A is for Asthma: Managing Asthma in Primary School Kids

By Adem Lewis / in , , /

Hello, I’m Norman Swan. Welcome to this program,
A is For Asthma: Managing Asthma
in Primary School Children. Back-to-school asthma
is a common problem in Australia with a spike in
asthma-related hospital visits for school-aged children occurring in the first few weeks
after each school holiday. With one in nine school-aged children
in Australia being affected by asthma, the highest annual peak is in February, as students return
from the long summer break and are exposed, presumably,
to a cocktail of viruses. Asthma in children
differs from asthma in adults in clinically important aspects, which includes the patterns of symptoms,
anatomical factors and recommended treatment. And that’s what
the program’s about tonight. And you’ll find
that some popular treatments are being given inappropriately. You’ll find
a number of useful resources, as always, available on the Rural
Health Education Foundation’s website, rhef.com.au. Now let’s meet our panel. Adam Jaffe is the
Director of Respiratory Medicine at Sydney Children’s Hospital
in Randwick. He chairs the Aiming for Asthma
Improvement in Children program in South East Sydney
and Illawarra Area Health Service. – Welcome, Adam.
– Thanks for having me. Kerry Hancock
is a general practitioner in Adelaide. She’s a founding member
of the National Asthma Council’s GP’s Asthma Group, and a medical adviser to the
Asthma Foundation of South Australia. – Welcome, Kerry.
– Good evening. Tracey Marshall is a clinical nurse
consultant in asthma education in the Department
of Respiratory Medicine at the Children’s Hospital at Westmead. – Welcome, Tracey.
– Thank you very much, Norman. Toni Riley is a community pharmacist
in Bendigo, Victoria, and she’s a founding member
of the National Asthma Council’s Pharmacists’ Asthma Group. – Welcome, Toni.
– Thanks, Norman. And another Tony for you, Tony Healy, who’s the National Coordinator
of the Asthma Friendly Schools program based in Adelaide. – Good evening, Norman.
– And welcome to you all. Are the schools all ready for this surge
in asthma cases as we speak? The Asthma Friendly Schools Program has penetrated into about 85%
of the schools around Australia. So they are informed about the fact that there is
a back-to-school asthma spike that occurs
at the beginning of each year. They have that information, and those schools are well prepared to deal with asthma exacerbations
when they do occur. NORMAN: Do you see them in pharmacies?
TONI: Yes, we do, Norman. I think, at the beginning
of each school term there’s always a sudden increase
in need for… ..especially for reliever medications. So, we do see an increased volume
of scripts at that time. But I think,
probably as we’ll talk about later, one of the things we also do see is an increase in scripts for other
things, like antibiotics in children. NORMAN: Is this a failure
of asthma action plans, Tracey? Well, it’s certainly a possibility. We know in this country
that we don’t have the percentage of asthma action plans,
as health professionals, that we would like to see. So, certainly, I think that would aid in helping for parents
to manage these asthma episodes at home
and definitely for at schools as well. And whilst it sounds
bureaucratically neat to have an asthma action plan, they actually do in children
make a difference? Absolutely. There’s evidence that
shows that they do make a difference. But there are many factors,
in terms of how they’re written and the types of medications they’re on
that can have an effect on them. So it’s important to
have a good asthma action plan. Kerry, what about general practice?
The surge hits you? We see the surge. I think it comes from
a number of reasons – that people become complacent
over that holiday break. All the kids go back to school exposed to the viruses. Children who should be on preventers, maybe not taking their preventers. Your group’s done some work on this. That’s right, Norman. Bill Rawlinson’s Professor of Virology
at Prince of Wales Hospital, and they looked at the sort of bugs
that are around in February in children with asthma and found that there’s a huge number of
children with rhinovirus in their nose. So it’s likely that this peak
is related to this mingling at schools between teachers and students and passing all these bugs around, which is likely to be causing…
be a major contributor. One of the themes tonight is that… It’s the usual stuff with kids –
that kids aren’t little adults. But it’s particularly true in asthma. My understanding is
that it’s actually a different disease in children from adults. You’re absolutely right. I think that the problem
with paediatrics, and particularly
the under-five-year-olds, is that what we’re learning is there
are different types of wheezy children, different phenotypes,
that are immerging. If you speak to an adult physician,
they think we’re crazy. They say they know exactly
what an asthmatic looks like. They’re usually atopic,
they wheeze a lot. There’s a strong family history. But certainly in the under-fives there’s a whole variety of children – some who only get wheezy with viruses. Some children are wheezy because
their mothers smoked antenatally, and therefore,
particularly if you’re a boy, have smaller airways. And then there’s that classic group who are atopic,
got a strong family history, who go on to get the classic asthma
that we’re all aware of. So, wheezy bronchitis
has returned as a diagnosis? Yes, it has.
It went out of favour for a while. In fact, work in the ’70s suggested that 1.3 or so American children
had wheezy bronchitis. That went out of fashion.
They said, ‘No, we termed it asthma.’ But it’s come back now. I think it’s an attempt for us
to understand the pathophysiology, what’s going on, what’s causing this. And, in fact, there was a plea by The
Lancet, an editorial, a few years back to abandon
the concept of asthma altogether. As Fernando Martinez says, in the
19th century we used to treat ‘fever’. Now that we know
that there’s a cause for fever, and that perhaps we shouldn’t be terming
asthma in children as one disease. We should be dismantling it,
which is what we’re trying. – Not all of them wheezers.
– Correct. Are you finding that
scripts for combination therapy’s marching out the door in pharmacies
for children? I guess there certainly has been
an increase in the use of combination therapy
in children. And as we all know, that’s not actually
recommended in younger children. So there is a concern about that, but I’m sure that Kerry and Adam are far more qualified
to speak about that than I am. That’s what I was talking about earlier
when I said it’s inappropriate. We’re seeing really
a lot of doctors thinking that what they’ve been taught
about adults applies to children. And there’s serious consequences. I think there’s always a temptation
in medicine, and especially in general practice, to transpose what we have learnt
in adults to children. And nothing could be
further from the truth in the management
of asthma in children. NORMAN: But there’s often
a huge marketing push. There probably is. Yeah. But I think we have guidelines
for appropriate management, pharmacotherapy
and management in children. And we have the evidence base
behind those guidelines. We don’t have the evidence base behind the use of
long-acting beta agonists in children. So what’s the problem, Adam? What happens when you put a child
on combination therapy when it’s not necessary? I think, just to iterate what Kerry said is that we did some work
looking at UK prescribing, and there’s some work
to come out of Canberra, showing that the prescribing
of combination therapy, including long-acting beta agonists,
is skyrocketing. So no-one’s listening to the guidelines,
for a start. That’s clearly obvious. And I don’t think people are aware
of the problems that the long-acting beta agonists
can cause. – Even in combination with steroids.
– Even in combination with steroids. Certainly, the evidence, originally looking at long-acting beta agonists
in the States when there was an increased risk
of death in adults, particularly African-Americans. And there’s a concern about using long-acting beta agonists
without steroids, so no-one would use it
without steroids now. They’ve just been
taken off the market in America. Correct. And therefore,
even with inhaled steroids there’s a concern
that they’re causing tachyphylaxis. In other words, children are not
able to respond even to beta agonists – salbutamol treatment. And we’ve certainly seen that
in our clinic where children have come in – very fine athletes
who are getting short of breath – they’re on long-acting beta agonist
combination therapy and take a long time
to recover from challenges. And when we take them off
long-acting beta agonists and the combination and treat them with inhaled steroid, they get better. And I think people have to be aware that the use of long-acting beta agonists
is potentially extremely dangerous. And even inhaled corticosteroids
don’t necessarily work as well, particularly in the young child,
as in the older child. Certainly, if used correctly, they’re
an extremely useful and good drug. There are obviously other potential
alternatives to inhaled steroids, such as
leukotriene receptor antagonists. So they do exist. But if used correctly, inhaled steroids is
a very good first-line preventer. Leukotriene receptor antagonists
are considered second-line here, but you actually disagree with that. Yes, it’s interesting. And if you look at the Australian
National Asthma Council guidelines, montelukast is a potential second-line
with inhaled steroids. But if you look at
the other guidelines – the European guidelines, the Scottish
guidelines and American guidelines – the second step is inhaled steroids. And montelukast comes later on. So the problem, I think, in Australia is driven by the PBS
and the authority prescribing that you cannot prescribe montelukast
unless it’s a single-line preventer, and therefore it’s gonna cost a patient
three times as much if they can’t get it on authority. And therefore
these guidelines and the PBS have actually, I suspect, driven the
prescribing practices in this country. This is relevant to one of the
questions. I might bring it in now. It’s from Marissa Pillar
in Far North Queensland. ‘What’s best used in young children – cortisone-based inhalers,
or your Intal or Atrovent? Also, is it safe to use
higher doses in children long-term? I’ve seen two-year-olds
on very high doses when the asthma’s not controlled
in any other way. I have concerns. Any comments?’ Kerry? I think there are concerns about when you’re needing to use
high-dose inhaled corticosteroid in a child of any age,
let alone a two-year-old. Certainly, you’d want to address
whether the diagnosis is right. I mean, are we dealing with asthma? Are we dealing with… ..something else that’s causing these asthma-type symptoms
in this young child? And Atrovent/ipratropium
is really a reliever, not a treatment. I’m not quite sure
whether the question is around ongoing preventer therapy
or for acute management. But even the role of Atrovent
in acute… NORMAN: That’s a no-no these days,
isn’t it? Toni? Atrovent – isn’t it considered…? Certainly not first-line treatment when you’re considering
a reliever medication, that’s for sure. It’s very much down the pathway
and used quite infrequently now. And what about cromoglycate, given that you’re down a bit
on steroids? In the old days, we seemed
to get a bit of sodium salt in children. The adult physicians
were always down on it. Yes, there’s certainly a role
in exercise-induced asthma, so it’s not used as widely. There are a few people left
who still use it. I will use it
in a certain subgroup of children with exercise-induced asthma. So there’s a role,
albeit in a specific population. What about Indigenous children? Are we talking about
a different situation here? In the epidemiology
of childhood asthma in Australia? If you look at the publication
of asthma in Australia who’ve looked at the prevalence
of asthma amongst different groups, certainly like all respiratory health
in Indigenous children, it’s worse off. Indigenous children have more asthma, a high risk of hospitalisation
and mortality. And that may be related
to a whole heap of factors, but particularly smoking. Smoking in the Indigenous communities is twice as prevalent
as in non-Indigenous communities. And I think that’s a very important
topic to address in all communities. What’s the School Friendly’s program
that you’ve got, Tony? The Asthma Friendly Schools program provides a framework
to schools across Australia to recognise best management practices to help prevent asthma
and to manage any asthma exacerbations. So there’s a staff-training package that’s delivered to teachers
around Australia. There’s information provided
to the parents and community about their connectivity
with the asthma foundations, so they can get individual advice. We also penetrate the school curriculum
through the use of resources. We have DVDs. The first one
is provided to primary schools. And on our website
we have backup lesson plans for junior, middle
and upper primary young people. And for the secondary component we have the Running Short DVD that was developed in consultation with
the Adolescent Asthma Action program. The work of Dr Smita Shah is well known
in schools across Australia. And I’d like to acknowledge her for
the use of this DVD within our program. That provides all young people in asthma-friendly schools
across Australia with the chance to have a bit of
an understanding of the condition, so that if it’s not them
that has asthma, they can provide some support
to friends or family in that regard. What’s the two-way communication like? Do you rely on the child
and the child’s parents telling you they’ve got asthma? Or is there a communication
with a general practitioner? The parents are the go-between
between the practitioner and the school, and the key critical component of that
is the written asthma action plan. That gives us the advice
that schools need to be able to react
on an individual basis. Adam, diagnosis. How to make the diagnosis
in general practice. What’s your view on this?
And I’ll come to Kerry in a moment. It’s not easy in the under-fives.
Let’s pick the easy one first. So the child that we all recognise
as having undisputed asthma is the child who’s atopic, who has perhaps rhinitis, eczema, perhaps a food allergy, strong family history, will have doctor-diagnosed wheeze. And that’s the child
that we all accept as having asthma. The child under five who wheezes
with various triggers, very difficult. And I’m glad I’m not a GP. So, Kerry,
what’s the role of spirometry? People like Adam say
that’s like a blood-pressure machine which should be done on every child
you suspect of a problem? We can’t do it on every child. I mean,
children have to be a certain age before we can effectively
undertake spirometry on them. So maybe from around about
the age of eight, certainly an attempt should be made
at doing spirometry. And that’s going to go a reasonable way to helping confirm that diagnosis in children where you’ve got
a suspicious history. And so you would look for reversibility? Look for reversibility,
but also bearing in mind that between the episodes of asthma,
children may have normal spirometry. And what about provocation tests
in general practice? It’s a matter of
whether they are accessible. A lot of GPs,
maybe in remote areas and rural areas, may not be able to
access provocation testing. But certainly if children could be sent
into provincial towns and major cities some provocation testings are available in some of the large
respiratory function labs or at the tertiary hospitals. And skin testing –
particularly in country towns – you can often get that done – does that make a difference
to the diagnosis? Yes. I think
it’s a very important test to do, because if a child’s atopic and wheezing then I think that will point you towards
the classical phenotype of asthma. So it’s an important investigation
to do. And the predictors of more severe asthma
in the years to come are things like eczema
and food allergies. That’s right. It’s atopic phenotype, particularly to have recurrent wheezing
throughout childhood. And, of course,
smoking is important here. Smoking’s crucial to address. – Not to treat it, but to…
– No, absolutely. Antenatally, if you smoke,
you have smaller airways. Passive smoking
has to be addressed at all times. Parents who say, ‘I always smoke
outside, never in the house, Doctor.’ If you measure cotinine in saliva,
there’s evidence of tobacco exposure. And we did some work
in the East End of London which looked at difficult asthmatics – those children on 800 micrograms
equivalent of budesonide a day. And smoking in the family was the strongest predictor
of difficult-to-control asthma. I should’ve done this at the beginning. Given that we’re talking about
a strongly pharmaceutical area, we should get a declaration
of any conflicts of interest. – Tony?
– No conflicts of interest, no. – Not for me, either.
– No. I sit on advisory boards
for AstraZeneca and GSK. NORMAN: So that’s Symbicort
and Seretide. – Seretide.
NORMAN: OK. And I’ve been paid by an honouree to give various talks
by GSK and AstraZeneca, and currently sit on MSD advisory board
who make Singulair. Fortunately, that’s all. So if you start peddling things,
we know where you’re coming from. Tell me about the classification here, just how GPs should be
thinking about asthma in terms of severity. It’s really important for GPs
to look at the pattern of asthma in order to make that classification. Because once
they’ve made the classification, then the guidelines for pharmacotherapy
fall into place. So bearing in mind that most of the children that we’re
going to see in our general practices are going to have
infrequent intermittent asthma. So 75% of children will have infrequent intermittent asthma. Then 20% will have
more frequent episodes but will still be intermittent. So those episodes may be
every six to eight weeks or even a little bit shorter space. And then you have a group of children, just a very small group of children –
5% – who have persistent asthma. So these are the children
who are going to have symptoms once a week, a few times a week,
or maybe daily. So just a very small amount. And depending on that classification will depend on what pharmacotherapies
we use for those children. Tracey, do you think
that education at the 75% end, where it’s just occasional asthma
once or twice a year, do you think education matters
in those children? Or it’s so infrequent
that it’s not important. Oh, no, it’s important across the board. Because for those group of children it could be six months
in between their episodes, it could be longer. And especially
as their age group changes, they can require more Ventolin
when they get older, or any other reliever type
of medication. So, yeah, education across the board, whether you have
an infrequent type of asthma or whether you have a persistent,
is very important. NORMAN: It puts in a foundation
for the future. Absolutely. And it’s about
self-management for the children. Especially as they move into
primary school and into high school. It’s to allow Mum and Dad
or the carers for the family to have a greater understanding
of what asthma is and how to manage it. So regardless of where they are
in their classification, education goes hand in hand
with management. Toni, do you find many people confused
when they come into the pharmacy? Probably less these days
than in previous days. But, yeah, people do get confused about which inhaler they’re meant to use
for which particular situation. Is this my reliever medication?
Is this my preventer medication? And I think one of the things
that’s really important to remember – we were talking about
rural health here – not all areas have the plethora
of health professionals available. Maybe in some regions you’ve just got
the GP and the pharmacist. So the team approach is really important and that certainly I think, carries
through with the education side of it. The pharmacist has the opportunity
to have another shot at… You know, we might actually
see the child in the pharmacy. We can actually run through
how they use their medication – which is their preventer,
which is their reliever? Those kind of things. I’ve got another question here. We’ve
got some case studies for you tonight. But there’s one question that’s
probably relevant to bring up here. This is from Marissa Pillar again
in Far North Queensland. ‘I understand
the importance of preventers, especially the new use of Symbicort.’ Symbicort’s not approved
for use in children. Is that right? No, it’s not approved. ‘However,
what is the true outcome on growth? Is it affected
at the end of a growth period, especially if there’s need
of a nasal cortisone spray?’ Which indeed there often is, because,
as we’ve shown in this program, rhinitis is
a significant predictor of severity. So, what’s the story with growth here? I think she raises
a very important point. So, if we talk about
nasal steroids to start with, a lot of people believe
that asthma’s a disease of the nose, and there’s a lot of evidence
to support that. And the feeling is
if you’ve got a lot of rhinitis and don’t treat the nasal symptoms, then you’re not gonna
get on top of the nasobronchial reflex. So it’s important to address that. And if you are using
lower airway inhaled steroids, you get a cumulative effect. So people are worried
about using inhaled steroids for a variety of reasons. Some have a misconception it’s the one that gives you breasts
and makes you a bodybuilder. And, of course, the effect on growth
and other problems like thrush orally, and adrenal insufficiency as well
in high doses. So the importance, looking at growth, is that it does affect – if you look at
collagen bone turnover – it does have an effect
which lasts six months. But the reassuring thing about that is that the children with asthma
on inhaled steroids obtain their final height,
which is genetically predetermined. Even though they remain on the steroids. Even though they’re on inhaled steroids. Although, they may obtain it
one or two years later than their peers. The other important point to say is that if you don’t treat asthma
appropriately, then you have a chronic
respiratory disease and you may end up shorter, because you’ve had
inappropriate treatment. And what about…? I often hear it say
that too high doses are used, in adults and in children. What’s the right dose? And do you add on the dose
for the nasal cortisones? Yes, it’s all cumulative. And the right dose is the lowest dose
that controls their symptoms. And I think that every opportunity… NORMAN: This business in the past of going to the highest dose and
titrating backwards has gone, hasn’t it? Yes. The step two is to start low… NORMAN: And go slow.
– Go slow. Absolutely. Absolutely right. And a child has died as a result,
in Glasgow, of being on an equivalent of 1,000
micrograms of fluticasone equivalent of inhaled steroids
from adrenal insufficiency. And if you look above 800 micrograms
of budesonide equivalent today, there’s evidence
of adrenal insufficiency. And we warn all our children
on that sort of dose that they should
carry around a letter saying if they get sick, they need
an oral steroid replacement. Because it’s having effects that we’re not seeing
and not measuring, necessarily. So high-dose inhaled steroids
do have some… I think you made the point
that if you’re on that dose, you really need
to be seen by a specialist. If you’re on very high dose, absolutely. It’s a worrying sign. Let’s go to our first case study. Emma is 12 years old. She’s been coughing for four days. She comes to see you, Kerry,
with her mother, who has a letter from Emma’s school about her reluctance to have PE lessons. Although her mother
hasn’t noticed anything at home, Emma says that she
coughs more than her friends and has difficulty keeping up with them. Emma’s records show that
she’s had five courses of antibiotics for cough and
upper respiratory tract infection in the past two years – always with a locum, Kerry,
never with you – and during these episodes she has
mild wheezing and is breathless. She’s often woken from sleep
with coughing and occasional wheezing at night
during these episodes. She describes the cough as dry. Your patient, Kerry. I don’t think that we should just assume
this is asthma without going further into the history. NORMAN: The coughing at night’s
pretty impressive, isn’t it? The coughing at night… Coughing
can be from a number of reasons. The wheezing points more to asthma. But I’d certainly want to know what Emma actually means
by the wheezing. Because wheezing can mean
different things to different people. And what Emma describes as wheezing or what her mother describes as wheezing might not be what we think is wheezing – sort of high-pitched noise
coming from the airways and the lung. It could be coming from
upper respiratory tract, it could be coming from nasal airways. I mean, I find from my experience, that a lot of people just call any noise
coming from the chest or nose as wheeze. The breathlessness,
I think we need to take note of that. But, once again, it might be breathlessness
associated with normal exercise. So there’s some things to tease out
in that history a little bit more. I’d be interested to know
in the family history, I’d be interested to know whether there’s some history of
atopic disease when she was younger, or whether there was any episodes
of typical wheezing in infancy, toddlerhood,
early childhood. And an examination at the moment. I mean, if I can hear a wheeze
in that chest at the moment, then I’m gonna feel more confident
that this is wheeze. And, at 12, I’d like to back that up with an objective measure
of lung function. – So you’d do spirometry on her?
– I’d do spirometry. What else would you do on her? Certainly think about
doing skin-prick testing and if that spirometry was normal,
think about provocation testing, depending on… It’s available to me,
but depending on whether it’s available. How did the school find out about this? Her reluctance to participate in
phys. ed. would be the first indicator that there needs to be
some sort of GP consultation to try and find out what the
underlying cause of that would be. And from that we would expect,
if asthma is the concern, that a written asthma action plan will then inform the school
on the appropriate action to take. So you’d expect
the parents to come in from Kerry, should it be asthma, with a plan
which they then hand to the school? Yes. As I said previously,
the parents need to be the go-between between the medical specialist
and the school so that the right information
is getting to the school and we’re reacting in the right way. But there are protocols that
override the individual situations – the 4×4 protocol – and the schools are well informed
how to react to asthma, whether it’s a first asthma attack that could be triggered by something that a child hasn’t been
exposed to previously or part of regular control. So, Tracey, while we’re still
working out what’s going on, is there a role for education
in this child, or we just wait and see… It’s only once they get the ticket,
the label ‘asthma’, that the practice nurse can kick in
with some education. I think, if Kerry had gone
through the consult with the parent and was satisfied with the physical
examination, the clinical history, and wanted, say,
a trial of Ventolin to be taken for when these symptoms arose again, then, yeah, absolutely,
there’s a role for education. It may be more basic,
in terms of just going through some of the possible components
of what to look for with asthma, what the medication is,
how to use the device. And then when and if the diagnosis
has been confirmed, then there would definitely be the need for some more in-depth education
at that stage. But whether you’re a community nurse,
a nurse in the hospital, whether you’re a practice nurse, actually any member
of the health care team, we all have a responsibility
to help educate these young people and children and their families so they’re able to treat appropriately
until a diagnosis is confirmed. Kerry, a general practitioner
in South Australia asks what role peak flow meters
have in the diagnosis. Or indeed the ongoing management,
even if you’re not sure it’s asthma. I think peak flow monitoring
has a limited role. I’d prefer a symptom diary
under these circumstances. I think that’s going to give me
a lot more information. I think there are problems in, especially adolescents
and younger children, doing peak flow monitoring. So I think a symptom diary would be
quite useful at this stage as well. So, do a chest X-ray, Adam, given that you’re not sure
what’s going on here? No, absolutely not. Try and avoid them as much as possible
in children. And I think that the approach
that Kerry’s taken is absolutely the right one. Really, to reinforce what she said, GPs are encouraged to do a spirometry. Spirometry is a standard management
in children who can do it. And it certainly has replaced peak flow, which is very effort dependent
and variable. So I think that we would encourage everyone with spirometry training
to do it on children. But hold off doing the chest X-ray
just at the moment, as children’s tissue are more sensitive
to ionising radiation than adults’. What are you gonna do for Emma
before you make the diagnosis here? Or even if you’ve made the diagnosis? Certainly at this stage,
I think, as needed, short-acting beta-2 agonists. Salbutamol, terbutaline,
is most appropriate. Preventive therapy’s
not really indicated if… NORMAN: Given even if it’s asthma…
– Even if it’s asthma. Because at this stage
she has intermittent asthma. It appears to be infrequent. She’s had five… If those five episodes
over the last two years were asthma, well, that certainly wouldn’t meet
the criteria for frequent intermittent asthma. So she’s certainly not going to need
preventive therapy at this stage. I think, as needed,
short-acting beta-2 agonist, education around that. I mean, bearing in mind
that these children who have infrequent intermittent asthma can still have
quite severe episodes at times and certainly can end up in hospital. So they still need the education, they still need
the written asthma action plan. Here’s another question.
In fact, a split-question here. ‘Some children are smoking
younger and younger. What can be done about it?’ What’s the role of the doctor
or the asthma educator, Tracey? Education… It’s all very well saying education –
they don’t listen to you. No, well, I suppose… Is there a shred of evidence that
education makes any difference here? – I thought there wasn’t.
– No, there is. I think it depends on the way
that you educate people and also in the way
that you reach them, as well. Some people are very affected
by anti-smoking campaigns on the TV or by looking at lung cancer
on a packet of cigarettes. Others, it doesn’t do anything to them. We’re talking about teenagers, they could look at it and go,
‘Oh, that’s gross, but, hey, it’s not gonna stop me
from doing it.’ I think persistence is the key
with most things, when it comes to medical education. It’s about drumming through
a consistent message and that message needs to be the same in
the hospitals, the GP, in the community. If it differs, then people doubt, and especially adolescents
will doubt what you’re saying. If Kerry was to give
one piece of advice, Adam was to give something else,
et cetera, and I was to say the complete opposite, then they wonder
where the true source is. And I think these days we’ve gotta take
advantage of things like using the net and iPods and lots of other
electronic types of equipment that we can get
the right messages through. And certainly when
you’re looking through the internet, it’s about getting onto the right sites and getting the right information
up there. Have you ever had to
use nicotine replacement therapy, say, in an adolescent, Kerry? No, I’ve had no experience of NRT
in an adolescent. So the next question here is, given the policy around the recent trial
on breathing exercises, not quite the Buteyko, but similar, just a steady diaphragmatic breathing
and the effectiveness of that – what’s the role of that in children?
If any. Seems to lower the use
of reliever medications in randomised controlled trial. There’s certainly some evidence
to suggest that it may be helpful. I think the important thing is that… ..any child with asthma has to have
a proper asthma management plan and seen by the GP or paediatrician and managed appropriately
with appropriate medications. So you’re teaching them
how to do diaphragmatic breathing? No. No, we don’t at the hospital
that I work at. But what we do is we look at
what type of approach is gonna suit the child and the parent and also weigh up the evidence
on both sides. But the main thing,
as Adam was just saying, is around having
your asthma action plan. It’s making sure that
reliever medications are first-line in asthma episodes and keeping in constant contact
with your GP or your specialist. So, but why not? If you’ve got a randomised…
This is better evidence than you got from most of
your other asthma treatments. There’s very limited…
My understanding is, for example, that most asthma trials in children
go down to about the age of 12. You’ve got some, if you’re lucky,
that go down to the age of 5. You know,
you’ve got pretty flimsy evidence for a lot of asthma treatments
in children, have you not? No, we’ve got pretty good evidence,
Norman. But you’re right – one of the trials you’re alluding to
is one that’s come out of the Woolcock, looking at breathing exercises… NORMAN: In adults.
– Yes, yes. And I think that’s right. And there are clinics around
that teach Buteyko methods in children and I suspect
that we’re out of our comfort zone and we don’t know
much more about it and… ..you know,
it becomes a personal preference whether we’re happy to accept it
as a complementary medicine, but, you know,
please do what we tell you, as well. Let’s go on to our next case study.
It’s Luke. He’s nine, he’s very active. He plays football, cricket,
swims 3, 4 times a week. He had allergic rhinitis
and eczema as a baby and has infrequent intermittent asthma since he was six. And that’s recently progressed, so that he’s getting quite
much more frequent attacks. His GP suggests to his parents that his asthma
will be better controlled with an inhaled corticosteroid. But Luke’s parents are
concerned about the side effects that they could have on Luke. Your patient, Kerry. Well, I think the first thing is
to acknowledge the parents’ concerns about the steroids,
not to just brush them aside, because they’ve probably already done
a search on the internet for steroids. NORMAN: They’re way ahead of you.
– They’re way ahead to start with. They’ve probably read the evidence
that the growth velocity may be slowed and the other side effects
that we talk about with steroids. But I think our job then
is to talk about that when we use steroids
at appropriate doses, that those side effects
are not significant, OK? And, you know, to really have
the open discussion about that. There’s also alternatives
to inhaled steroids. And the other thing is
making it almost like… NORMAN: Such as the leukotriene. Such as the leukotriene
for mild persistent asthma. And the other thing
is making a deal with them. That when, you know…
if we’re following guideline management, we’re going to be reviewing
this child regularly, that when their asthma’s controlled and has been controlled
for a certain period of time and lung function is normal, which, you know, we may be able to do
lung function on this nine-year-old boy, we can do a trial off inhaled steroids, and being open to that. It also encourages them
to come back for review. Do you get many questions at the
pharmacy when you’re dispensing? We do get asked questions, especially about the dangers
of taking steroids in children. And I think it’s important
that the pharmacist, like Kerry was suggesting,
acknowledges the parents’ concern, acknowledging that
there potentially may be an issue, but the dose that they use
is kept to a minimum, and regular review by your doctor
is the really important thing. I guess the side effect
we see the most often in pharmacy is the oral issue, with not only children, is not washing their mouth out
after they’ve had their… NORMAN: They’re not using spacers.
– ..inhalers, yeah. Yeah. In fact, what we’ve got, in fact, is a video
from the National Asthma Campaign – the National Asthma Council showing the correct use
of the spacer device. Hello, Mandy. I’m just wondering if you could show me how you use
your puffer and spacer for me. (Breathes deeply) (Breathes deeply) That was really great.
Thank you very, very much. So that’s from
the National Asthma Council. Tell me about the safety
of leukotriene receptor antagonists. They haven’t been around as long. It took many years for things
like the Blue Mountains Eye Study to show the relationship between
cataracts and the old doses here. And we’ve got
leukotriene receptor antagonists – are we sure they’re safe in children? They’ve been around
for quite a few years and obviously
like all newish medications there’s ongoing surveillance and people are reporting
any potential side effects. The sort of side effects that we see
if we were to see any would be sometimes
behavioural disturbance or headaches
or problems sleeping at night. In fact, the FDA recently looked at
some reports of suicides in adults with montelukast. So there’s clearly ongoing surveillance. And the report has recently
been updated by the FDA, saying they can’t find
the association with it. So clearly there’s ongoing surveillance but, generally, certainly
in my practice, it’s extremely safe and very occasionally
we’ve had to stop children because of behavioural
and sleep problems. So what are you going to do for Luke? Well, we’re saying
Luke has mild persistent asthma. His parents are concerned
about inhaled corticosteroids. Even though we may have had
that discussion with them about asthma
being an inflammatory disorder, we’d really like to…
inhaled corticosteroids are an option. But… I think we could give the choice
of low-dose inhaled steroids or montelukast. So I’d be keen to give him
a trial of montelukast to start with for mild persistent asthma. Especially when he has a significant
exercise component as a trigger. Um… And what would the asthma action plan
start to look like, Tracey? Well, it would start to form into certainly reinforcing
about use of the preventer medication. If it was the montelukast
that Luke was to go onto, then that’d be taken once a day. And the asthma action plan starts
to look like when well, when not well, and when your symptoms get worse. So it’s about reinforcing the use
of your regular preventer medication, but also looking at
the reliever medication in terms of how much you need
according to the signs and symptoms. But the asthma action plan is
a very fundamental part of management in helping for those basic concepts
to be reinforced in when you take your medication,
how often you need to take it and when you need to seek
medical advice. And presumably there’s gotta be a wide
range of adjustment in education depending on the age of the child. – Oh, absolutely.
NORMAN: And developmental status. Definitely – you need to tailor
your education to their age, to their developmental abilities and to certainly the needs
of not just the child but also the family as well. Another question – ‘Is swimming
still encouraged for asthma?’ Does it make any difference? Well, you’ve touched on a thorny issue,
actually, because there’s been recent work
coming out of Belgium suggesting that if you swim, you’re more at risk
of developing asthma. So there’s been a lot of work
going into this and it’s raised a few eyebrows, because clearly in Australia,
children drown. There’s a lot of water about
and swimming is extremely important – something that children
shouldn’t be discouraged from. However, because of the volatile
substances, particularly the chlorine, it can be toxic, and people have looked into
athletes’ exhaled breath condensate, we can actually measure
stuff that’s coming out. So, clearly,
if you’re gonna choose swimming, then an outdoor saltwater pool
has got to be the best. Indoor saltwater pool, the next, and then an indoor chlorinated pool. So we would encourage it… So presumably it’s the same advice – you take a couple of puffs
of your reliever before you jump in the water. Absolutely. And I think the advice
that we’re given is not enough evidence to discourage swimming. It’s an extremely important exercise. There’s evidence to suggest it improves
asthma in many children, they enjoy it. It’s exercise. But there’s some controversy
that is emerging, particularly, as I say,
from the Belgium group. So, Kerry, a question. It used to be true that we had amongst
the world’s highest rates of asthma, but that’s not so true anymore. The question is, do we still have
internationally high rates of asthma? We still have relatively high rates. I still think we rank fourth or fifth
at least. And we certainly… we have a prevalence of around about 11%
of school-aged children with asthma. So, it’s still significantly high. But it’s not the 20% to 25% figures that were quoted, you know,
10-15 years ago. And there’s a myriad of reasons
for that. Well, another question here, actually,
I think we’ve really covered that, but, how do we handle the concerns
people might have about combination therapy
with long-acting beta agonists when they’ve seen stuff on television
that they’re dangerous? But we’ve already answered that, that you shouldn’t be using that
much at all in children. I think that’s right.
There’s a huge growth. And, if anything, a very small
percentage of children should be on it – perhaps less than 5%. And the evidence, unfortunately,
is way against it – people are not listening to guidelines,
they’re not adhering to them and the growth in the combination
therapy industry is skyrocketing. And, really, people should be
looking at their practice if that is their current practice. So one year has passed
in the life of little Luke and he presents back to Kerry
with his mild persistent asthma. But he’s recently noticed that
there’s an increase in his symptoms, that he’s getting almost daily now. And in terms of the sports activities, he’s regularly having to come off
the field to manage his symptoms, which are heavy symptoms. He’s now classified, I suppose,
as moderate persistent asthma? Yes, the classification would be
moderate persistent asthma if he’s getting daily symptoms, or even severe persistent asthma,
with daily symptoms. But I think it’s really important
to find out whether Luke has been taking
his medication and whether, if he’s not been on
his preventer medication, that’s been the cause
of his breakthrough symptoms. Checking his inhaler technique. I mean, a lot of these children
don’t like using spacers, if they have been prescribed
a puffer with a spacer. He… So, looking at those sorts of things
before we just assume that his classification of his asthma
has changed. And is that the sort of approach
you take in the pharmacy if they come in
complaining to the pharmacist? One of the things that we do
in the pharmacy is very much about
checking inhaler technique, checking what inhalers they’re using, as in whether they’re using
their reliever or their preventer. I’ve had many situations where we’ve had children using their
preventers rather than their relievers because they’ve got confused. And also making sure that they’re using
their spacers appropriately and looking after their spacers. That’s the other thing –
we do see a lot of broken spacers. The valves aren’t working
and things like that ’cause they haven’t been replaced. While Kerry’s thinking hard
about what she’s gonna do about Luke, what are the instructions you give
teachers about exercise-induced asthma? First thing we alert teachers to
is that it is a major cause of asthma and to be alert for that, that it can occur during
and after exercise. The written asthma action plan,
as we’ve said several times tonight, is just a really fundamental
and important document to inform the school
on the individual needs. But exercise is a trigger for asthma
that is not to be avoided. It’s better to be managed so that the health benefits
of all sorts of exercise can be gained by all young people. We provide some information
about what to do before, during and after asthma. NORMAN: So what do you need to do
before? Before exercise, the critical thing
for a young person to do is to take their reliever medication
or other recommended medication. That’s usually about 5-10 minutes
before they would warm up and ease themselves into exercise
and sport. During sport… NORMAN: Is there any evidence that warm-up makes
the slightest bit of difference? People love warm-up and stretching,
but does it make any difference to the child with asthma? I think the fact that we’re giving
the airways a chance to get themselves ready and used to
the fact that we’re going to… NORMAN: Limbering up the airways.
– Yes, it’s that sort of thing. So, anecdotally, yes, we do know that
it’s going to prepare the young person a little bit better for what’s coming. So what about during exercise? During exercise, watching for symptoms
is the important thing. And if there are asthma symptoms
that do occur, either follow the asthma action plan or the 4x4x4 protocol, so that the young person’s
asthma symptoms could subside. And if they do,
they can return to the activity. The really important message is,
if the asthma does reoccur again, you continue to treat that asthma, but you do not allow them
to return back. It’s the alert that there is something
wrong at that particular point in time. And one thing
that a lot of people don’t understand is that exercise-induced asthma
is quite common after exercise has ceased, and for teachers to be alert for that,
as well. NORMAN: So you’ve got a protocol
for after, too. So what are you gonna do
for young Luke? Well, young Luke –
depends on what he’s already on. If he’s been adherent to his medication
and his technique’s good, now, he may have been on montelukast –
on the leukotriene receptor antagonist – and so if he was on
a leukotriene receptor antagonist, the next step would be
to introduce inhaled corticosteroids. NORMAN: Take him off the montelukast
and put him on? Yeah, take him off the montelukast, put him on
some low-dose inhaled steroids. We have a choice
of four inhaled steroids in Australia – all very good. Once again,
it comes down to a discussion about which sort of inhaler device
would suit Luke and whether we want to use once a day
or twice a day medication. Why would you take him off when they have different mechanisms
and presumably they could work together? Our hands are really tied
by PBS regulations – that we can’t prescribe
a second preventer. NORMAN: So if they could afford
a private script, it’d be alright. Afford a private script, that’s fine. NORMAN: What’s the evidence here, Adam?
ADAM: Of the two working together? There’s some evidence to suggest
that the two of them work together. And does the leukotriene receptor
antagonist act as a steroid sparer? It doesn’t act in that way…
when you have the two together. Certainly, there’s some work recently in
the New England Journal of Medicine that children on montelukast can come off effectively
straight onto inhaled steroids. And… Sorry, the other way round –
inhaled steroid can go on to montelukast without tailing off the inhaled steroid. So they’re obviously working
by different mechanisms, but the PBS here does influence
the way that we prescribe. But if a child doesn’t respond
to montelukast, it’s unlikely that they’re gonna respond
in combination to inhaled steroids. So it would be sensible to stop it
if they haven’t responded clinically. So what happens
if he’s been on inhaled corticosteroids at a modest dose, not working – just take us through your thinking
about how you escalate those. Well, one would hope that he’d just been
on a low-dose inhaled steroid, and, once again,
after checking adherence and inhaler technique, the next step is really
to just push those inhaled steroids up just a little bit more, OK? We don’t want to be using high doses. We don’t want to be tempted
to use high doses. But just, say, going from budesonide, he might have been on
400 micrograms a day, maybe pushing that up
to 600 micrograms a day. With fluticasone, he might have been
on two puffs twice a day of a 50-microgram one. Just maybe going up to
250 micrograms a day – 125 twice a day. And we do now have an indication
for children with ciclesonide, and the advantages of that
is that it’s once a day. Even thought the PI would say that
you don’t have to use it with a spacer, I think most of us would prefer
that it’s used with a spacer. The advantages of something
like ciclesonide is that it… the once-a-day dosage, that it doesn’t
actually become an active drug until it gets down into the lung tissue, so you don’t have those problems
with the oropharyngeal side effects, such as dysphonia,
potentially oral thrush. But if we’re using low doses, we shouldn’t be getting
those sorts of side effects anyway. If we come back to the comment
made at the beginning, once you’re getting up to
that sort of level, if it’s not working, this is an indication for a referral.
– I agree. I think rather than pushing up
higher, higher doses of steroids, think of referral to local paediatrician and then, beyond that,
respiratory paediatrician. And presumably you’d want to know
if he’s got rhinitis ’cause that could
significantly affect his asthma. I think controlling
his allergic rhinitis. I think when we first heard
Luke’s clinical presentation, he did have allergic rhinitis, so controlling his hay fever
would be really good. That’s why it would be nice to be able to keep him on
the leukotriene receptor antagonists. We may be able to do
a little bit of a crossover with that. And parents may be quite willing
to purchase montelukast privately as an alternative to nasal steroids
or antihistamines, which are actually not that good
to treat nasal congestion anyway. ADAM: One little trick, if I may,
just with inhaled steroids, is if you inhale –
it’s quite tricky to learn – but if you can get the child to do it,
inhale the steroid and exhale through the nose,
you can get nasal deposition… NORMAN: Waste not, want not.
– Absolutely. – Bit of a sort of green recycling.
– Correct. I shouldn’t have said that.
Sorry. Forget that I said that. And you can get some nasal deposition, which is a good way of monitoring
how much inhaled steroids you’re using. NORMAN: Well, they’re watching
so much smoking in the movies that they probably know
how to do it already. And some of us are old enough
to remember when the specialist used to put the asthma steroids
up the nose. TRACEY: Nice.
– Yeah. Remember that? Mm. And education or asthma action plan type
here for Luke in this situation? – Oh, yeah, again, absolutely.
NORMAN: It’s getting volatile. – We’ve got to get this under control.
– Yes. So it’s not necessarily an
asthma action plan for the next year. You’re wanting to review this regularly. Definitely. If he’s gonna be moved up in
terms from something like montelukast through to an inhaled steroid, you’d want the reviews
to be more regular. NORMAN: How regular?
– Maybe every three to six months, depending on what happens. If he has a hospital admission, especially if he needs to be admitted
to an intensive care unit, you’d want the reviews
to maybe come every six weeks until things are
well and truly under control. I think at the age of nine, hopefully he’s old enough to understand
about his own asthma and about how to help
with managing it with Mum and Dad. So it’s done as a team. It’s not like we want Luke
to take all the responsibility for it. But the fact is he’s at school,
going to camps, possibly staying at a mate’s place, so the education needs to be tailored
to his needs at this point, especially if you are dealing with
underlying adherence problems. NORMAN: So is this doctor review, Kerry, or you would be happy
for a practice nurse to do the review? I’d be happy
for a practice nurse review. I think if GPs have got
appropriately trained practice nurses in their practice, they don’t have to be fully-qualified
asthma nurse educators, but I think they do obviously need
to have a certain level of training and understanding to assist GPs. I’d certainly want to be reviewing Luke
within a few weeks of a change of therapy… NORMAN: Yeah, three months feels long. I think a review within a few weeks
is most appropriate for any change of therapy for anything. Sorry, Norman. Can I add about
spirometry, just to echo what they said? It’s very important. Some children will think
they’ve got normal lung function and they run a spirometry at 75%
and they’ve learned to adjust to that, so without objective evidence, it’s really important every time
they see the GP or the paediatrician to have the spirometry. – So the GP gets feedback to them.
– And they get a shock. And I think doing
that objective measurement, we find in my practice,
where we do lots of spirometry, that the fact that you’re going to
measure something when they come back is another hook
into that regular review. Just like people expect
to have their blood pressure measured. Luke’s at school a few weeks later
taking part in a football match and he comes off the field distressed and anxious. He can’t get a sentence out, his pulse is up. When you see him, Kerry, in the surgery, he’s got a moderately loud wheeze throughout the chest. He tells you he’s been using his puffer frequently today and it’s not really helping. KERRY: I’d be quite concerned about Luke at this stage. I’d have all guns firing. I’d have the oxygen there
ready to give him. He’s got a moderate-to-severe
exacerbation which needs to be managed efficiently
and quickly and assessed regularly. He needs to be monitored there and then. Just hold the thought for a moment. What does your guideline say that the teacher should be doing
in this situation? The 4x4x4 protocol
at this point in time… NORMAN: This is asthma first aid.
TONY: Yep. The asthma first-aid protocol
would be alerting the teacher that they’ve moved into
an area of concern about the young person’s condition and they should be phoning an ambulance
at that point in time. So we’re really firmly in step four now. NORMAN: But they should be
given an inhaler… TONY: And while we’re waiting
for an ambulance response, we continue the 4×4 treatment. NORMAN: So in the surgery,
just tell us what you’d do. In the surgery, he would be given oxygen and we would be giving him 12 puffs
of salbutamol via a spacer. We’d be assessing
the clinical response to that five to ten minutes later. So just on this 12 puffs –
is it 2 puffs at a time in the spacer, or 12 into the spacer and you just keep
on breathing it in and out? Just one puff and three or four tidal
breaths will empty a large volume… NORMAN: Just like the one we saw.
– Yep. And repeating that 12 times. We don’t need to be using nebulisers. We’ve had a problem with nebulisers,
or air pumps, in the past, and the actual nebuliser bowl’s
not been kept up to date and been dirty and not nebulising as they should be. So we know that 12 puffs
are the equivalent of the old 5mg of salbutamol
in a nebule. So we can give that,
it can be given quickly, it can be given efficiently,
it can be given easily… NORMAN:
Even to quite a distressed child. Even to a distressed child. And… NORMAN: How long do you wait
to see if there’s an improvement? Short-acting beta-2 agonists
work very quickly, so they’re going to start to work
within a few minutes, get to their peak effect maybe anywhere
between 10 and 20 minutes. So I’d be assessing this child
at about, you know, anywhere between 10 and 20 minutes, depending on how worried I was
about him. And I’d expect some clearing of
that airway obstruction listening to it. And giving another 12 puffs
at 20 minutes. I’d be thinking about, do I need
to transfer this child to hospital? In a rural and remote area, it might be that, you know,
I am the hospital, so I have to do all this. NORMAN: What about oral steroids? I’d be also considering giving him some
oral steroids – 50mg of prednisolone. Because I think I’d rather give that
sooner than later. This is a moderate-to-severe
exacerbation. It’s going to need treatment
with oral steroids anyway. What do you think? Absolutely couldn’t agree more. And just a word of warning is that,
of course, you can get paradoxically worse
with beta agonists as you bronchodilate and it increases
your ventilation/perfusion mismatch. And there have been unfortunate cases
of children dying in the GP surgery, particularly if there wasn’t
any oxygen around. So I think people just have to be aware
that you can actually be made worse… So oxygen abolishes that risk? It probably doesn’t,
but it treats hypoxia. So if you’re gonna die
because of hypoxia, then having oxygen there… NORMAN: So how scared should GPs be? That puts the fear of God into me,
if I was a GP, that I shouldn’t be treating the children
with acute exacerbations at all. I think you’ve gotta be cautious.
You know, asthma kills. Thankfully, very rarely. And particularly when you’re unwell, I think you’ve gotta understand
what you’re doing and if you’re going to treat
using beta agonists, realise that
you can increase mismatching. So essentially,
your essential thing here is that you assess the severity. How hypoxic is the child?
How distressed? What’s the pulse? Et cetera, et cetera. You’ve got a saturation monitor,
fantastic, oxygen nearby, and do exactly what Kerry’s been doing. NORMAN:
And have a short fuse for referral. But it might be difficult
in a country town. And I think with GPs,
not relying necessarily on oximetry, if they are using oximetry without
actually looking at the patient as well. I think there is a bit of a problem
out there in some environments of saying,
‘Oh, well, the figure’s OK,’ but not actually looking at the child. To what extent do you find that people
in the acute situation forget they’ve got an asthma plan? Oh, absolutely. Yeah, it’s very common. Yeah, they could have the plan
on the fridge at home, Mum and Dad could know it by heart
and memorise it, but when their child is having
an asthma episode in the middle of the night,
it’s 3:00 in the morning, you’ve got other kids to get to school,
all those other factors, it can go completely out the window. And they would think back to
something that happened with Kerry, something that happened at the hospital, ‘I can give it every 20 minutes and
maybe my child will turn that corner,’ and maybe they will, but it’s a dangerous situation
to be in at home. So the one thing that parents
can keep in the back of their mind is if they need to give the Ventolin
more than every three hours, they need to seek
medical advice straightaway. Isn’t the asthma action plan really
quite sort of a middle-class phenomenon? It’s great, you know, in a kid
that comes from, you know, Toorak or the wealthier side of town, but if you’re in a family
where there are lots of kids, where a woman’s struggling
to look after all these kids by herself on a pension, there’s smoking around… There are just too many other things
in that woman’s day to really focus
on an asthma action plan – it’s a luxury she can’t afford. I think that’s when you’ve got to
take the opportunity to sit down and engage with that parent and try to find out
what you can do to really help them. You know, maybe suggest having… But you can’t be there
at 1:00 in the morning. Absolutely not. But there’s certain things
that’s in our circle of control. There are things that we can’t influence and that might be that situation
at 1:00 in the morning where all six kids are screaming
and other things are going on, but if you can try to instil,
the best as we can, in parents that if your child needs
X amount of Ventolin depending on their age
and what their needs are, they need it
more than every three hours, the best thing
that they can do for their child is to seek medical advice straightaway. Do you have much experience
of treating Aboriginal children, particularly, you know, in the city
at Westmead? No, actually,
in the area that I work in, Daruk takes very good care of
the Aboriginal children that are there, so I haven’t had a lot of exposure to… NORMAN: So, really,
Aboriginal health workers… – ..and the community helps out there.
– Yep. Absolutely. Do a great job. So after this acute exacerbation, are
you gonna change his regular therapy? I’m going to bring Luke back
for a review very quickly. NORMAN: Like tomorrow?
– Probably within the next few days. Yeah, for sure. And I’m going to be keeping a very close
eye on him over the next few weeks before I let him go back
to sort of routine three-monthly review. And, once again,
it’s going back through the standard. You know,
has he been taking his medication? Has he been taking it correctly?
Do we have the correct diagnosis? And seeing what actually triggered,
looking at why he got worse. NORMAN: Response to triggers.
– Yeah. And he may have had a viral
upper respiratory tract infection, which was the aggravating factor
under these circumstances. One of the messages I’m getting is that when things change like this
in a child with wheezing, you go back to first principles
and you start all over again… Start all over again. ..is there something you’ve missed here? Thank you all very much.
Fascinating program. What are your takeaway messages
for those watching? There is an Asthma Friendly
Schools program. It’s a mature program. Most schools around Australia
are re-engaging with the program through a re-recognition process. So it’s fairly well-entrenched
in that sense. It provides for
written asthma action plans as the fundamental go-between
between the GPs and the school and providing good individual care
of asthma and also preventative care
of asthma overall. It will train the teachers and it’ll set up
good management practices in schools and it’s well accepted
in the school systems around Australia. NORMAN: Toni Riley? I think the take-home message
for pharmacists is make sure that your patients
know their medicines, know how they’re meant to be using them and make sure they understand
which is which – you know, which is the reliever,
which is the preventer. But the other thing, I think pharmacists
have a unique opportunity ’cause we possibly see these patients
more than any other health professional, is to remind, especially the parents,
of the importance of regular review. NORMAN: Tracey? Take-home message would be that education and management
go hand in hand and that you need to tailor
the education to suit the child and the parents and the family, and that whether it’s with
the pharmacist, with the GP, whether it’s with the specialist, with
an asthma educator in the community, it’s about us all being consistent,
being able to follow the guidelines and making sure we’re clear and concise
in the information we’re giving. NORMAN: Kerry? I think making the correct diagnosis
is really important. Taking a good clinical history, which will then follow through to the appropriate classification
of the asthma, which will then lead
to the appropriate pharmacotherapy so that we don’t have undertreatment,
we don’t have overtreatment. And the regular review. NORMAN: And don’t throw
around the combos. – Yeah.
– Absolutely. Don’t throw around the combos. Watch
your use of long-acting beta agonists. And make every opportunity
an opportunity to use spirometry. And of course the evil weed – smoking. Really address that
at every opportunity possible. NORMAN: Thank you all very much indeed. And I hope you’ve enjoyed
tonight’s program on managing asthma in primary school children. If you’re interested in obtaining more
information about the issues raised, there are a number
of resources available on the Rural Health Education
Foundation’s website, and that’s at: Don’t forget to complete
and send in your evaluation forms and register for CPD points
by completing the attendance sheet. Thanks to the National Asthma Council
for sponsoring this program with help from
the Australian Government’s Department of Health and Ageing. Thanks to you for taking the time
to attend and contribute. I’m Norman Swan. Bye for now. Captions by
Captioning & Subtitling International Funded by the Australian Government
Department of Families, Housing, Community Services
and Indigenous Affairs�

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