Re: comment from Dr Mark Levy and colleagues to conflicting asthma guidelines cause confusion in primary care
Dr. Levy and his colleagues highlight their concern about the “increasingly common advice by UK paediatricians for parents to administer 10 puffs SABA regularly as part of a ‘weaning plan’ after discharge from hospital or A and E (ED) following treatment for an acute asthma attack.” They highlight our BMJ learning module (1) where we give detailed guidance for the immediate few days following discharge from ED or hospital. In the module, we also provided examples of step-down ‘weaning plans’ currently used in two large UK paediatric centres. These plans provide pragmatic, ‘real world’ advice that help paediatric units cope safely with the high volume of wheezing children they have to deal with.
Dr. Levy is concerned that the regular use of SABA immediately following hospital discharge is not evidence based and may put patients at risk of undetected and possibly life-threatening deterioration. His particular concern is that using SABAs regularly may mask the warning sign that perceived increasing need for bronchodilators provides patients with when their asthma control is deteriorating. Instead, he commends the advice in the Global Initiative for Asthma Guidelines (GINA) that clinicians prescribe ‘as needed’ SABA for children and adults following treatment of attacks (2). In passing, the current GINA guidelines do not appear to provide any evidence to support this approach.
We think it is important to remember the context where ‘weaning plans’ are used. Asthma attacks are one of the commonest paediatric emergencies. Around 60% of children admitted to hospital with an acute attack are under 5 years (3). Asthma attacks are usually triggered by viral infections, over a period of hours to days and then take a number of days to resolve.
When children are brought to hospital with a severe asthma attack they will be treated aggressively with high dose SABAs and oral corticosteroids. Most children are discharged home within 4hrs, when they have been stabilized; if not stable, they will be admitted and treated until their condition has stabilized. In both situations, it is important to realise that when children are discharged, either from the ED or from a hospital ward, their asthma may have been been judged stable but the acute attack will not have completely resolved - although it is expected to do so over the next few days. On discharge, such children will commonly still be receiving high dose SABA, often 10 puffs via spacer every 3-4hrs (4).
What happens next? How should their parents adjust their bronchodilators in the next few days as their children recover, or not, from the acute attack. Dr. Levy is right to highlight the lack of a sound evidence base for any recommendations. As an example, if a child with an acute attack is discharged in the evening on 10 puffs 4hrly and the child is sleeping when the next multi-dosing is due should they be given the medicine or allowed to sleep, or given the medicine while they sleep?
Dr. Levy’s advice is use SABA “as needed” and if relief does not last 4 hours seek urgent medical advice. We think this is simplistic and places undue weight on the SABA requirement, which is expected to decrease as the child recovers, and gives no specific advice about how and when the high dose SABA should be reduced. The Asthma UK adult and child asthma plan Dr. Levy commends has a very brief section “After an asthma attack” and gives no advice about SABA dosing reduction. It advises that you should see your GP within 48 hours to make sure that you are not risk of another attack but also states that if you don’t improve after treatment that you see your GP urgently - with a previous section indicating that urgently means after seven days (5). In effect, this and other plans are missing a detailed section on what to do ‘When I feel better.’
It is this situation, where the majority of children have a process driven by a viral infection that will take a few days to resolve, that we have found ‘weaning plans’ useful. Parents want and value more detailed advice on how to manage the anticipated recovery and need specific advice about how treatment should be adjusted down and how to recognize and manage when thing things are not progressing as expected. A ‘weaning plan’ sets out how this should be done over 3-4 days while also providing safety-netting advice (Table 1). Such ‘weaning plans’ need to be delivered consistently by trained clinical staff who have a clear understanding of the safety netting issues for a child with an asthma attack. The advice to see your GP within 48hrs of discharge provides an important additional safety guard but in practice seems to be more often honoured in the breach.
Dr. Levy rightly highlights the UK’s poor record with regard to childhood asthma deaths. In the National Review of Asthma Deaths (NRAD) (6), 45% of patients (adults and children) died without seeking medical assistance or before emergency medical care could be provided. Only 27% had ever been provided with a Personal Asthma Action Plan, in either primary or secondary care. The report recommended that parents and children, and those who care for or teach them, should be educated about managing asthma. This should include emphasis on ‘how’, ‘why’ and ‘when’ they should use their asthma medications, how to recognise when asthma is not controlled and knowing when and how to seek emergency advice. We think the safety-netting and treatment advice encoded within a ‘weaning plan’ goes some way to addressing this recommendation and provides clearer and more detailed guidance for parents on managing the immediate period after an asthma attack than “take your inhaler as needed (up to every four hours).”
Table 1: safety netting advice for families
• Parents/caregivers should be aware of the symptoms that indicate current treatment is not working.
• These may include the need to give β2-agonist more often than 10 puffs every four hours, and their child becoming more short of breath, showing increased labour of breathing, or becoming unusually drowsy. In these circumstances, advise parents to call an ambulance
• Multiple dosing with up to 10 puffs of β2-agonist should provide relief from symptoms for three to four hours
• If symptoms recur within this period, parents/caregivers should give a further 10 puffs of the β2-agonist via spacer and seek urgent medical attention or call an ambulance. Parents often need reassurance that it is safe to give 10 puffs of β2-agonist in this situation
James Y Paton
Reader, School of Medicine, University of Glasgow, UK and Hon Consultant in Paediatric Respiratory Medicine, Royal Hospital for Children, Glasgow.
Richard Chavasse
Consultant in Respiratory Paediatrics at St George’s Hospital, London.
Steven Foster
Consultant in Paediatric Emergency Medicine at the Royal Hospital for Children, Glasgow.
Morag Wilson
Consultant Paediatrician at the Royal Hospital for Children, Glasgow.
2. The Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA).2018 Available from: http://www.ginasthma.org. (Accessed 13 November 2018)
Reader, School of Medicine, University of Glasgow, and Hon Consultant in Paediatric Respiratory Medicine, Royal Hospital for Children, Glasgow
Richard Chavasse, Consultant in Respiratory Paediatrics, St George’s Hospital, London; Steven Foster, Consultant in Paediatric Emergency Medicine, Royal Hospital for Children, Glasgow; Morag Wilson, Consultant Paediatrician, Royal Hospital for Children, Glasgow
Rapid Response:
Re: comment from Dr Mark Levy and colleagues to conflicting asthma guidelines cause confusion in primary care
Dr. Levy and his colleagues highlight their concern about the “increasingly common advice by UK paediatricians for parents to administer 10 puffs SABA regularly as part of a ‘weaning plan’ after discharge from hospital or A and E (ED) following treatment for an acute asthma attack.” They highlight our BMJ learning module (1) where we give detailed guidance for the immediate few days following discharge from ED or hospital. In the module, we also provided examples of step-down ‘weaning plans’ currently used in two large UK paediatric centres. These plans provide pragmatic, ‘real world’ advice that help paediatric units cope safely with the high volume of wheezing children they have to deal with.
Dr. Levy is concerned that the regular use of SABA immediately following hospital discharge is not evidence based and may put patients at risk of undetected and possibly life-threatening deterioration. His particular concern is that using SABAs regularly may mask the warning sign that perceived increasing need for bronchodilators provides patients with when their asthma control is deteriorating. Instead, he commends the advice in the Global Initiative for Asthma Guidelines (GINA) that clinicians prescribe ‘as needed’ SABA for children and adults following treatment of attacks (2). In passing, the current GINA guidelines do not appear to provide any evidence to support this approach.
We think it is important to remember the context where ‘weaning plans’ are used. Asthma attacks are one of the commonest paediatric emergencies. Around 60% of children admitted to hospital with an acute attack are under 5 years (3). Asthma attacks are usually triggered by viral infections, over a period of hours to days and then take a number of days to resolve.
When children are brought to hospital with a severe asthma attack they will be treated aggressively with high dose SABAs and oral corticosteroids. Most children are discharged home within 4hrs, when they have been stabilized; if not stable, they will be admitted and treated until their condition has stabilized. In both situations, it is important to realise that when children are discharged, either from the ED or from a hospital ward, their asthma may have been been judged stable but the acute attack will not have completely resolved - although it is expected to do so over the next few days. On discharge, such children will commonly still be receiving high dose SABA, often 10 puffs via spacer every 3-4hrs (4).
What happens next? How should their parents adjust their bronchodilators in the next few days as their children recover, or not, from the acute attack. Dr. Levy is right to highlight the lack of a sound evidence base for any recommendations. As an example, if a child with an acute attack is discharged in the evening on 10 puffs 4hrly and the child is sleeping when the next multi-dosing is due should they be given the medicine or allowed to sleep, or given the medicine while they sleep?
Dr. Levy’s advice is use SABA “as needed” and if relief does not last 4 hours seek urgent medical advice. We think this is simplistic and places undue weight on the SABA requirement, which is expected to decrease as the child recovers, and gives no specific advice about how and when the high dose SABA should be reduced. The Asthma UK adult and child asthma plan Dr. Levy commends has a very brief section “After an asthma attack” and gives no advice about SABA dosing reduction. It advises that you should see your GP within 48 hours to make sure that you are not risk of another attack but also states that if you don’t improve after treatment that you see your GP urgently - with a previous section indicating that urgently means after seven days (5). In effect, this and other plans are missing a detailed section on what to do ‘When I feel better.’
It is this situation, where the majority of children have a process driven by a viral infection that will take a few days to resolve, that we have found ‘weaning plans’ useful. Parents want and value more detailed advice on how to manage the anticipated recovery and need specific advice about how treatment should be adjusted down and how to recognize and manage when thing things are not progressing as expected. A ‘weaning plan’ sets out how this should be done over 3-4 days while also providing safety-netting advice (Table 1). Such ‘weaning plans’ need to be delivered consistently by trained clinical staff who have a clear understanding of the safety netting issues for a child with an asthma attack. The advice to see your GP within 48hrs of discharge provides an important additional safety guard but in practice seems to be more often honoured in the breach.
Dr. Levy rightly highlights the UK’s poor record with regard to childhood asthma deaths. In the National Review of Asthma Deaths (NRAD) (6), 45% of patients (adults and children) died without seeking medical assistance or before emergency medical care could be provided. Only 27% had ever been provided with a Personal Asthma Action Plan, in either primary or secondary care. The report recommended that parents and children, and those who care for or teach them, should be educated about managing asthma. This should include emphasis on ‘how’, ‘why’ and ‘when’ they should use their asthma medications, how to recognise when asthma is not controlled and knowing when and how to seek emergency advice. We think the safety-netting and treatment advice encoded within a ‘weaning plan’ goes some way to addressing this recommendation and provides clearer and more detailed guidance for parents on managing the immediate period after an asthma attack than “take your inhaler as needed (up to every four hours).”
Table 1: safety netting advice for families
• Parents/caregivers should be aware of the symptoms that indicate current treatment is not working.
• These may include the need to give β2-agonist more often than 10 puffs every four hours, and their child becoming more short of breath, showing increased labour of breathing, or becoming unusually drowsy. In these circumstances, advise parents to call an ambulance
• Multiple dosing with up to 10 puffs of β2-agonist should provide relief from symptoms for three to four hours
• If symptoms recur within this period, parents/caregivers should give a further 10 puffs of the β2-agonist via spacer and seek urgent medical attention or call an ambulance. Parents often need reassurance that it is safe to give 10 puffs of β2-agonist in this situation
James Y Paton
Reader, School of Medicine, University of Glasgow, UK and Hon Consultant in Paediatric Respiratory Medicine, Royal Hospital for Children, Glasgow.
Richard Chavasse
Consultant in Respiratory Paediatrics at St George’s Hospital, London.
Steven Foster
Consultant in Paediatric Emergency Medicine at the Royal Hospital for Children, Glasgow.
Morag Wilson
Consultant Paediatrician at the Royal Hospital for Children, Glasgow.
References
1. Step by step: How to manage acute asthma and wheezing in children in primary care https://learning.bmj.com/learning/module-intro/acute-asthma-wheezing-chi... (Accessed 13 November 2018)
2. The Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA).2018 Available from: http://www.ginasthma.org. (Accessed 13 November 2018)
3. British Thoracic Society. BTS National Paediatric Asthma Audit Summary Report National Audit Period: 1 November 30 November 2015. https://www.brit-thoracic.org.uk/document-library/audit-and-quality-impr... (Accessed 13 November 2018)
4. British Thoracic Society, Scottish Intercollegiate Guideline Network. SIGN 153 - The British Guideline on the Management of Asthma. 2016 [Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/a...
5. Your asthma plan – for older children and adults. https://www.asthma.org.uk/globalassets/health-advice/resources/adults/ad...
6. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report Royal College of Physicians. London; 2014 [Available from: https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
Competing interests: No competing interests