Pediatric Asthma Treatment & Management

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Pediatric Asthma Treatment & Management

Author: Girish D Sharma, MD, FCCP, FAAP; Chief Editor: Michael RBye, MD more...

Updated: Nov 25, 2013

Approach Considerations

The National Asthma Education and Prevention Program guidelines highlight the importance of treating impairment

and risk domains of asthma.[4] The goals for therapy are as follows:

Control asthma by reducing impairment through prevention of chronic and troublesome symptoms (eg,

coughing or breathlessness in the daytime, in the night, or after exertion)

Reduce the need for a short-acting beta2-agonist (SABA) for quick relief of symptoms (not including

prevention of exercise-induced bronchospasm)

Maintain near-normal pulmonary function

Maintain normal activity levels (including exercise and other physical activity and attendance at work or

school)

Satisfy patients' and families' expectations for asthma care

Reduction in risk can be achieved by preventing recurrent exacerbations of asthma and minimizing the need for

emergency room visits and hospitalizations, and preventing progressive loss of lung function. For children,

preventing reduced lung growth and providing optimal pharmacotherapy with minimal or no adverse effects is

important.

When a patient has major allergies to dietary products, avoidance of particular foods may help. In the absence of

specific food allergies, dietary changes are not necessary. Unless compelling evidence for a specific allergy

exists, milk products do not have to be avoided.

The goal of long-term therapy is to prevent acute exacerbations. The patient should avoid exposure to

environmental allergens and irritants that are identified during the evaluation.

Components of Asthma CareThe current guidelines emphasize 4 important components of asthma care, as follows[4] :

Assessment and monitoring

Education

Control of environmental factors and comorbid conditions

Pharmacologic treatment

Assessment and monitoring

Once the patient's condition is classified and therapy has been initiated, continual assessment is important for

disease control. Asthma control is defined as "the degree to which the manifestations of asthma are minimized bytherapeutic intervention and the goals of therapy are met." [4]Asthma can be classified as well controlled, not well

controlled, or very poorly controlled; classification criteria vary by patient age (view PDF).

In order to assess asthma control and adjust therapy, impairment and risk must be assessed. Assessment of

impairment focuses on the frequency and intensity of symptoms and the functional limitations associated with

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these symptoms. Risk assessment focuses on the likelihood of asthma exacerbations, adverse effects from

medications, and the likelihood of the progression of lung function decline; spirometry should be measured every

1-2 years, or more frequently for uncontrolled asthma.

Because asthma varies over time, follow-up every 2-6 weeks is initially necessary (when gaining control of the

disease) and then every 1-6 months thereafter.

Education

Patient education continues to be important in all areas of medicine and is particularly important in asthma. Self-management education should focus on teaching patients the importance of recognizing their own their level of

control and signs of progressively worsening asthma symptoms.

Both peak flow monitoring and symptom monitoring have been shown to be equally effective; however, peak flow

monitoring may be more helpful in cases in which patients have a history of difficulty in perceiving symptoms, a

history of severe exacerbations, or moderate-to-severe asthma.

Educational strategies should also focus on environmental control and avoidance strategies and medication use

and adherence (eg, correct inhaler techniques and use of other devices).

Using a variety of methods to reinforce educational messages is crucial in patient understanding. Providing written

asthma action plans in partnership with the patient (making sure to review the differences between long-termcontrol and quick-relief medications), education through the involvement of other members of the healthcare team

(eg, nurses, pharmacists, physicians), and education at all points of care (eg, clinics, hospitals, schools) are

examples of various educational tools that are available and valuable for good patient adherence and

understanding.

Control of environmental factors and comorbid conditions

As mentioned above, environmental exposures and irritants can play a strong role in symptom exacerbations.

Therefore, in patients who have persistent asthma, the use of skin testing or in vitro testing to assess sensitivity to

perennial indoor allergens is important. Once the offending allergens are identified, counsel patients on avoidance

from these exposures. In addition, education to avoid tobacco smoke (both first-hand and second-hand exposure)

is important for patients with asthma.

Lastly, comorbid conditions that may affect asthma must be diagnosed and appropriately managed. These include

the following:

Bronchopulmonary aspergillosis

Gastroesophageal reflux disease (GERD)

Obesity

Obstructive sleep apnea

Rhinitis

Sinusitis

Depression

StressLow vitamin D levels

Based upon reports of an inverse correlation between low vitamin D levels and asthma control, vitamin D

supplementation in children might enhance corticosteroid responses, control atopy, and improve asthma control.[26] In a long-term study of children with asthma, those with Vitamin D deficiency or insufficiency responded less

well to adequate doses of inhaled corticosteroids. [42]

A recent clinical trial of lansoprazole in children with poorly controlled asthma without gastroesophageal

symptoms showed no improvement in symptoms or lung function, but was associated with increased adverse

effects.[43]

Inactivated influenza vaccine may be helpful in those who are older than 6 months.

Pharmacologic treatment

Pharmacologic management includes the use of agents for control and agents for relief. Control agents include

inhaled corticosteroids, inhaled cromolyn or nedocromil, long-acting bronchodilators, theophylline, leukotriene
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modifiers, and more recent strategies such as the use of anti-immunoglobulin E (IgE) antibodies (omalizumab).

Relief medications include short-acting bronchodilators, systemic corticosteroids, and ipratropium.

For all but the most severely affected patients, the ultimate goal is to prevent symptoms, minimize morbidity from

acute episodes, and prevent functional and psychological morbidity to provide a healthy (or near healthy) lifestyle

appropriate to the age of child.

A stepwise approach to pharmacologic therapy is recommended to gain and maintain control of asthma in both

the impairment and risk domains. The type, amount, and scheduling of medication is dictated by asthma severity

(for initiating therapy) and the level of asthma control (for adjusting therapy). Step-down therapy is essential toidentify the minimum medication necessary to maintain control. See table below.

When children are well controlled, it is reasonable to try to reduce their therapy. Whether on relatively high-dose

inhaled steroids, or a combination of steroid/long-acting beta2-agonist, it is best to try to continue to control them

on a lower dose, or on less medication. Reducing inhaled steroids and/or eliminating the long-acting beta2-agonist

could result in a deterioration in asthma control. When such steps are taken, it is critical to see those children

frequently, monitoring their history, physical examination and spirometry. [44]

For pharmacotherapy, children with asthma are divided into 3 groups based on age: 0-4 y, 5-11 y, 12 y and older.

For all patients, quick-relief medications include rapid-acting beta2-agonists as needed for symptoms. The

intensity of treatment depends on the severity of symptoms. If rapid-acting beta2-agonists are used more than 2

days a week for symptom relief (not including use of rapid-acting beta2-agonists for prevention of exercise induce

symptoms), stepping up treatment may be considered. See the stepwise approach to asthma medications in

Table 1, below.

Table 1. Stepwise Approach to Asthma Medications(Open Table in a new window)

Intermittent

AsthmaPersistent Asthma: Daily Medication

Age Step 1 Step 2 Step 3 Step 4 Step 5 Step 6

< 5

y

Rapid-

acting

beta2-

agonist

prn

Low-dose inhaled

corticosteroid

(ICS)

Medium-dose

ICS

Medium-dose

ICS plus either

long-acting

beta2-agonist

(LABA) or

montelukast

High-dose ICS

plus either LABA

or montelukast

High-dose ICS plus

either LABA or

montelukast; Oral

systemic corticosteroidAlternate

regimen:

cromolyn or

montelukast

5-11

y

Rapid-

acting

beta2-

agonist

prn

Low-dose ICS Either low-dose

ICS plus either

LABA, LTRA, or

theophylline OR

Medium-dose

Medium-dose

ICS plus LABA

High-dose ICS

plus LABA

High-dose ICS plus

LABA plus oral

systemic corticosteroid

Alternate

regimen:

cromolyn,leukotriene

receptor

antagonist

(LTRA), or

theophylline

Alternate

regimen:

medium-doseICS plus either

LTRA or

theophylline

Alternate

regimen: high-

dose ICS pluseither LABA or

theophylline

Alternate regimen: high-

dose ICS plus LRTA or

theophylline plussystemic corticosteroid

12 y

or

older

Rapid-

acting

beta2-

agonist

as

needed

Low-dose ICS Low-dose ICS

plus LABA OR

Medium-dose

ICS

Medium-dose

ICS plus LABA

High-dose ICS

plus LABA (and

consider

omalizumab for

patients with

allergies)

High-dose ICS plus

either LABA plus oral

corticosteroid (and

consider omalizumab

for patients with

allergies)

Alternate

regimen:cromolyn, LTRA,

or theophylline

Alternate

regimen: low-dose ICS plus

either LTRA,

theophylline, or

zileuton

Alternate

regimen:medium-dose

ICS plus either

LTRA,

theophylline, or


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zileuton

In the Salmeterol Multicenter Asthma Research Trial (SMART), salmeterol use in asthma patients, particularly

African Americans, was associated with a small but s ignificantly increased risk of serious asthma-related events.[45] This trial was a large, double-blind, randomized, placebo-controlled, safety trial in which salmeterol 42 mcg

twice daily or placebo was added to usual asthma therapy for 28 weeks.

The study was halted following interim analysis of 26,355 participants because patients exposed to salmeterol (n

= 13,176) were found to experience a higher rate of fatal asthma events compared with individuals receiving

placebo (n = 13,179); the rates were 0.1% and 0.02%, respectively. This resulted in an estimated 8 excess deathsper 10,000 patients treated with salmeterol.

In the post-hoc subgroup analysis, the relative risks of asthma-related deaths were similar among whites and

blacks, although the corresponding estimated excess deaths per 10,000 patients exposed to salmeterol were

higher among blacks than whites.

A meta-analysis by Salpeter et al found that LABAs increased the risk for asthma-related intubations and deaths

by 2-fold, even when used in a controlled fashion with concomitant inhaled corticosteroids. However, the absolute

number of adverse events remained small. [46] The large pooled trial included 36,588 patients, most of them adults.

The US Food and Drug Administration (FDA) has reviewed the data and the issues and has determined that the

benefits of LABAs in improving asthma symptoms outweigh the potential risks when LABAs are usedappropriately with an asthma controller medication in patients who need the addition of LABAs. The FDA

recommends the following measures for improving the safe use of these drugs [47] :

LABAs should be used long-term only in patients whose asthma cannot be adequately controlled on

inhaled steroids

LABAs should be used for the shortest duration of time required to achieve control of asthma symptoms

and discontinued, if possible, once asthma control is achieved; patients should then be switched to an

asthma controller medication

Pediatric and adolescent patients who require the addition of a LABA to an inhaled corticosteroid should

use a combination product containing both an inhaled corticosteroid and a LABA to ensure compliance with

both medications

Concerns about the safety of long-acting beta2-agonists and resultant drug safety communications create a

question as to the course of treatment if asthma is not controlled by inhaled corticosteroids. [47]A study by

Lemanske et al addressed this question and concluded that addition of long-acting beta2-agonist was more likely

to provide the best response than either inhaled corticosteroids or leukotriene-receptor antagonists. [48]Asthma

therapy should be regularly monitored and adjusted accordingly.

A systematic review of 18 placebo-controlled clinical trials evaluating monotherapy with inhaled corticosteroids

supports their safety and efficacy in children with asthma. [49] In addition, the data provide new evidence linking

inhaled corticosteroids use in children with asthma to improved asthma control. A recent study to assess the

effectiveness of an inhaled corticosteroid used as rescue treatment recommends that children with mild persistent

asthma should not be treated with rescue albuterol alone and the most effective treatment to prevent

exacerbations is daily inhaled corticosteroids. This study suggests that inhaled corticosteroids as rescue

medication with albuterol might be an effective step down strategy for children as it is more effective at reducing

exacerbations than is use of rescue albuterol alone. [50] . A recent Cochrane review concluded that more research

is needed to assess the effectiveness of increased inhaled corticosteroid doses at the

onsetofasthmaexacerbation.[51]

In children, long-term use of high-dose steroids (systemic or inhaled) may lead to adverse effects, including growth

failure. Recent data from the Childhood Asthma Management Program (CAMP) study and results of the long-term

use of inhaled steroids (budesonide) suggest that the long-term use of inhaled steroids has no sustained adverse

effect on growth in children.[52, 53]

A review by Rodrigo et al looked at 8 s tudies of omalizumab in children with moderate to severe asthma andelevated IgE levels.[54] Children treated with omalizumab were more significantly able to reduce their use of rescue

inhalers and their inhaled and/or oral steroid dose than patients in the placebo group. Although no significant

differences in pulmonary function were observed, patients receiving omalizumab had fewer exacerbations than the

children receiving placebo. These studies lasted a year or less and did not reveal any s ignificant adverse effects of

the omalizumab.


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A randomized trial of omalizumab for asthma in inner-city children showed improved asthma control, elimination of

seasonal peaks in asthmatic exacerbations, and reduced need for other medications for asthma control.[55]

Another study, by Deschildre et al, indicated that adding omalizumab to maintenance therapy can improve asthma

control in children with severe, uncontrolled allergic asthma. In a study of 104 such children, Deschildre and

colleagues found that adding omalizumab increased the rate of good asthma control from 0% to 53% and reduced

exacerbation and hospitalization rates by 72% and 88.5%, respectively. By 1-year follow-up, FEV1 (forced

expiratory volume in 1 second) had improved in the study's patients by 4.9%, and inhaled corticosteroid dose had

decreased by 30%.[56, 57]

Delivery devices and best route of administration

In pediatric asthma, inhaled treatment is the cornerstone of asthma management. Inhaler devices currently used to

deliver inhaled corticosteroids (ICSs) fall into the following 4 categories:

Pressurized metered dose inhaler (pMDI) - Propellant used to dispense steroid when canister is pressed

manually

Dry powder inhaler (DPI) - Does not require hand-breath coordination to operate

Breath-actuated pMDI - Propellant used to dispense steroid when patient inhales

Nebulized solution devices

Go to Use of Metered Dose Inhalers, Spacers, and Nebulizersfor complete information on this topic.

In pediatric patients, the inhaler device must be chosen on the basis of age, cost, safety, convenience, and

efficacy of drug delivery.[6]

Based on current research, the preferred device for children younger than 4 years is a pMDI with a valved holding

chamber and age-appropriate mask. Children aged 4-6 years should use a pMDI plus a valved holding chamber.

Lastly, children older than 6 years can use either a pMDI, a DPI, or a breath-actuated pMDI. For all 3 groups, a

nebulizer with a valved holding chamber (and mask in children younger than 4 y) is recommended as alternate

therapy.[6]

Valved holding chambers are important. The addition of a valved holding chamber can increase the amount of drug

reaching the lungs to 20%. The use of a valved holding chamber helps reduce the amount of drug particlesdeposited in the oropharynx, thereby helping to reduce systemic and local effects from oral and gastrointestinal

absorption.

A Cochrane review on the use of valved holding chambers versus nebulizers for inhaled steroids found no evidence

that nebulizers are better than valved holding chamber. [58] Nebulizers are expensive, inconvenient to use, require

longer time for administration, require maintenance, and have been shown to have imprecise dosing.

Newer devices are showing greater efficacy. For MDIs, chlorofluorocarbon (CFC) propellants (implicated in ozone

depletion) have been phased out in favor of the hydrofluoroalkane-134a (HFA) propellant. Surprisingly, the HFA

component is more environmentally friendly and has proven to be more effective, due to its smaller aerosol particle

size, which results in better drug delivery. MDIs with HFA propellant have better deposition of drug in the small

airways and greater efficacy at equivalent doses compared with CFC-MDIs.

Treatment of Status Asthmaticus

Treatment goals for acute severe asthmatic episodes (status asthmaticus) are as follows:

Correction of significant hypoxemia with supplemental oxygen; in severe cases, alveolar hypoventilation

requires mechanically assisted ventilation

Rapid reversal of airflow obstruction with repeated or continuous administration of an inhaled beta2-agonist;

early administration of systemic corticosteroids (eg, oral prednisone or intravenous methylprednisolone) is

suggested in children with asthma that fails to respond promptly and completely to inhaled beta2-agonists

Reduction in the likelihood of recurrence of severe airflow obstruction by intensifying therapy: Often, a shortcourse of systemic corticosteroids is helpful

Achieving these goals requires close monitoring by means of serial clinical assessment and measurement of lung

function (in patients of appropriate ages) to quantify the severity of airflow obstruction and its response to

treatment. Improvement in FEV1after 30 minutes of treatment is significantly correlated with a broad range of
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indices of the severity of asthmatic exacerbations, and repeated measurement of airflow in the emergency

department can help reduce unnecessary admissions.

The use of the peak flow rate or FEV1values, patient's history, current symptoms, and physical findings to guide

treatment decisions is helpful in achieving the aforementioned goals. When using the peak expiratory flow (PEF)

expressed as a percentage of the patient's best value, the effect of irreversible airflow obstruction should be

considered. For example, in a patient whose best peak flow rate is 160 L/min, a decrease of 40% represents

severe and potentially life-threatening obstruction.

An Australian study by Vuillermin et al found that asthma severity decreased in school-aged children when parentsinitiated a short course of prednisolone for acute asthma.[59] Children who received parent-initiated prednisolone for

episodes of asthma had lower daytime and nighttime asthma scores, reduced risk of health resource use, and

reduced school absenteeism compared with children who received placebo.

Consultations

Any patient with high-risk asthma should be referred to a specialist. The following may suggest high risk:

History of sudden severe exacerbations

History of prior intubation for asthma

Admiss ion to an ICU because of asthmaTwo or more hospitalizations for asthma in the past year

Three or more emergency department visits for asthma in the past year

Hospitalization or an emergency department visit for asthma within the past month

Use of 2 or more canisters of inhaled short-acting beta2-agonists per month

Current use of systemic corticosteroids or recent withdrawal from systemic corticosteroids

Referral to an asthma specialist for consultation or comanagement of the patient is also recommended if additional

education is needed to improve adherence or if the patient requires step 4 care or higher (step 3 care or higher for

children aged 04 y). Consider referral if a patient requires step 3 care (step 2 care for children aged 04 y) or if

additional testing for the role of allergy is indicated. [4]

The choice between a pediatric pulmonologist and an allergist may depend on local availability and practices. Apatient with frequent ICU admissions, previous intubation, and a history of complicating factors or comorbidity (eg,

cystic fibrosis) should be referred to a pediatric pulmonologist. When allergies are thought to significantly

contribute to the morbidity, an allergist may be helpful.

Consider consultation with an ear, nose, and throat (ENT) specialist for help in managing chronic rhinosinusitis.

Consider consultation with a gastroenterologist for help in exc luding and/or treating gastroesophageal reflux.

Long-Term Monitoring

Regular follow-up visits are essential to ensure control and appropriate therapeutic adjustments. In general,

patients should be assessed every 1-6 months. At every visit, adherence, environmental control, and comorbid

conditions should be checked.

If patients have good control of their asthma for at least 3 months, treatment can be stepped down. However, the

patient should be reassessed in 2-4 weeks to make sure that control is maintained with the new regimen. If

patients require step 2 asthma medications or higher, consultation with an asthma specialist should be

considered.

Outpatient visits should include the following:

Interval history of asthmatic complaints, including history of acute episodes (eg, severity, measures and

treatment taken, response to therapy)

History of nocturnal symptoms

History of symptoms with exercise, and exercise toleranceReview of medications, including use of rescue medications

Review of home-monitoring data (eg, symptom diary, peak flow meter readings, daily t reatments)

Patient evaluation should include the following:


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Assessment for signs of bronchospasm and complications

Evaluation of associated conditions (eg, allergic rhinitis)

Pulmonary function testing (in appropriate age group)

Address issues of treatment adherence and avoidance of environmental triggers and irritants.

Long-term asthma care pathways that incorporate the aforementioned factors can serve as roadmaps for

ambulatory asthma care and help streamline outpatient care by different providers.

In the author's asthma clinic, a member of the asthma care team sits with each patient to review the written

asthma care plan and to write and discuss in detail a rescue plan for acute episodes, which includes instructions

about identifying signs of an acute episode, using rescue medications, monitoring, and contacting the asthma

care team. These items are reviewed at each visit.

One study using directly observed administration of daily preventive asthma medications by a school nurse

showed significantly improved symptoms among urban children with persistent asthma. [60]

Contributor Information and DisclosuresAuthor

Girish D Sharma, MD, FCCP, FAAP Professor of Pediatrics, Director, Section of Pediatric Pulmonology and

Rush Cystic Fibrosis Center, Rush Medical College; Senior Attending, Department of Pediatrics, Rush

University Medical Center

Girish D Sharma, MD, FCCP, FAAP is a member of the following medical societies:American Academy of

Pediatrics,American College of Chest Physicians,American Thoracic Society, and Royal College of

Physicians of Ireland

Disclosure: Nothing to disclose.

Coauthor(s)

Payel Gupta, MD Department of Allergy and Immunology, ENT Faculty Practice

Payel Gupta, MD is a member of the following medical societies:American College of Physicians


Specialty Editor Board

Thomas Scanlin, MD Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of

Pediatrics, Rutgers Robert Wood Johnson Medical School

Thomas Scanlin, MD is a member of the following medical societies: American Association for the

Advancement of Science,American Society for Biochemistry and Molecular Biology,American Thoracic

Society, Society for Pediatric Research, and Society for Pediatric Research


Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of

Pharmacy; Editor-in-Chief, Medscape Drug Reference


Charles Callahan, DO Professor, Deputy Chief of Clinical Services, Walter Reed Army Medical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics,

American College of Chest Physicians,American College of Osteopathic Pediatricians,American Thoracic

Society,Association of Military Surgeons of the US, and Christian Medical & Dental Society


Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of

Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo
http://www.cirtl.org/cmds.htmhttp://www.amsus.org/http://www.thoracic.org/http://www.acopeds.org/http://www.chestnet.org/http://www.aap.org/http://www.aps-spr.org/http://www.aps-spr.org/http://www.thoracic.org/http://www.asbmb.org/http://www.aaas.org/http://www.acponline.org/http://www.rcpi.ie/http://www.thoracic.org/http://www.chestnet.org/http://www.aap.org/


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Michael R Bye, MD is a member of the following medical societies:American Academy of Pediatrics,American

College of Chest Physicians, andAmerican Thoracic Society


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Pediatric Asthma Treatment & Management