NHS FORTH VALLEY Guideline for the Management of Asthma

Transcription

1 NHS FORTH VALLEY Guideline for the Management of Asthma Date of First Issue 2004 Approved 18/09/2013 Current Issue Date 18/09/2013 Review Date 18/09/2016 Version 3.0 EQIA Yes 15/05/2009 Author / Contact Olwyn Lamont Group Committee NHS Forth Valley Respiratory MCN Steering Group Final Approval This document can, on request, be made available in alternative formats Version 3.0 September 2013 Page 1 of 6 UNCONTROLLED WHEN PRINTED

2 NHS Forth Valley Consultation and Change Record Contributing Authors: Consultation Process: Distribution: Ms Clare Colligan, Clinical Pharmacist Mrs Olwyn Lamont, Lead Respiratory Nurse Dr Dougie Morrison, Lead Respiratory Physician Dr Una MacFadyen, Consultant Paediatrician Maggie MacKinnon, Airways MCN Manager Mrs Nan O Hara, Practice Nurse Facilitator Dr Scott Williams, GP Viewfield Medical Practice, Stirling Dr Stan Wright, Cancer and Palliative Care Physician Dr Melanie Cross, Respiratory Physician Ms Yvonne Kerr, Community Children s Nurse NHS Forth Valley Respiratory MCN Core and Steering Groups To all NHS Forth Valley accessible via the Quality Improvement page on the NHS Forth Valley Intranet and Internet. Educational Launch Evenings to raise awareness invitation to all NHS Forth Valley healthcare professionals involved in the management of asthma. Change Record Date Author Change Version September 2013 Review of guideline changes highlighted in red on index page 1.1 Version 3.0 September 2013 Page 2 of 6 UNCONTROLLED WHEN PRINTED

3 Introduction Welcome to the updated NHS Forth Valley Guideline on the Management of Asthma, which replaces the 2009 guideline. It draws on existing local information and guidelines, and national guidelines (largely the updated joint BTS 1 /SIGN 2 Guideline No101) to provide clinicians with a concise local asthma management plan. The guideline is intended for use by all healthcare professionals in NHS Forth Valley and it is available on the NHS Forth Valley intranet/internet, where it will be regularly updated It is hoped that you will find the materials useful in supporting your patients to take care of their asthma condition and in recording the care which you provide. The guideline includes information on: Diagnosis, assessment, follow-up and disease registers in primary care Referral to secondary care Treatment and prescribing in accordance with the Joint Forth Valley Formulary Inhaler assessment technique Personal Asthma Plan templates Patient information leaflets Patient recall in primary care This guideline is not intended to serve as a standard of care or be applicable in every situation. Decisions regarding the treatment of individual patients must be made by the clinician in light of that patient s presenting clinical condition and with reference to current good medical practice. The guideline steering group is grateful to SIGN who have given permission to reproduce specific information from SIGN No101, which is accurate at the time of review in September Quality Improvement The pack contains information about education, continuing professional development and audit. Please advise the Forth Valley Airways Managed Clinical Network (MCN) of any further resources that you think would be useful: David Munro, Respiratory MCN Manager david.munro@nhs.net 1 British Thoracic Society 2 Scottish Intercollegiate Guideline Network Version 3.0 September 2013 Page 3 of 6 UNCONTROLLED WHEN PRINTED

4 Guideline Development In 2004, this guideline was developed by the then NHS Forth Valley Airways Group in a multidisciplinary and multi-agency collaborative approach, with the assistance of support services Guideline Update The NHS Forth Valley Respiratory Managed Clinical Network is responsible for reviewing this local guideline and would like to acknowledge the following members who contributed to the development of the 2013 update: Clare Colligan, Clinical Pharmacist, NHS Forth Valley Olwyn Lamont, Lead Respiratory Nurse Specialist, NHS Forth Valley Dr Dougie Morrison, Lead Respiratory Physician, NHS Forth Valley Dr Una MacFadyen, Consultant Paediatrician, NHS Forth Valley David Munro, Respiratory MCN Manager, NHS Forth Valley Nan O Hara, Practice Nurse Facilitator, NHS Forth Valley Dr Scott Williams, GP Viewfield Medical Practice Stirling, NHS Forth Valley Dr Fraser Wood, Consultant Physician, NHS Forth Valley Dr Melanie Cross, Respiratory Physician, NHS Forth Valley Yvonne Kerr, Community Children s Nurse We would also like to acknowledge the WoSCOR MCN for the Understanding Asthma Booklet we recommend, the Attacking Asthma programme for children and parents and for the updated adrenal suppression protocol. The Respiratory MCN meets regularly to discuss respiratory services and patient care. The membership is multidisciplinary and multi-agency and includes representation from specialist healthcare professionals, voluntary organisations, patients and carers. Key Sources of Evidence & Websites Scottish Intercollegiate Guidelines Network and the British Thoracic Society British Guideline on the Management of Asthma (Revised 2012); September 2013 NHS Forth Valley Joint Formulary. m_formulary.asp September 2013 New GMS Contract 2003 Quality and Outcomes Framework. September September 2013 Scottish Programme for Improving Clinical Effectiveness in Primary Care. and September 2013 British Thoracic Society. September 2013 Version 3.0 September 2013 Page 4 of 6 UNCONTROLLED WHEN PRINTED

5 Asthma UK September 2013 National Institute for Clinical Excellence. September 2013 Version 3.0 September 2013 Page 5 of 6 UNCONTROLLED WHEN PRINTED

6 Table of Contents Red print indicates alteration/addition to the policy Title Section Quick Reference Guide 1 Diagnosis of Asthma in Children 2.1 Indications for Referral and Clues to Alternative Diagnoses in Wheezy Children Diagnosis of Asthma in Adults 2.2 Indications for Referral for Specialist Opinion or Further Investigation in Adults Initial Assessment of Asthma Proforma 3.1 Initial Assessment & Diagnosis of Asthma Summary 3.1 Asthma Follow Up Proforma 3.2 Non-pharmacological Management 4 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison 5.1 Stepping Down Treatment in Children Management of Acute Asthma in Children in General Practice 5.2 Management of Acute Asthma in Children in Emergency Department 5.3 Management of Acute Asthma in Children in Hospital 5.4 Drug Preparation Guidance Management of Acute Asthma in Infants Aged <2 years in Hospital 5.5 Adverse Effects of Treatment in Children 5.6 Stepwise Management in Adult Asthma Treatment Cost Comparison 6.1 Stepping Down Treatment in Adults Prescribing Symbicort SMART Treatment of Exacerbations of Asthma in Adults Management of Acute Severe in Adults in General Practice 6.2 Management of Severe Acute Asthma of Adults in Emergency Department 6.3 Inpatient Management of Acute Asthma in Adults 6.4 Severe or Difficult to Manage Asthma in Adults 6.5 Adverse Effects of Treatment in Adults 6.6 Occupational Asthma 6.7 Asthma in Pregnancy 6.8 Exercise Induced Asthma 7 Inhaler Assessment Information 8.1 Peak Expiratory Flow Rate Normal Values 8.2 Asthma Recall Process in Primary Care 9 Self Management and Patient Information 10 Education and Continuing Professional Development 11.1 Organisation and Delivery of Care and Audit 11.2 Version 3.0 September 2013 Page 6 of 6 UNCONTROLLED WHEN PRINTED

7 1 NHS Forth Valley Guideline for the Management of Asthma Quick Reference Guide Diagnosis Patients suspected of having a diagnosis of Asthma should have differential tests undertaken and/or trials of asthma therapy, or referred for specialist opinion. (Section 2) Initial Assessment Once a diagnosis is confirmed, ensure an initial assessment proforma is completed, in the primary care setting. (Section 3.1) Asthma Register in Primary Care Maintain a Register of all patients with a diagnosis of Asthma. Personal Asthma Action Plans Patients with asthma should have a Personal Asthma Plan to facilitate self-management, and locally developed and endorsed templates are available to download online. (Section 7) Treatment Prescribing should be in accordance with the local Joint Formulary. Inhaler technique should be evaluated (Section 8). Guidance on treatment (depending upon age, severity and setting, and including non-pharmacological treatment) is included in the pack. (Sections 4, 5, 6 and 7) Patient Recall in Primary Care A robust system of patient recall should be implemented to facilitate annual review or more frequent follow-up accordingly. Guidance for primary care setting is included. (Section 9) Patient Information/Advice Written information should be provided as part of a continuing education programme, and a series of locally developed and endorsed leaflets are available to download online. (Section 10; Leaflets 1-8) Quality Improvement The pack contains information about Education, CPD and audit. Contract Reporting tools and SPICEpc reports can provide a dataset on asthma indicators in primary care. (Section 11) Patient Follow-up All patients should have at least annual review. Ensure that review data are collated, using the contract compliant proforma in the primary care setting. (Section 3.2) This guidance has been developed by a multidisciplinary and multiagency collaborative approach and is endorsed by the NHS Forth Valley Airways MCN. It is informed by evidence from RCGP SPICEpc, ngms Quality Indicators, SIGN101/BTS British Guideline on the Management of Asthma, 2008 (updated 2012), and current good practice. September 2013

8 2.1 NHS Forth Valley Guideline for the Management of Asthma Diagnosis of Asthma in Children Features that increase the probability of asthma: More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness particularly if these are frequent and recurrent; are worse at night and in the early morning; occur in response to, or are worse after, exercise or other triggers, such as exposure to pets; cold or damp air, or with emotions or laughter; or occur apart from colds: Personal history of atopic disorder Family history of atopic disorder and/or asthma Widespread wheeze heard on auscultation History of improvement in symptoms or lung function in response to adequate therapy Features that lower the probability of asthma: Symptoms with colds only, with no interval symptoms Isolated cough in the absence of wheeze or difficulty breathing History of moist cough Prominent dizziness, light-headedness, peripheral tingling Repeatedly normal physical examination of chest when symptomatic Normal peak expiratory flow (PEF) or spirometry when symptomatic No response to trial of asthma therapy Clinical features pointing to alternative diagnosis N.B. Atopy = eczema, hayfever, rhinitis, allergic conjunctivitis, allergic reactions Presentation with suspected asthma Clinical assessment Consider potential effect of exposure to tobacco smoke High probability: diagn osis of asthma likely Intermediate probability: diagnosis uncertain Low probability: other diagnosis likely Consider referral Trial of treatment Consider tests of lung Investigate/treat +ve -ve function* and other condition atopy Good response Poor response Poor response Good response Continue treatment and find minimum effective dose September 2013 Assess compliance and inhaler technique Consider further investigation and/or specialist referral (see 2.2): Paediatric respiratory clinic or general paediatric clinic Sci gateway Continue treatment *Lung function tests include spirometry before and after bronchodilator (test of airway reversibility) and possible exercise or methacholine challenge (test of airway responsiveness). Most children over the age of 5 can perform lung function tests.

9 2.1.1 NHS Forth Valley Guideline for the Management of Asthma Clues to Alternative Diagnoses in Wheezy Children All respiratory problems are made worse by exposure to tobacco smoke. Clinical Clue Perinatal and Family History Symptoms present from birth or perinatal lung problem Family history of unusual chest disease Possible Diagnosis Cystic fibrosis: chronic lung disease; ciliary dyskinesia; developmental anatomy Cystic fibrosis, congenital lung anomaly; neuromuscular disorder Severe upper tract disease Defect of host defence Symptoms and Signs Persistent wet cough Cystic fibrosis; recurrent aspiration: host defence disorder Excessive vomiting or posseting Reflux (± aspiration) Dysphagia Swallowing problems (± aspiration) Abnormal voice or cry Laryngeal problem Focal signs in the chest Developmental disease; postviral syndrome; bronchiectasis; tuberculosis Inspiratory stridor as well as wheeze Central airway or laryngeal disorder Failure to thrive Cystic fibrosis; host defence defect; gastro-oesophageal reflux Investigations Focal or persistent radiological changes Congenital lung disorder; postinfective disorder; recurrent aspiration; inhaled foreign body; bronchiectasis; cystic fibrosis; tuberculosis Newborn screening for cystic fibrosis may have occasional false negatives when either initial IRT is normal or a rare gene deletion is not detected on molecular genetic testing. Clinical vigilance remains important in diagnosing CF, especially in infants identified as heterozygote. September 2013

10 2.2 NHS Forth Valley Guideline for the Management of Asthma Diagnosis of Asthma in Adults Features that increase the probability of asthma: More than one of the following symptoms: wheeze; breathlessness, chest tightness and cough, particularly if: o symptoms worse at night and early in the morning o symptoms in response to exercise, allergen exposure and cold air o symptoms after taking aspirin or beta blockers History of atopic disorder Family history of asthma and/or atopic disorder Widespread wheeze heard on auscultation of the chest Otherwise unexplained low FEV 1 or PEF (historical or serial readings) Otherwise unexplained peripheral blood eosinophilia Features that lower the probability of asthma: Prominent dizziness, light-headedness, peripheral tingling Chronic productive cough in the absence of wheeze or breathlessness Repeatedly normal physical examination of the chest when symptomatic Voice disturbance Significant smoking history (i.e. >20 pack years) Cardiac disease Normal PEF or spirometry when symptomatic* *A normal spirogram/spirometry when not symptomatic does not exclude the diagnosis of asthma. Repeated measurements of lung function are often more informative than a single assessment. Presentation with suspected asthma Clinical assessment including occupation and spirometry. High probability: diagnosis of asthma likely Intermediate probability: diagnosis uncertain Low probability: other diagnosis likely Trial of treatment FEV 1 /FVC <0.7 FEV 1 /FVC >0.7 Investigate/treat other condition Good response Poor response Poor response Good response Diagnosis confirmed Continue treatment and code diagnosis of Asthma Assess compliance and inhaler technique Consider specialist referral (see 2.2): Continue treatment NHS Forth Valley Respiratory Physicians: September 2013 Sci gateway

11 2.2.1 NHS Forth Valley Guideline for the Management of Asthma Indication Indications for Referral for Specialist Opinion or Further Investigation * in Adults Diagnoses unclear or in doubt Unexpected clinical findings e.g. crackles, clubbing, cyanosis, cardiac disease Unexplained restrictive spirometry Suspected occupational asthma Persistent non-variable breathlessness Monophonic wheeze or stridor Prominent systemic features (myalgia, fever, weight loss) Chronic sputum production CXR shadowing Marked blood eosinophilia (> 1x10 9 /l) Poor response to asthma treatment Severe asthma exacerbation Differential Diagnosis According to the presence or absence of airflow obstruction (FEV1/FVC <0.7) Without Airflow Obstruction Chronic cough syndrome Hyperventilation syndrome Vocal cord dysfunction Heart failure Pulmonary fibrosis With Airflow Obstruction COPD Bronchiectasis* Inhaled foreign body* Obliterative bronchiolitis Large airway stenosis Lung cancer Sarcoidosis* *may also be associated with non-obstructive spirometry Patients presenting atypically or with additional symptoms or signs and are being referred for specialist opinion should have chest x-ray performed prior to referral September 2013

12 3.1 NHS Forth Valley Guideline for the Management of Asthma Initial Assessment and Diagnosis of Asthma Summary of Initial Assessment Form Patient Details Personal details Occupation Pets Exercise tolerance grade Smoking Status Present Symptoms Wheeze, shortness of breath, exercise intolerance, chest tightness, cough. Symptoms worse at night and early morning Symptoms worse with exercise, allergens, cold air, aspirin or Beta-blocker Episodic or persistent Time off work/education in the past year Number of puffs of β 2 agonist daily(if applicable) Trigger Factors URTI, Exercise, Stress, Tobacco, Smoke, Dust, Pollen, Animals, Food, NSAID, Aspirin, Other Medication, Cold Air, Chemicals/irritants/aerosols Relevant atopic history e.g. nasal polyps, hayfever, eczema Family History Relevant Past Medical History Current Medication Examination Height, Weight, Blood pressure, BMI FEV 1 (Expected and Actual) FEV 1 /FVC ratio Date of last chest x-ray and result (if applicable) Inhaler technique (if applicable) Details of contra-indicated drugs Record method of confirmation of diagnosis Checklist Check understanding of asthma Discuss trigger factors and their avoidance Does the patient have a peak flow meter and can they use it competently? Agree and give a personal asthma plan Arrange follow-up appointment September 2013

13 3.1 Initial Assessment & Diagnosis of Asthma Fields marked with an asterisk* ngms contract data Date*..../..../. GP.. Patient details Name DOB..../..../. Gender M F Occupation.... If considering diagnosis of occupational asthma, consider referral to Respiratory Physician Exposed to: Dusts / Chemicals? Yes No Any Better Days? (e.g. away from work, on holiday) Yes No Not Sure Pets? Yes No... Exercise Tolerance Grade: (See classification on page 2 overleaf) Smoking Status*: Never Smoked Ex-smoker No. of years smoking Current Smoker No. per day. Smoking Cessation Advice Given* Yes No Passive Smoking? Yes No If yes, Home Work other e.g (child care). Symptoms Date of Onset:../.../ Episodic Persistent Wheeze S.O.B Chest Tightness Cough Worse at night and early morning Symptoms in response to exercise allergen cold air Symptoms after taking aspirin Beta-blocker Childhood symptoms (if adult) Yes No Time off work/education in past year (days).. Puffs of 2 agonist daily.. not applicable Pre-exercise 2 agonist Yes No Trigger factors and their avoidance discussed*: Yes No Aggravating factors: URTI Exercise Stress Tobacco Smoke Dust Pollen Animals Food Other medication Cold air NSAID Aspirin Chemicals/irritants/aerosols Atopic History: Eczema Hay Fever Nasal Polyps rhinitis conjunctivits Other (e.g. food). Family history of asthma/ atopy Yes No September 2013 Page 1 of 2

14 Relevant Past Medical History Current Medication Drug Strength Dosage Device Examination Height: Weight:. BP: /. BMI: Date of last chest X-ray.../..../ Result... Expected FEV 1*:.. Actual FEV1*:.. FEV1 /FVC:.. Present inhaler device Present Inhaler Technique*: Satisfactory Unsatisfactory Present level of understanding of asthma: Satisfactory Incomplete Information given/accessed: Information Leaflets Websites Diagnosis Confirmed by*: History Follow-up appointment: Y N Wheeze Response to treatment Objective Measurement (See below) Contra-indicated drugs? Blocker Y N Aspirin Y N NSAIDs Y N Other(s) Y N.. Peak Flow Meter (has own device) Y N Personal Asthma Plan agreed? Y N Uses Peak Flow Meter competently Y N Personal Asthma Plan given? Y N Main carer (if applicable).. Others who need to know about asthma and its management.. Objective Diagnostic Measurements 1. Spirometry Reversibility Positive FEV 1 15% (and 200ml) increase after trial of beclomethasone 200mg (or equivalent) twice daily 2. Positive Reversibility Test Salbutamol FEV 1 15% (and 200ml) increase after short acting 2 agonist e.g. Salbutamol 400mcg by MDI and Spacer or 2.5mg by Nebuliser 3. Serial Peak Expiratory Flow Rate 20% diurnal variation on 3 days in a week for 2 weeks on PEF diary twice daily (4 times may be more sensitive) Exercise Tolerance Grading Criteria Grade 1: Asthma but with no limitation of physical activity Grade 2: Asthma with slight limitation of physical activity but by limiting physical activity, can lead a normal social life. Grade 3: Asthma resulting in marked limitation of physical activity. Grade 4: Asthma resulting in being unable to do any physical activity without shortness of breath. September 2013 Page 2 of 2

15 3.2 Asthma Follow- up Fields marked with an asterisk* are ngms contract data Name: DoB:./../.. FOLLOW-UP DATE*: /./... /./... /./... For children read you as the child Symptoms Do you cough, wheeze or get short of breath? Y N Y N Y N In the last week* / month: 1. Have you had difficulty sleeping because of your Asthma symptoms (including cough)? Y Week* Month Week* Month Week* Month N No of nights Y N No of nights Y N No of nights Y N No of nights Y N No of nights Y N No of nights 2. Have you had your usual Asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? Week* Month Week* Month Week* Month Y N Y N Y N Y N Y N No of days No of days No of days No of days No of days Y N No of days 3. Has your asthma interfered with your usual activities (e.g. housework, school/work, etc)? Week* Month Week* Month Week* Month Y N Y N Y N Y N Y N Y N PEFR* Predicted* Best* Actual* Trigger factors and their avoidance discussed* Y N Action. No. of unscheduled asthma appointments*.. Y N Action... Y N Action... Current Asthma Medication No. of puffs of 2 agonist daily No. of short courses of oral steroids since last review Other medication including over the counter Changes in Asthma medication including over the counter September 2013 Page 1 of 2

16 3.2 Asthma Follow- up Fields marked with an asterisk* are ngms contract data Name: DoB:./../.. DATE: /./... /./... /./... Inhaler technique* Assessment Result* Assessment Result* Assessment Result* Satisfactory Unsatisfactory Satisfactory Unsatisfactory Satisfactory Unsatisfactory Action Action Action Steroid Adverse Effects Testing ( For further information please refer to 5.6 for Children or 6.6 for Adults ) Y N N/A Y N N/A Y N N/A Weight / Height* (Annually < 18yrs*) Kg m Kg m Kg m Asthma education/concordance discussed Y N Y N Y N Asthma literature offered Y N Y N Y N Written Personal Asthma Plan Reviewed/Given*? Record the date the plan was last updated* Y N Y N Y N Action Action Action Advised to inform school of plan given/changed Y N N/A Y N N/A Y N N/A Flu Vaccination* Pneumococcal Vaccination* Date:.. / /.. Date:.. / /.. Date:.. / /.. Date:.. / /.. Date:.. / /.. Date:.. / /.. Smoking status* (include passive smoking) Smoking Cessation Advice*? Y N N/A Y N N/A Y N N/A Pregnant Y N N/A Y N N/A Y N N/A Planning pregnancy/ Personal worries /concerns? Y N N/A Y N Y N N/A Y N Y N N/A Y N Is there anything you avoid due to your asthma? Y N.. Y N.. Y N.. Next appointment: Nurse / GP/ Hospital N GP H Date:.. / /... N GP H Date:../ /... N GP H Date:../ /... September 2013 Page 2 of 2

17 4 NHS Forth Valley Guideline for the Management of Asthma Source: SIGN101 Quick Reference Guide. Reproduced with the permission of and thanks to SIGN, and accurate at the time of review in NHS Forth Valley, September 2013 September 2013 Page 1 of 2

18 4 NHS Forth Valley Guideline for the Management of Asthma Families with evidence of dust mite allergy and to wish to try mite avoidance may consider the following: Complete barrier bed-covering systems Removal of carpets Removal of soft toys from bed High temperature washing of bed linen Acaricide to soft furnishings September 2013 Page 2 of 2

19 5.1 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison NB. IN CHILDREN UNDER 5 YEARS MDI AND SPACER ARE DEVICES OF CHOICE Step 4: Persistent Poor Control Increase dose of ICS to 800mcg * /day (with LABA if some response) ENSURE STEROID CARD GIVEN Beclometasone Clickhaler Clenil Modulite Pulvinal Easyhaler + max. licensed dose = 400mcg/day Budesonide Easyhaler Novolizer Turbohaler Fluticasone Accuhaler MDI Combined: Not licensed at this dose of ICS Seretide Accuhaler MDI Symbicort Turbohaler Step 3 : Add-on Therapy 1. Add LABA 2. ICS to 400mcg * /day 3. Combined (400mcg * /day) Consider trial of: Formoterol Turbohaler Foradil Easyhaler Salmeterol Accuhaler MDI Assess control Good control, continue Some response, increase dose of ICS No response, stop LABA Beclometasone Clickhaler Clenil Modulite Pulvinal Easyhaler Salbutamol MDI Easyhaler Accuhaler Easibreathe Pulvinal Clickhaler Beclometasone Clickhaler Clenil Modulite Pulvinal Easyhaler Budesonide Easyhaler Novolizer Turbohaler Fluticasone Accuhaler MDI Step 2: Regular Preventer Therapy 200mcg * / day Budesonide Easyhaler Turbohaler Step 1: Mild Intermittent Asthma Novolizer Refer to Respiratory Paediatrician Fluticasone Accuhaler MDI Seretide MDI 50 Accuhaler 100 Indicated if: Exacerbation of asthma in last 2 years, inhaled 2 agonist > 3x week, symptomatic >3x week or waking one night a week then Rx mcg BDP equivalent, starting at dose appropriate to disease severity continue at lowest effective dose to maintain control Terbutaline Turbohaler Symbicort Turbohaler 100/6 1. LTRA Montelukast Treatment trials of 1-3 months. Discontinue if ineffective. Key 5 5 < Reference: BNF March 2013 Based on usage over 30 days at average doses for each step * BDP Equivalents: 2mcg Beclometasone/Budesonide = 1mcg Fluticasone = 1mcg CFC - Free Beclometasone(QVAR) ) (Costs on step 2 based on 200mcg/day*) Check licensing of medicines in children some drugs listed here are not licensed in all age groups BDP = Beclometasone Diproprionate; ICS = inhaled corticosteroids; MDI = metered dose inhaler; LABA = long acting beta agonist; LTRA = leukotriene receptor antagonist March 2013 Always check inhaler technique and concordance before changing, and remember to Review and Step Down.

20 5.1 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison NB. IN CHILDREN UNDER 5 YEARS MDI AND SPACER ARE DEVICES OF CHOICE Bronchodilators - Cost per Average Child Daily Dose Analysis (equivalent to 400mcg salbutamol daily (cost for 28 days)) Bricanyl Turbohaler Salbutamol Easi-Breathe Airomir Autohaler Asmasal Clickhaler Ventolin Accuhaler Pulvinal Salbutamol Salbutamol Easyhaler Salbulin Novolizer Salbutamol CFC free MDI Cost ( )

21 5.1 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison NB. IN CHILDREN UNDER 5 YEARS MDI AND SPACER ARE DEVICES OF CHOICE Corticosteroid Cost per Average Child Dose Analysis (equivalent to 200mcg BDP equivalents per day (cost per 28 days therapy)) Flixotide Accuhaler Pulmicort Turbohaler Beclometasone Easyhaler Pulvinal Beclometasone Asmabec Clickhaler Flixotide MDI Budesonide Easyhaler Clenil Modulite Cost ( )

22 5.1 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison NB. IN CHILDREN UNDER 5 YEARS MDI AND SPACER ARE DEVICES OF CHOICE Combination Therapy Costs per 28 days (BDP equivalent 400mcg/day) Symbicort 100/6 (2p bd) 30.8 Seretide 100 Accuhaler (1p bd) 16.8 Seretide 50 MDI (2p bd) Cost ( )

23 5.1 Stepwise Management of Asthma in Children 5-12 years Treatment Cost Comparison NB. IN CHILDREN UNDER 5 YEARS MDI AND SPACER ARE DEVICES OF CHOICE Equivalent Inhaled Corticosteroid Doses BECLOMETASONE / dose 100mcg 200mcg QVAR (CFC Free BDP)/dose FLUTICASONE / dose 50mcg 100mcg FLUTICASONE / dose not licensed in children <12 years 50mcg 100mcg BUDESONIDE / dose 100mcg 200mcg 400mcg 50mcg 100mcg FLUTICASONE / dose 50mcg 100mcg 200mcg Titrate the dose of inhaled steroid to the lowest dose at which effective control is maintained

24 5.1.1 NHS Forth Valley Guideline for the Management of Asthma Stepping Down Treatment in Children Patients should be maintained at the lowest possible dose of inhaled steroid. Reduction in inhaled steroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every 3 months, decreasing the dose by approximately 25-50% each time. Decisions on which drug to step down first should be determined by the recorded effect on symptoms. Minimising exposure to steroids is a priority and patient preference should also be considered. Record the rationale for each change of treatment and how response will be monitored. Revise Personal Asthma Plan appropriately for home and school. September 2013

25 5.2 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in General Practice Children Age 2-5 Years Assess Asthma Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features Moderate Exacerbation SpO 2 92% Able to talk Heart rate 130/min Respiratory rate 50/min Severe Exacerbation SpO 2 <92% To breathless to talk Heart rate >130/min Respiratory rate >50/min Use of accessory neck muscles Life Threatening Asthma SpO 2 <92% plus any of: Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis ß 2 agonist 4-6 puffs via spacer ± facemask Consider soluble Prednisolone 20mg Increase ß 2 agonist dose by 2 puffs every 2 minutes up to 10 puffs according to response. If poor response arrange admission Oxygen via face mask 10 puffs of ß 2 agonist (given one at a time single puffs, tidal breathing and inhaled separately) at intervals of minutes or nebulised salbutamol 2.5mg or terbutaline 5mg delivered with oxygen if available Soluble prednisolone 20mg Assess response to treatment 15 minutes ß 2 agonist. after If poor response repeat ß 2 agonist and arrange admission Oxygen via face mask Nebulise with oxygen if available: o Salbutamol 2.5 mg or terbutaline 5mg + o Ipratropium 0.25mg Soluble prednisolone 20mg or IV hydrocortisone 50mg Repeat ß 2 agonist via oxygendriven nebuliser whilst arranging immediate hospital admission Good Response Continue ß 2 agonist via spacer or nebuliser, as needed but not exceeding 4-hourly If symptoms are not controlled repeat ß 2 agonist and refer to hospital Continue prednisolone for up to 3 days Arrange follow-up clinic visit Poor Response Stay with patient until ambulance arrives Send written assessment and referral details Repeat ß 2 agonist via oxygen-driven nebuliser in ambulance September 2013 Lower threshold for admission if: Attack in late afternoon or at night Recent hospital admission or previous severe attack Concern over social circumstances or ability to cope at home

26 5.2 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in General Practice Age > 5 Years Assess Asthma Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features Moderate Exacerbation SpO 2 92% PEF 50% best or predicted Able to talk Heart rate 120/min Respiratory rate 30/min Severe Exacerbation SpO 2 <92% PEF <50% best or predicted Too breathless to talk Heart rate >120/min Respiratory rate >30/min Use of accessory neck muscles Life Threatening Asthma SpO 2 <92% plus any of: PEF <33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis ß 2 agonist 4-6 puffs via spacer ± facemask Consider soluble Prednisolone 30-40mg Increase ß 2 agonist dose by 2 puffs every 2 minutes up to 10 puffs according to response. If poor response arrange admission Oxygen via face mask 10 puffs of ß2agonist (given one at a time single puffs, tidal breathing and inhaled separately) at intervals of minutes or nebulised salbutamol 5mg or terbutaline 10mg Soluble prednisolone 30-40mg Assess response to treatment 15 minutes after ß 2 agonist. If poor response repeat ß 2 agonist and arrange admission Oxygen via face mask Nebulise with oxygen if available: o Salbutamol 5 mg or terbutaline 10mg + o Ipratropium 0.25mg Soluble prednisolone 40mg or IV hydrocortisone 100mg Repeat ß 2 agonist via oxygendriven nebuliser whilst arranging immediate hospital admission Good Response Continue ß 2 agonist via spacer or nebuliser, as needed but not exceeding 4-hourly If symptoms are not controlled repeat ß 2 agonist and refer to hospital Continue prednisolone for up to 3 days Arrange follow-up clinic visit Poor Response Stay with patient until ambulance arrives Send written assessment and referral details Repeat ß 2 agonist via oxygen-driven nebuliser in ambulance September 2013 Lower threshold for admission if: Attack in late afternoon or at night Recent hospital admission or previous severe attack Concern over social circumstances or ability to cope at home

27 5.3 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in Emergency Department Children Age 2-5 Years Assess Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features Moderate Exacerbation SpO2 92% No clinical features of severe asthma Severe Exacerbation SpO 2 <92% in air Too breathless to talk or eat Heart rate >130/min Respiratory rate >50/min Use of accessory neck muscles Life Threatening Asthma SpO 2 <92% plus any of: Silent chest Poor respiratory effort Agitation Altered consciousness or exhaustion Cyanosis Salbutamol 100mcgx10 puffs Give nebulised salbutamol 2.5mg with oxygen as driving gas via spacer + facemask Continue O 2 via face mask/nasal prongs Reassess after 15 minutes Give soluble prednisolone 20mg or IV hydrocortisone 50mg Send U&E and venous gas if IV cannula sited Responding Continue inhaled ß 2 agonist 1-4 hourly Give soluble oral prednisolone 20mg Discharge Plan Continue ß2 agonist 4 hourly prn Consider prednisolone 20mg daily for up to 3 days Advise to contact GP (or NHS 24 if out of hours) if not controlled on above treatment Provide written asthma plan for next days and Asthma UK leaflet After your Child s Asthma Attack Advise avoidance of tobacco smoke exposure Review regular treatment Check inhaler technique Arrange GP follow-up within 3 days September 2013 Not Responding Repeat inhaled ß 2 agonist Give soluble oral prednisolone 20mg Arrange Admission (Lower threshold if concern over social circumstances) If Life Threatening Features Present Discuss with senior clinician and paediatrician Repeat nebulised ß2agonist plus Ipratropium bromide 0. 25mg Consider Portable chest x-ray Capillary blood gases Plus Bolus IV salbutamol 15 mcg/kg over 10 minutes to maximum dose of 250 mcg over 10 minutes (see PICU folder for IV salbutamol monograph) Continuous salbutamol = infusion or nebulised Arrange immediate transfer to HDU if poor response to treatment PEWS every 15 minutes including signs of fatigue Consider discussing with PICU and FV critical care anaesthetist

28 5.3 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in Emergency Department Age > 5 Years Assess Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features Moderate Exacerbation SpO 2 92% PEF 50% best or predicted No clinical features of severe asthma Able to talk in sentences Severe Exacerbation SpO 2 <92% in air PEF <50% best or predicted Heart rate >120/min Respiratory rate >30/min Too breathless to talk Use of accessory neck muscles Life Threatening Asthma SpO 2 <92% plus any of: PEF <33% best or predicted Silent chest Poor respiratory effort Altered consciousness or exhaustion Cyanosis Salbutamol 100mcgx10 puffs via spacer ± facemask Add 30-40mg soluble oral prednisolone Reassess after 15 minutes Give nebulised salbutamol 5mg with oxygen as driving gas Continue O 2 via face mask/nasal prongs Give soluble prednisolone 30-40mg if not already given or IV hydrocortisone 100mg if vomiting or not tolerating oral Send U&E and venous gas if siting IV cannula Responding Continue inhaled ß 2 agonist 1-4 hourly Not Responding Repeat inhaled ß 2 agonist Arrange Admission (lower threshold if concern over social circumstances) Discharge Plan Continue ß 2 agonist 4 hourly as necessary Prednisolone 30-40mg daily for up to 3 days Advise to contact GP (or NHS 24 if out of hours) if not controlled on above treatment Provide written asthma action plan Review regular treatment Check inhaler technique Arrange GP follow-up If Life Threatening Features Present Discuss with senior clinician and consultant paediatrician Repeat nebulised Salbutamol 5mg + Ipratropium bromide 0.25mg 4 hourly Consider Bolus IV salbutamol 15 mcg/kg to maximum dose 250 mcg of over 10 minutes (see PICU folder for IV salbutamol monograph) Repeat nebulised Salbutamol or commence infusion at 2 mcg/kg/min Portable chest x-ray and capillary blood gases Plus Consider IV Magnesium if poor response and normovolaemic Arrange immediate transfer to Children s Ward if poor response to treatment Admit all cases if features of severe exacerbation persist September 2013

29 5.4 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in hospital Children age 2 5 years Assess Asthma Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features Moderate Exacerbation SpO 2 92% No clinical features of severe asthma Severe Exacerbation SpO 2 <92% in air Too breathless to talk or eat Heart rate >130/min Respiratory rate >50/min If vomiting cannulate and give steroid IV as hydrocortisone 4mg/Kg slowly then maintenance IV fluids as Sodium Chloride 0.45%:Glucose 5% with KCl Use of accessory neck muscles or abdominal muscles in expiration Life Threatening Asthma SpO 2 <92% as for severe plus any of: Silent chest Poor respiratory effort Agitation Altered consciousness or exhaustion Cyanosis Oxygen via face mask/nasal prongs to achieve saturations >94% refer for admission to hospital ß 2 agonist via spacer ± facemask (given one puff at a time, tidal breathing 5-10 breaths then shake MDI reload spacer and repeat) 1 puff every minute up to 10 puffs Soluble oral prednisolone 20mg Review and record precipitating cause for exacerbation Reassess within 1 hour ß 2 agonist 10 puffs via spacer ± facemask or nebulised salbutamol 2.5mg with oxygen Soluble prednisolone 20mg Repeat ß 2 agonist up to every minutes according to response If poor response add 250 micrograms nebulised ipratropium bromide If vomiting cannulate and give steroid IV as hydrocortisone 4mg/Kg slowly then maintenance IV fluids as 5%:0.45 with KCl Nebulised ß 2 agonist: salbutamol 2.5mg plus nebulised ipratropium bromide 250 micrograms Weigh child or estimate weight from length, cannulate and take U&E and venous gas Keep nil by mouth IV hydrocortisone 4mg/kg give slowly as risk for vomiting Discuss with paediatric and ED consultant Repeat bronchodilators every minutes Bolus IV salbutamol 15microg/kg over 5 minutes to maximum 250 mcg total dose see PICU folder for drug preparation. Start IV fluids as 5% dextrose and 0.45% saline with KCl at 75% maintenance rate Contact Children s Ward for admission as HDU patient ASSESS RESPONSE TO TREATMENT: record respiratory rate, heart rate and oxygen saturation every 1-4 hours Responding Repeat multi-dose salbutamol after 1 hour Review inhaler technique with MDI and spacer Reinforce use of multi-dose for severe wheeze Review preceding asthma control with parents Advise any change in management Update Personal Asthma Action Plan for home and nursery/school Observe for 4 hours to confirm response Advise viewing of Attacking Asthma programme while in hospital Offer parents Understanding Asthma booklet Advise 2013 against exposure to tobacco smoke Discharge with 3 day course of prednisolone and acute asthma action plan GP review within 3 days Consider referral to paediatric respiratory clinic if additional concerns Not Responding Arrange HDU/admission to Children s Ward FVRH Tel: Consider: Portable chest x-ray and capillary blood gases IV salbutamol 15mcg/kg bolus over 10 minutes (if not already given) followed by continuous infusion 1-2mcg/kg/min (dilute to 200mcg/ml) see Purple retrieval folder for drug preparation IV Salbutamol infusion requires HDU care (cubicle and one to one care) and 12 hourly electrolyte check as K+ can be low Consider IV Magnesium 40mg/Kg max 2g over 20mins (see PICU folder for drug preparation) IV aminophylline 5mg/kg loading dose over 20 minutes (omit loading in those receiving oral theophyllines) followed by continuous infusion 1mg/kg/hour FV consultant to discuss with FV ITU and PICU if deteriorating or becoming exhausted Tel (Yorkhill direct line) or (RHSC)

30 5.4 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in hospital Age > 5 years Assess Asthma Severity NB: If a patient has signs and symptoms across the categories, always treat according to their most severe features If not responding treat as next level of severity Moderate Exacerbation SpO 2 92% PEF 50% predicted No clinical features of severe asthma Severe Exacerbation SpO 2 <92% PEF <50% best or predicted Heart rate >120/min Respiratory rate >30/min Use of accessory neck muscles Life Threatening Asthma signs as for severe SpO 2 <92% plus any of: PEF <33% best or predicted Silent chest Poor respiratory effort, exhausted Altered consciousness Cyanosis Oxygen via face mask/nasal prongs to achieve oxygen saturations >94% refer for admission to hospital ß 2 agonist up to 10 puffs via spacer (given one minute at a time single puffs, 5-10 breaths tidal breathing and inhaled separately) Oral prednisolone 30-40mg If SpO2 < 94% give oxygen via facemask to achieve normal saturations. Reassess within 1 hour See below for management when responding ß 2 agonist 10 puffs via spacer one puff per minute or nebulised salbutamol 5mg Oral prednisolone 30-40mg or IV hydrocortisone 4mg/kg if vomiting. Inject slowly If poor response add nebulised ipratropium bromide 250 micrograms Repeat ß 2 agonist and ipratropium up to every minutes according to response Nebulised salbutamol 5mg plus nebulised ipratropium bromide 250 micrograms Weigh child or estimate weight from length Cannulate and take U&E and venous gas Keep nil by mouth Monitor ECG IV hydrocortisone 4mg/kg give slowly as risk for vomiting Discuss with paediatric and ED consultants Repeat bronchodilators every minutes Bolus IV salbutamol 15microg/kg over 5 minutes to maximum 250 mcg total dose see PICU folder for drug preparation. Start IV fluids as 5% dextrose and 0.45% saline with KCl at 75% maintenance rate Contact Children s Ward for admission as HDU ASSESS RESPONSE TO TREATMENT Record respiratory rate, respiratory effort, heart rate, oxygen saturation and PEF/FEV every 1-4 hours Not Responding Continue minute ipratropium nebulisers while further treatment below is administered Arrange HDU care (i.e. one to one nursing in HDU cubicle) Discuss with PICU if deteriorating or no response to further steps below Consider: Portable chest x-ray and capillary blood gases Ensure serum potassium is normal before giving IV salbutamol Consider risks and benefits of: Bolus IV salbutamol 15mcg/kg to maximum 250mcg over 5 minutes. Bolus IV infusion of magnesium sulphate 40mg/kg max 2g over 20 minutes (unlicensed but evidence based use) (beware risk for hypotension if hypovolaemic) Continuous IV salbutamol infusion 1-5mcg/kg/min (see PICU folder for drug preparation) IV Salbutamol infusion requires 12 hourly electrolyte check as K+ can be low especially with steroids and aminophylline Stop long acting beta agonist while on IV salbutamol IV aminophylline 5mg/kg loading dose over 20 minutes (omit in those receiving oral theophyllines) followed by continuous infusion 1mg/kg/hour. Monitor BP and side effects 6 hourly IV Hydrocortisone 4mg/Kg given slowly to avoid vomiting until tolerating oral steroid IV 2013 fluids to maintain blood pressure and consider referral to ITU/PICU for inotrope support if hypotensive Reduce nebuliser frequency to 4 hourly when on IV salbutamol Consider omeprazole 20mg o.d during acute severe exacerbation and may benefit from continuing long term if difficult to control asthma persists Check capillary blood gas if clinical deterioration or no improvement after treatment Contact FVRH consultant for critical care and confirm referral to PICU if PCO2 rising or clinically exhausted

31 5.4 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in hospital Age > 5 years (cont) After the crisis is over Child with Acute Asthma Attending Hospital Following immediate management in OOH, ED or PAU Responding Repeat multi-dose Salbutamol after 1 hour Review inhaler technique with MDI and spacer Reinforce use of multi-dose for severe wheeze Review preceding asthma control with parents Record trigger for exacerbation if known and advise avoidance if possible Advise any change in management Update Personal Asthma Action Plan for home and nursery/school Observe for at least 4 hours to confirm response Advise viewing of Attacking Asthma programme while in hospital Advise against exposure to tobacco smoke Discharge to complete a 3 day course of prednisolone Consider need for a home supply of oral steroid as part of acute asthma action plan Ensure discharge note for GP is given to parent or sent electronically GP review within 3 days Refer to children s respiratory clinic if ongoing concerns about asthma management Confirm GP asthma clinic review continues and informs school health Child with Acute Asthma Attending Hospital following admission to Children s Ward Responding Maintain oxygen saturation at > 94% Reduce IV aminophylline to half then stop when observations satisfactory When off aminophylline, reduce IV salbutamol infusion rate 4 hourly as tolerated Start PEFR record when child can co-operate Reduce nebulised ipratropium to prn when wheeze free after 4 hours When off IV salbutamol prescribe prn multi-dose or nebulised salbutamol up to 2 hourly Continue regular 4 hourly nebulised salbutamol till out of oxygen Observe with SaO2 monitoring for at least 4 hours post bronchodilator and during sleep to confirm recovery Review inhaler technique with MDI and spacer Reinforce use of multi-dose for severe wheeze Review preceding asthma control with parents Identify any suspected new triggers especially rhinitis/hay fever or exposure to animals Advise any change in management Update Personal Asthma Action Plan for home and nursery/school Arrange viewing of Attacking Asthma programme while in hospital Offer Understanding Asthma booklet to parents with Asthma UK leaflets Advise against exposure to tobacco smoke Discharge with 3 day course of prednisolone and acute asthma action plan and Advise primary care review within 3 days Ensure GP and practice nurse have an eward IDL and asthma care plan at discharge Respiratory Clinic follow up for all life threatening asthma admissions with alert as high risk on e ward Ensure GP Asthma Clinic review continues and informs School Health GP review within 3 days Community 2013 Children s Nurse for Complex Respiratory Disease to review etc If this was a life threatening attack or there are additional concerns after a severe attack: Request Children s Complex Respiratory Nurse to review Asthma Action Plan Request respiratory clinic new patient appointment within a month

32 5.4.1 NHS Forth Valley Guideline for the Management of Asthma Management of Acute Asthma in Children in Hospital Life-Threatening Asthma Infusion Guidelines for Salbutamol and Magnesium Refer to BNFfC and PICU website for additional information Approved Name: Salbutamol Application: Bronchodilator Contra-indications: Nil relevant Precautions: Tachycardia, hypokalaemia, QT interval prolongation, hyperglycaemia, diabetes (risk of ketoacidosis) hyperthyroidism Drug Interactions: Corticosteroids: increased risk of hypokalaemia Theophylline/Aminophylline: increased risk of hypokalaemia Dose: Loading Dose: 15 microgram/kg over 15mins to maximum dose of 250 micrograms as a single dose Maintenanc e Dose: 2-5microgram/kg/ min Maximum rate 10microgram/kg/min in consultation with PICU Stability in IV Solutions: Sodium Chloride 0.9% Glucose 5% Water for Injections Sodium Chloride 0.45%:Glucose 5% Reconstitution: This requires 20 (twenty) ampoules of Salbutamol Remove 100ml from a 500ml bag Use 5mg/5ml salbutamol ampoules Replace with 20 (twenty) x5ml ampoules =100mg Salbutamol Concentration = 200microgram/ml Administration: Loading dose 0.075ml/Kg over 15mins gives 15mcg/Kg Maintenance infusion: 0.3ml/kg/hr = 1microgram/kg/min Stability: Stable for 24hours Physical Compatibility with other Drugs: Incompatible with Aminophylline Side Effects: Tachycardia, tremor, hypokalaemia Comments: Venous irritant, central access preferable Monitor blood glucose and serum potassium Monitor ECG Approved Name: Magnesium Sulphate (use in asthma) Application: Adjunct to bronchodilators in severe status asthmaticus Contra-indications: Nil relevant Precautions: Monitor blood pressure, avoid hypovolaemia Drug Interact ions: Nil relevant Dose: 40mg/kg (=0.08 ml/kg of 50% Magnesium Sulphate), Max 2g Reconstitution: Further dilution is required Stability in IV Solutions: Sodium Chloride 0.9% Glucose 5% Flushes compatible: Sodium Chloride 0.9%, Glucose 5% Administration: Dilute dose 5 times before administration (e.g. dose = 1ml, dilute to 5ml) Administer over 20 minutes Stability: Use dilute solution immediately Physical Compatibility with other Drugs: Do not mix with other drugs Side Effects: High magnesium levels can cause dystonia, nausea, vomiting, flushing Comments: 1g magnesium sulphate = 4mmol magnesium