Our 10 top tips for asthma reviews
Asthma reviews are key to giving children and their families the education and information they need for supported self management, and checking they are on an the right treatment for their symptoms
For children and their families to manage a variable condition like asthma, it’s important that they’re able to recognise and act on symptoms and can tell when asthma control is slipping.
Asthma reviews in primary care should take place at least yearly, but also after trials of treatment or changes to treatment. Everyone with asthma should also be reviewed within 48 hours of an exacerbation, asthma attack or admission to hospital (including ED and primary care attendances)
Reviews should ideally be at least a 20- to 30-minute face-to-face consultation which covers all aspects of the child’s asthma care.
Asthma reviews should only be carried out by healthcare professionals who have completed training in asthma management.
For advice on asthma training, see our Professional Development page
Greener Practice have a guide for conducting asthma reviews which includes a video which you can find on their website. You can use this, and our top tips below to structure your reviews.
1. Check the diagnosis is correct
30% of asthma diagnoses are estimated to be incorrect. Check that the diagnosis of asthma is supported by clinical assessment and objective testing. If there is any uncertainty, you can repeat objective testing.
This is especially important for children who have a ‘suspected asthma’ diagnosis. If you think that they are ready to have a go at trying an objective test such as FeNO, spirometry or peak flow then go ahead, as at the least it will help them to get familiar with the equipment.
Don’t forget to ensure that their peak flow is a paediatric one. You can show them this video explaining how to use a peak flow monitor.
2. Explain the diagnosis
For self management to work effectively, children and their families need to understand what asthma is, how their medications work and how they can tell when their asthma's getting worse. This will help improve their confidence and increase adherence to their treatment regime.
You can signpost older children and teenagers the resources on the Moving On Asthma website, which is specifically created for this age group. Younger children can be shown Dr Ranj’s Get Well Soon asthma episode.
For extra support, signpost the family to the A+LUK Helpline and Parent and Carer Network.
3. Assess asthma control
Assessing how well the child’s asthma is controlled is fundamental to the asthma review process. The Child Asthma Control Test uses a series of questions for children and their families to assess their asthma control.
Some HCPs send the asthma control test electronically and use the results to prioritise which children they will bring for a face-to-face appointment. It’s important to remember that the ACT is designed to support the asthma review consultation rather than to be used as a risk-stratification tool to help you identify children with uncontrolled asthma. Use of the ACT in this way is not recommended practice.
Check how often are they are requesting short acting bronchodilator inhalers.
• People with well-controlled asthma should be using no more than 3 SABA inhalers a year
• If your patient is requesting more, this should trigger a review to find out why
• SABA prescriptions should not be limited until you have helped your patient regain asthma control, but must be closely monitored.
For children on MART or AIR regimes, ask how often they’re using extra doses of their inhaler. 3 or more doses a week or regularly using extra doses most days indicates poor control.
If the child’s asthma has been well controlled for 3 months or longer, consider stepping down therapy. You may choose not to depending on prior history, exposure to triggers and previous responses to stepping down therapy
If they are poorly controlled, think about the factors which can affect asthma control before you consider stepping up therapy.
4. Ask about adherence
It is really important to examine find out if the child is taking their medication regularly. Poor adherence to inhaled corticosteroids is an important reason why asthma becomes uncontrolled and increases the risk of asthma attacks.
Are they taking their preventer medication as prescribed? If not, ask what they are struggling with. FeNO can be used to
Do they forget? No family is perfect and it’s not always easy to stick to a routine, especially during less structured times such as school holidays. It’s important to be understanding of the complexities of family life and work in partnership with the family to find ways of helping them support their child, whatever age they are. Try suggesting
• Setting a reminder on their phone, or their parent’s phone
• Downloading an app or
• Keeping their inhaler next to their toothbrush, or in the kitchen where the family eat together – anywhere it will be visible! Some children might be tempted to say that they’ve used their inhaler when they haven’t so it’s best if an adult can see them use it.
• Our asthma calendar and stickers can help some children to remember to take their inhaler.
• For teenagers, the Moving on Asthma website has a wealth of resources.Do they have worries or concerns about their medication? Discuss these with the child and their family.
5. Check the number of flare-ups in last 12 months, or since last review
Look through the notes to find any flare-ups, admissions to hospital or attendances at the emergency department/urgent treatment centres.
If asthma is uncontrolled in 5-11 year olds despite moderate dose therapies or if they have needed 2 or more courses of corticosteroid tablets (Prednisolone) in the past 12 months, you should refer to a specialist in asthma care.
For preschool children under 5 years of age, you shouldrefer those who have been admitted to the hospital or have had two or more emergency department visits for suspected asthma within a 12-month period.
Ask if they have had time off school due to their asthma, and how their asthma is affecting their extra curricular activities.
6. Review inhaler technique and consider if the child would benefit from and be willing to switch to a lower carbon inhaler.
It is essential that children and their families are shown how to use their inhalers and are prescribed a device that is suitable for them.
QoF also requires that an HCP observes their children and their families using their inhalers. Click here for guidance on inhaler techniques
Here’s a video aimed at very young children.
It is good practice to consider the environmental impact and cost of inhaler devices but you need to prescribe an inhaler which the child can, and will, use and this decision needs to be made together with the patient and their family.
If the child is aged over 5, you can discuss swapping to a lower carbon alternative if they are using a pressurised-Metered Dose Inhaler (pMDI). Many primary school-aged children have the ability to use a DPI with effective training, support and practice. You can contact pharmaceutical companies for training aids to help with this.
However, you should consider providing an additional pMDI SABA inhaler plus spacer for emergency use for children under 12 years who might not be able to activate a dry powder inhaler during an acute asthma attack.
Remember to replace spacers yearly. Children should move from a spacer with a facemask to a spacer with a mouthpiece as soon as they can drink through a straw.
Demonstrate how to use the inhaler and remember to give an additional SABA and spacer for the child to take to any childcare settings they attend. If the child lives between two homes, you may want to prescribe an additional ICS, SABA and spacer.
7. Review triggers
If the child and their family understand and recognises their triggers, you can work out how to reduce exposure to them and limit their impact. Ask about indoor and outdoor air quality and how it affects their asthma.
Adolescents may have different triggers to younger children, for example, stress at home or school or periods may worsen their asthma. Experimenting with alcohol, smoking or vaping, recreational drugs can all impact upon asthma control. It’s not unusual for adherence to slip during adolescence too, so switching the child to a MART or AIR regime might help them manage their asthma better and more safely
Moving on Asthma provides supportive resources for adolescents, and you can also signpost them to the A+LUK Helpline, which also has WhatsApp service for people who prefer to message rather then speak with a specialist nurse.
8. Check exposure to cigarette smoke and vaping
It’s essential to know if a child is being exposed to second hand smoke but this can be a very sensitive subject to broach with parents so it’s important to be supportive of families where tobacco or vape addiction is a problem.
The Take it Right Outside campaign provides advice for families on how to minimise second hand smoke exposure. Explain to families that smoking not only harms children, it also makes inhaled corticosteroids less effective. Offer smoking cessation support. You can also send them A+LUK's Stopping Smoking leaflet
For young people who smoke or vape, NICE has guidance on how they can be supported to quit.
9. Check vaccination status
Explain to your patient that people living with asthma are more likely to develop potentially serious complications from influenza.
Click here for information for children and their families on the flu vaccine.
10. Review asthma action plan
Personalised asthma action plans (PAAPs) are an essential part of the child’s self management. They should be developed and reviewed together with the child and their family so that they understand their day-to-day treatment, know what to do if their symptoms are worsening and what to do in an emergency.
Find out from the family how their child looks, acts and feels when their asthma is getting worse and document this on the action plan so that the adults caring for the child will be able to recognise when they’re getting worse. Ask if the child is able to ask for their reliver inhaler when they need it and if not, ensure that this is recorded on their action plan.
For older children, ask if they feel confident using their inhaler at school. Transition to secondary school can be a vulnerable time for children so it's important that they understand how to ask for help if they need it.
Make sure that everyone who cares for the child has a copy of the plan.
Find our asthma personal asthma action plans and a step by step guide to filling them out here