Overview
This Guidelines summary is part of a series of summaries of the British Thoracic Society/Scottish Intercollegiate Guidelines Network Guideline 158: British guideline on the diagnosis and management of asthma.
This summary focuses on recommendations for the management of asthma in adolescents. Recommendations on risk factors, comorbidities and modifiable behaviours, asthma attacks and the risk of hospital admissions, are not included in this summary. For the complete set of recommendations, please refer to the full guideline.
Follow the links for summaries of British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) recommendations on the diagnosis and management of asthma in the following groups:
Grades of Recommendation
The grade of recommendation relates to the strength of the supporting evidence on which the evidence is based. It does not reflect the clinical importance of the recommendation.[A] At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results.
[B] A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1.
[C] A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++.
[D] Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+.
Good-Practice Points
[✓] Recommended best practice based on the clinical experience of the guideline development group.
For the full key of evidence statements and recommendations, please see the full guideline.
- Adolescence is the transitional period of growth and development between puberty and adulthood, defined by the World Health Organization as between 10 and 19 years of age
- Key elements of working effectively with adolescents in the transition to adulthood include:
- seeing them on their own, separate from their parents, for part of the consultation, and
- discussing confidentiality and its limitations.
Prevalence of Asthma in Adolescents
- Asthma is common in adolescence with a prevalence of wheeze in 13–14 year olds in Western Europe in the past 12 months (current wheeze) of 14.3%. For more severe asthma (defined as ≥4 attacks of wheeze or ≥1 night per week sleep disturbance from wheeze or wheeze affecting speech in the past 12 months) the prevalence was 6.2%
- There is evidence of underdiagnosis of asthma in adolescents, with estimates of 20–30% of all asthma present in this age group being undiagnosed. This has been attributed to under reporting of symptoms. A number of risk factors have been independently associated with underdiagnosis including: female gender, smoking (both current smoking and passive exposure), low socioeconomic status, family problems, low physical activity and high body mass, and race/ethnicity. Children with undiagnosed frequent wheezing do not receive adequate healthcare for their illness and the health consequences of not being diagnosed with asthma are substantial
- Although feasible, there is insufficient evidence to support screening for asthma in adolescents
[✓] Clinicians seeing adolescents with any cardiorespiratory symptoms should ask about symptoms of asthma.
Diagnosis and Assessment
Exercise-related Symptoms
- Exercise-related wheezing and breathlessness are common asthma symptoms in adolescents. However, these symptoms are poor predictors of exercise-induced asthma. Only a minority of adolescents referred for assessment of exercise induced respiratory symptoms show objective evidence of exercise-induced bronchospasm
- Most exercise-related wheezing in adolescents can be diagnosed and managed by careful clinical assessment The absence of other features of asthma and an absent response to pretreatment with β2 agonist make exercise induced asthma unlikely. Exercise testing with cardiac and respiratory monitoring that reproduces the symptoms may be helpful in identifying the specific cause.
Use of Questionnaires
- When using questionnaires, the prevalence of current symptoms is higher when the adolescent completes the questions rather than the parents, while questions about the last 12 months give similar results between the parents and the adolescent.
Quality of Life Measures
- Quality of life scales (such as AQLQ12+) can be used in adolescents.
Lung Function
- In adolescents with asthma, tests of airflow obstruction and airway responsiveness may provide support for a diagnosis of asthma. However, most adolescents with asthma have normal lung function despite having symptoms.
Bronchial Hyper-Reactivity (BHR)
- Although many children with asthma go into long-lasting clinical remission at adolescence, BHR may persist. Whether persisting BHR reflects ongoing airway inflammation is debated.
Asthma Attacks and the Risk of Hospital Admission
- Clinical characteristics and markers of severity, including frequent respiratory symptoms, airway hyper-responsiveness, atopy, and low lung function, identify those at high risk of hospitalisation for asthma, particularly with respect to multiple admissions.
Long-term Outlook and Entry Into the Workplace
- Adolescents and young adults (10–22 years) with relatively mild asthma have slightly more limitations in vocational and professional careers than those without asthma. Young adults with asthma have a low awareness of occupations that might worsen asthma (e.g. exposure to dusts, fumes, sprays, exertion, and temeprature changes)
[✓] Clinicians should discuss future career choices with adolescents with asthma and highlight occupations that might increase susceptibility to work-related asthma symptoms.
Non-pharmacological Management
Tobacco Smoking and Environmental Exposure to Tobacco Smoke
[✓] Adolescents with asthma (and their parents and carers) should be encouraged to avoid exposure to environmental tobacco smoke and should be informed about the risks and urged not to start smoking.
[✓] Adolescents with asthma should be asked if they smoke personally. If they do and wish to stop, they should be offered advice on how to stop and encouraged to use local NHS smoking cessation services.
Complementary and Alternative Medicine
[✓] Healthcare professionals should be aware that complementary and alternative medicine use is common in adolescents and should ask about its use.
Pharmacological Management
Specific evidence about the pharmacological management of adolescents with asthma is limited and is usually extrapolated from paediatric and adult studies. Recommendations for pharmacological management of asthma in children and adults can be found in section 7 of the full guideline.
Inhaler devices
Specific evidence about inhaler device use and choice in adolescents is also limited. Inhaler devices are covered in section 8 of the full guideline.
[✓] Adolescent preference for inhaler device should be taken into consideration as a factor in improving adherence to treatment.
[✓] As well as checking inhaler technique it is important to enquire about factors that may affect inhaler device use in real life settings, such as school.
[✓] Consider prescribing a more portable device (as an alternative to a pMDI with spacer) for delivering bronchodilators when away from home.
Organisation and Delivery of Care
[B] School-based clinics may be considered for adolescents with asthma to improve attendance.
[B] Peer-led interventions for adolescents in the school setting should be considered.
[✓] Integration of school-based clinics with primary care services is essential.
Transition to Adult Services
- Transition to adult services is important for all adolescents with asthma, irrespective of the asthma severity.[✓] In the initial period after transition to adult services in secondary care, adolescents are best seen by one consultant to build their confidence and encourage attendance.
Patient Education and Self Management
- Effective transition care involves preparing adolescents with asthma to take independent responsibility for their own asthma management and enabling them to negotiate the health system effectively. Clinicians need to educate and empower adolescents to manage as much of their asthma care as they are capable of doing while supporting parents to gradually hand over responsibility for management to their child.[D] Design of individual or group education sessions delivered by healthcare professionals should address the needs of adolescents with asthma.
Adherence
- When directly asked, most adolescents admit they do not always follow their treatment plans. Strategies to improve adherence in adolescents emphasise the importance of focusing on the individual and their lifestyle and using individualised asthma planning and personal goal setting.