Asthma: current therapeutic approach

Variations in the treatment of childhood asthma

OBJECTIVE

To survey the assessment and management of childhood asthma by paediatricians, general practitioners, and respiratory physicians, and compare these findings with the Australian and New Zealand Consensus Statement guidelines on asthma management in children.

SETTING AND DESIGN

A six-item postal questionnaire designed to cover assessment, management of acute and mild asthma, use of prophylaxis and methods of delivery of medication.

PARTICIPANTS

A random sample of 100 paediatricians, 300 general practitioners and 100 respiratory physicians.

RESULTS

Response rates were: paediatricians, 88%; general practitioners, 66%; and respiratory physicians 51%. There was agreement between all three groups in most aspects of asthma management. Deviations from the Consensus Statement guidelines included: between 38% and 49% not using oxygen as one of the first-line treatments for acute asthma; a higher use of orally administered beta 2-agonists by general practitioners (up to 40% for children between one and three years compared with 17% of paediatricians and 12% of respiratory physicians); a tendency to use intravenously administered aminophylline before corticosteroids (20% of paediatricians, 40% of general practitioners and 30% of respiratory physicians); a preference among general practitioners and respiratory physicians to prescribe inhaled corticosteroids rather than sodium cromoglycate for prophylaxis in older children; and a low incidence of use of spacer devices in older children.

CONCLUSIONS

If currently published recommendations on managing asthma in children are followed, there should be: more education and emphasis on the value of oxygen and short courses of orally administered corticosteroids in acute asthma management; less reliance on intravenously administered aminophylline; decreased use of orally administered beta 2-agonists coupled with a more wide-spread use of spacer devices; and an increased emphasis on sodium cromoglycate as first-line daily prophylaxis.

Trends and district variations in the hospital care of childhood asthma: results of a regional study 1970-85

Trends and district variations in the pre-hospital and hospital care of children aged 0-14 years admitted with acute asthma were surveyed in all 13 districts of a health region by examining case notes for 1970, 1978, and 1985. From 1970 to 1985 there was a substantial increase in admissions and some reduction of hospital stay. Over this time adrenergic drugs remained the most frequently used treatment with a large shift towards selective beta2 agonists administered by nebulisation. Use of corticosteroids fell in the under 5s with a decrease in the parenteral route of administration but rose in the 5-14 age group with an increase in the oral route of administration. There was an increase the use of oral xanthines but this was outweighed by falls in the use of suppositories and in parenteral administration. The use of antibiotics became less frequent and that of sedatives and antihistamines fell to almost nil. There were also important changes in other aspects of management, notably an increase in the use of lung function tests (from 3% to 70%) and falls in the use of chest radiographs, blood tests, bacteriology, and physiotherapy. In nearly all aspects of management there were significant and often very extreme variations in practice between districts, which were unlikely to be explained by differences in morbidity. These variations would be a suitable focus for medical audit, with the aim of establishing which treatment regimens have the best outcome and avoiding unnecessary cost and discomfort. Because early hospital drug treatment is closely related to the type of treatment given before admission such audit activities would need to include general practitioners.