Bronchial Asthma Management in Children

Table 3. Recommendations
A.    Diagnosis and management of asthma in children 5 years and younger Q1. For children 5years&younger What is the best practice in the diagnostic criteria of asthma?
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
1.a	- Is there clinical assessment for probability of asthma in children 5 years and younger	Canadian thoracic society 2021                                               Japanese 2020	Clinical assessment to assess for the initial probability of asthma is based on: • a history of recurrent episodes (3 attacks) of wheeze, cough, breathlessness and chest tightness that vary over time • recorded observation of wheeze heard by a healthcare professional • personal/family history of other atopic conditions (in particular, atopic eczema/dermatitis, allergic rhinitis) • no symptoms/signs to suggest alternative diagnoses.       Symptom improvement can be observed after beta-2 agonist inhalation.	intermediate                                   intermediate	Strong                                 strong                (GPS)
1.b	Is assessing clinical improvement after using regular low-dose inhaled corticosteroids (ICS) and as-needed SABA within 2–3 months’ support diagnosis of asthma in children 5 years and younger?	GINA 2024	A trial of treatment for at least 2–3 months with as-needed SABA and regular low-dose ICS may provide some guidance about the diagnosis of asthma. Marked clinical improvement during treatment, and deterioration when treatment is stopped, support a diagnosis of asthma.	Very low	Weak (conditional)
1.c	Is chest X-ray indicated for diagnosis of asthma?	GINA 2024	Chest X-ray Radiographs are rarely indicated; except, if there is doubt about the diagnosis of asthma help to exclude other diagnoses.		GPS
Q2. For children aged 5 years and younger: What is the best practice for assessing asthma severity?
2	How to assess pulmonary function in children 5 years and younger?	GINA 2024	Due to the inability of most children 5 years and younger to perform reproducible expiratory maneuvers, lung function testing, do not have a major role in the diagnosis of asthma at this age. However, by 5 years of age, many children are capable of performing reproducible spirometry if coached by an experienced technician and with visual incentives		GPS
	Q3- For children aged 5 years and younger: What is the best practice for the initial asthma management based on asthma severity?
3.a	Which children should be initiated on regular low dose ICS as controller treatment?	GINA 2024	If symptoms pattern is consistent with asthma, and asthma symptoms are not well controlled, or > 3 exacerbations per year.	Very low	Weak (conditional)
		GINA 2024	If symptoms pattern is not consistent with asthma but wheezing episodes requiring SABA occur frequently e.g > 3 per year. Give diagnostic trial for 3 months	Very low	Weak (conditional)
3.b	When to use double low dose ICS as controller therapy in children 5 years and younger	GINA 2024	Doubling the initial low dose of ICS may be the best option if asthma is not well controlled on low dose ICS after checking inhaler technique and adherence	Low	Weak (conditional)
3.c	What is the role of LTRA in asthma management?	Japanese 2020	LTRA can be added to ICS for children whose asthma is not controlled well with ICS alone.	low	Weak (conditional)
3.d	Can we use LABA in the management of asthma in children  5 years and younger?	GINA 2024	There are insufficient data about the efficacy and safety of ICS in combination with a long-acting beta2 agonist (LABA) in children <4 years old to recommend their use.		GPS
3.e	How often should a child be reviewed after initial treatment to review response and adjust treatment?	GINA 2024	-Assessment at every visit (every 2-3 months) should include asthma symptom control and risk factors and side-effects.  -If therapy is stepped-down or discontinued, schedule a follow-up visit 3–6 weeks later to check whether symptoms have recurred, as therapy may need to be stepped-up or reinstituted   The child’s height should be measured every year, or more often.	Very low                                     Very low	Weak (conditional)                                   Weak (conditional)
	For children aged 5 years and younger:  when to refer to asthma specialist	GINA 2024	The child should be referred for expert assessment if symptom control remains poor and/or flare-ups persist, or if side-effects of treatment are observed or suspected	low	Weak (conditional)
3.f	4- Is self-management education, including a written personalized asthma action plan should be offered to parents of children 5 years and younger?	British 2019	All people with asthma (and/or their parents or carers) should be offered self-management education, which should include a written personalized asthma action plan and be supported by regular professional review.	High	Strong

➡️Evidence to recommendations: Considerations

The GDG was guided by the results of the AGREE II appraisals of the eligible CPGs and thoroughly reviewed the recommendations of the original sources of appraised Guidelines CPGs in consideration of local contextual factors related to the national Egyptian health system like burden of the disease, equity, acceptability, feasibility, and other relevant factors. The GDG decided through an informal consensus process to adopt most recommendations however, there was a need to change the strength of 2 recommendations (B2 and B3) as they lack feasibility. Also, GDG develops group of good practice statements to improve acceptability and feasibility.

➡️Implementation considerations

To improve Asthma care and patient outcome, evidence-based recommendations must not only be developed, but also disseminated and implemented at national and local levels and integrated into clinical practice.

Dissemination involves educating related healthcare providers to improve their awareness, knowledge and understanding of the guideline’s recommendations. It is one part of implementation, which involved translation of evidence-based guidelines into real life practice with improvement of health outcomes for the patients.

Implementation requires an evidence-based strategy involving professional groups and stakeholders and should consider the local cultural and socioeconomic conditions. Cost-effectiveness of implementation programs should be assessed.

Specific steps need to be followed before clinical practice recommendations can be integrated into local clinical practice, particularly in low resource settings.

Steps of implementing bronchial asthma diagnosis, treatment, and prevention strategies into the Egyptian health system:

1.  Develop a multidisciplinary working group.

2.  Assess the status of asthma care delivery, care gaps and current needs.

3. Select the material to be implemented, agree on the main goals, identify the key recommendations for diagnosis, treatment and prevention and adapt them to the local context or environment.

4. Identify barriers to, and facilitators of implementation.

5. Select an implementation framework and its component strategies.

6. Develop a step-by-step implementation plan:

▪️  Select the target populations and evaluate the outcome.

▪️  Identify the local resources to support the implementation.

▪️ Set timelines.

▪️   Distribute the tasks to the members.

▪️Evaluate the outcomes.

7. Continuously review the progress and results to determine if the strategy requires modification.

Guideline implementation strategies will focus on the following: -

1.  For Practitioners

▪️  Educational meetings: conferences, lectures, workshops, grand rounds, seminars, and symposia.

▪️  Educational materials: printed or electronic information (software).

▪️   Web-based education: computer-based educational activities.

▪️  A trained person meets with providers in their practice setting to provide information with the intention of changing the provider’s practice. The information may include feedback on the performance of the provider(s).

▪️  Reminders: the provision of information verbally, on papers or on a computer screen to prompt a health professional to recall information or to perform or avoid a particular action related to patient care.

▪️ Optimize professional-patient interactions, through mass media campaigns, reminders, and education materials.

▪️ Practice tools: tools designed to facilitate behavioral/practice changes, e.g., flow charts.

2. For Patients and care givers

▪️   Patient education materials (Arabic booklet): Printed/electronic information aimed at the patient/consumer, family, caregivers, etc.

▪️Reminders: the provision of information verbally, on papers or electronically to remind a patient/consumer to perform a particular health-related behaviors.

▪️  Mass media campaigns.

3.  For Nurses

▪️Educational meetings: lectures, workshops or traineeships, seminars, and symposia.

▪️  Educational materials: printed.

▪️ A trained person meets with nurses in their practice setting to provide information with the intention of changing the provider’s practice.

▪️  Reminders: the provision of information verbally, on paper or on a computer screen to prompt them to recall information or to perform or avoid a particular action related to patient care.

▪️   Practice tools: tools designed to facilitate behavioral/practice changes.

4. For Stakeholders

Plans have been made to contact with all the health sectors in Egypt including all sectors of the Ministry of Health and Population, University Hospitals, Ministry of Interior, Ministry of Defense, Non-Governmental Organizations, Private sector, and all Health Care Facilities.

▪️   Information and communication technology: Electronic decision support, order sets, care maps, electronic health records, office-based personal digital assistants, etc.

▪️ Any summary of clinical provision of health care over a specified period may include recommendations for clinical action. The information is obtained from medical records, databases, or observations by patients. Summary may be targeted at the individual practitioner or the organization.

▪️  Administrative policies and procedures.

▪️  Formularies: Drug safety programs, electronic medication administration records.

5. Other activities to assist the implementation of the adapted guideline’s recommendations include:

▪️  International initiative: Dissemination of the presented adapted CPG internationally via sending the final adapted CPG to the Guidelines International Network (GIN) Adaptation Working Group and contacting the CPG developers.

▪️  Gantt chart has been designed to manage the dissemination and implementation stages for the adapted CPG over an accurate time frame (Appendix).

➡️Implementation Tools

Educational materials based on this Adapted CPG for treatment of asthma in children have been made available in several forms including:

1. Manual for physician for diagnosis and algorithm for management of bronchial asthma

2. Arabic Educational materials for nurses and mothers

https://www.magonlinelibrary.com/doi/abs/10.12968/bjsn.2016

1-     MDI without spacer

2-     MDI with spacer

https://www.saintlukeskc.org

3- How to use a DPI ?

https://www.saintlukeskc.org

4-Nebulizer   

https://bluefishmd.com2017