Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report. is limited and no recent international guidelines have focused exclusively on. Guidelines for the Diagnosis and Management of Asthma,. (NAEPP) (7), the Diagnosis and treatment of Asthma in Childhood: a PRACTALL Consensus. PRACTALL is an initiative of the European Academy of Allergy and Clinical . Download high-res image (KB) · Download full-size image . into pathway- specific diagnostic tests is essential and should guide the design of future large.
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Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report a guideline for clinical practice in Europe as well as in North America. This. The PRACTALL consensus statement for childhood asthma is just published and is available, together with a pocket guide, on the EAACI. food challenges: American Academy of Allergy, Asthma & Immunology– European Academy of Allergy and Clinical Immunology PRACTALL consensus report.
Yes Yes Are there any other considerations that would justify referral? The majority of rhinitis patients will be managed in the community; an effective mechanism for directing the right patient to the specialist is necessary. The proposed limits for the definition of persistent rhinitis 4 days a week and 4 consecutive weeks a year , although tested in large patient groups 45 , are arbitrary and should be understood as suggestions. Additional AR phenotyping could be based on the pattern of sensitization monosensitized vs polysensitized 46 or the existence of concurrent asthma. Indeed, the unified airway concept is well documented and there is a strong correlation between the upper and lower respiratory tract allergy symptoms. Thus, the concomitant presence of asthma could affect the course of AR and vice versa and could also dictate different treatments for AR More studies are needed to evaluate its underlying mechanisms and confirm its prevalence in different countries.
As the possibility for food to be a trigger of AD is higher at younger ages, food management at this age is critical for AD management. Dietary management is classified into food avoidance and preparation of a diet for proper nutrient supply. Food avoidance: Because the results of a laboratory test are not always consistent with symptoms, food cannot be restricted based only on the result of a laboratory test.
Food diary and challenge test are necessary for the confirmations. When food challenge is conducted, careful attention should be paid to the possibility of anaphylaxis in patients with urticaria or angioedema rather than AD. For the prevention of AD, breast feeding is commonly recommended. However, it should be considered that the maternal diet can produce symptoms of AD.
Probiotics are sometimes recommended in high-risk infants [ 37 ]. Nutrient management: When a food that is confirmed to be associated with AD is avoided, food substitution should be provided.
The cooking method is also considered. For example, raw rice shows an allergenic band in immunoblotting but the band disappears after boiling [ 38 ]. Cooking methods such as roasting were reported to enhance allergenicity [ 39 ]. Indoor environmental management Studies in Korea and other countries have reported that residential environmental pollution is a factor in the development of symptoms of AD [ 2 , 40 - 44 ]. Our clinical study on the therapeutic effect of a low-pollutant PM10, formaldehyde, bacterial and mold suspension ward also revealed that improvement of the environment had a positive effect.
The duration of treatment was reduced and the pollutant levels were measured to be higher at the patient's home than in the wards. Children spend over 20 h a day in indoor environments including childcare facilities, daycare centers, kindergartens, schools and private educational institutions, so reducing pollution in the indoor environment is important for AD management.
Ventilation: Ventilation is the first step to reduce indoor pollution. Pollutants from new furniture, furnishing materials including wallpaper, air-conditioning and heating equipment and cooking utensils should be decreased by ventilation. New interiors or new furniture need more frequent ventilation. An air cleaner is also helpful but a habit of frequent ventilation is more effective and reliable.
Cleaning: Fungi and bacteria can be factors in worsening symptoms of AD and can provoke more severe symptoms in skin lesions with infection. Cleaning is the best way to decrease fungi and bacteria in the indoor environment [ 45 , 46 ]. Adequate humidity: Maintaining adequate humidity is effective in reducing the deterioration of lesions by preventing dry skin.
Psychological management The most common problem in severely affected AD children is exhaustion from not sleeping well, leading to poor concentration at school [ 47 ]. Dietary restriction and anxiety can negatively affect the development of confidence, autonomy and personal initiative. In most cases of moderate to severe AD, counseling is required to help overcome the emotional burdens associated with the disease itself and the fears that most parents have about treatment, such as steroid phobia.
Step 2 Management: first stage of pharmacological intervention Step 2 therapy should be added for acute symptoms of AD if the skin lesion is not improved by step 1 management. The targets of step 2 therapy are to break out of the vicious cycle of disease and to treat skin inflammation. Antipruritic medications Antihistamines are widely used for the management of pruritus.
Antihistamines are generally divided into six groups. Depending on their action time and sedative properties, each group is classified into first- and second-generation drugs.
When tachyphylaxis occurs, an antihistamine from another group can be used.
Sedating first-generation antihistamines are still more useful in AD than the nonsedating antihistamines [ 48 ], but their use in children is often reserved for nighttime dosing to minimize drowsiness and lack of concentration during the daytime [ 49 ]. Treatment of skin infection Disruption of the skin barrier and a deficiency in the expression of antimicrobial peptides may account for the susceptibility of AD patients to various skin infections by bacteria, fungi and viruses [ 26 , 27 , 50 - 52 ].
Heavy colonization of AD patients' skin with S. Skin infection is a major factor in aggravating symptoms of AD. Suspected skin infection is hard to differentiate from progressive lesions in many cases.
Generally, an infected lesion tends to have a well-defined margin compared with early lesions that have poorly defined margins. For bacterial infection, systemic antibiotics are preferred rather than topical agents.
Generally, a first- or second-generation cephalosporin for days is recommended. In case of infections with viruses, fungi or scabies, it is better to use individualized therapy. If there is no therapeutic ef fect, skin culture for microorganisms should be performed. Treatment of skin inflammation For early and progressive lesions of acute symptom not improving with step 1 management, topical anti-inflammatory therapy should be applied.
Although TCS is most widely used, many patients and their guardians are reluctant to use it because of anxiety over possible adverse effects.
Education about safe use of TCS to minimize adverse reactions and the rebound phenomenon is necessary. TCI can also be safely used for skin inflammation. TCSs: TCSs have been the mainstay of treatment of inflammation and are usually divided into grades by their strength: mild, moderate, strong and very strong ointments, respectively.
The therapeutic effect of TCSs is obvious for early and progressive lesions of acute symptom. Currently, numerous guidelines are available that provide guidance on when a patient with asthma should be referred to a specialist. For optimal management of these patients, it is important that guideline recommendations for specialist referrals are implemented fully and consistently.
In this regard, an overview of the current practice of specialist referrals, possible hurdles in the implementation of referrals and possible strategies for improved rate of referrals would be helpful.
All well-documented international and national guidelines were obtained Figure 1. The retrieved publications from this search were manually reviewed and nonrelevant publications were excluded based on several criteria as outlined in Figure 1.
The International Primary Care Respiratory Group asthma guideline database was also searched for national asthma guidelines Figure 1. Figure 1 Guideline selection process.
For this review, literature searches were restricted to guidelines, as previously stated, or manuscripts in English language; limited information from regional guidelines has also been included due to their international impact e.
Asthma guidelines as sources for indications for specialist referrals Global and national guidelines aim to improve the diagnosis and management of asthma and ensure that the best practice is implemented consistently. The Global Initiative for Asthma GINA has developed a detailed recommendation on the global strategy for asthma management, but because it is only a strategy, the indications for referral may vary due to variations across health care systems.
Several of the guidelines confirm an uncertain diagnosis of asthma as a reason to refer patients to a specialist, except for the PRACTALL consensus report 13 and the Japanese guideline for children 16 Table 2. Several factors aid asthma diagnosis, such as a carefully recorded history, and clinical and diagnostic assessments spirometry and biomarkers , and all of the guidelines presented in Table 1 allude to these to some extent. GINA recommends spirometry as the preferred diagnostic test for asthma, whereby measurements of airflow limitation, reversibility or bronchial challenge are also used to establish a diagnosis of asthma, 5 and the involvement of a specialist can result in better access to this tool.
An example of this would be the test for FeNO, where GINA states that this test has not been established as being useful in making a diagnosis of asthma. Clinical symptoms of asthma e.
NAEPP guidelines highlight that patients with conditions such as sinusitis, nasal polyps, aspergillosis, severe rhinitis, vocal cord dysfunction, gastroesophageal reflux disease and chronic obstructive pulmonary disease should be referred to a specialist.
Therefore, there is a fundamental need to select appropriate uncontrolled asthma patients for referral to a specialist. A review of the guidelines in Table 1 suggests a substantial variation in recommendations for high-risk patients seeking a referral.
Prior to a referral, primary care physicians PCPs play a pivotal role in addressing the factors behind poor control e. In the guidelines addressing children with asthma, lack of control despite recommended treatment, usually medium- or high-dose ICS, is sufficient to seek a referral Table 2.
GEMA highlights that patients classified as having difficult-to-control asthma should be treated in a specialized setting. According to the NAEPP and Japanese adult guidelines, patients with other comorbidities that could affect asthma control 30 constitute a high-risk group and should be referred to a specialist. Aside from uncontrolled patients, some of the guidelines suggest that other patient cohorts should be referred to a specialist. The South African guidelines for adults and the AAAAI consultation and referral guideline suggest that severe asthma is a reason to seek a specialist referral.
The Australian guidelines indicate that patients who have evidence of poor lung function despite the use of a high dose of ICS for 3 months should seek a referral. GEMA recommends that patients who fail to respond to treatment must be referred to a hospital emergency department ED.
For example, there is a lack of clarity on whether patients should go to step 3 or step 4 or even step 5 treatment if they are uncontrolled, clearly indicating that the threshold for change in treatment step is not clear. The Irish guidelines follow this suggestion with some more specificity, stating that patients could be referred post-hospitalization if uncontrolled at step 3. Furthermore, every year it is estimated that a quarter of a million deaths worldwide are asthma related.
Use of corticosteroid treatment Steroids play an important role in the management of asthma in the form of ICS and oral corticosteroids. These therapies have a positive impact on controlling symptoms and exacerbations.