Asthma is defined as a chronic inflammatory disorder of the airways associated with an increase in airway hyper-responsiveness that leads to one or more symptoms of breathlessness, wheeze, cough and/or chest tightness; particularly at night. These symptoms can vary in severity, frequency and duration. When treated appropriately, the occurrence of these symptoms can be avoided and asthma can be well controlled (Masoli et al, 2004; Global Initative for Asthma [GINA], 2019). Symptoms of asthma are often reversible, either spontaneously or with treatment (Masoli et al, 2004; GINA, 2019).
Asthma is one of the most common long-term conditions in the UK, affecting both adults and children. Asthma prevalence, related mortality and health-care utilisation in the UK are estimated to be among the highest in the world (Nwaru et al, 2015). With approximately 1.1 million children being treated (1 in 11) (Asthma UK, 2019), asthma continues to be a burden on the NHS, especially in the weeks after the summer holidays. A seasonal peak in asthma attacks has been consistently demonstrated following the summer school holiday, and this is in line with the start of the autumn term.
Children with asthma are up to three times more likely to need medical help in September compared to any other time of the year, accounting for 20–25% of all asthma attacks requiring hospitalisation (Bundle et al, 2019). In 2018, there were a total of 25 128 recorded cases of children (under 16 years) going to hospital with asthma, with 6000 of these occurring between August and September (NHS England, 2019). A recent analysis published by Public Health England has also found that GP appointments for children with asthma increase in September (NHS England, 2019). Other countries have also identified a similar peak in asthma attacks: in February following the long summer break in Australia; 2–3 weeks after the start of the autumn term in Canada; and 2 weeks earlier in Scotland compared to England, in line with the Scottish autumn term (NHS England, 2019). Evidence, therefore, does suggest a significant association with the return to school and the increased risk of asthma attacks in children under the age of 16 years (Bundle et al, 2019).
Asthma symptoms are triggered by a variety of factors including environmental challenges, such as pollution, physical activity and respiratory infections (particularly viral infections) or allergens (Pike et al, 2018). Asthma attacks have frequently been associated with human rhinovirus infections, and these infections possibly interact with allergen sensitisation, allergen exposure and lack of medication use.
Those who have poorly controlled airway inflammation are more vulnerable to asthma attacks than those who are adequately controlled with good treatment adherence (Engelkes et al, 2015). Poorly controlled day-to-day asthma symptoms can limit activities, including schooling, and impair sleep and overall quality of life (Bundle et al, 2019). Exacerbations of asthma symptoms are associated with reduced school attendance (Pike et al, 2018). While the exact aetiology of the seasonal peak is unknown, there are several factors that have been identified as possible reasons for this (Bundle et al, 2019).
Reasons for the seasonal peak in asthma attacks
Viral infections
On return to school in the autumn, children are exposed to allergens and respiratory infections by close contact with other children (Cai et al, 2011). There is evidence that viral infections, particularly rhinovirus, may contribute to this seasonality. Not only do viral infections trigger asthma attacks, but there is also evidence that people with asthma are more susceptible to rhinovirus infections than those without asthma (Pike et al, 2018).
Allergies
Spores from moulds usually start to be released in the autumn months (Wolfe, 2015). It is estimated that around 3–4% of the general population get allergy symptoms from fungal spores, including the majority of asthma sufferers (Wolfe, 2015).
Air pollution
There is growing concern that air pollution is having an impact on human health—especially in children. Asthma symptoms can be triggered by air pollution, particularly traffic fumes, but this can be difficult for people with asthma to avoid. On days that the pollution levels are high, children with asthma can be left short of breath and wheezing, increasing their risk of an asthma attack.
Air pollution contains fine particulate matter—PM2.5. As these particulates are almost weightless, they can remain in the air for long periods and cause harm to humans who unavoidably inhale them on a regular basis. Particulate matter has been linked to asthma, as it can be inhaled deep into the lungs. NO2 can inflame the airways and long-term exposure can affect lung function and worsen asthma symptoms (Kelly and Fussell, 2015). The Health Effects Institute (HEI) panel have concluded that there is sufficient evidence to support a causal relationship between exposure to traffic-related air pollution and exacerbation of asthma symptoms (Kelly and Fussell, 2015).
Living near or attending schools near high-traffic density roads exposes children to high levels of air pollutants, increasing the incidence of childhood asthma and wheeze (Gasana et al, 2012). Currently there are several primary schools in London that are in areas that are in breach of the legal limit for NO2 (Mayor of London and London Assembly, 2019). Adherence to preventative inhaled corticosteroids can reduce the risk of exacerbating symptoms and/or an asthma attack. If asthma is well-controlled, air pollution will have less of an effect on children. Children and young adults with asthma, however, are at a slightly higher risk from the effects of pollution, as they have faster breathing rates. Pollution can also make other allergies—such as to pollen or house dust mite—worse, as air pollutants are likely to cause oxidative injury to the airways, leading to inflammation, remodelling and an increased risk of sensitisation (Guarnieri and Balmes, 2014).
All children should have a spacer device to aid lung deposition of medication
Air pollution affects people with asthma in different ways, but it is advisable that on days that pollution levels are high, people with asthma avoid areas with lots of traffic, especially at rush hour. Pollution levels are usually higher in the evenings, or when it's humid, still, sunny or cold, and if there are high winds or atmospheric changes. Children with asthma should stick to the back streets when walking to and from school, keep windows closed and avoid taking part in physical activities close to main roads. Pollution levels can be checked on: https://uk-air.defra.gov.uk/forecasting/.
Stress of starting school
Returning back to school or starting a new school can be a stressful time for children. It is recognized that emotion and stress can affect immune function (Wright, 2005). It is believed that psychological stress can affect the release of cortisol and the expression of inflammatory mediators in a complex and time-dependent way, with increased airway inflammation associated with stress (Forsythe et al, 2004; Thomas et al, 2011).
Another hypothesis involves the classroom environment, which provides persistent exposure to a mixture of airborne viruses, viral proteins, endotoxins, community allergens and other human-derived aerosols. During the preceding school term, this exposure is established and maintains a level of immune tolerance and immunity. During the 6–8 week holiday, due to the continued lack of exposure, this tolerance declines, creating a transitory window of susceptibility to viral infections and asthma. The return to school re-establishes exposure to these aerosols resulting in an acceleration of symptoms until the tolerance and immunity are re-established (Tovey et al, 2011).
Interventions
Given the predictability of worsening asthma control and the increased risk of asthma attacks in the back-to-school period, successful interventions could substantially reduce the overall asthma attack rate as well as the strain placed on health services during this period (Pike et al, 2018). A number of interventions including asthma education programs, action plans and self-monitoring have been shown to reduce both symptom exacerbations and the need for unscheduled acute care in children with asthma (Pike et al, 2018).
One intervention was the administration of seasonal omalizumab, a monoclonal antibody which reduced symptoms among children with severe or poorly controlled asthma. Despite its success, this intervention is expensive and invasive (Teach et al, 2015).
A study determining the effectiveness of montelukast therapy in reducing the asthma burden in children when initiated prophylactically on return to school did not find this to be of benefit (Weiss et al, 2010). Another study included a medication reminder letter to parents, but this showed no evidence that it reduced unscheduled contacts for a respiratory diagnosis between September and December (Pike et al, 2018).
Although not specifically associated with return-to-school asthma attacks, the influenza vaccination has been shown in a meta-analysis to prevent 59–78% of asthma attacks leading to emergency visits and/or hospitalisations, thus it is imperative that children with asthma receive the influenza vaccination (Vasileiou et al, 2017).
Assessing control
Annual asthma reviews are the ideal time to assess asthma control and people with asthma should be reviewed after any change in treatment. When asthma is well controlled, patients should be symptom-free; not requiring use of their emergency reliever inhaler, not waking up at night due to asthma, have no limitations on activity and have normal lung function, as measured by peak flow. If a child is requiring use of their reliever inhaler more than 3 times a week, is coughing and/or wheezing or saying their chest hurts, is more breathless than usual and is waking up at night, this would indicate a deterioration of control and that they are at increased risk of an asthma attack.
Careful review of the impact of asthma on a child's daily activities, including sports, play and social life, and on school absenteeism, is important, especially when considering previous back-to-school asthma attacks. Many children with poorly controlled asthma avoid strenuous exercise so their asthma may appear to be well controlled. This may lead to poor fitness and a higher risk of obesity (GINA, 2019).
Children vary considerably in the degree of airflow limitation observed before they complain of breathlessness and use their reliever inhalers. When a child has poorly controlled asthma, parents may report irritability, tiredness and changes in mood in their child as the main problem, but perhaps not identify that this is as a result of poorly controlled asthma. Parents have a longer recall period than children and therefore it is important to include both the child and the parent when reviewing asthma control (GINA, 2019).
The childhood asthma control test is useful in establishing the level of control and offers a questionnaire for both the parent and child (GSK, 2018). It is designed for use with children from 4 to 11 years of age. Those at particular risk of an asthma attack have been identified as those with more severe disease, greater degree of atopy and recent asthma attacks (Pike et al, 2018).
How to prevent deteriorating asthma control
Adherence to inhaled corticosteroids should be emphasised, with focus on treatment aims. One measure of adherence involves looking at the prescription refill found on the patient medication records. This provides an estimation of perceived adherence, but nurses should bear in mind that despite being prescribed medication, patients may not use it. Further questioning about missed doses or intentional non-adherence should also be explored. Many of the factors listed in this article can have less impact if asthma has been well controlled with treatment adherence. If despite adherence to current treatment, the child continues to be symptomatic, inhaler technique should be checked and, if clinically appropriate, an increase in treatment considered.
A self-management plan should be issued to every child and discussed with parents, carers and schools with clear instructions on how to step up treatment if symptoms deteriorate. A Cochrane review found that children assigned to a symptom-based plan less frequently required an acute care visit for asthma compared to those who received a peak flow-based plan (Bhogal et al, 2006). Reliever inhalers and spacers should be readily available at home and in school to alleviate symptoms immediately, and children should then proceed to continue administration of inhaled corticosteroids. Self-management plans are available at www.asthma.org.uk.
Inhaler technique
One of the most important interventions in asthma is correct inhaler technique and this should be checked at every opportunity by health professionals to ensure it is optimised. Inadequate inhaler technique reduces lung deposition, increases waste medication and may lead to poor disease control, reduced quality of life, increased emergency admissions and higher treatment costs (Sanchis et al, 2016).
Video resources for inhaler technique are available on www.rightbreathe.com and https://www.asthma.org.uk/ which patients and health professionals can access online.
All children should have a spacer device to aid lung deposition. A spacer device should be used with both the preventer and reliever inhaler. If a metered dose inhaler (MDI) and spacer are not suitable, a dry powder inhaler (DPI) may be used if inspiratory effort is adequate. This can be assessed using placebos or the In-Check dial.
Conclusion
Given the increase in asthma attacks in children when returning to school is predictable, management strategies need to be employed to prevent the increased risk during this period. Practice nurses can ensure good adherence to inhaled therapies and a comprehensive self-management plan is provided. Despite the lack of evidence available to prevent asthma attacks when returning to school, adherence to medication, early identification of deteriorating symptoms and utilisation of self-management plans can potentially help.
KEY POINTS:
- Asthma attacks are often preventable when medication is taken every day and correctly
- Inhaler technique should be checked regularly and changes made if technique cannot be improved with current inhalers
- All children using a metered dose inhaler should be prescribed a spacer
- Adherence is key in maintaining good asthma control
- Pollution can be problematic for children. Providing advice about avoiding highly polluted areas can help control asthma
- Self-management plans should be issued to parents/carers/teachers and discussed to ensure understanding
CPD reflective practice:
- How would you define good asthma control?
- What advice would you give to parents/carers/teachers about reducing exposure to pollution?
- How would you advise parents/carers/teachers to respond to deteriorating symptoms, such as an increase in night time wakening?
- What can you do to ensure that all children continue to take their preventer inhalers during the school holidays, when undertaking an annual review of asthma?