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Biological, psychological and social complexities in childhood development
Biological, psychological and social complexities in childhood development

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1.2 Diagnosis and day-to-day management of uncontrolled asthma

The National Institute for Health and Care Excellence (2020) defines uncontrolled asthma as:

asthma that has an impact on a person’s lifestyle or restricts their normal activities. Symptoms such as coughing, wheezing, shortness of breath and chest tightness associated with uncontrolled asthma can significantly decrease a person’s quality of life and may lead to medical emergency.

Uncontrolled asthma is determined by having symptoms for three or more days per week, having to use a ‘short-acting beta antagonist’ (SABA) (reliever) inhaler such as salbutamol for three or more days per week or waking up from sleep once or more in a week. For an occasional wheeze or asthma that is considered ‘controlled’ (i.e. it does not meet these criteria), a SABA might be the only course of treatment required. Inhaled corticosteroid (ICS) (preventer) inhalers are recommended for children and young people if they meet these criteria or if they have had an asthma attack in the preceding two years (British National Formulary, BNF, 2019). Preventer inhalers build up asthma protection over time by reducing inflammation in the lungs.

Activity 3 Having asthma

Timing: Allow 45 minutes

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Transcript: Audio 1

FATHER
My son’s asthma was finally diagnosed – I think he was about five years old. But it was always something we were expecting. We knew that one day they were going to say he’s got asthma, and so in one way it was bit of a relief. But on the other side of it – well, we’d basically known this for years.
The process of diagnosis came about from another admission into hospital from an asthma attack. They literally just kept reading through his charts, saw that he had been in and out of hospital a number of times that included overnight stays in hospital… personally I think they just saw, okay, he is five years old now, these symptoms don’t seem to go away – so they confirmed that he did have asthma and then we were invited to go and see an asthma specialist through our GP.
We were quite pleased about the diagnosis in a strange way. I’ve always been quite keen for him to be into sports, to be quite active. When he was younger, you could see he was just getting out of breath and he couldn’t run around all the time with the other kids.
Managing medication for our son was pretty much getting into a routine, just knowing that whenever he wakes up he’s either got to take a tablet or do an inhaler. When he goes to bed he’s got to take a tablet, do his inhalers again. Whenever you’re going out anywhere you do need to make sure that you’ve got his medication on you at all times because it never seemed to be much of a pattern – when he was younger he could be absolutely fine one day or for a week or so but then out of the blue he could start displaying symptoms and be struggling to breathe, and he would need his medication.
We had to be quite mindful of the environment that my son was in. It would appear sometimes dust would start him off. Other animals could be a trigger as well – cat fur, dog fur, that sort of thing.
There weren’t many challenges day to day. As long as you were just constantly knowing that he’s sticking to his routine for medication and that you’ve also got inhalers handy. Not so much a problem at the age he is now. He’s approaching fourteen years old, so he’s taken a bit of responsibility, as he should. He’s always got an inhaler in his pocket – he knows his routine for his medication, so that means taking tablets in the morning, taking tablets of an evening. If we’re going to be in an environment where there could be other triggers such as animal fur, a dusty environment, you make sure you take an antihistamine as well just to give himself a bit of an extra layer of protection.
As my son’s got older, it has eased a little bit as the sort of pressure on a parent. He knows that his health is his responsibility and that involves taking your medication, having an inhaler handy, don’t put yourself into an environment where you could put yourself at risk.
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Look through the diagnosis and treatment sections of the NICE guidelines on diagnosing, monitoring and managing asthma [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)]  and conduct your own internet search on the diagnosis and treatment of asthma. Remember, to avoid losing your place in the course, if you are studying on a desktop you should open the link in a new tab or window by holding down Ctrl (or Cmd on a Mac) when you click on it. If you are studying on a mobile device hold down the link and select to ‘Open in New Tab’. Then return here when you have finished.

Make sure you are familiar with the advice on managing an asthma attack and then complete the next part of this activity.

In the audio you heard a parent talking about their experience of having a child diagnosed with asthma and some of the day-to-day considerations. Using the clinical guidance and what you have found from your own internet search, indicate the type of advice you would provide to this parent for their son, whose usual peak flow is 120.

You might also find this asthma action plan from Asthma UK useful when completing this activity.

Outline of the diagnostic process

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Everyday asthma care

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When they feel worse

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What to do in an asthma attack

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Discussion

This activity has allowed you to use clinical guidance to produce patient-facing information to help them manage their asthma.

Diagnostic process:

For children under 5 with suspected asthma, treat symptoms based on observation and clinical judgement, and review the child on a regular basis. If they still have symptoms when they reach 5 years, carry out objective tests.

If a child is unable to perform objective tests when they are aged 5:

  • continue to treat based on observation and clinical judgement
  • try doing the tests again every 6 to 12 months until satisfactory results are obtained
  • consider referral for specialist assessment if the child repeatedly cannot perform objective tests and is not responding to treatment.

Everyday asthma care:

  • Personal best peak flow is 120
  • ICS (preventer) such as beclomethasone (Clenil) – one puff twice daily
  • SABA (reliever) such as salbutamol – take two puffs at a time
  • They may use a spacer to administer their inhaler.

When they feel worse:

  • My peak flow drops below 115 (you may have estimated this differently)
  • ICS (preventer) – two puffs twice daily
  • Take reliever inhaler up to 10 puffs every 4 hours (if they need to do this then it is likely they are having an asthma attack and need urgent attention). They should not exceed the daily maximum dose
  • They may be prescribed a nebuliser.

What to do in an asthma attack:

  • You should have noted the actions to take when someone is having an asthma attack
  • If they are taking a maintenance and reliever inhaler in one (maintenance and reliever therapy, or MART) then it’s likely they will have been prescribed a reliever inhaler for use in emergency situations.

You will now explore what treatment is provided in hospital when someone has a severe exacerbation of asthma.