Developing a Diagnostic and Management

1
In Partnership with Primary Care
Royal Liverpool Childrens NHS Trust
Liverpool Primary Care Trust

• Developing a Diagnostic and Management
• Tool for Paediatric Asthma

2
In the Beginning

• What is the difference between Salbutamol and
  Flixotide?
• Asthma UK Report 2004 Asthma Admissions
• Liverpool PCTs 6th, 10th 49th of 318 PCTs in
  England

3
Alder Hey Asthma Admissions
4
Need for Practise Nurse Survey

• No recent information on PNs
• involvement with asthmatic children
• responsibility for asthma management
• level of training in paediatric asthma
• confidence
• what training they would like

5
Working Group (Oct 2005)

• RLC NHS Trust
• Chris Doyle ANP Asthma Allergy
• Louisa Heaf Paediatric Respiratory Coordinator
• Elaine Kelly Asthma Nurse Specialist
• Vicky Worrall Asthma Nurse Specialist
• PCT
• Steve Callaghan Respiratory Lead Nurse
  Clinician
• Lynda Carey Head of Nursing
• Meet 4-6 weekly at RLC

6
Asthma UK Challenge Fund

• Joint proposal between RLC NHS Trust the
  Liverpool
• PCTs submitted to Asthma UK Challenge Fund (Nov
  05)
• to set up a three tier service improvement model.
• Aim
• To establish a high standard of knowledge, care
  and
• skills within the primary care organisations in
  order to
• improve the management of asthma in children.

7
Improvement Model

• Level 1 Learning Needs Assessment
• Level 2 Education Training
• Level 3 Development of a Paediatric Asthma
  Care Pathway for use in Primary Care

13th December 2005 awarded 15,000 by Asthma UK
8
Level 1 Learning Needs Assessment

• Practice Nurse Survey (February 2006)
• Developed by the working group
• 14 Questions
• RLC Audit Dept.
• Joint covering letter
• Posted to practice nurses and made available at
• PN's meetings

9
Results of Survey - 85 responses

• Type of clinic
• Asthma clinics (all ages) 35
• Asthma clinics (paediatric) 2
• General clinic 65
• Nurse Led 83

10
Nurses Role with asthmatic children 0-16 years

• a) Education, checking inhaler technique,
  teaching PF monitoring. Spotting poor control
  referring on. 18
• b) As in a) plus, changes in devices, writing
  Asthma Action Plans. 45
• c) As in a) and b) plus, changes in treatments,
  diagnosing. Working with full autonomy.
  27
• d) No regular involvement with asthmatic children
  or young people. 10

11
Nurses with Asthma Training
NTRC Asthma Diploma 18 AMT Asthma
Certificate 29 RETC Asthma Course
8 Other 22
12
Nurses Confident in Managing Childhood Asthma

• 0 - 2yrs 25
• 2 - 5yrs 51
• 5 - 12yrs 86
• 12 - 16yrs 89

13
What the nurses would find helpful

• Asthma study days 74
• Hospital asthma clinics 66
• Asthma workshops 49
• On site training 24

14
Level 2 Education Training

• Define role of practise nurse in management of
  paediatric asthma.
• Establish KSF
• Develop training programme

15
Role of the Practice Nurse

• All practices nurses who have regular contact
  with
• asthmatic children should be able to competently
• Provide asthma education for the patient /
  parent.
• Teach and check inhaler technique.
• Teach use of peak flow meter.
• Spot poor control and when to refer patients.
• Select appropriate delivery devices
• Write asthma action plans.

16
Practice Nurse Asthma KSF

• Diagnostic and assessment
• Management and monitoring
• Knowledge and evidence based practice
• Teaching and training - Patients and carers
  - Health care professionals
• Communication - Patients and carers
  - Multidisciplinary team -
  Liaison
• Trust and national policies
• Continuing education

17
Nurse Training Programme

• All Nurses
• An initial paediatric asthma training day
• Update session every 2 years.
• Autonomous Practitioners
• Nationally recognised Asthma Diploma

18
Level 3 Primary Care Pathway

• Based on nationally agreed (BTS/SIGN) guidelines
• Available on intranet in surgeries
• Web links to BTS
• Paediatric Asthma IT template

19
First Visit
First Visit
Paediatric Asthma 2 - 15 years Primary Care
Pathway
Key features present in asthma are Episodic Dry
Cough Breathlessness Noisy Breathing
Wheeze Asthma should be suspected in any
child with wheezing, ideally heard by a health
professional on auscultation, and distinguished
from upper airway noises. It can be difficult to
give a definitive diagnosis of asthma in children
under two years as symptoms can often be due to
post viral wheeze. The key to correct diagnosis
in primary care is a full clinical history and
physical examination, there should be careful
consideration of alternative diagnoses.
Key features present in asthma are Episodic Dry
Cough Breathlessness Noisy Breathing
Wheeze Asthma should be suspected in any
child with wheezing, ideally heard by a health
professional on auscultation, and distinguished
from upper airway noises. It can be difficult to
give a definitive diagnosis of asthma in children
under two years as symptoms can often be due to
post viral wheeze. The key to correct diagnosis
in primary care is a full clinical history and
physical examination, there should be careful
consideration of alternative diagnoses.
Is it Asthma?
Is it Asthma?
Assessment
History / Physical Examination / Record of
height and weight centile
Documented history should include,
Problems due to respiratory symptoms Daytime
Cough Night time Cough Tight chest Breathlessness
Physical activity restricted e.g. PE, football
Days off school
Asthma triggers Viral infection
Smoking Allergies e.g. pets, pollens,
dust Stress / emotion
Asthma indicators Episodic dry cough Wheeze heard
on auscultation Repeat antibiotics for chest
infections Eczema Hay fever / Allergic rhinitis
Family history of atopy
The presence of asthma indicators increases the
probability of the patients symptoms being due
to asthma.

• YES
• Prescribe treatment in line with the current
• BTS /SIGN Asthma Guidelines
• Provide the appropriate inhaler device
• Check correct inhaler technique is used
• Give explanation of asthma to the patient/parent
  
• Give explanation of different asthma medications
• Give a written asthma action plan
• Book follow up appointment for 6 - 8 weeks

• NO Consider other diagnosis and referral to a
  
• paediatric respiratory specialist if
• Symptoms present from birth
• Abnormal voice or cry
• Inspiratory stridor as well as wheeze
• Focal signs in chest
• Failure to thrive
• Excessive vomiting or posseting
• Persistent wet cough
  
• Family history of unusual chest disease

Is Asthma suspected?
www.brit-thoracic.org.uk/asthma-guideline
20
First Visit
Paediatric Asthma 2 - 15 years Primary Care
Pathway
Key features present in asthma are Episodic Dry
Cough Breathlessness Noisy Breathing
Wheeze Asthma should be suspected in any
child with wheezing, ideally heard by a health
professional on auscultation, and distinguished
from upper airway noises. It can be difficult to
give a definitive diagnosis of asthma in children
under two years as symptoms can often be due to
post viral wheeze. The key to correct diagnosis
in primary care is a full clinical history and
physical examination, there should be careful
consideration of alternative diagnoses.
Is it Asthma?
Problems due to respiratory symptoms Daytime
Cough Night time Cough Tight chest Breathlessness
Physical activity restricted e.g. PE, football
Days off school
Assessment
History / Physical Examination / Record of
height and weight centile
Asthma indicators Episodic dry cough Wheeze heard
on auscultation Repeat antibiotics for chest
infections Eczema Hay fever / Allergic rhinitis
Family history of atopy
Assessment
Asthma triggers Viral infection
Smoking Allergies e.g. pets, pollens,
dust Stress / emotion
Documented history should include,
Problems due to respiratory symptoms Daytime
Cough Night time Cough Tight chest Breathlessness
Physical activity restricted e.g. PE, football
Days off school
Asthma triggers Viral infection
Smoking Allergies e.g. pets, pollens,
dust Stress / emotion
Asthma indicators Episodic dry cough Wheeze heard
on auscultation Repeat antibiotics for chest
infections Eczema Hay fever / Allergic rhinitis
Family history of atopy
The presence of asthma indicators increases the
probability of the patients symptoms being due
to asthma.

• YES
• Prescribe treatment in line with the current
• BTS /SIGN Asthma Guidelines
• Provide the appropriate inhaler device
• Check correct inhaler technique is used
• Give explanation of asthma to the patient/parent
  
• Give explanation of different asthma medications
• Give a written asthma action plan
• Book follow up appointment for 6 - 8 weeks

• NO Consider other diagnosis and referral to a
  
• paediatric respiratory specialist if
• Symptoms present from birth
• Abnormal voice or cry
• Inspiratory stridor as well as wheeze
• Focal signs in chest
• Failure to thrive
• Excessive vomiting or posseting
• Persistent wet cough
  
• Family history of unusual chest disease

Is Asthma suspected?
www.brit-thoracic.org.uk/asthma-guideline
21
First Visit
Paediatric Asthma 2 - 15 years Primary Care
Pathway
Key features present in asthma are Episodic Dry
Cough Breathlessness Noisy Breathing
Wheeze Asthma should be suspected in any
child with wheezing, ideally heard by a health
professional on auscultation, and distinguished
from upper airway noises. It can be difficult to
give a definitive diagnosis of asthma in children
under two years as symptoms can often be due to
post viral wheeze. The key to correct diagnosis
in primary care is a full clinical history and
physical examination, there should be careful
consideration of alternative diagnoses.
Is it Asthma?
Assessment
History / Physical Examination / Record of
height and weight centile
Documented history should include,
Problems due to respiratory symptoms Daytime
Cough Night time Cough Tight chest Breathlessness
Physical activity restricted e.g. PE, football
Days off school
Asthma triggers Viral infection
Smoking Allergies e.g. pets, pollens,
dust Stress / emotion
Asthma indicators Episodic dry cough Wheeze heard
on auscultation Repeat antibiotics for chest
infections Eczema Hay fever / Allergic rhinitis
Family history of atopy

• YES
• Prescribe treatment in line with the current
• BTS /SIGN Asthma Guidelines
• Provide the appropriate inhaler device
• Check correct inhaler technique is used
• Give explanation of asthma to the patient/parent
  
• Give explanation of different asthma medications
• Give a written asthma action plan
• Book follow up appointment for 6 - 8 weeks

The presence of asthma indicators increases the
probability of the patients symptoms being due
to asthma.

• YES
• Prescribe treatment in line with the current
• BTS /SIGN Asthma Guidelines
• Provide the appropriate inhaler device
• Check correct inhaler technique is used
• Give explanation of asthma to the patient/parent
  
• Give explanation of different asthma medications
• Give a written asthma action plan
• Book follow up appointment for 6 - 8 weeks

• NO Consider other diagnosis and referral to a
  
• paediatric respiratory specialist if
• Symptoms present from birth
• Abnormal voice or cry
• Inspiratory stridor as well as wheeze
• Focal signs in chest
• Failure to thrive
• Excessive vomiting or posseting
• Persistent wet cough
  
• Family history of unusual chest disease

Is Asthma suspected?
Is Asthma suspected?
www.brit-thoracic.org.uk/asthma-guideline
22
First Visit
Paediatric Asthma 2 - 15 years Primary Care
Pathway
Key features present in asthma are Episodic Dry
Cough Breathlessness Noisy Breathing
Wheeze Asthma should be suspected in any
child with wheezing, ideally heard by a health
professional on auscultation, and distinguished
from upper airway noises. It can be difficult to
give a definitive diagnosis of asthma in children
under two years as symptoms can often be due to
post viral wheeze. The key to correct diagnosis
in primary care is a full clinical history and
physical examination, there should be careful
consideration of alternative diagnoses.
Is it Asthma?
Assessment
History / Physical Examination / Record of
height and weight centile
Documented history should include,
Problems due to respiratory symptoms Daytime
Cough Night time Cough Tight chest Breathlessness
Physical activity restricted e.g. PE, football
Days off school
Asthma triggers Viral infection
Smoking Allergies e.g. pets, pollens,
dust Stress / emotion
Asthma indicators Episodic dry cough Wheeze heard
on auscultation Repeat antibiotics for chest
infections Eczema Hay fever / Allergic rhinitis
Family history of atopy

• NO Consider other diagnosis and referral to a
  paediatric respiratory specialist if
• Symptoms present from birth
• Abnormal voice or cry
• Inspiratory stridor as well as wheeze
• Focal signs in chest
• Failure to thrive
• Excessive vomiting or posseting
• Persistent wet cough
  
• Family history of unusual chest disease

The presence of asthma indicators increases the
probability of the patients symptoms being due
to asthma.

• YES
• Prescribe treatment in line with the current
• BTS /SIGN Asthma Guidelines
• Provide the appropriate inhaler device
• Check correct inhaler technique is used
• Give explanation of asthma to the patient/parent
  
• Give explanation of different asthma medications
• Give a written asthma action plan
• Book follow up appointment for 6 - 8 weeks

• NO Consider other diagnosis and referral to a
  
• paediatric respiratory specialist if
• Symptoms present from birth
• Abnormal voice or cry
• Inspiratory stridor as well as wheeze
• Focal signs in chest
• Failure to thrive
• Excessive vomiting or posseting
• Persistent wet cough
  
• Family history of unusual chest disease

Is Asthma suspected?
Is Asthma suspected?
www.brit-thoracic.org.uk/asthma-guideline
23
Follow Up
Paediatric Asthma 2 - 15 years Primary Care
Pathway
History / Physical Examination / Record of
height and weight centiles
Patient Review
Patient Review
Documented history should include,
Asthma indicators Episodic dry cough Wheeze heard
on auscultation Repeat antibiotics for chest
infections Eczema Hay fever / Allergic rhinitis
Family history of atopy
Asthma triggers Viral infection
Smoking Allergies e.g. pets, pollens,
dust Stress / emotion
Problems due to respiratory symptoms Daytime
Cough Night time Cough Tight chest Breathlessness
Physical activity restricted e.g. PE, football
Days off school

• NO
• Check treatment is appropriate
• Check device is appropriate
• Check concordance
• Consider increasing treatment
• Consider other diagnosis and referral to
  paediatric
• respiratory specialist

• YES
• Continue treatment, in line with the BTS /SIGN
• Asthma Guidelines
• Check written asthma action plan
• Give information for school or nursery
• Arrange follow up, see Ongoing Management

• YES
• Continue treatment, in line with the BTS /SIGN
• Asthma Guidelines
• Check written asthma action plan
• Give information for school or nursery
• Arrange follow up, see Ongoing Management

Are symptoms reduced?
Are symptoms reduced?

• NO
• Check treatment is appropriate
• Check device is appropriate
• Check concordance
• Consider increasing treatment
• Consider other diagnosis and referral to
  paediatric
• respiratory specialist

Ongoing Management
.
www.brit-thoracic.org.uk/asthma-guideline
24
Follow Up
Paediatric Asthma 2 - 15 years Primary Care
Pathway
History / Physical Examination / Record of
height and weight centiles
Patient Review
Documented history should include,
Asthma indicators Episodic dry cough Wheeze heard
on auscultation Repeat antibiotics for chest
infections Eczema Hay fever / Allergic rhinitis
Family history of atopy
Asthma triggers Viral infection
Smoking Allergies e.g. pets, pollens,
dust Stress / emotion
Problems due to respiratory symptoms Daytime
Cough Night time Cough Tight chest Breathlessness
Physical activity restricted e.g. PE, football
Days off school

• NO
• Check treatment is appropriate
• Check device is appropriate
• Check concordance
• Consider increasing treatment
• Consider other diagnosis and referral to
  paediatric
• respiratory specialist

• YES
• Continue treatment, in line with the BTS /SIGN
• Asthma Guidelines
• Check written asthma action plan
• Give information for school or nursery
• Arrange follow up, see Ongoing Management

Are symptoms reduced?
Ongoing Management
.
www.brit-thoracic.org.uk/asthma-guideline
25
Ongoing Management

• Children with asthma need regular routine review
  of their treatment, symptoms and inhaler
  technique.
• Treatment should be stepped up or down
  according to symptoms.
• Frequency of review will depend on the level of
  treatment required.

26
Acute Exacerbation
Paediatric Asthma 2-15 years Primary Care
Pathway
Severe
Mild / Moderate
Life Threatening

• Breathless at rest
• Talk / babble with difficulty
• Heart rate gt130/min
• Respiratory rate gt50/min lt5yrs
• gt30/min gt5yrs
• Use of accessory neck muscles

• SpO2 lt92
• Silent chest
• Poor respiratory effort
• Agitation / exhaustion
• Altered consciousness
• Cyanosis

• SpO2 gt 92
• Able to talk / babble
• Heart rate 130/min
• Respiratory rate lt50/min lt5yrs
• lt30/min gt5yrs

ß2 bronchodilator10 puffs via MDI LVS If SpO2
? 92 give via oxygen-driven nebuliser if
available and add ipratropium Oxygen via face
mask to maintain SpO2 gt92 Commence 3 days oral
prednisolone
ß2 bronchodilator and ipratropium via
oxygen-driven nebuliser Oxygen via face
mask Oral prednisolone Arrange IMMEDIATE
hospital admission Stay with patient until
ambulance arrives Send written assessment
/referral details
ß2 bronchodilator via MDI LVS lt 5yrs 5 puffs
gt 5yrs 10 puffs 1 puff every 30
seconds Consider oral prednisolone
Assess response to treatment 15 mins after ß2
bronchodilator
If oxygen-driven nebuliser not available give
ß2 bronchodilator via MDI LVS 1 puff every 30
secs up to 10 doses, then 1 puff every minute
until ambulance arrives.

• GOOD RESPONSE
• Continue 2 - 5 puffs of ß2 bronchodilator
  
• as needed, not exceeding 4 hourly
• Continue prednisolone for 3 days
• Arrange follow-up clinic visit

• POOR RESPONSE
• If symptoms are not controlled repeat ß2
• bronchodilator and refer to hospital
• Stay with patient until ambulance arrives
• Send written assessment / referral details

27
Paediatric Asthma Template
28
Paediatric Asthma Template
(BTS Step1) (BTS Step2) (BTS Step3) (BTS Step45)
29
Implementation

• Launch day September 6th
• 2 Study days (September 21st February 18th)
• On going training for practise nurses
• Mentorship by ANP/ANSs
• RLC in Surgeries
• Asthma Champions
• Paeds Asthma Diploma July 7th (Liverpool)
• Places funded from Asthma UK award

30
OK, wheres that nurse that works in the asthma
clinic?
Any Questions?