Q and A

Correlation of answers; two replies:

1. Community nurse team follow up post discharge within the first 24-48 hours (acute phase); community nurse follow up if in the home (post acute phase) if 2 or more emergency portal attendances/admissions (educational role – not diagnostic or prescribing) and patient can be managed appropriately by GP. Secondary/tertiary outpatient review, 3 or more admissions in preceding 12 months, post CICU, HDU attendance, persistent symptoms despite step, 3, 4 or 5 treatment. Poor response to therapy. Diagnostic doubt.

2. Four-tiered approach:

Correlation of answers: there were 7 responses covering north and middle England, Scotland and Wales.

Interestingly, no-one mentioned whether 10 puffs via an aerochamber is as effective as nebulised salbutamol as compared to 10 puffs via a large volume spacer.

I am in the process of devising flashcards/ poster information on inhaler devices available that can be used in clinic settings. A common problem when parents who come to nurse and consultant clinic is that they are unsure of the strength of doses being used and do not bring the inhalers with them. I am trying to include the different colours of the strengths of medication in this information. Does anyone have something similar that they use in their clinics? Kelly Davies, Paediatric respiratory/eczema nurse, Royal Glamorgan Hospital, Llamtrisant, S.Wales, Cwm Taff Health Board. Date question asked: 29/03/2017.

Response:

• Replies from many different areas, some sharing and sending copies of different kinds of flipcharts/flashcards that they have devised.
• Also directed to posters that are available particularly one from Asthma Society of Ireland.
• All these responses helped me to devise flashcards that we can currently use if needed.

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We are currently reviewing the service that we provide to our patients with asthma, and invite responses from the group to a questionnaire about this (see below). Kate Baker and Lucy Mallin, Leeds Children’s Hospital. Date questions asked: 04/12/2016.

10 completed questionnaires were received. Summary of responses:

• 10 responses, all performing nurse led clinics.
• 70% within a secondary care service, 20% tertiary.
• 70% have a weekly clinic.
• 80% have 5 to 8 patients on each list.
• 55% have support with their clinics, ranging from 55% having support with height, weight and sats, 33% have physiology and secretarial support and 11% have administration support.
• 80% have referral from GP’s, A&E, ward’s, consultants and other health professionals.
• 70% receive referrals to provide education and review.
• 70% are independent nurse prescribers
• 90% are band 7’s (a few commented that when posts are replaced they will probably be band 6’s)

Questionnaire (with total responses for each option):

1. Is the asthma service that you work within a secondary or tertiary service?

Secondary	7
Tertiary	2
Secondary and Tertiary	1

 

2. Do you have a nurse led asthma clinic?

Yes

10

 

3. Are your clinics weekly?

Yes	7
No	2
Clinics per week
1			2
1+(1 alt weeks)			1
2			3
4			1
8			1

 

4. Are your clinics monthly?

Yes	3 (1-joint allergy and dermatology x3 pts)
No	5
Ad hoc	1

 

5. How many patients do you have on each clinic list?

5-8	8
7-10	1

 

6. Do you have any support within your clinic?

Yes	5
No	4

What support do you receive?

Clinical support worker	Height, weight, sats	5
Physiologist	spirometry	3
Secretarial	Clinic letters	3
Administration	Provide notes	1

 

7. Within your nurse led clinic where are your referrals from?

Ward, consultants	1
GP, A&E, Ward, Consultants, other health professionals-	8
Consultants and follow up from clinic	1

 

8. Do you have specific criteria of which patients you will see eg review or education? If yes we would be grateful if you could share this with us.

Education, review	7
Unable to gain control	3
3 or more admissions	3
3 or more oral steroids	2
HDU/ITU/ life threatening	2
Lots of days off school	1
Spirometry, Inhaler technique	2
Asthma with multiple food allergy	1
SPT	1

 

9. Are you an Independent Nurse Prescriber?  YES  /  NO ?

Yes	7
No	3

 

10. Are you Band 6 / 7?

6	1
7	9

 

11. Any other information that you would like to share with us regarding your nurse led   asthma clinic

Ensure support services in place	2
Ensure clear referral criteria	1
Give yourself plenty of time with each pt	3
Proforma useful	1
Who will cover you if off	1
Text reminders improve attendance	1

 

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We are developing a new protocol for the use of hypertonic saline 3% for patients with bronchiolitis, does anyone have any information on its use or protocols they would be willing to share? June Hartfield, Paediatric Respiratory & Cystic Fibrosis Nurse Specialist, Wye Valley NHS Trust (Hereford)

• Responses from 5 members; 3 were very happy to share their present protocols, Birmingham, Belfast and Nottingham, all of which are very similar in content, including description of when and how hypertonic saline is used. Sheffield are completing a study into its cost effectiveness and use which should be available in time to inform protocols prior to next season. Gloucester are also looking into developing a protocol around bronchiolitis, into which they are hoping to incorporate both hypertonic saline and high flow oxygen therapy. It was very useful to look at other areas’ protocols and also share information on where bronchiolitis care is going in the near future.

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Could I put a topic out for comment to the NPRANG group please regarding the peak flow in the BTS paediatric asthma audit? It’s one of the discharge parameters measured alongside other generally accepted good practice (action plans etc..). However, we like many other areas only use home peak flow monitoring for a select group of patients and wonder whether it ought to be on there as its use here is variable depending on the patient group. I fed this back to the BTS last year and I know the use of home peak flow monitoring was touched on at last year’s NPRANG study day. What do others think and do you have the same issues? Lesley Barrett, George Coller Asthma Nurse, Birmingham Children’s Hospital

10 responses:

• Some use peak flow routinely for all patients old enough as part of an asthma management plan (n=3), mentioning its use alongside symptom recognition.
• One respondent reported being very proactive with peak flow monitoring.
• Symptom recognition as a focus for asthma management was raised (n=9). Some mentioning that this is easier for patients (n=2).
• Some areas use peak flow with selected patients (n=6), reasons for this were: poor perception of symptoms (n=4), new patient to aid diagnosis (n=1), post admission (n=1), post treatment change (n=1), motivated patients (n=1) and patient preference (n=1). 1 respondent replied that they wouldn’t use it for any length of time. 2 respondents report that they rarely use peak flow.
• One respondent includes peak flow as part of the in patient pathway but it was only used a small % of the time.
• Issues raised include difficulties with funding of peak flow meters on discharge (n=1) and problems outweighing benefits (n=1) with peak flow.
• 2 respondents raised the issue of concerns about asking unwell and breathless children in ED or GP surgeries to measure peak flow and discourage this practice.
• One respondent felt that we should lobby to have this removed from the good practice guide.
• Another issue raised was the issue of timing of oral steroids in the BTS audit, asking whether they have been given within an hour of triage, there is no way of recording when patients have already been given this dose prior to admission, hence it incorrectly looks as if some patients are not getting steroids.

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Information requested about Omalizumab protocols and asthma care pathways. Abbie Rickards, Paediatric Respiratory Nurse Specialist,Royal Devon and Exeter NHS Foundation Trust

• There were three replies who sent information on Omalizumab protocols, assessments, home visit reports, care plans for the administration which has been really useful. One of these was interested in having some information about a care pathway too but nobody has replied to say they have one.

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Does anyone have any ideas about how to give Colomycin nebulisers via a 15mm ventilator circuit? We have a patient who is ventilated 24 hours a day – he cannot come off his ventilator for anytime. In non ventilated patients we would use a Pari nebuliser and a filter but we cannot do this via a ventilator circuit – it has been suggested that we use the same nebuliser unit that we would use for a saline nebuliser and accept that some of the Colomycin would come out of the exhalation port and the deposition would not be so good. Catherine Crocker, Paediatric Respiratory Nurse Specialist, Southampton University Hospitals NHS Foundation Trust

• From June, Wye Valley NHS Trust: I had this issue for potentially adding to a BiPap circuit. Intersurgical do a ‘self sealing in line nebuliser T-Piece 22m-22f (ref 1814), this in addition with their Cirus 2 nebulizer (ref 1402) working of either oxygen or a mains driven nebuliser works in a ventilator circuit.
• From Dave, Brompton LTV service: We recommend the Medix Econoneb Nebuliser with the Sidestream and Intersurgical T-piece connector (code 1980e) with a filter before the exhalation leak (diagram reference also provided)
• From Kelly, North Staffordshire NHS Trust: We would normally give this in the same way as other nebs on a vented circuit, a filter is not needed as the circuit is closed.
• From Sarah, West Yorkshire Region: We would use a similar neb set to that used for saline (acorn and T piece) but would add a low volume bacterial filter into the circuit between the T piece and the exhalation port, thus preventing escape via the exhalation port. We would label the neb set so that it is only used for colomycin.

It was great to get so many responses to the question, as you can see everyone had different ideas. The problem was related to the fact that the child cannot come off their ventilator for any time (we would normally give a Colomycin nebuliser for when they are off their vent) and normally we would ventilate or filter the exhaled antibiotic to prevent (I realise some places do not do this Colomycin in other patients) and as his ventilator tubing is a single limb circuit we could not think of a way to do this. We are investigating the answers that June and Dave gave us, so hopefully we will have some answers soon. Many thanks to all who took the time to respond

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Re. sibling testing of Nut allergic children – to SPT, check SIgE levels or food challenge. Helen Smith, CNS Paediatric Respiratory, Gloucestershire Hospitals NHS Foundation trust

5 responses:

• General consensus is ‘not to test, food challenge at home’. All agree that both skin prick testing and SIgE levels can give both false positives and false negative results, particularly If the sibling has never been exposed to nuts (e.g. nut free household). A food challenge in Hospital would be ideal but very impractical to accommodate all of these children in an already very busy service.
• The majority of parents are advised to try nuts at home, one nut at a time in daylight hours when the child is otherwise well and with anti-histamine to hand.
• The exceptions people suggested are; the sibling has underlying asthma, the allergic child has a very severe allergy or if parents are not happy to carry this out at home – rather than the sibling remaining (potentially unnecessarily) nut free then a food challenge to mixed nuts may be offered in the hospital setting.
• There seems very little literature on the topic when I looked. One American article explained that they carry out food challenges in Hospital for every sibling of a nut allergic child (or if the child’s parent is nut allergic). Locally we are very busy with egg, dairy, nut etc challenges and would struggle to deliver this service to children in this criteria.

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1. With the addition of MgSO4 nebulisers to the new BTS guidance for acute asthma, can I ask if other areas are using them?

2. Also, we changed our order of IV bronchodilator usage a few years ago and currently use salbutamol as first line IV therapy, however, some clinicians have expressed a preference for magnesium sulphate. With the lack of research and preferential order from BTS guidance as to what to use we are interested to see if others use this. Some of the reasons for the preference for Mg were ease and speed of administration and concerns re: salbutamol toxicity in some patients.

3. When checking inhaler technique we clean and re-use spacers and placebos if the patients do not bring their own in as asked to. What do other areas do? If you clean them, what do you use? Our infection control team have asked that we review practice.

Lesley Barrett, George Coller Paediatric Respiratory Nurse, Birmingham Children’s Hospital

Responses:

Q1. One reply from Edinburgh who are revamping their protocol to include MgSO4 nebulisers pre-IV treatment.
Q2. One reply from Edinburgh who use aminophylline as first line IV treatment.
Q3. Five responses:

• 3 areas do not re-use spacers.
• 1 area cleans with hot soapy water and air dry and the other area who re-use wash with detergent, dry and then clean with alcohol wipes, wiping the mouthpiece afterwards.
• Ideas expressed include asking the patient/parent to teach us how to do it using our own spacers or talking through what to do without touching the spacer.
• We all seem to face similar problems with patients not having their own with them despite reminders.
• Inhalers were considered single use only and disposed of as such in 2 replies and one area mentioned re-using these.

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Any guidance on size of caseload? Moira Gibbons, Nurse Specialist Asthma for Rotherham FT

6 responses:

• Confirmed thoughts that there is no guidance.  Difficult to deduce anything else from answers other than this as it was not clear whether patients were managed exclusively by Asthma Nurse or jointly with medics.

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Does anyone have any experience of using the Airsonett laminar airflow device? Mary E Malone, NHS Tayside

• Replies from 7 centres who say they have used the Airsonett with mixed results and only in very small numbers (16 in total) with these centres continuing to trial with other children. 8 positive, 4 no difference, 4 still undergoing trial. Bids in for funding for 5 more children in 3 centres. Most were using this with children on Asthma step 5 treatment and they had either tried or were unsuitable for other treatments such as Omalizumab. Regular reviews were carried out with some using formal assessment tools such as ACT or QoL. One centre has developed guidance on its use. Some noted improvement in eczema.

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Question to NPRANG re Annual National BTS Paediatric Wheeze/Asthma Audit in Children one year and above with wheeze/asthma. Jane Peach, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust

As you will probably agree it is an extremely valuable audit. It enables us to compare our in-patient hospital standards from admission through to discharge planning with the other participating centres. In addition to this, it enables centres to compare their own  performance to performance  in previous years  with reference to the standards in the BTS Asthma Guidelines.

Thank you to the 10 NPRANG members who replied to me. Here in Stoke at the University Hospital of North Midlands we have taken part in this audit since it was first developed approx. 1998.This year the national audit was not available, however in Stoke we decided to continue with just the local audit so that we could compare our own performance. I have the responsibility of the data entry. As our admission numbers have increased year on year with total admissions of wheeze/asthma reaching between 90 and 100 (November 2014) I did recruit help from a junior doctor and my respiratory nurse colleague. This was greatfully received as completion of this audit is not without the difficulty of ensuring a good system of medical note collection and the data entry itself is time consuming.

To summarise the comments – four of those who replied felt that recruiting the junior doctors to complete the audit may cause more work for the nurse specialist and that there is a potential for some of the finer detail of the audit to be lost. The presentation of the results is done either by the nurse specialists or junior doctors, depending on who takes the lead with the audit. If junior doctors are entering data it does require some supervision in data retrieval to ensure consistency. Although completing the audit is time consuming it is a great tool for monitoring the performance of your centre’s standards of wheeze /asthma care during an admission to hospital as well as the other national centres. It enables us to focus the education which is required to improve the standards highlighted by the audit results. The number of centres participating nationally has increased to 148 possibly due to the audit being included in the list of national audits approved by the Department of Health Quality Accounts in England.

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Are any of you using or looking to use nebulised magnesium as considered in the new BTS guidelines after the Magnetic trial? Laura Kandola, Paediatrics, UHCW NHS Trust, Coventry

3 responses:

• Lesley Barrett (George Coller Respiratory Nurse Specialist at Birmingham Childrens Hospital) referred to a similar question posed in December. She attached a copy of the feedback in her email.
• Royal Stoke University Hospital is not currently using it due to poor evidence base.
• Ninewells Hospital in Dundee have decided not to use it at the moment. They have also been made aware by pharmacy that the nebulised form may be difficult to get hold of. However, they are changing their guideline to include IV MgSO4 as a first line.

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Do you provide children on ‘high dose ICS’ with a steroid alert card? If so which one do you use? Louise Cherry, NELFT

4 responses:

• Yes we give the blue card available from the pharmacy to any child taking more than 500 mcgs (total daily dose).
• We don’t for high dose inhaled steroids but do if they have regular/intermittent oral steroids. BTS guideline says we should! The one we use is the one in the BNF.
• We use a small folder card (folds to credit card size) with a warning on the front, patient information and drug information on the inside, and a prompt on the back to ensure it is shown to any doctor/nurse/pharmacist/dentist. I’d send you a copy, but we don’t keep them electronically. And I’m not sure where we order them from (they mysteriously arrive in outpatients, but I could investigate if you like?)
• We use the wee blue one (attached) which is dispensed by pharmacy on discharge from hospital and from community pharmacies. We get a few from our pharmacist to keep in case the family don’t recognise that they should have kept it!

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The BTS discharge criteria for sending patients home following acute asthma attack include ‘on 3-4 hourly bronchodilators that can safely be continued at home’. We currently have ‘stable on up to 10 puffs 4 hourly’ on our pathway but would be interested to know how other areas have interpreted this. Lesley Barrett, Birmingham Children’s Hospital

11 responses:

• 10 respondents report discharging patients home on 4 hourly inhalers. Within this total 1 respondent discharges to Hospital at Home care on 4 puffs 2 hourly and one reports that their ED will discharge on 3-4 hourly inhalers
• 1 respondent reports discharging on 3-4 hourly inhalers
• 6 respondents discharge on 10 puffs
• 2 on 6 puffs (although 1 ED dept. uses 8-10)
• 1 on 4 puffs
• 1 on 2-4 puffs

Concerns raised include that if you say no more than 4 hourly we know that people give it more frequently and if you say 3 hourly, will you then have people giving them 2.5 hourly?

One respondent mentioned trying to keep 10 puffs as a ‘rescue’ dose for deteriorating symptoms.

Two respondents mentioned sometimes having to argue for patients to be kept until stable on 4 hourly rather than early discharges.

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Has anyone any ideas to improve adherence to chest physio for a 4 year old please? We have tried a flutter device on the flutter and also a cliniflo with a smiley face. Viv Marsh, Education for Health

Correlation of answers:

• My advice would be speak to physio about using Bubble PEP and also interesting star chart (eg minions following a squiggly path with stickers filling in shapes until gets to goal ? small reward).
• Our physios also do bubble PEP with the wee ones. Also use the cardboard tubes that you attach to the spirometer/paek flow meter to do huffs – pop a bit of cotton wool in and big blow to get in a bin or hit a target.
• Trampolines are popular but maybe not so good in the colder weather.
• PEP masks used with CF from infants and then as they get older maybe 5 or 6.
• Is a physio involved with them??? They might need to be reviewed by one. It’s tricky to answer without knowing the child and the reason that they need to do airway clearance.
• In my experience, 4 year olds are very difficult to do airway clearance with as they have a poor attention span. The flutter is quite a difficult PEP device for younger children as it is position dependent – the acapella is an easier device as it requires less expiratory flow to make it work and you can do it in any position. The other thing that may be easier and more fun is bubble PEP! All of these need huffing and coughing after a cycle of breaths. Sometimes I will do a cycle of airway clearance (10 breaths with huff+cough), then some physical activity like star jumps/burpees etc and then come back to the airway clearance.
• Sticker charts work quite well for some children or a reward system.

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Do any of the NPRANG members have experience in the use of DispoZABLE and collapsible spacers that are available from Clement Clark? Are these a more cost effective way rather than using volumatics? Laura Morris, George Coller Respiratory Nurse, Birmingham Childrens Hospital

Correlation of answers:

• I have not seen these spacers as yet so am unable to comment, but would love to know how people find them – Karen Fuller Clinical Nurse Specialist, Children’s Allergy
• I have come across these disposable spacers – personally I don’t rate them, they don’t fit together well and are in my view wholly unsuitable for an emergency situation. Doesn’t seem terribly helpful – Nickola Rickard, Asthma Friendly Schools Project Lead (Islington Schools)
• We haven’t tried the dispozable spacers in our unit. I did take a look via one of the reps (I think during last years NPRANG conference). I would have thought that they would be great for use in schools, however in hospital I’d want to ensure every patient goes home with a spacer that will last – Laura Kandola, Paediatric Respiratory Clinical Nurse Specialist, University Hospitals Coventry and Warwickshire NHS Trust
• We don’t use the collapsible spacers from Clement Clark. I don’t feel they are robust enough and we still use the Volumatic spacer or the Aerochamber spacer. I also think that the deposition is greater in the Volumatic or Aerochamber. I know other areas probably have different ideas – Jane Peach, Children’s Asthma Nurse Specialist, Cheetham’s Children’s Centre, Royal Stoke University Hospital
• In distant past a pt has used for camping trip. Not a regular substitute to volumatic – Debra Forster, Children’s Respiratory/Allergy & Community Nurse, Nottingham Children’s Hospital

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Does anyone know where I can purchase model airways for teaching? Ann McMurray, RHSC, Edinburgh

There are currently no airway models available to purchase. GSK had previously given some models however these are no longer available. This could potentially be an issue and I will liaise with Viv Marsh from EFH to take this forward. The models previously available from them are excellent.

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Which autoinjector do you routinely prescribe for anaphylaxis? Debra Forster, Nottingham Children’s Hospital

Correlation of Answers:

I had 14 replies, (including mine) Thank you to everyone who replied, made interesting reading.

• Six areas prescribe Epipens. Two of these areas will be moving to Jext.
• Four areas prescribe Jext, but one of those area is moving from Jext to Emerade. One of these areas is prescribing Jext to NEW patients.
• Four demonstrate both autoinjectors and get parent to choose. Most parents seem to choose Epipens, mainly because they have heard of these autoinjectors.
• Three of the thirteen areas ask the GPs to prescribe the autoinjector
• Three areas stated that they would prescribe the Emerade for the older teenager.

Reasons for demonstrating both autoinjectors or changing from one device to another included;

• If there were any supply issues then the family does not panic as the autoinjectors are similar to use.
• CCGs recommending one autoinjector and the hospitals another, which may lead to confusion.

The areas that use Jext like the free app.

One other comment was that a change from Epipen to Jext was made to save money, Meda then reduced price and because of the longer shelf life, they re-verted back to prescribing Epipens.

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I am wanting to get an idea about the practices of other non medical prescribers when it comes to children with nut allergy. Currently all our nut allergic children that have displayed signs of a severe allergic reaction will get an epipen. We are currently undecided in our dept as to whether we should be giving all children with a nut allergy an epipen irrespective of previous reactions.  Louise Bashford, University Hospitals Coventry & Warwickshire NHS Trust

5 responses:

• Our policy is to only give epipens to nut allergy children if they have asthma or if they have had previous anaphylaxis. Anyone who has had attended A and E for anaphylaxis also has one prescribed.
• Not all of our nut allergy children get epipens unless they have severe reaction and/or coupled with other foods and asthma, or live remotely. We have quite a lot that have antihistamine only for reactions.
• We do the same as you re epipens. Do give all children with cashew nut allergy epipens though, irrespective of type of previous reaction.
• All individuals who have had anaphylactic reaction should be issued with adrenaline auto-injectors. However, there are probably no right or wrong answers and the issue needs to be discussed on an individual basis in clinic with the patient, and their parents to ensure that they are comfortable with the decision.The protocol we generally follow for the patients that we see in our clinics that have not had anaphylactic symptoms are to give adrenaline auto injectors to: Adolescents; Asthmatics; Previous severe/anaphactic reaction; Living or travel to remote places; Reported reaction to traces; Parental anxiety
• We prescribe EpiPens based on clinical history/atopic co-morbidities rather than the fact it’s a nut allergy. We’d prescribe EpiPens to children with nut allergy if they had asthma (esp if on inhaled steroids), previous life-threatening reactions, wheeze associated with reactions, systemic reaction to trace amounts or severe complex atopy.

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Is everyone aware about the impending supply problem from GSK- the only supplier of IV salbutamol in UK? Our pharmacy has been informed that the factory has closed down until at least September 2016. So with this in mind (I know we have had similar questions in the past) my question to the group is – what is everyone now using as first line IV treatment? Are you using salbutamol and not aware of the situation? Were you already moving to IV magnesium (some clinicians are preferring this due to its ease, especially if they have been used to using this in adults)? Sue Frost, BCH

5 responses:

• Our protocol in Belfast is: 1) IV Magnesium followed by 2) IV aminophyliine followed by 3) IV salbutamol (by which stage they are in PICU).
• We stopped using IV salbutamol over a year ago due to salbutamol toxicity. We have recently started using nebulised magnesium (hypoxic, over 2yrs old, increased WOB) with success! We had been using IV magnesium. We use IV aminophylline for acute severe/life threatening.
• Didn’t know that but we rarely use IV salbutamol. First line is IV mag sulph then old fashioned IV aminophylline.
• We use IV Magnesium Sulphate as a first line, then aminophylline and tend not to use IV Salbutamol unless in PHdu. I would be interested to hear the results from this as it is something our team will be looking into.
• We tend to opt for aminophylline 1st but we do use iv salbutamol as well. I was unaware so thanks for highlighting this.

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