Child and Adolescent Asthma Guidelines - Amazon S3...child •Maximize quality of life (reduce...
Transcript of Child and Adolescent Asthma Guidelines - Amazon S3...child •Maximize quality of life (reduce...
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ChildandAdolescentAsthmaGuidelines
AsthmaandRespiratoryFoundationNZ2017
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Acknowledgements• InnesAsher• CherylDavies• TeresaDemetriou• TerryFleming• MatireHarwood• LorraineHetaraka-Stevens• Tristram Ingham• JohnKristiansen• JimReid• DeniseRickard• DebbieRyan
• Consultedorganisations
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Mainsources
• BTS/SIGNAsthmaGuideline2017• AustralianAsthmaHandbook2015• GINAguidelines• UKNationalReviewofAsthmaDeaths2015• HeMāramatanga Huangō:AsthmaHealthLiteracyforMāoriChildreninNewZealand2015
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TheWhys
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AsthmaMortality
• 65- 70deathsperyearinNZ• UKnationalreview2014suggestsmanypreventable– >80%deficienciesinacuteorchroniccare– 45%didnotseekhelp– Diagnosticprocessunclear
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AsthmamortalitydisparitiesinNZ
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Despitethistherearealsotreatmentdisparities
• MaoriandPacificchildrenmorelikelytoreceiveoralsteroidsandnebulisers
• ButlesslikelytoreceiveICS• Lesslikelytoreceiveasthmaeducation• Lesslikelytobegivenanactionplan
Crengle,Thesis2008Gillies,PrimCareResp J2013
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Adherence(world-widedata)
• Only30- 50%ofasthmapatientsarewellcontrolled(adultsandchildren)
• CompliancewithICSpreventersonly20-30%• 34%ofpatientswithuncontrolledasthmauseapreventerlessthanonceperweek
• Adherencehasnotimprovedinthelast3decades
Rabe JACI2004Reddell MJA2015BenderJACI:InPractice2016
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AsthmaHealthLiteracyforMaoriChildreninNZReport2015
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Whanaureported:
• Nothavingadequateknowledge• <50%understoodwhatasthmais• 1/3notknowinghowtoseekurgenthelp• Notbeinglistenedto• Toomuchinformationatonce• Notbeingtaught“why”
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“Theresponsibilityforhealthliteracyliesprimarilywithhealthprofessionals”
- AsthmaHealthLiteracyForMaoriChildrenReport2015
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TheGuideline
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Goalsfromtheguideline
• Allaspectsofthehealthsystemwillsupportbetterasthmacare,aimingtodecreaseinequitiesandimproveoutcomes
• Māorichildrenhaveasthmaoutcomesequaltonon-Māoriandnon-Pasifika children
• Pacificchildrenhaveasthmaoutcomesequaltonon-Pacific&non-Māorichildren
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Top10wayshealthprofessionalscanhelp(apartfromprescribingmedicines)
• Relationships• Wellness• Smokeexposure• Housing• Income• Healthliteracy• Adherence• Actionplan,Access,Ambulance
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Asthmamanagementasacontinuouscycleofmonitoringandreassessment• Requirementforfollowupandrepeatedreview
• Changefromepisodichealthcare• Useofrecallsystems
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Goal:Allchildrenwhohaveasthmaarecorrectlydiagnosedpromptly
• Diagnosisinchildren– basedonhavingcharacteristicsymptomsinabsenceofanothercause
– ANDassessingresponsetotreatment
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LikelihoodofAsthma
Incr Likelihood• Typicalepisodicwheeze/cough/SOB
• Typicaltriggers• Atopy• Familyhistory
Decr Likelihood• Lackofintervalsymptoms
• Isolatedcough• Moistcough• Dizzy/light-headed• Stridor• Signsofspecificdisease
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RedFlags
• Dailyorconstantsymptoms– Infantwithwheezeeverydaysincebirth–Dailywetormoistcough
• Failuretothrive• Digitalclubbing
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• Currentparadigm– <1year“bronchiolitis”– 1– 4year“pre-schoolwheeze”– >4yearasthma
Whatagedowediagnoseasthma?
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Pre-SchoolWheeze
• Twodistinctgroups– Thosewhoonlywheezewithviruses(infrequent)– Thosewithfrequentwheeze– Patterndoesnotpredictlaterasthmaornot
• Onlyregularwheezers (incl thosewithfrequentviralexacerbations)benefitfrompreventersàtreatasasthma
• Canswapgroups– reviewandtrialoffmedseach3months
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Goal:Allchildrenwithasthmaareassessedfortheirseverity,controlandfuturerisk
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Goal:Therightstepofmedicineintherightdeviceisusedfortheageandsymptomsofthe
child• Maximizequalityoflife(reducesymptoms)• Reducerisk• Avoidadversetreatmenteffects• Utilising astep-wiseapproachtomanagement
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Pre-schoolpreventermanagement
• Initiallyasneededsalbutamol• Severeflareupswithoutfrequentsymptoms
àMontelukast• Frequentflareupsorfrequentsymptomsbetweenflareupsà Inhaledcorticosteroid
• Stillpoorcontrol?– Addotheroption
• NeverforLABAs
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Klok,ERJ,2014
Goal:ForallchildrenwithasthmaitshouldbeclearifICSshouldbeprescribed,andifso,aprescriptiongivenandthemedicinetaken
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Assessingadherence
• Prescribingrecords– AtthePractice– Pharmacydatabase
• Selfreport– “Howoftendoyouforgettotakeyourinhalerinaweek?”
• Physicianjudgement• Electronicmonitoringdevices
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Goal:Thecorrectinhalerdeviceisconsideredandageappropriate
• Spacerwithmask– <2years
• Spacernomask– transition2– 4years– Improvedlungdepositionby60%– Notwhensevereexacerbation
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• Turbuhaler - from5- 7years
• MDIalone– never(possiblefrom8years)
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NZchildren
• Only80%ofchildrenunder6useaspacer• Only30%ofchildrenover7useaspacer• Lessthan35%givenanactionplan
Crengle NZMJ2011Crengle Thesis2008
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Assessinginhalertechnique:Checkeveryvisit
• Only7- 22%havehadtechniquetested• 20- 50%ofhealthprofessionalsincorrecttechnique!– upto85%fordrypowderinhalers
• Repeatededucationnecessary• Drypowderinhalerstake3sessions• Skillsdecayover2-6weeks
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Goal:Identifyandaddresspersonal,whānau orenvironmentalfactorswhichmaybeunsettling
asthma• Smokeexposure• Housing• Allergenavoidance• Anxietyandpsycho-socialtriggers• Associatedconditions– Rhinitis
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Goal:Achievingeffectiveself/familyeducationandmanagement
• Goodasthmaeducation– Enhanceshealth-literacy– Enhancesself-efficacy
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Educationtakestimeandrepeatedeffort
• Educationateveryvisit(chunks)• Incorporateavarietyofmedia• Buildrapportbybuildingpartnership• Useasharedlanguageforbetterunderstanding– “Puffers”– “RelieversandPreventers”– “Flareups”
• Goalisimprovedself-management
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Goal:Allchildrenwithasthmashouldbeprovidedwithanasthmaactionplan
AsthmaFoundationNZ
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Goal:Allchildrenshouldbemanagedtoavoidlife-threateningasthmaordeath
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SUMMARY:Inordertoreduceinequalityandimproveoutcomes
• Childrenwithasthmarequire– Time– Repeatedvisits
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