by Tori Hadaway, Community Children’s Specialist Asthma Nurse
Schools are a great way to provide group education about asthma and allergy; they form a safe, local environment where children and young people (CYP) are geared to learn important lessons. What better space to improve knowledge and awareness, empowering them to take responsibility for their own improved asthma control? Group sessions provide a convenient opportunity for clinical review and peer to peer support.
In the words of one of our young people, our aim was to “stop the monster days”.
What did we do?
We began by holding a listening exercise to discover what our CYP and their families wanted from their asthma service.
- A questionnaire was completed to quantify knowledge and understanding before and after the training session.
- An Asthma Control Test (ACT) questionnaire was used to screen for poor asthma control; this allowed targeted referral of those with low ACT into the Community Children’s Specialist Asthma Clinic for further assessment.
- Small group sessions proved optimal as this allowed responsiveness to the varying levels of professional support required by different children (some families could complete the ACT independently while others needed assistance to understand or translate).
- Children, parents and teachers were offered an interactive training session on asthma and allergy.
What did we find?
- In all I visited 10 schools across Tower Hamlets and delivered training to 287 CYP aged 4-11. While all parents were invited, only 93 attended, along with 23 staff members with a role supporting CYP with asthma and allergy.
- CYP and their families had poor perception of poor asthma symptoms: 30% had an ACT lower than 19 (indicates poor asthma control) and yet had not sought medical review in primary or secondary care.
- Only 68% had an annual asthma review, anecdotally due to a reluctance or under confidence in diagnosing children with asthma (especially the under 5s) in primary care.
- 62% of CYP had an a developmentally inappropriate spacer or else had a spacer that required replacement due to age or damage.
- 53% of CYP lacked an asthma management plan.
- Our team have since delivered training to support primary care asthma diagnosis and have developed guidance and an asthma toolkit to support asthma and wheeze management across North East London.
What did our patients think?
All participants gained experience in managing symptoms and would recommend the sessions. In their own words:
“This session helped me feel more confident in managing asthma”
“I understand more about my asthma”
“Now I know how to use my inhaler and keep my attacks under control”
“I liked that people are learning about asthma and how to manage it”
Pre- and post-session questionnaire data show a clear increase in understanding.
Combatting Week 38 and the shadow of Covid-19
COVID19 has changed the observed patterns of wheezing disease in children.
September will see the infamous week 38 in September, traditionally notable for peaks of hospitalisation for asthma and wheeze. The fact of lockdown means that many CYP will have been shielding for anywhere up to 6 months when they return to school in September; during this period we have seen a dramatic reduction in wheezing attendances compared to the same period in previous years, and we speculate that this results from a combination of improved treatment compliance, and reduced respiratory virus, exercise, aeroallergen and pollution exposure.
We anticipate a large spike in hospital attendances as these mitigations come to an end. While we believe that treatment compliance improved during lockdown, we know that some of our patients will wrongly take the resultant improvement in symptoms as a signal to relax preventer therapy, further exacerbating the week 38 symptom spike.
Families of wheezing children must absolutely continue to take their preventer treatment if they are to avoid falling foul of the week 38 effect!
COVID-19 has, by necessity, changed our ways of working and interacting with patients. We are making increased use of telemedicine, and as government restrictions on unnecessary congregation preclude revisiting the runaway success of our school-based group education sessions, we must rethink. Pertinent questions include:
- Can we leverage emerging technology in video conferencing to deliver education and asthma care in school and home settings?
- How do we address the inequalities ushered in by differential access to and comfort with these technologies?
- Will clinicians miss alternative and comorbid diagnoses in the absence of face to face review, how will this be prevented?
- We are open to any sensible ideas about how we can move forward in this area and will post new initiatives as they are developed.
 Most commonly a mask in child who should be using a mouthpiece device – no child over 5 years should use a masked spacer unless developmentally or anatomically unable to make a seal around a spacer mouthpiece, as doing so can reduce drug delivery and increase local steroid side effects.
 A plan was provided at the close of the session.