The paediatric respiratory service at UHW provides a comprehensive service for children with severe asthma. We follow all patients who have been admitted to PICU and take referrals for patients with severe asthma with refractory or multifactorial disease from secondary care colleagues from across South wales. .
We provide the difficult asthma service for South Wales – the detailed protocol involves a 4 day admission to hospital for intensive investigation and is outlined below.
We run the All Wales Paediatric Respiratory Network, helping to standardise respiratory care across Wales.
Downloads:
Difficult asthma protocol
Difficult asthma nurse home-visit proforma
Difficult asthma admission leaflet
Summary. The difficult asthma protocol at The Children’s Hospital for Wales is designed to structure appropriate investigation for children with asthma who have persistent symptoms despite significant treatment burden. It has been developed with reference to the Brompton paediatric difficult asthma protocol. The protocol is divided into 3 stages.
Aims of protocol
• Exclude other diagnoses.
• Identify environmental, social and psychological contributions to disease.
• Clarify steroid responsiveness.
• Clearly identify those patients who may benefit from Omalizumab therapy.
Inclusion criteria
• Any child on maintenance systemic corticosteroids
• Poor control despite:
• Inhaled corticosteroids (> 500mcg/day fluticasone; > 800 mcg/day budesonide)
• LABA
• Failed trials or current treatment with Montelukast and/or oral theophyllines
Poor control of asthma is defined by any of the following:
• Persistent symptoms (>3 days/week)
• FEV1 <70% post-bronchodilator
• Repeated exacerbations (>6/year)
• Repeated severe exacerbations (>2/year)
Stage 1: Background (nurse-led)
• Background proforma
• Prescription check
• School check
• Home visit
• Lung function with reversibility testing (without exercise)
• CXR
• Asthma control test
Stage 2: Hospital admission
Tuesday
• Spirometry diary (twice/day)
• FeNO
• Lung function with reversibility testing (without exercise)
• FBC, immunoglobulins, Vaccine responses, total IgE
• Specific IgE to cat, dog, horse, grasses, HDM, aspergillus, alternaria alternata, cladosporium
• Fungal and avian precipitins
• C3, C4, ANA, ANCA, RF, CRP, ESR, urine dipstick, blood pressure
• Nasal NO
• Asthma control test
Wednesday
• Spirometry diary (twice/day)
• Formal lung function, exercise test and reversibility testing (Paul Thomas, Llandough)
Thursday
• Ward round with discharge planning
• Spirometry diary (twice/day)
• Sweat test
• HRCT
Friday
• Spirometry diary (twice/day)
• Bronchoscopy (microbiology, AFB, cytology, viral PCR, lipid laden macrophages)
• IM Triamcinalone (single injection)
Stage 3: Assessment of steroid responsiveness
Two week ward review (nurse-led)
• Asthma control test
• Lung function with reversibility testing (without exercise)
• FeNO
Three week multidisciplinary difficult asthma meeting
• Outcomes discussed and treatment interventions agreed
Four week clinic appointment (named consultant)
• Asthma control test
• Lung function with reversibility testing (without exercise)
• FeNO
• Treatment options discussed with patient and parents
Treatment strategies
Omalizumab. All eligible patients irrespective of any other findings should have a trial of therapy
Fungal sensitization. 3 month trial of itraconazole, check home environment for fungal exposure.
Steroid sensitive eosinophilic asthma, not eligible for omalizumab or failed trial. Long term daily or alternate day prednisolone with careful monitoring of side
Steroid sensitive eosinophilic asthma, not eligible for omalizumab or failed trial with intolerable side effects. Steroid sparing agent (methotrexate or cyclosporin)
Non-atopic asthma (persistently low FeNO, absence of eosinophils on BAL cytology). Consider alternative diagnosis and reassess investigations
Consider empirical treatments for post nasal drip and GORD