16/09/2015 1 ROYAL FREE CHILDREN’S SERVICES Rahul Chodhari , Consultant Paediatrician 07711808012, [email protected]Aims of the talk • Opportunities to improve asthma care in Camden • Diagnosis in primary care • Preschool wheeze v asthma – When to refer? A belief that asthma could be cured by the sound of a violin Asthma, caricature from 'Album Comique de Pathologie Pittoresque', published in Paris, 1823
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Rahul Chodhari Consultant Paediatrician · 16/09/2015 1 ROYAL FREE CHILDREN’S SERVICES Rahul Chodhari, Consultant Paediatrician 07711808012, [email protected] Aims of the talk
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• Asthma is a chronic disease characterised bywheezing, breathlessness, night time or earlymorning coughing– Episodes are usually associated with airflow obstruction
within the lungs that is reversible with treatment
• Hospital admissions are falling• Risk of asthma rises with:
– positive family history atopy– maternal smoking in pregnancy– early sensitisation to aeroallergens
Burr Thorax 2006, Asthma UK, National statistics
British Thoracic Society (BTS) guideline Oct 2014
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Case: High v Low probability of asthma?• 5 year old Josh:
– 4 episodes of wheezingin the past, mostly withURTI
– Improvement insymptoms after startingRx
– Symptoms are worse atnight and in the earlymorning
– Widespread wheezeheard on auscultation
Royal Free OPD
High probability of asthma• More than one of the following symptoms:• Wheeze, cough, difficulty breathing, chest
tightness, particularly if these symptoms:• are frequent and recurrent• are worse at night and in the early morning• occur in response/worse after triggers, such as
exposure to pets, cold or damp air, or with emotions orlaughter
• occur apart from cold• personal/ Family history of atopy or asthma• wheeze heard on auscultation• improvement in symptoms or lung function in response
to adequate therapy
Case: High v Low probability ofasthma?
• 13 year old Jenny:– Isolated cough in the absence of
a wheeze or difficulty breathing– Dizziness, light-headedness and
peripheral tingling– Normal peak expiratory flow
when symptomatic– No response to a trial of asthma
therapy
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Low probability of asthma• Symptoms only with colds and with no interval symptoms• Isolated cough in the absence of a wheeze or difficulty
breathing• Prominent dizziness, light-headedness and peripheral tingling• Repeatedly normal physical examination of the chest when
symptomatic• Normal peak expiratory flow (PEF) or spirometry when
symptomatic• No response to a trial of asthma therapy• Clinical features pointing to alternative diagnosis
Clinical features pointing to alternativediagnosis
• Symptoms are present from birth or perinatallung problem
• Persistent moist cough• Failure to thrive• Abnormal voice or cry
When should you refer?• Investigations - SPT, PEFR or spirometry
• Escalating dosages above BTS step 2/3• To establish and review definitive diagnosis
• Poor response +/- compliance• Trigger avoidance advice• Education & device technique• Risk assessment – severity and home visits• Management of co-morbidities• Communication with other agencies
• Involved people (doctor, child, family) areunhappy with outcomes
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Clinical Gems• Clarify what the family means by wheezing• Isolated dry cough in a community setting is
rarely due to asthma• Preschool wheeze - “episodic viral” or
“multiple trigger”• Pre school wheeze treatment is driven
solely by current symptoms• Prednisolone is not indicated in preschool
children with wheezing attacks• Focus clinical assessment of school wheeze