthma education |
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tion in the group aged 6-11. Newer combination inhalers with rapid-acting LABA( eg, budesonide / formoterol) are increasingly used in those older than 12 and adults with mild asthma. Large studies examining the efficacy of these inhalers in those aged 6-11 are still in their infancy, so their routine prescription is not currently supported by the PBS advisory committee in those aged 6-11. 35 Have a low threshold for specialist referral with a child at step 3 and / or who requires a combination inhaler. 35
Twelve and over Prescribe a minimum of regular ICS and SABA as required( see figure 5) for adolescents aged 12 or older. The combination of ICS / formoterol, which contains a rapid-acting LABA and can be used as a single agent( both preventer and reliever), can also be considered as alternative first-line therapy. ICS / formoterol may be preferable in those with suspected medication compliance issues. 36 SABA only and other combination inhalers are not recommended as first-line therapy.
Consider other options if asthma control remains an issue. These include tiotropium, a long-acting antimuscarinic inhaler that works in a similar way to beta 2 agonists in relaxing bronchial smooth muscle. 37 For those eight and older with severe and uncontrolled asthma on
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Figure 4. Stepped approach to adjusting asthma medications in children aged 6-11. SABA = short-acting beta 2 agonist; ICS = inhaled corticosteroid. |
Source: Adapted from the Australian Asthma Handbook 7 |
• Provide access to age-appropriate written and online asthma materials for both the parent / carer and the child to which they can refer when the consultation is complete.
• Encourage opportunities for child, parents / carers to document and ask questions.
• Demonstrate airway changes, action of medications on the airways and correct use of asthma delivery devices.
• Have the child demonstrate their skill in using the delivery device.
• Explain and reiterate the importance of good asthma management and medication adherence.
• Educate on signs of poor asthma control, including the appropriate use of reliever medication.
• Explain how to use and ensure their understanding of their asthma action plan and steps to take in an asthma emergency.
• Provide detailed asthma management instructions for the child’ s childcare service / school.
• Assess the child’ s understanding of symptom monitoring and requirement to give feedback to parents about their use of short-acting beta 2 agonists.
ASTHMA ACTION PLANS Personalised AAPs are a cornerstone of paediatric asthma manage-
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maximal inhaled therapy, biolog- |
ment and education. They provide |
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ical agents may be considered by respiratory specialists( see box 3). Omalizumab, an anti-IgE monoclonal antibody, is PBS approved for those eight and older. Dupilumab |
Figure 5. Stepped approach to adjusting asthma medications in young people and adolescents aged 12 and over. SABA = short-acting beta 2 agonist; ICS = inhaled corticosteroid; LAMA = long-acting antimuscarinic. |
Source: Adapted from the Australian Asthma Handbook 7 |
detailed instructions for parents / carers and young people, including for day-to-day management, what to do when symptoms worsen, and, importantly, emergency asthma |
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( anti-interleukin [ IL ] 4 and IL13) or |
management. |
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mepolizumab( anti-IL5a) are available for those aged 12 and over and are also approved for other atopic conditions like eczema. If biological agents are being considered the Asthma Control Questionnaire( ACQ-5) is one of several recom- |
Box 3. PBS criteria for biologic prescriptions
• Must be treated by and have confirmed asthma diagnosis from a respiratory physician, clinical immunologist, allergist or general physician experienced in the management of patients with severe asthma.
• Disease duration at least 12 months.
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effective delivery of medications. Poor inhaler technique is common. 43 Children with incorrect inhaler technique are more likely to have poorly controlled asthma, increased healthcare utilisation, reduced confidence in their asthma |
The routine use of AAPs results in fewer asthma exacerbations, fewer missed days of school / childcare, and better asthma control compared with those who do not have an AAP. 46-48 Lack of an AAP has also been implicated as a key factor in asthma |
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mended measures for assessing asthma control. 38 The ACQ-5 is a validated tool consisting of five questions, each scored from 0 to 6, with the final score being calculated as the mean. 39, 40 A score of less than 0.75 signifies well-controlled asthma, while a score of greater than 1.5 signifies uncontrolled asthma.
39, 40 Regardless of a child’ s age, it
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• Confirmed evidence of atopy including skin prick testing, raised serum immunoglobulin E greater than 30 IU / mL and / or serum eosinophils greater than 300 cells per microlitre within last 12 months.
• A failure to control symptoms on maximal inhaled therapy:
— Asthma Control Questionnaire score greater than 2.0 in the past one month.
— More than one hospitalisation and / or more than one course of oral corticosteroids in past 12 months.
Source: PBS 2023 38
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management and poor treatment compliance. 44
While there are many inhaler devices available, it is important to note that children may be unable to generate sufficient inspiratory airflow to use the device correctly, such as is the case with dry powdered inhalers( DPIs). A child’ s attention and effort can also impact greatly on medication delivery. For
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deaths, and the consistency with which parents are provided an AAP varies greatly across all healthcare settings. 49-52 It is therefore vital that AAPs are discussed at each consultation and revised annually, or when a change occurs.
Several different types of AAPs are available. All are available in a coloured format, which is strongly recommended( see figure 7), as par-
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is important that with each treat- |
this reason, DPIs are typically rec- |
ents report better knowledge reten- |
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ment titration there is a follow-up review within 4-6 weeks to assess response. The type of delivery device chosen, child’ s preference, |
adolescents. 36 Salbutamol overuse reduces its effectiveness over time, so it is less helpful in acute and life-threatening episodes, and it is |
their parent / carer; use culturally, age-appropriate language and make the education interactive. This will aid the parent / carer in develop- |
ommended for children aged over seven. Exercise caution with DPIs in children who have a confirmed cow’ s milk protein allergy, as sev- |
tion with the‘ traffic light’ system approach compared with black and white versions. 53 Regular access to AAPs is also important, so advise |
price of individual inhaler, and |
also associated with a significant |
ing the necessary skills and knowl- |
eral contain cow’ s milk protein |
parents / carers to display the AAP |
inhaler technique can all impact treatment compliance. At each review ask yourself the question: |
increase in both asthma related morbidity and mortality. 36, 42 Using three salbutamol canisters per year, |
edge to understand and support the management of their child’ s asthma. Aim for opportunistic |
derivatives like lactose which are used as excipients. 45
A metered pressured inhaler with
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prominently at home and take a photograph with their phone for access when required. For adoles- |
“ Is the child’ s uncontrolled asthma |
equivalent to 12 puffs per week, |
asthma education at every point of |
a spacer device remains the most |
cents, digital apps and AAPs( for |
a result of poor treatment compli- |
increases the risk of hospitalisation |
contact, irrespective of reason for |
commonly used device in asthma |
example, Asthma Buddy) are help- |
ance or suboptimal treatment?” |
with asthma. Using eight salbuta- |
review, so that parent / carer and the |
management. Spacers should be |
ful in increasing both access to and |
mol canisters per year, equivalent |
child’ s / adolescent’ s understanding |
used in all age groups as they enable |
the use of AAPs. 54 |
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SHORT-ACTING BETA 2 AGONISTS |
to four puffs per day, increases the |
can be reinforced. Utilising online |
optimum medication delivery to the |
In addition to personalised AAPs, |
SABAs, like salbutamol, are very effective bronchodilators. 41 They are cheap, available without a pre- |
36, 42 risk of mortality from asthma. Regular monitoring of salbutamol use is critical. |
education resources in between reviews may also be useful. 33 Box 4 lists several strategies that may |
airways. It is important to instruct the patient in the correct use of the chosen delivery device and to assess |
parents / carers are also required to provide a child / student-specific written AAP in childcare and school |
scription at pharmacies and are useful in acute flare-ups because |
Non-pharmacological |
optimise a personalised asthma education experience for children, |
their technique at every point of contact( see figure 6). Ensure they |
settings. These plans are more concise and focus mainly on emergency |
of their rapid onset of action, offer- |
ASTHMA EDUCATION |
parents and carers. |
know how to care for their device |
management, including exercise |
ing children symptomatic relief. |
National and international guide- |
( including regular cleaning of both |
induced asthma. Update the plan |
|
However they do not treat the |
lines unanimously recognise the |
INHALER TECHNIQUE AND DEVICES |
spacer and delivery device). Check |
annually. School and childcare-spe- |
underlying inflammatory disease |
importance of asthma education in |
Always confirm the type of |
the dose counter regularly as it is |
cific plans can be accessed online |
process, so SABA use can be detrimental for many older children and |
establishing good asthma control. 1, 7 Include the child / adolescent and |
inhaler delivery device and associated technique to ensure the |
not uncommon for children to be using an empty inhaler device. |
via the NSW Health or Asthma Australia websites. |