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Conflicting asthma guidelines cause confusion in primary care

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k29 (Published 09 January 2018) Cite this as: BMJ 2018;360:k29

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Re: Conflicting asthma guidelines cause confusion in primary care

We are concerned about the increasingly common advice by United Kingdom paediatricians for parents to administer 10 puffs of salbutamol regularly as part of a ‘weaning plan’ after discharge from hospital or Accident and Emergency following treatment for an acute asthma attack.. We believe that this practice has the potential to put patients at risk of undetected and possibly life-threatening deterioration.

This issue has led to content in a BMJ Learning module that we think could lead to inappropriate care of children with asthma. [1] The module refers to gradual step down treatment with short acting beta-2-agonist bronchodilators (SABAs) and provides an example of a ‘weaning plan’ from one of the major teaching hospitals in London. In this plan, salbutamol is prescribed routinely 10 puffs every 4 hours on the first day after discharge, 8 puffs every 4 hours on the second day, 6 puffs every 6 hours on the 3rd day, then continuing with 4 puffs every 6 hours “until symptoms have fully settled”.

We are not aware of any evidence in the UK or the rest of the world for this approach, nor for that in the UK BTS/SIGN asthma guideline [2] that states “Children can be discharged when stable on 3-4 hourly inhaled bronchodilators that can be continued at home”. The reference cited [3] for this statement relates to a 1999 Australian study of 63 children randomised on discharge to either 3 or 4 hourly nebulised salbutamol with an outcome based on re-presentation to hospital or primary care within a week. This study bears no resemblance to, and certainly cannot justify, the current ‘weaning plan advice’ in the UK. Instead, the Global Initiative for Asthma (GINA) recommends that clinicians prescribe ‘as needed’ SABA for children (and adults) following treatment of attacks. [4]

In our view, prescribing ‘regular’ SABA for children following asthma attacks is potentially unsafe, because one of the key warning signs of deteriorating asthma is the perceived need by patients (due to flare up of symptoms) for reliever medication, ie β-2 agonist. So logically, bronchodilators should only be prescribed ‘as needed’ for symptoms of cough, wheeze or shortness of breath. As a result, parents and patients will become very aware from the flare up of symptoms and hence the need for medication because all is not well. Since bronchodilators should be effective for at least 4 hours, parents should be clearly advised to seek urgent medical assistance if relief does not last at least that long. The ‘weaning regimen’ in the BMJ module removes that warning signal and in our view potentially puts patients at risk.

The UK has a poor record with regard to childhood asthma deaths compared with the rest of Europe. [5] Treatment was considered to be below the expected standard in 27 of the 28 children and young people (<18 years old) included in the UK National Review of Asthma Deaths (NRAD) [6], and in the last BTS audit, at least 15% of children discharged from hospital for acute asthma were readmitted within 3 months. [7] The post-attack management of childhood asthma in the UK needs revision based on good quality evidence.

In the meantime, post discharge salbutamol use should be the same as that advised in the Asthma UK adult and older children’s personal asthma action plan [8] for deteriorating control. This states: “ Take your reliever inhaler as needed (up to every four hours)”; with clear safety netting, i.e. “if you need your reliever inhaler more than every four hours, you’re having an asthma attack and you need to take emergency action now”. The current Asthma UK under 12 years Child’s plan [9] advises regular SABA for poorly controlled asthma which is inconsistent with the advice for adults and older children; in our view this should also be amended.

Dr Mark L Levy FRCGP, London, United Kingdom, Clinical Lead UK National Review of Asthma Deaths (2011-2014)

Professor Andrew Bush, Professor of Paediatric Respirology, National Heart and Lung Institute, London, United Kingdom

Dr Louise Fleming, Clinical Senior Lecturer, National Heart and Lung Institute, Imperial College London, Consultant Respiratory Paediatrician, Royal Brompton Hospital, United Kingdom

Professor John O Warner MD FRCPCH FMedSci, Professor of Paediatrics, Imperial College London, United Kingdom

Allan Becker MD, FRCPC, FCAHS, Professor and Head, Section of Allergy and Clinical Immunology, Department of Pediatrics and Child Health, University of Manitoba, Canada

Professor Helen Reddel MBBS PhD, Woolcock Institute of Medical Research, Sydney, Australia

Dr Richard Iles, Consultant in Respiratory Paediatrics, Evelina London Children's Hospital, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, United Kingdom

Soren Pedersen MD, DMsc, Professor of Pediatric Respiratory diseases at The University of Southern Denmark, Denmark

References:

1. Step by step: How to manage acute asthma and wheezing in children in primary care https://learning.bmj.com/learning/module-intro/resume-module.html?module...
2. 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...
3. Stormon MO, Mellis CM, Van Asperen PP, Kilham HA. Outcome evaluation of early discharge of asthmatic children from hospital: a randomized control trial. J Qual Clin Pract 1999;19(3):149-54.
4. The Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA).2018 Available from: http://www.ginasthma.org.
5. Wolfe I, Thompson M, Gill P, Tamburlini G, Blair M, van den Bruel A, et al. Health services for children in western Europe. The Lancet. 2013;381(9873):1224-34.
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
7. Dr James Paton . British Thoracic Society. BTS National Paediatric Asthma Audit Summary Report National Audit Period: 1 November 30 November 2015
8. Your asthma plan – for older children and adults. https://www.asthma.org.uk/globalassets/health-advice/resources/adults/ad...
9. My asthma plan – for children. https://www.asthma.org.uk/globalassets/health-advice/resources/children/...

Competing interests: No competing interests

16 November 2018
Mark L Levy
Locum General Practitioner
Professor Andrew Bush, Professor of Paediatric Respirology, National Heart and Lung Institute, London, United Kingdom; Dr Louise Fleming, Clinical Senior Lecturer, National Heart and Lung Institute, Imperial College London Consultant Respiratory Paediatrician, Royal Brompton Hospital, United Kingdom; Professor John O Warner MD FRCPCH FMedSci, Professor of Paediatrics, Imperial College London, United Kingdom; Allan Becker MD, FRCPC, FCAHS, Professor and Head, Section of Allergy and Clinical Immunology, Department of Pediatrics and Child Health, University of Manitoba, Canada; Professor Helen Reddel, MBBS PhD, Woolcock Institute of Medical Research, Sydney, Australia ; Dr Richard Iles, Consultant in Respiratory Paediatrics, Evelina London Childrens Hospital, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, United Kingdom; Soren Pedersen MD, DMsc., Professor of Pediatric Respiratory diseases at The University of Southern Denmark, Denmark
Clinical Lead National Review of Asthma Deaths (2011-2014)
Kenton Bridge Medical Centre, Harrow, London