Ask About Asthma – the four ‘Asks’
1. Get an asthma action plan in place
If a child has a personalised asthma action plan they are four times less likely to have an asthma attack that requires emergency hospital treatment. The plan should have information on triggers; what the medicines do (preventers and relievers); how and when to take treatment; current treatment; how to spot asthma getting worse (symptoms and peak expiratory flow); what treatment to take in an emergency; how and when to call for help and how to manage indoor and outdoor air pollution.
Parents should be encouraged to share their asthma action plan with their child’s school and any activity clubs that they regularly attend.
Resources
London Asthma Leadership and Implementation Group for CYP (LALIG) has produced a suite of Personalised Asthma Action Plans (PAAPs) for use across London. These have drop-down boxes so clinicians completing them can include the medication used and indicate the colour of the inhaler. In addition, there is a logic function around the peak flow highlighting when individual levels are too low and what action should be taken, in conjunction with symptoms.
Personalised Asthma Action Plans including for Maintenance and Reliever Therapy are accessible via the NHS Futures Platform or, others are available for example via Asthma + Lung UK.
PAAPs – London region Children and Young People’s Asthma – Futures
Your asthma action plan | Asthma + Lung UK
2. Understand how to use inhalers
Correct inhaler technique is essential to ensure that the prescribed medicine reaches the lungs. Children and young people should be shown how to use their own inhaler and asked to demonstrate their technique. Technique should be visually checked whenever an inhaler is prescribed or changed, at every asthma review and before treatment is increased.
Every time a CYP is prescribed an inhaler, check technique, the correct spacer and adherence. If a blue reliever or rescue inhaler is used, check that it is used alongside a preventer inhaler or as part of a combined Maintenance and Reliever Therapy (MART) or Anti-Inflammatory Reliever (AIR) regimen, where prescribed.
Resources
Asthma + Lung UK provides device-specific inhaler technique videos, including guidance on pMDIs, dry-powder inhalers and spacers with or without a face mask. Beat Asthma provides additional inhaler and spacer guidance designed for children, young people and families.
How to use your inhaler | Asthma + Lung UK
Managing my child’s asthma | Beat Asthma
3. Schedule an asthma review, every year and after every attack
Asthma Reviews
Asthma reviews should be undertaken annually and after every asthma attack. Reviews after an asthma attack are referred to as 48-hour reviews and often take place in primary or community care. Doing a thorough asthma review takes at least 20 minutes and should be a combination of clinical assessment and patient education.
The child’s personal asthma action plan should be reviewed with the child and family so that they understand what steps should be taken for their self management and inhaler technique should be visually checked.
It is important to conclude if it is asthma, if it is controlled and do I need to change management through asking the right questions and following the steps included in asthma review templates.
This article by Dr Mark Levy, published in the journal Practice Nurse, provides a helpful guide.
- ensure that the correct diagnosis has been made
- ensure the child is on the appropriate prescribing management step and it is clearly documented
- identify potential barriers and reasons for poorly controlled asthma: using an Asthma Control Test (ACT) see examples below
48-hour reviews
The NICE quality statement 4 (2018), NHS England’s National Bundle of Care for children and young people with asthma requires any child who has received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma, a follow up by their own GP practice within two working days of discharge.
This review allows an assessment of the patient as they recover from an exacerbation and to review if their background control is optimal. The 48 hours is in keeping with observations that the majority of these children will have been discharged with at least three days of oral steroids following their exacerbation.
Acute care should ensure that notification of a child’s presentation out of hours or in an emergency is sent to the primary care provider within 24 hours. Primary care need to ensure that there is a system in place to flag these summaries and to feedback to the acute care provider if this requirement is not met.
Example review templates are available via the NBC or via organisations such as Asthma and Lung UK which has produced some top tips.
Asthma reviews for children | Asthma + Lung UK
4.Consider air quality and its impact on lung health
Pollution in the air – both internal and external – can trigger asthma in people of all ages. The effect of external air pollution, from traffic fumes and other sources, has been recognised for some time and the UK Health Security Agency estimates that long-term exposure to man-made air pollution has an effect equivalent to 29,000-43,000 deaths every year. Awareness of the impact of poor internal air quality is also growing. This page includes resources to help families, schools, NHS and other organisations increase awareness of air pollution and reduce its negative effects.
The health effects of air pollution on asthma are described in this webinar and associated slides, recorded as part of the #AskAboutAsthma campaign in 2023.
London has high levels of air pollution due to traffic fumes and other sources of particulate matter. Outdoor air pollution acts as a trigger for many children and young people with asthma, contributing to emergency department attendance and intensive care admissions.
On days when pollution levels are high, people with asthma should avoid areas with heavy motor traffic, especially at rush hour. They should keep windows closed and avoid physical activity in high traffic areas. Pollution levels are usually higher in the evenings, when it’s humid or cold, and when there are high winds or atmospheric changes.
Tower Hamlets and Global Action Plan have produced this short video to help empower health professionals to talk about air pollution with their young asthma patients and families.
You can check pollution levels using airText or the DEFRA website.
Evidence of the impact of air pollution on health and ways to address it
Committee on the Medical Effects of Air Pollutants: COMEAP advises on all matters concerning the health effects of air pollutants. This page contains useful facts and figures.
Pollution evidence review: Public Health England (now the UK Health Security Agency, UKHSA) published a review of evidence on how to improve air quality in the UK in March 2019. It includes advice for local and national government on actions to improve outdoor air quality and health.
Indoor air pollution can have a significant effect on health, particularly in people with lung conditions. Particulate matter from gas boilers, indoor fires, stoves, candles, chemical cleaners and air fresheners can exacerbate or trigger asthma. Evidence of the impact of internal damp and mould is also growing.
This 2020 Inside Story Report from the Royal College of Paediatrics and Child Health highlights the health effects of indoor air quality on children and young people.
Housing, damp and mould
New government guidance outlining the legal standards on damp and mould for landlords, as well as advice for tenants, can be found here: Understanding and addressing the health risks of damp and mould in the home
In 2020, NICE produced a set of actions on improving indoor air pollution aimed at healthcare professionals, local authorities and builders/architects.
The Asthma + Lung website includes a set of tips for families on improving indoor air quality.
A checklist and associated resources for health visitors and other healthcare professional who visit patients’ homes, compiled by the Office for Health Improvement and Disparities (OHID), UKHSA and the NHS can be found here.
These housing letter templates are designed to support clinicians and others who are concerned that their patients’ health is suffering due to housing issues, to raise these issues with landlords. They can be adapted by local organisations and edited to reflect specific concerns.
- North East London letter to housing association/landlord 1, from local asthma leadership team.
- North East London housing support letter to landlord 2
- North East London letter to housing association/landlord 3, specialist asthma nurse
- Evelina letter to housing officer/association
This report describes the Impact of the initial Ultra Low Emission Zone (ULEZ) expansion on air pollution; information on the impact of lower speeds on air pollution can be found here.
CHILL (Children’s Health in London and Luton): CHILL is a cohort study funded by the NIHR Public Health Research Programme. It will determine whether reducing air pollution from traffic improves lung growth and respiratory health in primary school children.
Vaping
An NHS survey from 2021 indicated that vaping had increased to 9% among children and young people, representing a rise of 50% from 2018. Around 1 in 5 (21%) 15-year-old girls were classified as current e-cigarette users. Additional research has found that young people who vape are also more likely to start smoking.
Vaping is not recommended for children and young people, whose developing lungs and brains are more sensitive to its effects. It may be a useful tool to help adults stop smoking, but it is not harmless. This podcast, recorded for #AskAboutAsthma in 2023, describes the risks and discusses why vaping is so popular among young people currently. This short video outlines the areas of most concern to paediatricians about this trend.
Vaping exposes users to toxins, and we do not yet know what the risks might be in the longer term. It took many years to fully describe the links between smoking and lung cancer – which are so widely accepted today.
Most vapes contain nicotine, an addictive substance that can be hard to stop using. Nicotine is riskier for young people than for adults, as evidence suggests the developing brain is more sensitive to its addictive effects.
In the UK, it is against the law to sell nicotine vaping products to under-18s or for adults to buy them on their behalf.
More information from the NHS can be found here: Young people and vaping – Better Health – NHS (www.nhs.uk) and you can also find advice on the FRANK website. Resources about the risks of vaping for young people, developed by Smokefree Sheffield and ASH for families and schools, can be found here.
These leaflets (original and easy read), created by the London Boroughs of Camden and Islington, and two (original and easy read) by BEAT asthma may also be helpful.
Smoking
The risks of smoking are well documented. Second hand (passive) smoking is a trigger for asthma and increases people’s risk of getting the same health conditions as smokers. Babies and children are particularly vulnerable to the effects of second- and third-hand smoke (third-hand smoking is when a child breathes in the chemicals that remain on clothes, hair and skin even if an adult has smoked outside the home). A child who is exposed to passive smoke is at increased risk of developing chest infections, meningitis, a persistent cough and, if they have asthma, their symptoms will get worse.
North East London has developed smoking cessation advice and information for parents of asthmatic children. This letter can be adapted by other areas to include locally relevant information.
Children and young people may smoke themselves. Current smoking prevalence (including occasional and regular smoking) among children and young people was 6% in 2022, compared with 4.1% in 2021 and 6.7% in 2020 (source: ASH-Youth Survey, 2022, cited here).
NHS advice on smoking cessation can be found here. Note: the use of vapes or e-cigarettes is not for anyone aged under 18.
A Clinical Knowledge Summary from NICE on smoking cessation advice to 12-17-year-olds can be found here.
Hospital trusts
NHS organisations cover some of the largest estates, with one of the greatest workforces, in London. They hold contracts worth millions of pounds with companies providing diverse goods and services. They are a major player in the local economy.
Because of their size, hospital Trusts and other NHS organisations contribute to London’s air pollution in any given local area. But their size could also be part of the solution, both through actions and expectations of the companies that supply them.
Global Action Plan’s Clean Air Hospital Framework can be used to develop a clean air action plan for Trusts to improve air quality. The framework allows organisations to self-assess progress and set ambitions on tackling air pollution in several key areas.
Additional resources
Air pollution training from North East London. Aimed at healthcare professionals, this short presentation from Dr Rachel Parker describes the impact of internal and external air pollution on health and how GPs and others can advise and support their patients. Supporting evidence can be found here.
Impact of inhalers. London’s Children and Young People’s Asthma Pharmacy Group, a subgroup of the London Asthma Leadership and Implementation Group, have developed a leaflet on inhalers and the green agenda for professionals: Top tips for professionals in greener respiratory prescribing, available in A3 and A4 format.
For more in-depth information on air pollution and asthma for healthcare professionals, see videos from experts in this field, Professor Jonathan Grigg and Professor Stephen Holgate. Additional online content, recorded for #AskAboutAsthma, can be found here.
These slides, developed by the North Central London Child Death Overview Panel, describe the risks of air pollution for people with asthma and the scale of the problem.
Families can sign up for free air pollution messages via text or email. This includes forecasts for Greater London, including air quality, UV, pollen and temperature.
This video, aimed at CYP and their families, has been produced by North Central London. It describes what air pollution is and how to limit exposure it, alongside tips for good asthma management. It is available with captions in Arabic, Bengali, Polish, Somali, Turkish and Spanish as well as English. On the same page, you can find a poster, patient information leaflet and other resources.
This video outlines potential indoor triggers for asthma, with useful information to help families address them.
This short video – available with and without captions – also describes five simple actions that families can take to reduce their exposure to air pollution.
Impact of inhalers. London’s Children and Young People’s Asthma Pharmacy Group, a subgroup of the London Asthma Leadership and Implementation Group, have developed two patient information leaflets on inhalers and the green agenda. These detail what young asthma patients and their families can do to protect the environment and how professionals can inform themselves and advise their patients in relation to the environmental impact of inhalers:
Internal and external air pollution at school can affect children’s health and wellbeing. Research from the Technical University of Denmark found that improving air quality within schools improves children’s concentration levels as well as reducing various health issues such as headache and eye irritation.
Schools can sign up to receive free air pollution messages via text or email. This includes air pollution forecasts for Greater London, plus UV, pollen and temperature. On high pollution days, schools may wish to suggest that parents walking their children to school avoid busy roads, for example, or remind those with asthma to carry their preventer inhalers.
Global Action Plan’s London Schools Pollution Helpdesk offers free guidance and advice to help staff and students improve air quality inside and outside schools. Schools can create their own Clean Air Action Plan using the Clean Air for Schools Framework and there are educational resources to help children and young people understand air pollution and how they can tackle it.
Tackling Air Pollution at School (TAPAS). The TAPAS Network is a collaboration of stakeholders from academia, education, public policy, civil society and business. It aims to improve air quality within schools through sharing research and innovation. Schools can sign up to receive updates and invitations to online educational events.
Please see this video on how schools can build a Corsi Rosenthal box to help with indoor air pollution. In addition, schools can download this report on mitigating exposure to traffic pollution in and around schools.