In the UK, approximately 1.1 million children are being treated for asthma, two thirds of school-aged pupils with asthma will have an asthma attack in school and almost 70 children are admitted to hospital each day because of asthma, with 21 deaths in children aged 0–14 years recorded in 2012.
The Royal College of Physicians report ‘Why asthma still kills: The National Review of Asthma Deaths (NRAD)’, published in May 2014, highlighted that in children, poor perception by healthcare professionals of the risk of adverse outcomes was found to be an important avoidable factor in 70% of the deaths that were investigated, as well as poor prescribing practice, lack of a structured asthma review with a specialist and lack of a personal asthma action plan.
Looking at these statistics, it was obvious to me that the way we have managed asthma in children and young people up until now has not been working. South Pembrokeshire Cluster in Wales, where I work as a respiratory pharmacist, had identified a population need in this area and were keen to work in collaboration with other agencies and organisations to address it.
There could be many reasons for this poor care: a common low expectation of living with asthma; a poor standard of asthma reviews; conflicting guidelines; and a tendency to talk to the parent, rather than engage with the child and empower them with the knowledge and skills to safely manage their own life-long condition. I know I have been guilty of this last point in the past.
I also wonder if children ‘medicalise’ each visit to a surgery. This is the place they attend to have injections or when they feel unwell — do they find it difficult to separate out the long-term management of a condition when they are feeling well?
With my teaching background, I know that primary schools are a setting where children of all ages are used to engaging with adults in open, two-way conversations in an environment conducive to learning. So, I felt it was the perfect place to have a child-centred consultation.
The NRAD report recommends that parents, children, and those who care for or teach them should be educated about managing asthma, emphasising the ‘how’, ‘why’ and ‘when’ children should use their asthma medications, recognising when asthma is not controlled, and knowing when and how to seek emergency advice.
Following these recommendations, I contacted the primary schools near the surgeries I worked in. Neyland Community School was particularly keen for me to pilot a project with it. I held educational sessions with the school staff and the parents of all children with an asthma diagnosis or a reliever inhaler, before holding a consultation in the school with each of these pupils, with a parent present. During this consultation, I had remote read/write access to the patient’s surgery patient medical record and, in addition to writing my consultation in the notes, I was able to change treatment and issue prescriptions where required.
The consultation concentrated on:
- Diagnosis — not all who wheeze have asthma;
- Education, education, education for pupil and parent on:
- Asthma pathophysiology;
- Action and use of medication;
- Inhaler technique and importance of adherence;
- Worsening symptom management.
- Treatment according to guidelines;
- Treatment of other atopy, eczema, allergic rhinitis, simple allergies;
- All pupils were issued with asthma action plans, both paper and digital;
- The school was issued with a worsening symptom management plan for each pupil.
I followed up all pupils at least once at the school between four and six weeks after the consultation.
At the initial consultation, I found that many pupils and parents were unclear about their diagnosis and there was poor understanding of the pathophysiology of asthma and the action and use of asthma medication. None of the pupils had an asthma action plan, and repeated A&E attendance without follow-up was common.
Owing to COVID-19 and this being a trial of concept, my initial cohort only comprised ten pupils, but the results were encouraging. In this cohort, following the consultation, there was increased diagnostic certainty, no unscheduled care visits, school attendance improved, participation in sports increased and quality of life appeared to improve (assessed by way of the Childhood Asthma Control Test).
It would be unwise to read too much into this small sample but, in the past three months, I have seen more pupils in the school and the results have been similar. This leads me to conclude that conducting an asthma review in school allows the child to play a bigger part in the review and, with appropriate treatment and education, their asthma management improves.
The method of review has evolved throughout the course of the project, and involving the staff and parents enables them to identify worsening asthma symptoms and either flag for review or take appropriate immediate action.
One resource I massively advocate for is the NHS Wales ‘Asthmahub for Parents’ app. In the trial, I encouraged all parents to download it as it contains a great deal of information from a trusted source that supported all I had talked about. It also contains a digital asthma action plan that aids in the management of worsening asthma symptoms.
What I’ve done is really no more than the fundamentals of asthma care, but the environment in which I’ve done it appears to hit home with school staff, parents and, most importantly, the children who have a life-long, variable but, ultimately, eminently manageable condition.
The plan for the project now is to scale up and roll out across the 52 primary schools in Pembrokeshire, with the aim of linking with GP practices and working alongside, and upskilling, existing surgery staff.
Dave Edwards, respiratory pharmacist for South Pembrokeshire Cluster, Hywel Dda University Health Board, Wales