{"id":943,"date":"2013-03-17T13:10:47","date_gmt":"2013-03-17T13:10:47","guid":{"rendered":"http:\/\/uhwchildren.com\/general\/?page_id=943"},"modified":"2023-09-20T16:37:28","modified_gmt":"2023-09-20T16:37:28","slug":"difficult-asthma","status":"publish","type":"page","link":"https:\/\/www.uhwchildren.com\/respiratory\/difficult-asthma\/","title":{"rendered":"South Wales Difficult Asthma Service for children"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br \/>  <br \/><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n<p>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. .<\/p>\n<p>We provide the\u00a0<span style=\"color: #ff0000;\"><strong>difficult asthma service <\/strong><\/span>for South Wales &#8211; the detailed protocol involves a 4 day admission to hospital for intensive investigation and is outlined below.<\/p>\n<p>We run the <span style=\"color: #ff0000;\"><strong>All Wales Paediatric Respiratory Network,<\/strong><\/span> helping to standardise respiratory care across Wales.<\/p>\n<h4>\u00a0<\/h4>\n<p><em>Downloads:<\/em><br \/><a href=\"http:\/\/www.uhwchildren.com\/respiratory\/wp-content\/uploads\/2014\/10\/20120515_Difficult-asthma-protocol_RPM_final.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Difficult asthma protocol<\/a><br \/><a href=\"http:\/\/www.uhwchildren.com\/respiratory\/wp-content\/uploads\/2014\/10\/20111115_Difficult-Asthma-Home-Visit_RPM_final.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Difficult asthma nurse home-visit proforma<\/a><br \/><a href=\"http:\/\/www.uhwchildren.com\/respiratory\/wp-content\/uploads\/2014\/10\/20131107_difficult-asthma-admission-leaflet_final.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Difficult asthma admission leaflet<\/a><\/p>\n<p><strong>Summary<\/strong>. The difficult asthma protocol at The Children\u2019s 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.<\/p>\n<p><strong>Aims of protocol<\/strong><\/p>\n<p>\u2022 Exclude other diagnoses.<br \/>\u2022 Identify environmental, social and psychological contributions to disease.<br \/>\u2022 Clarify steroid responsiveness.<br \/>\u2022 Clearly identify those patients who may benefit from Omalizumab therapy.<\/p>\n<p><strong>Inclusion criteria<\/strong><\/p>\n<p>\u2022 Any child on maintenance systemic corticosteroids<br \/>\u2022 Poor control despite:<\/p>\n<p style=\"text-align: left; padding-left: 10px;\"><em>\u2022 Inhaled corticosteroids (&gt; 500mcg\/day fluticasone; &gt; 800 mcg\/day budesonide)<br \/>\u2022 LABA<br \/>\u2022 Failed trials or current treatment with Montelukast and\/or oral theophyllines<\/em><\/p>\n<p style=\"padding-left: 10px;\"><em><strong>Poor control of asthma is defined by any of the following:<\/strong><\/em><br \/><em>\u2022 Persistent symptoms (&gt;3 days\/week)<\/em><br \/><em>\u2022 FEV1 &lt;70% post-bronchodilator<\/em><br \/><em>\u2022 Repeated exacerbations (&gt;6\/year)<\/em><br \/><em>\u2022 Repeated severe exacerbations (&gt;2\/year)<\/em><\/p>\n<p><a href=\"#\"><em>top of page<\/em> <\/a><\/p>\n<p><span style=\"color: #ff0000;\"><strong>Stage 1: Background (nurse-led)<\/strong><\/span><br \/>\u2022 Background proforma<br \/>\u2022 Prescription check<br \/>\u2022 School check<br \/>\u2022 Home visit<br \/>\u2022 Lung function with reversibility testing (without exercise)<br \/>\u2022 CXR<br \/>\u2022 Asthma control test<\/p>\n<p><span style=\"color: #ff0000;\"><strong>Stage 2: Hospital admission<\/strong><\/span><\/p>\n<p><strong>Tuesday<\/strong><br \/>\u2022 Spirometry diary (twice\/day)<br \/>\u2022 FeNO<br \/>\u2022 Lung function with reversibility testing (without exercise)<br \/>\u2022 FBC, immunoglobulins, Vaccine responses, total IgE<br \/>\u2022 Specific IgE to cat, dog, horse, grasses, HDM, aspergillus, alternaria alternata, cladosporium<br \/>\u2022 Fungal and avian precipitins<br \/>\u2022 C3, C4, ANA, ANCA, RF, CRP, ESR, urine dipstick, blood pressure<br \/>\u2022 Nasal NO<br \/>\u2022 Asthma control test<\/p>\n<p><strong>Wednesday<\/strong><br \/>\u2022 Spirometry diary (twice\/day)<br \/>\u2022 Formal lung function, exercise test and reversibility testing (Paul Thomas, Llandough)<\/p>\n<p><strong>Thursday<\/strong><br \/>\u2022 Ward round with discharge planning<br \/>\u2022 Spirometry diary (twice\/day)<br \/>\u2022 Sweat test<br \/>\u2022 HRCT<\/p>\n<p><strong>Friday<\/strong><br \/>\u2022 Spirometry diary (twice\/day)<br \/>\u2022 Bronchoscopy (microbiology, AFB, cytology, viral PCR, lipid laden macrophages)<br \/>\u2022 IM Triamcinalone (single injection)<\/p>\n<p><span style=\"color: #ff0000;\"><strong>Stage 3: Assessment of steroid responsiveness<\/strong><\/span><\/p>\n<p><strong>Two week ward review (nurse-led)<\/strong><br \/>\u2022 Asthma control test<br \/>\u2022 Lung function with reversibility testing (without exercise)<br \/>\u2022 FeNO<\/p>\n<p><strong>Three week multidisciplinary difficult asthma meeting<\/strong><br \/>\u2022 Outcomes discussed and treatment interventions agreed<\/p>\n<p><strong>Four week clinic appointment (named consultant)<\/strong><br \/>\u2022 Asthma control test<br \/>\u2022 Lung function with reversibility testing (without exercise)<br \/>\u2022 FeNO<br \/>\u2022 Treatment options discussed with patient and parents<\/p>\n<p><span style=\"color: #ff0000;\"><strong>Treatment strategies<\/strong><\/span><\/p>\n<p><strong>Omalizumab<\/strong>. All eligible patients irrespective of any other findings should have a trial of therapy<br \/><strong>Fungal sensitization<\/strong>. 3 month trial of itraconazole, check home environment for fungal exposure.<br \/><strong>Steroid sensitive eosinophilic <\/strong>asthma, not eligible for omalizumab or failed trial. Long term daily or alternate day prednisolone with careful monitoring of side<br \/><strong>Steroid sensitive eosinophilic asthma, not eligible for omalizumab or failed trial with intolerable side effects<\/strong>. Steroid sparing agent (methotrexate or cyclosporin)<br \/><strong>Non-atopic asthma<\/strong> (persistently low FeNO, absence of eosinophils on BAL cytology). Consider alternative diagnosis and reassess investigations<br \/>Consider empirical treatments for post nasal drip and GORD<\/p>\n<p><a href=\"#\"><em>top of page<\/em> <\/a><\/p>\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>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\u00a0difficult asthma service for South Wales [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"nf_dc_page":"","footnotes":""},"class_list":["post-943","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/www.uhwchildren.com\/respiratory\/wp-json\/wp\/v2\/pages\/943","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.uhwchildren.com\/respiratory\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.uhwchildren.com\/respiratory\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.uhwchildren.com\/respiratory\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.uhwchildren.com\/respiratory\/wp-json\/wp\/v2\/comments?post=943"}],"version-history":[{"count":5,"href":"https:\/\/www.uhwchildren.com\/respiratory\/wp-json\/wp\/v2\/pages\/943\/revisions"}],"predecessor-version":[{"id":2640,"href":"https:\/\/www.uhwchildren.com\/respiratory\/wp-json\/wp\/v2\/pages\/943\/revisions\/2640"}],"wp:attachment":[{"href":"https:\/\/www.uhwchildren.com\/respiratory\/wp-json\/wp\/v2\/media?parent=943"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}