QuestionSBA
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This would only be indicated in an acute asthma attack, which is not the case here.
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Oral prednisolone
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In children whose asthma is not well controlled on salbutamol and a low dose inhaled corticosteroid and who cannot tolerate a MART regimen, it is recommended to start montelukast. 
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Add on montelukast
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In children whose asthma is not well controlled on salbutamol and a low dose inhaled corticosteroid, it is recommended to start montelukast. However, salbutamol should not be stopped as it is the mainstay of reliever therapy. Instead, salmeterol might be stopped if it does not appear to be working.
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Stop salbutamol and start montelukast
QuestionChoice
This boy has poorly controlled asthma on his current regime, as evidenced by his symptoms and need for reliever inhaler use more than three times a week. The next step would be to add montelukast as he has already not been able to tolerate a MART regimen.
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Switch to maintenance and reliever therapy (MART)
QuestionChoice
The patient is currently on a low dose of inhaled corticosteroids (100-200mcg). It would be more appropriate to trial combined maintenance and reliever therapy first before moving on to an increased dose of steroids.
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Increase beclometasone to 300mcg daily
QuestionComment
The answers for this are muddled? If he's not doing great on salmeterol and beclometasone (LABA + ICS) surely go for a MART. If the salmeterol is a typo and they mean salbutamol then you'd go for a LTRA like montelukast?
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I thought the same but the stem says "salButamol" and the answer is montelukast, just unlike the step up from a LABA you dont have to discontinue a SABA.
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Witzelsucht
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Wilsons Hematoma
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all wales national guidelines say to Step 2 of persistent asthma include management with  MART or LABA/ICS , so seeing as he has trailed the latter and it hasn't worked, it is reasonable to move to step 3 and commence trail of montelukast for 6 weeks, 10mg nocte ,
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Outpatient Embolism
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who writes this shite man
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HarryDM
Concept
Chapter
# Summary

Asthma is the commonest chronic condition in children in the UK, affecting 1 in 11 children. Diagnosis and management, although there are similarities with the adult pathways, have some important differences and vary between young children aged under 5 and those aged above 5. Under 5s are diagnosed clinically, whereas older children the first investigation to offer is FeNO testing. Management is holistic and involves regular reviews, reducing exposure to triggers and ensuring families have a personalised asthma plan with education on how to manage exacerbations. Pharmacological treatment involves a ladder of escalating inhaled medications, as well as considering leukotriene receptor antagonists (an oral medication) in some cases.

# Definition

Asthma is a common condition in children and young people which usually presents with a triad of wheeze, cough and shortness of breath. Symptoms are intermittent and occur in response to triggers, such as dust mites, viral respiratory infections, smoke or exercise. 

# Epidemiology

Asthma is the commonest chronic condition in childhood in the UK and affects 1 in 11 children. Unfortunately outcomes in the UK are some of the worst in Europe, with approximately 25-30 children per year dying of asthma. 90% of these deaths are thought to be preventable with better care and tackling the deprivation that contributes to poor outcomes. 

# Aetiology 

The characteristic intermittent bronchoconstriction that causes shortness of breath and wheezing can be caused by a variety of triggers, including:

- Air pollution
- Dust mites
- Viral respiratory tract infections
- Exercise
- Cold air
- Strong emotions 
- Medications (e.g. NSAIDs)
 
Children who have asthma often have other conditions caused by atopy (the tendency to produce an exaggerated IgE mediated response to benign triggers) including allergic rhinitis, eczema or food allergies. There may also be a family history of these conditions. 

Other risk factors for paediatric asthma include preterm birth, low birth weight and obesity in childhood. Environmental contributors to the development of asthma include air pollution, exposure to damp or mould in the home and exposure to secondhand smoke. 

# Signs and Symptoms

Examination may be normal in between exacerbations, or the following may be found:

- Widespread wheeze on auscultation
- Chest hyperinflation
- Signs of respiratory distress during an exacerbation, e.g. tachypnoea, accessory muscle usage

# Differential Diagnosis

- **Respiratory tract infection** - may present with wheeze, cough and difficulty breathing, often accompanied by fever, malaise and coryzal symptoms.
- **Cystic fibrosis** - lifelong symptoms, as well as respiratory manifestations would have gastrointestinal symptoms and failure to thrive.
- **Bronchopulmonary dysplasia** - chronic lung disease caused by prematurity, usually presents in babies who required ventilation for respiratory distress syndrome. Presents with respiratory distress and low oxygen saturations in infants, asthma-like symptoms can develop in childhood.
- **Bronchiectasis** - often follows severe lower respiratory tract infection, persistent productive cough with copious sputum.
- **Gastro-oesophageal reflux or aspiration** - can present with cough and wheeze due to irritation from gastric contents, may have vomiting and failure to thrive.
- **Foreign body inhalation** - may mimic asthma symptoms, acute onset and focal wheeze.
- **Bronchiolitis** - common infection in the under 2s caused by RSV, causes coryzal symptoms, fevers, cough, shortness of breath and wheeze.

# Investigations

Children under 5:

- In the under 5s, after a detailed history and examination a provisional diagnosis of asthma can be made and treatment initiated based on clinical judgement.
- This should be reviewed regularly and the diagnosis reconsidered if response to treatment is not as expected.

Children aged 5 and above:

- At the age of 5, investigations should be offered to aid in diagnosis. If children are unable to perform the tests, these should be offered every 6-12 months with treatment based on clinical impression in the meantime.
- The first investigation to offer is **FeNO testing** (fractional exhaled nitric oxide) which quantifies eosinophilic inflammation in the airways - if this is 35 parts per billion or more this is diagnostic of asthma.
- If this is not raised or FeNO testing is not available, offer **spirometry with bronchodilator reversibility** - if this finds reversible obstruction (FEV1 increase of 12% or more from baseline, or an increase 10% or more of the predicted normal FEV1) this is sufficient to diagnose asthma.
- If spirometry is delayed or not available, advise patients/families to measure peak flow twice daily for 2 weeks - variability over 20% is diagnostic of asthma.
- If all of FeNO, bronchodilator reversibility and peak flow variability are negative but asthma is still suspected, either take bloods for eosinophil count and total IgE level, or do skin prick testing to the house dust mite:
        - Negative skin prick testing or a normal total IgE level can be used to rule out asthma.
        - A raised IgE and eosinophil count or evidence of sensitisation on skin prick testing are diagnostic of asthma.
- Children in whom there is ongoing diagnostic uncertainty should be referred to specialist services for further investigations (e.g. a bronchial challenge test).

# Management

- All children and young people should have regular reviews in primary care (at least annually), with monitoring of asthma control using symptoms, peak flow or spirometry.
- Inhaler technique should be checked and all patients should have an up-to-date personalised asthma action plan with details of current treatments and instructions on what to do in case of an acute asthma exacerbation.
- Education of both children and caregivers on modifiable risk factors (such as smoke exposure, household chemicals and obesity) is also key.

## Under 5 years old

- For children with suspected asthma and either a history of severe asthma exacerbations or interval symptoms, consider a trial of a twice-daily paediatric low-dose inhaled corticosteroid (ICS) as maintenance therapy with a short-acting beta-2 agonist (SABA) reliever inhaler.
- If symptoms do not resolve, check adherence and inhaler technique, look for environmental triggers such as mould or smoke exposure, and review the diagnosis of asthma.
- Refer children who do not respond to treatment and where there is no clear explanation for this to specialist asthma services.
- If symptoms resolve with treatment, consider stopping inhalers after 8-12 weeks with a planned review of symptoms in 3 months time.
- If children respond to initial treatment but symptoms recur or they have a significant exacerbation (requiring hospital admission or oral steroids), restart treatment with an ICS and SABA.
- The ICS may be titrated up to a paediatric moderate dose if required.
- If this is not sufficient to control symptoms, the next step is a trial of a leukotriene receptor antagonist (LTRA) e.g. montelukast - this should be stopped if ineffective after 8-12 weeks.
- If asthma is still uncontrolled, children should then be referred to secondary care for further assessment.

## 5 to 11 years old

- As in the under 5s, a twice-daily paediatric low-dose inhaled corticosteroid (ICS) as maintenance therapy with a short-acting beta-2 agonist (SABA) reliever inhaler is the first step in management.
- If this does not control symptoms, there are two options to step up treatment:
        - A single maintenance and reliever therapy (MART) inhaler  may be started, which contains both a paediatric low-dose ICS and a fast-acting long-acting beta-2 agonist (LABA).
        - If the child isn't able to manage a MART regimen, the alternative is adding a LTRA and assessing response to this after 8-12 weeks.
- The next steps after this are respectively:        - Increasing the low-dose ICS in the MART to a moderate-dose ICS
        - Switching the low-dose ICS to a combination inhaler with a low-dose ICS with a LABA, as well as continuing the SABA +/- the LTRA if this was effective 
- For patients on a low-dose ICS//LABA inhaler + SABA +/- LTRA, this could then be increased to a moderate dose ICS if needed
- If asthma is not controlled at this stage, patients should be referred to specialist services - options include switching to a high dose ICS or adding another medication e.g. theophylline.

## 12 years or older

- Young people from the age of 12 should be managed as per the adult guidelines - please see the separate Asthma chapter for details

# NICE Guidelines

[Click here for the NICE Guidelines](https://www.nice.org.uk/guidance/ng245/)

# References

[RCPCH - State of Child Health](https://stateofchildhealth.rcpch.ac.uk/evidence/long-term-conditions/asthma)

[Asthma and Lung UK](https://www.asthmaandlung.org.uk/conditions/asthma/child)






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In children aged 5-11 whose asthma is uncontrolled while on salbutamol and low-dose ICS, if they are unable to tolerate MART therapy, montelukast (LTRA) should be trialled.
A 7-year-old boy attends his General Practitioner for a routine asthma review. His regular inhalers include salbutamol and beclometasone 200 micrograms (mcg) daily. He was previously unable to tolerate a MART regimen. He has been compliant with his inhalers but has been using his salbutamol inhaler every other day for the past two months due to wheezing. He is an active boy at school and plays sports; however his symptoms limit his exercise tolerance. 

Which of the following is the next best management for his asthma?
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