Query about Asthma and FeNo testing

[Peapodpanda]

Hi,
When my child was 5yrs old he was admitted to hospital with ?asthma attack. First episode of it. He was in for 24hr and discharged home. He is now 10. In the following weeks he had another flare up but we used his inhaler the hospital gave us and he managed to stay home that time. Ever since then he has been treated as ‘suspected asthmatic’ and has been on daily steroid inhalers. He was on this twice a day, but was reduced to once a day last year.

He recently had another review and we agreed to stop the inhaler for a month so he would be able to undergo diagnostic testing to confirm/rule out asthma. We went for FeNo testing today and his result was 61.

With a history of suspected asthma, and a FeNo of 61 NICE guidelines suggests that he should be formally diagnosed.. but the nurse who we saw said that FeNo can sometimes be high even if they are not asthmatic.. and recommended we continue without inhalers as he hasn’t had symptoms in the last month.

Surely this is wrong? If FeNo isn’t accurate, why use it at all? I don’t understand how he can have suggested asthma for years, have formative testing and get a high result, but still not diagnosed..

Can any resp nurses/person with experience offer any advice? At present we’ve come away with the plan to just go without any inhalers and have another review in 6 months.

thanks in advance

What is FeNo??

I'm 54, asthmatic as is my son who is 27. He was diagnosed aged 4. But I've never heard of FeNo. I know I'm old but I'm up to date with stuff!

I wrote a whole university research ptoposal
on feno. It can be unreliable. However if it were me I would likely diagnose asthma and put him on an AIR regime.

I have had asthma since childhood. I absolutely refused the FeNo test. I know I have asthma, the doctors know I have asthma. Why should I suffer ill health while they mess about checking now.
A nurse told me inhalers are very expensive and there needs to be cutbacks on how many are given out. Cost cutting???
Another, very pushy nurse, made an appointment for me , very early, in another town.
I had already declined the FeNo test so I simply didn't go!!!

@dinolilFeNO is measurement of exhaled nitric oxide, a gas which inflamed lungs produce. I had mild asthma in earlier years (before FeNO was a thing!), stopped inhalers and remained symptom free but my FeNO was 50 when it was measured for the first time ever, recently. I started a combination inhaler and it came down to 20 (upper limit of normal is 25). I’m still symptom free, but the change in FeNO suggests it’s doing something, and inflamed airways aren’t good in the long term, so I’ve decided to stay on the inhaler.

It’s slightly comical as the ‘SMART’ regime is all about using inhalers ‘as needed’ - no use in my case, I can’t tell if I need them! So I do 1 puff twice a day.

Thanks for your reply, I think she was going to do this (AIR), but I mentioned him being on a beta blocker which can make salbutamol ineffective so she didn’t. I just wish I had pushed for the formal diagnosis and recognition that he has it. I worry without inhalers long term, he will have another flare up, his salbutamol won’t be as effective because of his cardiac meds and he will end up hospitalised again. He already has a lot going on and it just feels risky to leave him without anything.

I just came away feeling like ‘what was the point in that?! We suspect it, we’ve had supposedly diagnostic testing which said he had it, but we’re not going to say he has it’ 🤦🏻‍♀️

Thank you. I think I may just put him back on it. It feels safer. My 7 year old also was just diagnosed, after 2x 2night admissions within a 2 month period. She was given the testing and her result was over 120. Then she had the inhalers and her result drastically reduced (can’t remember what it was - but it was within normal range). It obviously works. Maybe as someone else said, it’s a cost saving exercise

Yeh I’m starting to think this was just a cost-saving attempt. I think I’m going to just put him back on it.. 🤷🏻‍♀️

There’s the drip feed that probably makes this beyond what MN can help with. A child with a heart condition/possible asthma/needs and tolerates beta blockers and doesn’t have asthma symptoms off medication is not quite your average straightforward patient. Best bet is to go back to the medical people that have all the information about him.

With your update, the serious cardiac condition, there is no way I’d let a community asthma nurse take my child off an inhaler he’s been stable on for years. Nor would I consider advice from MN. Ask for a referral to paediatric respiratory. Your boy needs/requires proper review.

AIR regimes don’t rely on salbutamol. They are combined inhalers which include an inhaled steroid and formoterol used on an as needed basis only. Salbutamol should not be required as the formoterol part is the quick but longer lasting ‘reliever’, ie such as Symbicort. AIR is only licensed for over 12’s, but using clinical judgement can be prescribed for younger if appropriate.
MART therapy with regular maintenance doses may be more appropriate using a combined inhaler with formoterol, but again, no salbutamol required.
No child or adult should be using a Saba alone now as it does nothing to treat the inflammation, it’s in the updated guidelines which are nearly two years old. The changes are nothing to do with cost cutting and all to do with a more proactive treatment using inhaled steroids to treat the cause and not just the symptoms of asthma to try and reduce asthma deaths.
Your child however, sounds complex. I would restart regular ICS as before and request respiratory referral.
Practice nurse.

Probably beyond the remit of most asthma nurses too I would have thought

Asthma all my life and never had a FeNo test but strongly suspected asthma in my DD (9) Doctor got out the FeNo and she got 60 and he prescribed clenil. Were due a review soon as he said she may switch to a MART regime.

That’s not what SMART is - it’s Single Maintenance And Reliever Therapy.

That means you use it regularly (maintenance) and as a reliever as and when you need it. So twice a day regardless, and extra puffs if needed as you would have used your blue salbutamol inhaler. You just have one inhaler instead of 2 separate ones.

AIR is different - Anti Inflammatory Reliever. So just one combi inhaler used as a reliever as and when needed. If needing about three times a week or more, then you’d step up to MART.

@Peapodpanda I’d be disinclined to stop regular inhaled steroids in a child with a complex history, previous hospital respiratory admissions and a Feno of 61 that’s been off their ICS for a month. The reason he’s probably been so well is because he had beautiful clear airways from regular ICS use, and even though he’s been ok for the last month his elevated Feno could suggest a creeping inflammation and before you know it he’ll be symptomatic again. (Disclaimer - I obviously don’t have all his history and this is speculation as I don’t know him). I’d also want to give him that diagnosis to allow effective treatment and review, and if the GP practice are reluctant to do that they should refer to Paeds respiratory so they can do it.

Thank you all for your advice. It is appreciated. I think I will bypass the GP surgery and will ask his paediatrician to refer to paediatric respiratory team, in the meantime, I’ll put him back on his steroid inhaler. Thanks again