Week 38 (generally falling in mid-September) tends to be regarded as the week when the highest number of children are admitted to local accident and emergency (A&E) departments due to asthma exacerbations.
There are a number of reasons why this happens, consisting of a mix of change of routine, environmental changes and factors affecting asthma self-management:
- Children's routine for taking their preventer inhaler regularly is disrupted during the school holidays
- Build up of dust in unused classrooms
- Use of strong chemical cleaning products prior to school reopening
- Spread of common upper respiratory tract infections in schools
- High levels of pollens and spores causing hay fever and asthma exacerbations
- Stress and/or excitement of returning to school
- Potential increase in air pollution caused by traffic.
Will back to school be different this year?
Back to school planning in 2021 may be hampered by a primary care system facing a backlog of care, plus a patient population who may be reluctant to access care. According to surveys by Asthma UK (2020), 27.5% of people with asthma have been avoiding or delaying receiving asthma care from their GP. Just over 60% of asthma patients said it was because they ‘didn't want to over-burden health services’, with 61.4% saying that they didn't think it was safe to use health services. Whether this has changed as society is now opening up again is hard to know.
Unsurprisingly, therefore, 5% fewer patients with asthma, according to Asthma UK's annual survey (2020), have had an annual review across all 4 nations of the UK, reversing an 8-year improvement trend. This means that some children returning to school may be doing so without support from a health professional.
Just under 35% of respondents to the Asthma UK survey had received the basic components of asthma care: an annual asthma review, an inhaler technique check and a written asthma action plan. Asthma UK cites the transition to remote working practices as a factor:
‘..our research found that the quality of care provided remotely did not always match that provided in a face-to-face setting, and that people with asthma did not always think that they received the same quality of care remotely.’
General practice nurse (GPN) responses on social media contrast this with reports of being able to conduct reviews with young adults in particular more easily, revealing and improving poor control (Henry, 2020).
A second significant factor in the 2021 back-to-school season comes from a report from national experts warning of rises in respiratory infections such as influenza and respiratory syncytial virus (RSV). The Academy of Medical Sciences (AMS) released a report in July, compiled by a panel of experts, warning not only of the rise in coronavirus infections and the possibility of multiple variants, but also of a surge of typical winter infections such as RSV, bronchiolitis, parainfluenza and rhinovirus (AMS, 2021). The AMS warns that respiratory infections such as SARS-CoV-2 and other respiratory viruses could potentially interact to increase disease severity.
The implications for GPNs at the moment are unclear, but continuing with primary and booster vaccinations for COVID-19, encouraging influenza vaccination in both parents/grandparents and children, encouraging concordance with personal asthma action plans (PAAPs) and prioritising good hygiene measures at home and at school are clear top priorities.
The AMS report (2021) recommends that government continues to provide additional funding to support primary care this winter and to consider pausing non-urgent, non-clinical work such as Care Quality Commission (CQC) inspections.
Preventing back-to-school asthma exacerbations
Because of the pressures on primary care, GPNs may want to conduct an audit of the children on their asthma register to prioritise those who present with ‘red flags’ (see Box 1) by working with IT leads.
Box 1.Actions to avoid back to school exacerbations in primary care
- Conduct annual reviews on ‘red flagged‘ groups (Primary Care Respiratory Society (PCRS), 2021)
- Using ≥4 reliever inhalers in the past year
- Requiring <60% prescribed maintenance therapy in the past year
- Requiring ≥2 courses of oral steroids in the last year
- Eosinophil count >400
- Been to A&E or out of hours care at all in the last year
- Seen by the ambulance service at all in the last year
- Admitted to acute hospital care at all in the last year
- Prioritise schoolchildren with uncontrolled asthma for face-to-face consultations (Asthma UK, N.D.)
- Introduce video-based groups consultations to deliver education and offer peer support in a resource-efficient way (see resources section)
- Encourage families to access structured medication reviews, inhaler technique checks and asthma reviews in community pharmacy (PCRS, 2021)
- Offer ‘Very Brief Advice’ (National Centre for Smoking Cessation and Training – see resources section) at every opportunity to parents and young people who smoke
- Consider the use of maintenance and reliever therapy (MART) as an option in children over 12 years who have a history of asthma attacks despite medium-dose inhaled corticosteroids (ICS) or combination ICS/long-acting beta agonists. The self-management instructions for MART must be clear to the child and parent (PCRS, 2020)
It should be born in mind during prioritisation that a health inequalities gap exists in asthma care. Those families on low income and/or facing social disadvantage are likely to have the poorest care and have the worst health outcomes for their asthma (Asthma UK, 2020; 2021).
Children and young people may be reviewed either by arranging a review if they present with a ‘red flag’ (Box 1) or opportunistically. National guidance is available to enable asthma consultations to be conducted remotely (Henry, 2021).
Consultations must include a:
- Check of inhaler technique
- Valid and reliable child asthma control test
- Review or supply a personal asthma action plan (PAAP).
Box 2 provides advice that GPNs can offer to parents of children returning to school to help reduce the risk of exacerbations.
Box 2.Advice for GPNs to offer to parents
- Keep a regular eye on your child's inhaler technique – watch videos on Asthma UK website (see resources section)
- Supply the school with a copy of the child's personal asthma action plan
- For primary school-aged children, supply the school with a reliever inhaler and spacer in original packaging showing the child's name and prescription, to be kept in the classroom
- Encourage a child in Year 6 to start being responsible for their own care, in preparation for secondary school where they are able to carry/administer their own medications
- Encourage a child in secondary school to tell someone if they have had to use their reliever so staff are aware of signs of poor control (using relievers 3 or more times a week) and can alert the parent
- Tell the school about any changes in your child's health that they should be aware of
- If a child in secondary school wants to move from using a spacer to another device, come to see the GPN to discuss suitable devices
- Keep spacers and inhalers in cotton or material bags to avoid the build up of static charge that can affect administration
- Start hay fever medications two weeks before they know the child starts having symptoms
- Contact the practice for a review if the child needs their reliever more than 3 times a week, wakes with asthma at night or asthma symptoms interfere with daily activities
- Regular exercise, including walking, cycling or scooting to school can reduce both asthma symptoms and air pollution
- Consent to influenza vaccination, unless contraindicated
Asthma UK online; Royal College of Paediatrics and Child Heath, 2018
Box 3.Latest COVID-19 clinical guidance for childrenThe Joint Committee on Vaccination and Immunisation (JCVI) has advised that young people aged 12 to 15 across the UK at an increased risk of coronavirus (COVID-19) should be offered the Pfizer/BioNTech vaccine. This includes children and young people with (NHS England, 2021a; NHS Inform, 2021):
- Severe neuro-disabilities
- Down's syndrome
- Underlying conditions resulting in immunosuppression, such as severe asthma
- A diagnosis of learning/intellectual disability
The JCVI also recommends that those aged 12 to 15 who live with someone who is immunosuppressed should also be offered the vaccine.In mid-August, practices were required to run local searches to identify any children aged 12-15 who are eligible for COVID vaccination (NHS England, 2021a).16 and 17 year olds can now get their first dose of the COVID-19 vaccine. They'll be contacted and invited by the NHS but cannot book online (NHS England, 2021b; Swansea Bay University Health Board, 2021)
Conclusion
Autumn 2021 will perhaps be the most challenging of all for GPNs, as they prepare children with asthma for school. Not only do medication routines need re-establishing but the risk of exacerbation due to respiratory infection is predicted to be increased. Prioritising the most at risk and smart working, using remote and group consultations, may help to balance workload with patient benefit.
Resources
- Inhaler technique videos from Asthma UK: https://www.asthma.org.uk/advice/inhaler-videos
- Evidence and training on group consultations: https://www.networks.nhs.uk/nhs-networks/releasing-capacity-in-general-practice/documents/2-4-group-consultations-evidence-summary-elc
- National Centre for Smoking Cessation and Training. Very Brief Advice (VBA) training: https://www.ncsct.co.uk/publication_very-brief-advice.php
- NHS Go is a confidential health advice and information service for 16-25 year olds: https://nhsgo.uk/
- Schools COVID-19 operational guidance: https://www.gov.uk/government/publications/actions-for-schools-during-the-coronavirus-outbreak/schools-covid-19-operational-guidance
KEY POINTS
- The 2021 back-to-school season presents a greater challenge this year due to the backlog in routine asthma care plus the threat of further respiratory infections
- General practice nurses can stratify their child asthma register to search for and review those children at increased risk of exacerbation
- To maximise effectiveness and efficiency, consultations can be proactive or opportunistic, face-to-face or remote, one to one or in groups
CPD reflective practice
- Why are children and young people more at risk of asthma exacerbations during the back-to-school period?
- How could you advise parents and children to help minimise this risk of exacerbations?
- Will this article change your clinical practice? If so, how?