Transcript ASI DR. DERMOT NOLAN

Under 6yr-Asthma in
Primary Care
Asthma Society of Ireland
April 2016.
Dr Dermot Nolan
GP Tramore
Tramore
 85%
of asthma in managed
in GP
 450,000
Pts
 7.1% of Pt over 18
 18% of kids ( 28% Wheeze)
 About 12-15% under 6
 Ireland 4th highest in world ( after Uk, NZ,
Australia)
Ireland
 50-
60 deaths
 5000 Admissions
 20,000 A+E
 50-70,000 GP OOH visits
 Secondary
care is expensive for asthma
 Cost over €460 million per yr ( 2003)
Under 6s
Under 6!
 Most
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common chronic childhood disease
Assoc with School absences, ED+OOH visits.
Leading cause of morbidity due to chronic
disease.
Similarities/Differences to older kids
About 50% improve in adolescence but 25%
will return in 30-40s
Primary prevention
or single allergen reduction –no
 Pets – No reduction , ??not have cat.
 Foods – No
 Breast feeding – Probably no good but
other benefits
 Fish oils – no.
 Weight reduction – Helps
 Cigs - Avoid
 HDM
Secondary prevention
– Not recommended
 Fungal – related to hospitalisation.
 Smoking
 Air pollution. ??Higher rates in clear air
 Weight loss – yes.
 Probiotics – No good
 Vaccines – No link ?Kids on high dose ICS
 Ionisers – no
 Breathing techniques - Yes
 HDM
Asthma in U6
 Wheeze (Parents interpretation diifers to Drs)
 SOB
 Tightness
(Cough induced asthma – rare!)
Varies over time in their occurrence,
frequency and intensity.
 Cough
Patterns
Viral wheeze Vs Multiple Trigger
factor wheeze.
 Commonest
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wheeze is the viral wheeze.
Assoc with viral illness
8-10 per yr
Non in-between episodes
Grown out by school age.
Minority will go on to develop symptoms in
between viral illnesses.
Persistent symptoms likely to benefit from Tx
Diagnosis – Difficult!
 Increased
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
probability
Cough/wheeze, SOB - Freq and recurrent,
worse at night and early am, occur/worse with
tiggers( exercise, pollen, emotions etc)
Atopy
FHx
Widespread wheeze on auscultation.
Hx improvement with Tx
Lower probability of asthma
 Only
occur with colds
 Isolated cough with no wheeze or SOB.
 Moist cough
 Normal examination
 Normal lung function
 No response to Tx
 Differential Dg
Differential
 Since
birth - ?CF, Cilary dyskinesia, prem
lung disease.
 Fhx unusual disease - ?CF
 Severe upper airway - ? Cilary dyskinesia
 Moist cough- CF, b’ectasis
 Vomiting - ?GOR
 Tingling - ?Panic attacks
 Focal signs – Post infectious, TB etc
Persistent symptoms
 Earlier

2yr is cut off.
 Atopy

presentation –Likely to grow out
( Indvidual or Fhx) less likely
+SPT or raised Eosin count
 Boys
more likely to grow out
 More freq attacks – less likely to grow out
Probability
 High
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Straight to trial of Tx
RV after 2-3/12
? Further test if no response.
 Low
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probability
probability
Another diagnosis
?Refer
Intermediate
 No
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clear answer!
Watchful waiting – Do NADA
Start Tx – ICS
• - Singulair ( Intermittent use)
Peoples loves tests!
Tests
 12%
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change in FEV1?
Testing – Diffic under 6! Not definitive. New
tests in 2ndry care( Sraw – specific
resistance). FeNO
Spirometry/PEF
• Changes with Tx ( Happy days! – find lowest dose)
• No change- ?Refer.
 Allergy
test - ?
 CXR – Not usually needed.
Refer
 Diagnistic
challenge
 Since birth
 Severe upper airway infections
 Persistent wet cough
 Fhx – unusual chest disease
 Failure to thrive
 Large nasal polyps
 Failure to respond >400mcg of ICS
 Parental anxiety
Monitoring
 Symptom
based approach
Daytime symptoms > few mins more than
once per week
 Restriction in activities.
 Night time waking/coughing
 Reliever more that once per week
Well – None, Partial 1-2, Uncontrolled 3-4

 Growth
( Height /weight) annually
 Education
Risk factors
 Uncontrolled
 One
or more severe exacerbation
 “Flare up” season
 Cigs+
 Psychological or socio economic issues in
the family
 Poor adherence to meds/Poor technique
Self management
 U6
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?? Poor evidence
Written better
Recognise deterioration
Contact numbers – OOH etc
Medication ( Restart early or double up)
• (Adults >400mcgof ICS – Orals, low dose
<200mcg – up to 1200mcg)
Cycle of care
2 – 5yr
 Diagnosis
 Review
of Tx
 Compliance
 Inhaler technique
 Education ( Reliever vs Preventer)
 Self Mgt plan discussed and printed
 Flu Vaccine ( Mod or severe)
 Smoking
Tx
 Step
wise approach ( ICGP)

Step 1 – As needed B2
Step 2 Low dose ICS ( LRTAs)
Step 3 Double ICS dose ( Add LRTA)

Before doubling – check compliance
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Refer
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Device
 PMDI
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with Spacer
Young children take 5-10 breathes per
actuation.
?Nebs – move away from these, protect eyes.
• Crying
MDIs work better with a spacer
 BABY
HALER ( 0 -2yr) (GMS)
 VOLUMATIC ( 6yrs onward) ( GMS)
 AEROCHAMBER ( €40)
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ORANGE ( 0-2yr)
YELLOW ( 2 – 10)
BLUE ( Adult)
 Change
every yr! Clean monthly!
Acute care
 Assesment
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( Mild Vs Severe)
LOC No
Oximetry >92%
Speech – sentences
Pulse <200 ( 0-3yr) <180 (4-5yr)
RR <50
Cyanosis No
Wheeze – variable ( Vs Silent chest)
 Salbutamol
2 puff every 20 mins ( or
2.5mg Neb)
 Oral pred 1-2mg /kg – x 3-5days
 Follow
up after exacerbation - VIP
Education
 Only
16% of PN have had any formal resp
training
 Online

3 modules and practical day
 GP

– HSEland and ASI website
training
ICGP/CME
New issues
 Spiriva
Respimat for Asthma – Step 3
 SLIT
 FeNO
 New
devices
 Generic Seretide/Symbicort
 ASI
 Itchywheezysneezy.co.uk
Summary
 Asthma
care is pretty easy.
 Takes time to do properly
 A good PN is a great asset.
 Education
 Correct device
 Smoking
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