Asthma

Description

Other Names

Reactive airways disease

Diagnosis Coding

ICD-10

J45.2x, mild intermittent asthma

J45.3x, mild persistent asthma

J45.4x, moderate persistent asthma

J45.5x, severe persistent asthma

J45.9xx, other and unspecified asthma

The x indicates that an additional digit is required. ICD-10 Asthma Coding Reference provides more detail.

Description

Asthma is a complex, recurrent disease of the small airways that causes shortness of breath, wheezing, and cough (particularly at night or early in the morning). Asthma is episodic in nature and usually reversible, either spontaneously or with treatment; however, chronic inflammation, associated with persistent symptoms, may contribute to airway remodeling that may not be completely reversible. Airflow limitation occurs as a result of varying degrees of airway hyper-responsiveness, airway edema, and bronchoconstriction. [National: 2007] Asthma symptoms are often "triggered" by environmental stimuli (smoke, perfumes, dust mites, animals, fungi/molds, cold air) and aggravating conditions (viral upper respiratory infections or URIs, rhinitis, sinusitis, gastroesophageal reflux, stress, exercise). The importance of such triggers, as well as patterns of inflammation and treatment response, may vary across differing phenotypes. (Asthma, Causes.) Clinicians should follow the 2007 National Heart, Lung, and Blood Institute Guidelines for assessment, treatment, and management of asthma. These are summarized in 12 pages (comprising mostly useful charts) in the Asthma Care Quick Reference - Diagnosing and Controlling Asthma (PDF Document 719 KB).

Prevalence

  • Approximately 7.1 million children (9.5%) in the United States have asthma. [Bloom: 2011]

    Asthma Prevalence by State Among Children Ages 0 through 17, 2001-2005
    Asthma Prevalence among Children (Age 0-17) in the United States from 2001-2005
    Image: Centers for Disease Control and Prevention [Akinbami: 2006]

  • Annual national costs of treating pediatric asthma are estimated to be $18 billion. Direct costs account for nearly $10 billion (primarily hospitalizations) and indirect costs account for $8 billion (primarily lost earnings due to illness or death). [Asthma: 2000]
  • Racial and ethnic differences in asthma prevalence, morbidity, and mortality are highly correlated with poverty, urban air quality, indoor allergens, lack of patient education, and inadequate medical care. [Asthma: 2013]
  • Sixty percent of annual school absences are attributed to asthma. Children with severe asthma may miss >30 school days per year. [Celeste: 2012]

Asthma Prevalence by Age, Sex, Race
  • Non-Hispanic black children are more likely to have ever been diagnosed with asthma (21%) and to still have asthma (16%) than Hispanic (15%) and (10%) or non-Hispanic white (12%) and (8%) children. [Bloom: 2011]
  • Males ages 0 through 17 have a higher rate of asthma than females of the same age.
  • Asthma is the third-ranking cause of hospitalization for children. [Akinbami: 2006] Despite a recent plateau in asthma prevalence, ambulatory care has continued to grow since 2000. [National: 2003]
Image: Centers for Disease Control and Prevention [Centers: 2013]

Genetics

Asthma is 1 of 3 atopic conditions (asthma, hay fever, eczema) that appears to result from a combination of environmental and genetic factors. If one parent has asthma, chances are 1:3 that the child will have asthma. If both parents have asthma, chances are 7:10. [Asthma: 2013]

Prognosis

Approximately 1/3 of children with asthma (usually those with milder symptoms) will "outgrow" the condition by the time they are adults. Children who develop asthma after age 5 are less likely than those who did so before age 3 to have long-term residual effects. Although there is a risk of severe disease and death with asthma, this is increasingly unusual, and the majority of children with appropriately treated asthma function as well as those without asthma. [National: 2007] Children most at risk of dying from asthma are those with severe, uncontrolled disease, a near fatal attack of asthma, a history of recurrent hospitalization, or intubation for asthma. [Akinbami: 2006]

Roles Of The Medical Home

The medical home should assure continuity of asthma care by collaborating and sharing Asthma Action Plans with other providers, the family, and relevant community services, such as school nurses, sports programs, asthma education resources, etc. Understanding and addressing the impact of the child’s environment (at home, school, other activities) and lifestyle (physical activity or lack thereof, stressors) on their asthma symptoms and control may require engaging extended family or social services. Managing the practice’s asthma population usually requires using a registry (free-standing or as a component of the electronic health record) to track visit frequency, symptom scores, flu shots, ED or hospital visits, asthma education and technique verification, and other parameters to guide management and, when needed, outreach. Collaboration with health care delivery systems and/or insurance companies may allow timely notification of urgent/emergent visits to other settings, overuse of rescue medications, or underuse of controller medications. (Asthma, Services & Other Resources)

Practice Guidelines

In 2007 the National Heart, Lung, and Blood Institute published a 440-page comprehensive guideline for the care of asthma in all age groups [National: 2007]; the summary is listed below.

National Asthma Education and Prevention Program Expert Panel.
Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007.
National Institutes of Health: National Heart, Lung, and Blood Institute; (2007) http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm. Accessed on 9/12/16.

Helpful Articles

Centers for Disease Control and Prevention (CDC).
Vital signs: asthma prevalence, disease characteristics, and self-management education: United States, 2001--2009.
MMWR Morb Mortal Wkly Rep. 2011;60(17):547-52. PubMed abstract

Winer RA, Qin X, Harrington T, Moorman J, Zahran H.
Asthma incidence among children and adults: findings from the Behavioral Risk Factor Surveillance system asthma call-back survey--United States, 2006-2008.
J Asthma. 2012;49(1):16-22. PubMed abstract

Spahn JD, Chipps BE.
Office-based objective measures in childhood asthma.
J Pediatr. 2006;148(1):11-5. PubMed abstract

Clinical Assessment

Overview

Initial diagnosis of asthma is based on history and physical exam findings, spirometry, and exclusion of other diagnoses.

Screening

No screening related to asthma in children is recommended.

Presentations

Signs and symptoms at presentation may vary by age, severity of asthma, and the trigger(s). Wheezing may occur in young children who don't have asthma and some children with asthma do not wheeze. Typical symptoms include:
  • Wheezing
  • History of:
    • cough, particularly at night or after exercise, with or without wheezing
    • recurrent wheeze
    • recurrent difficulty in breathing
    • recurrent chest tightness
  • Worsening with:
    • sleep, awakening patient (and family)
    • exercise
    • viral infection
    • inhalant allergens (e.g., animals with fur or hair, house-dust mites, mold, pollen)
    • irritants (tobacco or wood smoke, airborne chemicals)
    • changes in weather
    • strong emotional expression (laughing or crying hard)
    • stress
    • menstrual cycles
Atypical symptoms may include:
  • Rapid breathing
  • Sighing
  • Fatigue, inability to exercise properly
  • Difficulty sleeping
  • Anxiety, difficulty concentrating
In some children, exercise-induced bronchospasm (EIB) may be the only manifestation of asthma. EIB may begin during or after vigorous exercise and typically takes about 20-30 minutes to resolve after peak symptoms are experienced.

Cough variant asthma (CVA) occurs in all ages and is commonly seen in young children. CVA typically manifests with nighttime cough without wheezing and is thought to be a subset of asthma.

Recurrent, persistent cough may be the presenting symptom in some children. Between 1/3 and 1/2 of children with chronic cough may go on to develop typical asthma. [Todokoro: 2003]

Diagnostic Criteria

Three general criteria for the diagnosis of asthma include:
  • Symptoms of recurrent airway obstruction or airway hyperresponsiveness
  • Airway obstruction that is at least partially reversible
  • Alternative diagnoses have been excluded, which may require additional studies
These criteria are determined by a detailed history, physical exam, and, in patients ≥5 years of age, spirometry testing. In children with asthma, airflow obstruction should be reversible within 15-20 minutes after inhalation of a short-acting bronchodilator. Airflow obstruction is measured by comparing the forced expiratory volume in 1 second (FEV1) and the FEV1 to functional vital capacity (FVC) ratio to normal values for age. Reversibility is demonstrated by an increase in FEV1 by ≥12% or by 200 ml or more. However, it is important to note that normal spirometry results do not rule out a diagnosis of asthma.

Spirometry, required by the second criterion, cannot be reliably performed in children who are younger than 5 years of age in most settings. Younger children should be given a provisional diagnosis of asthma and treated appropriately, but the diagnosis should be frequently reassessed to avoid prolonged, unnecessary treatment in a child who doesn't really have asthma.

Clinical Classification

Severity of asthma, used to determine initial therapy, is classified as Intermittent, Persistent/Mild, Persistent/Moderate, or Persistent/Severe. Asthma control is classified as Well Controlled, Not Well Controlled, and Very Poorly Controlled. Levels of severity and control are based on assessment of impairment and risk as described by the NHLBI Guidelines. The Asthma Care Quick Reference (NHLBI) and Asthma, Treatment & Management contain further details.

Differential Diagnosis

Symptoms of asthma do not necessarily mean a diagnosis of asthma. Wheezing, especially, may occur due to other conditions such as bronchiolitis (although children who experience bronchiolitis as infants may be more likely to develop asthma later in life). [Cassimos: 2008] If wheezing does not respond to treatment to reverse airflow obstruction, additional studies may be needed to identify other causes (e.g., additional pulmonary function studies, laboratory studies to assess for alternative diagnoses such as cystic fibrosis or immunodeficiency, and/or chest imaging).

The following differential diagnoses are from the NHLBI Guidelines. [National: 2007]
  • Vascular rings or laryngeal webs
  • Upper airway disease
  • Allergic rhinitis and sinusitis
  • Foreign body in trachea or bronchus
  • Obstruction involving large airways
  • Vocal cord dysfunction (VCD)
  • Laryngotracheomalacia, tracheal stenosis, or bronchostenosis
  • Enlarged lymph nodes or tumor
  • Obstructions involving small airways
  • Viral bronchiolitis
  • Cystic fibrosis
  • Bronchopulmonary dysplasia
  • Heart disease
  • Other causes
    • Recurrent cough, not due to asthma
    • Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux

Comorbid Conditions

Gastroesophageal reflux disease (GERD) should be suspected when the child with asthma isn't responding well to asthma medications. Acid from reflux may cause injury to the lining of the throat, airways, and lungs causing a persistent cough. Children with reflux may have shortness of breath when acid enters the esophagus, triggering airway narrowing to prevent the acid from entering.

Sinusitis, which is relatively common in children with atopy, may trigger and/or exacerbate asthma symptoms.

Depression, anxiety, behavioral problems, and learning disabilities have been identified by the Centers for Disease Control and Prevention (CDC) as comorbidities common among children with asthma. [University: 2013] An association between asthma and internalizing disorders in children, such as panic disorder, social phobia, separation anxiety, and generalized anxiety, has been observed. [Carrera-Bojorges: 2013]

Obstructive sleep apnea and asthma are highly prevalent respiratory disorders and are frequently comorbid. Risk factors common to the 2 diseases include obesity, rhinitis, and gastroesophageal reflux. [Prasad: 2013]

Children who are obese or overweight are 1.16 to 1.37 times more likely to develop asthma than normal-weight kids, with the risk growing as their body-mass index increases. Obese children also experience more frequent and severe episodes of asthma, requiring more medical attention and drug therapy. [Oxford: 2013]

Pearls & Alerts

Spirometry in Children

Though a key component of diagnosis and monitoring of asthma, obtaining accurate spirometry in children, especially those under 5 years of age, can be difficult. Seek the most experienced available resource when spirometry is needed for younger patients. If performing spirometry in a primary care setting, assure reliable flow-volume loops. Spirometry360 provides a training program for office staff that involves distance verification of reliability.

History & Examination

Goals include:
  • assessment of asthma severity/control to guide therapeutic decisions
  • understanding the impact of asthma on the child and family to guide accessing needed resources and/or accommodations in the school or community
An Initial Asthma History Questions for Children (NHLBI) (PDF Document 57 KB) offers a comprehensive list.

Family History

History of asthma, allergy, sinusitis, rhinitis, eczema, or nasal polyps

Pregnancy Or Perinatal History

Premature delivery and subsequent respiratory complications may be relevant

Current & Past Medical History

Current symptoms: cough, wheezing, shortness of breath, chest tightness, nighttime cough/awakening

Pattern of symptoms: perennial, seasonal, or both; continual, episodic, or both; onset, duration, frequency, diurnal variations, especially nocturnal and on awakening or with exercise

Precipitating and/or aggravating factors: symptoms of comorbid conditions, such as reflux, viral exposures, allergens, home characteristics, etc.

Disease course: age at onset, progression, current management, frequency of using short-acting beta2-agonist (SABA), oral corticosteroids, current Asthma Action Plan

History of exacerbations: usual prodromal signs and symptoms, rapidity of onset, duration, frequency, need for urgent or emergent care, hospitalization, intensive care unit (ICU) admission, limitations to physical activity, exertion, play, exercise, sleep

Comorbid conditions: gastroesophageal reflux, obesity, obstructive sleep apnea, rhinitis or sinusitis, stress and depression, or Allergic Bronchopulmonary Aspergillosis (ABPA)

Current medications: frequency and technique, complementary and alternative medications (CAM), reasons for not using prescribed medications (inadequate technique and/or adherence are very common)

Medication side effects: headache, sleeplessness, nausea, nervousness/tremors, thrush, and behavioral changes

The Asthma Control Test (ACT) is a validated assessment tool that provides a score for recent asthma symptoms. Scores of 19 or below suggest suboptimal control.

Developmental & Educational Progress

How much school has been missed due to asthma-related issues?

How is school performance affected by asthma symptoms or medications? Is the child able to fully participate in sports and physical education?

Does the student have an active health plan at school and rescue medications available?

Does the student have or need a 504 plan or other accommodations?

Social & Family Functioning

Social situations, including at daycare or school, which may interfere with adherence; social support/social networks. How has asthma affected the child's social interactions and recreation?

Impact of asthma on patient and family, including episodes of unscheduled care (emergency department, urgent care, hospitalization), number of days missed from school/work; limitation of activity, especially sports and strenuous work; history of nocturnal awakening; effect on growth, development, behavior, school or work performance, and lifestyle; impact on family routines, activities, or dynamics; and, economic impact. Have there been problems with family adjustment to asthma?

Patient's and family's perceptions of disease, including knowledge of asthma and treatment, beliefs or concerns regarding use and long-term effects of medications; ability of patient and parents to cope with disease; level of family support and patient's and parents' capacity to recognize severity of an exacerbation; economic resources; and sociocultural beliefs. (See Asthma, Services & Other Resources.)

Physical Exam

Vital Signs

RR | HR | BP (medications may cause elevation) | SpO2 (especially if any current symptoms)

Growth Parameters

Height and weight (current and patterns of gain) for evidence of other chronic underlying disease (e.g. cystic fibrosis), effect of medications, obesity (might complicate asthma)

Skin

Evidence of atopy/eczema

HEENT

Evidence of allergy (periorbital swelling, conjunctival injection or edema, nasal discharge, nasal polyps, pale or swollen nasal turbinates, Denny's lines, mouth breathing), sinusitis, otitis media or effusion

Chest

Evidence of accessory muscle use (tracheal tugging, intercostal retractions, nostril flaring, increased abdominal movement), sounds of expiratory wheezing with normal breathing or with forced expiration, hyper-expansion of the thorax (barrel chest), hunched shoulders

Extremities/Musculoskeletal

Cyanosis, clubbing (suggests other diagnoses, particularly cystic fibrosis)

Testing

Laboratory Testing

Allergy testing may be helpful to confirm allergies as an asthma trigger or as a cause of related symptoms. It can also help guide avoidance or immunotherapy.

Imaging

Chest X-rays or other imaging may be useful to rule out other diagnoses, such as aspirated foreign body, tracheal ring, pneumonia, or congestive heart failure. Though chest X-ray cannot be relied upon to make or rule out the diagnosis, findings associated with asthma include: hyperaeration, flattened diaphragms, and bronchiolar thickening. Sinus imaging may be helpful if chronic sinusitis is suspected.

Genetic Testing

Although there is a genetic susceptibility to asthma, specific genetic causes have not been identified and testing is not currently readily available. (See Asthma, Causes.)

Other Testing

Spirometry: Spirometry should be performed in children 5 and older to assess airflow obstruction and reversibility with treatment. Spirometry should be repeated 1) after treatment has resulted in symptom control to document attainment of (near) normal airway function, 2) when symptoms seem poorly controlled, to evaluate causes, and 3) every 1 to 2 years to detect decreasing control or decline in pulmonary function over time. [National: 2007] In children, optimal technique is crucial for obtaining accurate results. One study found more than 3/4 of spirometries in primary care pediatric clinics were unacceptable. [Gillette: 2011] For children younger than 5, spirometry may be attempted but may not be as reliable. [Jallon: 1975]

Peak Flow: Although there is less emphasis on peak expiratory flow (PEF) measurement in the most recent guidelines, these measurements are still in widespread use. Taking peak flow measurements is quick, easy, and inexpensive, and, with practice, can be sufficiently reliable to guide daily therapy or in-office assessment. After initial diagnosis, peak flow measurements can be used to monitor response to treatment. Understanding the intricacies of peak flow use helps achieve more accurate readings:
  • They are extremely effort dependent.
  • Personal best, rather than predicted value, should be used as the 100% value.
  • Many children cannot perform an adequate peak flow maneuver.
  • Personal best increases with height (as do predicted values).
  • They are not as sensitive in children as FEV1 or FEF 25-75 for assessing airflow obstruction.
Peak Flow Meter Information (ALA), from the American Lung Association, provides how-to information for taking peak flow measurements. The Peak Flow Chart (NACA) shows normal peak flow based on height of child.

Exercise Challenge: If necessary for diagnosis, an exercise challenge with PEF or FEV1 measurements before, at 5-minute intervals during, and following a 20- to 30-minute exercise period may be performed. The test is considered positive if either measure declines by 15% or more.

Subspecialist Collaborations & Other Resources

Pulmonary Function Testing (see Services below for relevant providers)

Spirometry, challenge testing, and full pulmonary function testing may be available, depending on the laboratory. Education regarding symptoms, how to use a peak flow meter and inhaler, etc. is also offered in many PFT labs. Inquire regarding experience and comfort in testing children.

Pediatric Pulmonology (see Services below for relevant providers)

Referral to an asthma specialist may be helpful if symptoms are atypical or additional testing is needed for diagnosis. Also consider referral if response to initial therapy is not consistent with an asthma diagnosis.

Pediatric Allergy (see Services below for relevant providers)

Consider referral for evaluation of allergies, particularly if environmental exposures are triggers for asthma symptoms or seem related to poor asthma control.

Treatment & Management

Overview

Management recommendations are based on the 2007 National Heart, Lung, and Blood Institute (NHLBI) Guidelines [National: 2007] and differ by age group – 0-4 years of age, 5-11 years, and >12 years. Although inhaled corticosteroids (ICS) remain preferred for long-term control in all groups, other options, such as long-acting beta2-agonists (LABA), montelukast, and omalizumab, may be used as an alternative in children 12 and older and adults. The goals of treatment are:
  1. Reduce impairment by:
    • Preventing chronic and troublesome symptoms (e.g., cough, breathlessness)
    • Decreasing symptoms enough that only infrequent use (2 days a week or less) of inhaled short-acting beta2-agonists (SABA) for quick relief is required
    • Maintaining (near) normal pulmonary function
    • Maintaining normal activity levels, including exercise and school/work attendance
    • Meeting families' and patients' expectations of and satisfaction with, asthma care
  2. Reduce risk by:
    • Preventing exacerbations of asthma and minimizing the need for ED visits or hospitalizations
    • Preventing loss of lung function (maximizing lung growth in children)
    • Providing optimal pharmacotherapy with minimal or no adverse effects
If the child with asthma is not responding well to treatment, consider an alternative diagnosis and referral to an asthma specialist. Monitor for, evaluate, and potentially treat comorbid conditions, such as gastroesophageal reflux disease, obesity, sinusitis, stress and depression, and obstructive sleep apnea.

The image below depicts the flow of asthma care from the initial visit through ongoing treatment.

Flow of Asthma Care
Flow of Asthma Care 1
Flow of Asthma Care 2
Image adapted from Asthma Care Quick Reference (NHLBI)

How should common problems be managed differently in children with Asthma?

Growth Or Weight Gain

Carefully measure and plot height/weight at every encounter. If there is a slowing of height velocity that is felt to be related to ICS use, may need to consider modification of the medication regimen.

Viral Infections

Viral infections play a key role in triggering many asthma exacerbations; for example, the “September epidemic” of asthma exacerbations is likely related to viral illnesses, in particular rhinovirus. [Sears: 2007]

Over The Counter Medications

Antihistamines do not play a central role as controller therapy in asthma. The may have some beneficial effects in certain patients but not enough to be considered as an alternative to ICS or leukotriene receptor antagonists (e.g., montelukast). Primatene Mist (an OTC aerosolized epinephrine product) is not currently available but its manufacturer is seeking FDA approval for a new formulation – it's use is not recommended.

Pearls & Alerts

Surgery

Well-managed asthma reduces potential complications of surgery. Optimize control prior to surgery, including use of a short course of oral corticosteroids, if needed. [Expert: 2007]

Pregnancy

Asthma worsens in one-third and improves in one-third of women during pregnancy; medications should be adjusted accordingly. Maintaining lung function helps ensure oxygen supply to the fetus. Albuterol is preferred for rescue and inhaled corticosteroids (ICS) for long-term control. [Expert: 2007] Budesonide is the preferred ICS because more data are available on this medication during pregnancy. [National: 2007]

Depression

For children with asthma, treatment for comorbid depression increases compliance and improves outcome; early recognition may allow intervention before significant symptoms develop. In cases of severe asthma, treatment of depression may also decrease mortality. [Galil: 2000]

Neuropsychiatric complications

Neuropsychiatric events have been reported in some patients taking montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo and Zyflo CR). The Food and Drug Administration (FDA) has requested that manufacturers include a precaution in the drug prescribing information. Reported neuropsychiatric events include postmarket cases of agitation, aggression, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor.

Systems

Respiratory

Initial Visit: After initial diagnosis, or for children who are not currently on treatment, asthma should be classified by severity, age, and risk of exacerbation. The classification then guides the level of initial treatment, which usually involves medication, an action plan, and family education. Consider a return visit in 2 weeks to assess response to treatment and the family’s ability to accurately assess and adequately respond to symptoms.

The table below, from the 2007 NHLBI Guidelines [National: 2007], summarizes the age-based classification of asthma severity and initiation of treatment. Components of severity include impairment (reduction in lung function, frequency of symptoms, daily activity limitations, frequency of night awakenings, and medication use if pertinent) and risk (frequency and intensity of exacerbations).

Classifying Asthma Severity and Initiating Therapy
from the Asthma Care Quick Reference (NHLBI)

Click on the image to download a PDF of the table
Classifying Severity tiny

Follow-Up Visits: After initial treatment, patients should be seen again within a few weeks to check medication technique, compliance, and side effects. Frequency of further visits should be determined by level of control, anticipated seasonal or other changes in triggers, and confidence in their adherence with the Asthma Action Plan. At each visit, assess asthma control and adjust therapy and the Asthma Action Plan as needed. If symptoms have been in excellent control for 3 months or more, a step-down from one treatment level to another may be considered.

The table below, from the 2007 NHLBI Guidelines [National: 2007], can be used to guide the assessment of asthma control and changes in treatment during follow-up visits. Assessment of control is based on impairment and risk. Components of impairment include frequency of nighttime awakenings, SABA use, normal activity interruptions, lung function, and validated questionnaire scores (e.g., the Asthma Control Test Asthma, Services & Other Resources). Components of risk include exacerbations, corticosteroid use, lung health, and side-effects of treatment.

Assessing Asthma Control & Adjusting Therapy
from the Asthma Care Quick Reference (NHLBI)

Click on the image to download a PDF of the table
Assessing Control & Adjusting Therapy

Treatment: The 2007 NHLBI Guidelines [National: 2007] describe six Steps in treatment for asthma. Recommended treatment varies by age and the appropriate Step for a given patient is based on their asthma severity or control. In a child with poorly controlled asthma, stepping up to the next treatment level should be considered after assessing adherence to medication, knowledge of inhaler technique, and control of comorbid conditions and environmental factors. Stepping down may be appropriate for the child whose asthma has been well controlled for several months and if no new or increased exposures to triggers are anticipated. The previous 2 tables outline recommended Steps for various ages and levels of severity/control. The following tables detail the medications recommended for each Step and their dosages.

Stepwise Approach for Managing Asthma Long Term
from Asthma Care Quick Reference (NHLBI)
Stepwise Management
Usual Dosages for Quick-Relief Medications
from Guidelines for Diagnosis & Management of Asthma - Summary (NHLBI)
Usual dosages quick-relief meds
Comparative Dosages of Inhaled Corticosteroids
from Asthma Care Quick Reference (NHLBI)
Comparative Doses ICS
Usual Dosages of Other Long-Term Control Medications
from Asthma Care Quick Reference (NHLBI)

Click on images to download PDFs of the tables
Usual Doses Other

In some children, exercise induced bronchospasm (EIB) may be the only manifestation of asthma and children with known asthma may experience worsening of symptoms during physical exertion. EIB may begin during or after vigorous exercise, and takes about 20 to 30 minutes to resolve after peak symptoms are experienced. EIB should be controlled so that it does not limit participation in sports. The severity of EIB will depend on the duration and vigor of exercise, the dryness/coolness of the air, and factors intrinsic to the child.

Pre-treatment with inhaled beta2-agonists before exercise is successful in more than 80% of patients. In children with frequent symptoms, addition of long-term control medications or stepping up treatment for children who have asthma in addition to EIB, is indicated. Simple remedies, including warming-up before exercise and wearing a mask or scarf over the mouth when exercising in cold weather, may be helpful. Being physically fit helps postpone the onset of EIB in susceptible patients. Children with EIB alone should be monitored periodically by pulmonary function tests (PFTs) to ensure that they continue to have no evidence of asthma without exercise. [National: 2007] [Randolph: 2008]

Chronic cough is a common presentation of asthma in children; if the cough is mainly nocturnal and has been present for greater than 2 weeks, response to a trial of asthma medication may raise suspicion of cough-variant asthma (CVA). [Johnson: 1991] This is particularly likely if there is a personal history of allergy and a family history of allergy and/or asthma. Medications may consist of bronchodilators, inhaled or oral corticosteroids, or leukotriene modifiers; no controlled studies to favor one class over the other have been performed. [Antoniu: 2007] [Todokoro: 2003]

Ongoing Education: Education begins with in-office demonstrations for the patient and family on how to administer medication. (See Administering Asthma Medication Video.) The clinician also involves patients and their families in developing strategies for self-assessment, avoidance of triggers, and Asthma Action Plans for home and school. Ongoing education involves patient/family education, school support, and referrals to local asthma resources, such as asthma camps or parent organizations. See Educational Goals for Asthma (2007 NHLBI Guidelines) (PDF Document 97 KB) for more information on how to discuss asthma with patients and families.

Printable and online fillable Asthma Action Plans and other tools for educational purposes can be found under Asthma, Services & Other Resources.

Subspecialist Collaborations & Other Resources

A referral for specialty consultation and/or management should be considered if control has been erratic.

Pediatric Pulmonology (see Services below for relevant providers)

Consider referral when: 2 or more bursts of oral steroids are needed within 6 months, an exacerbation requires hospitalization, care is at the Step 4 level or higher (Step 3 care or higher for children 0-4 years), additional testing is needed, or comorbid conditions present management challenges.

Pediatric Allergy (see Services below for relevant providers)

Consider referral for evaluation and immunotherapy if there is a relationship between persistent symptoms and exposure to particular allergens, if asthma is difficult to manage and there is personal or family history of allergy, or for management of refractory cases of asthma. Allergists are more numerous than pediatric pulmonologists and, in some geographic areas, may be the specialists with the most experience.

Departments of Health, State (see Services below for relevant providers)

Consider referring if the state has an asthma home-visiting program. Such programs can provide home trigger education and assessment, and trigger remediation referral.

Immunology/Infectious Disease

A child with atopy produces IgE antibodies after exposure to common environmental allergens. Asthma is attributable to atopy in 56.3% of cases in the United States, however 95% of children with asthma have allergy. [Samuel: 2008] The individual risk of developing asthma or other atopic diseases results from the interaction of hereditary factors and environmental stimuli.

Common allergens include dust mites, mold, cockroach feces, pollens, and exposure to animals. Dust mite, mold, and cockroach allergy are very rare in children and adults that grow up in the arid west because the humidity is generally too low to support those organisms. [Nelson: 1995] In children with seasonal allergies, asthma symptoms may worsen during certain pollen seasons. Symptoms can also flare as a result of mold exposure (e.g., during rainy seasons or in damp areas). While uncommon, food allergies can be a factor in asthma. Foods to which American children are commonly allergic include eggs, cow's milk, wheat, soybean products, tree nut, and peanuts. Food additive allergy is extremely rare but may include sodium bisulfite, potassium bisulfite, sodium metabisulfite, potassium metabisulfite, and sodium sulfite, which are commonly used in food processing or preparation and can be found in foods such as dried fruits or vegetables, potatoes (packaged and some prepared), bottled lime or lemon juice, shrimp (fresh, frozen, or prepared), and pickled foods. Food allergies that trigger symptoms of an asthma attack likely produce allergy symptoms (hives, rash, nausea, vomiting, and diarrhea) followed by coughing and wheezing. And if not caught quickly, anaphylaxis may result.

The presence of specific IgE antibodies to environmental allergens is determined with skin prick or in vitro testing, such as radioallergosorbent testing (RAST) or enzyme-linked immunosorbent assay (ELISA), in children with atopy.

Management of allergens includes rational environmental avoidance strategies for at-risk populations. When this is not possible, consider allergy immunotherapy. Antihistamine drugs, while helpful for allergy, are not effective for asthma. Studies suggest that immunotherapy may be appropriate when a causative allergen has been demonstrated. [Cox: 2011] Anti-IgE monoclonal antibody (omalizumab) may be useful as add-on therapy in patients with severe persistent asthma who are inadequately controlled by optimal pharmacological therapy.

Viral upper respiratory infections commonly trigger asthma exacerbations and may warrant a change in management of asthma symptoms. Limit infections through routine immunizations and teach preventive skills such as proper hand-washing. Some studies suggest that certain childhood viral infections, like rhinovirus, respiratory syncytial virus (RSV), and parainfluenza virus, can predispose children to developing asthma later in life. Consultation with an asthma specialist is recommended for patients for whom omalizumab is being considered.

Subspecialist Collaborations & Other Resources

Pediatric Allergy (see Services below for relevant providers)

Consider referral for evaluation if there is a relationship between persistent symptoms and exposure to particular allergens, if asthma is difficult to manage and there is personal or family history of allergy, or for management of refractory cases of asthma. Allergists are more numerous than pediatric pulmonologists and, in some geographic areas, may be the specialists with the most experience.

Pharmacy & Medications

Evaluation and Treatment/Management

The recommended medications to manage asthma are found in the 2007 NHLBI Guidelines.Asthma Care Quick Reference - Diagnosing and Controlling Asthma (PDF Document 719 KB)

Some considerations regarding long-term controller medications:
  • Inhaled corticosteroids (ICS) vary in terms of pharmacokinetic/pharmacodynamic properties, delivery, incidence of adverse effects, and cost to patient. Decisions regarding which ICS to use should take these into consideration. [Kelly: 2009] A comparison of recommended doses for different ICS based on age and step can be found in Asthma Care Quick Reference - Diagnosing and Controlling Asthma (PDF Document 719 KB).
  • Leukotriene receptor antagonists (LTRA) may be considered as an alternative to ICS in mild persistent asthma or in step-up therapy along with ICS in patients who are not well controlled with ICS alone. In mild persistent asthma, controlled trials have shown that ICS have greater efficacy and are more cost-effective than LTRA. However, montelukast has some advantages, including ease of administration, benefit in treating allergic rhinitis and exercise-induced bronchoconstriction, lack of demonstrated adverse effect on growth, and availability as a generic formulation. Of note, neuropsychiatric events have been reported in adult, adolescent, and pediatric patients taking montelukast and the clinical details of some post-marketing reports appear consistent with a drug-induced effect.
  • Long-acting beta-2 agonists (LABA) should not be used as monotherapy for asthma. The main role of LABA is in step-up therapy along with ICS in patients who are not well controlled despite the use of ICS alone. The FDA has placed a warning on LABA-containing medications primarily due to a US study that showed an increase in asthma-related deaths in patients receiving salmeterol. [Nelson: 2006] Also, LABA may increase the risk of asthma-related hospitalization in pediatric and adolescent patients.
  • Step-up therapy for children with uncontrolled asthma already receiving ICS: A study comparing increasing the dose of ICS vs. adding LABA vs. adding LTRA (i.e., Step 3 therapy) demonstrated that while adding LABA to ICS was more likely to provide the best response, many children had a best response to LTRA or ICS step-up therapy. The authors felt that this study underscored the need to routinely monitor and appropriately adjust a child’s asthma treatment individually within Step 3 care. [Lemanske: 2010]

Complementary & Alternative Medicine

Many families use complementary and alternative medicine (CAM) for asthma, whether out of frustration with lack of effectiveness of standard therapies, in seeking safer or more natural approaches, or trying to manage symptoms not addressed by medical treatment. [Philp: 2012] Examples of CAM include breathing exercises, herbal remedies, vitamins, acupuncture, and other treatments. Given the uncertain benefits and potential side effects of some CAM and possible drug interactions, it is important for physicians to be aware of their use among their patients and understand the reasons for their use. [Chen: 2013] Probiotics may reduce the risk of atopy and asthma in children. However, results from clinical trials have been conflicting and several studies may have been underpowered. [Elazab: 2013]

Frequently Asked Questions

FAQs and answers for parents can be found in For Parents and Families at Asthma and at:

Can you suggest an online education program to help me best care for my patients with asthma?

The American Academy of Pediatrics' Education in Quality Improvement in Pediatric Practice (EQIPP) offers a program on diagnosing and managing asthma.

What ICD-10 coding would you use for a child with viral-induced asthma severe enough to need controllers or hospitalizations?

ICD-10 provides codes specific for severity, as detailed in the NHLBI guidelines, and for exercise induced, cough variant, and "other" asthma; the need for controllers and hospitalization would suggest at least moderate persistent asthma (J45.4) with a fifth digit to specify whether uncomplicated (0), with exacerbation (1), or with status asthmaticus (2). ICD10Data.com provides more detail (search for "asthma").

Where can I learn more about the role of office-based spirometry and asthma?

A very helpful article on this topic and other objective measures used in childhood asthma such as peak flow is [Spahn: 2006]. Spirometry360 is a program of the University of Washington that offers web-based training for office staff performing spirometry.

Issues Related to Asthma

Resources

Information for Clinicians

Asthma Care Quick Reference (NHLBI)
A 12-page summary of the Guidelines for Diagnosis and Management of Asthma from the National Heart, Lung, and Blood Institute; provides condensed charts and bulleted lists, along with practical tips for educating patients; click the PDF link on this page to download.

Guidelines for Diagnosis & Management of Asthma - Summary (NHLBI)
Summarizes in 74 pages the National Heart, Lung, and Blood Institute's 2007 Guidelines for Diagnosis and Management of Asthma; click the PDF link to download.

Guidelines for Diagnosis and Management of Asthma (NHLBI) (PDF Document)
The 440-page Expert Panel Report 3: Guidelines on Asthma was commissioned by the National Asthma Education and Prevention Program (NAEPP) and coordinated by the National Heart, Lung, and Blood Institute (NHLBI); published in 2007; click the PDF link on this page to download.

Asthma, for Professionals (ALA)
Data, statistics, and links to asthma programs, for health care professionals and volunteers; American Lung Association.

National Asthma Education and Prevention Program (NHLBI)
Offers links to information about asthma for providers, families, and schools; a program of the National Heart, Lung, and Blood Institute.

Physician Asthma Care Education Program (PACE) (NHLBI)
Information about an interactive multimedia seminar to improve awareness, ability, use of communication and therapeutic techniques for reducing the effects of asthma on children and their families; offered by the National Heart, Lung, and Blood Institute.

Asthma Online Tool Kit (NASN)
An extensive compilation of asthma resources and tools for schools and school nurses; National Association of School Nurses.

Asthma Provider Manual - Pediatrics (UDOH) (PDF Document 3.4 MB)
Links to a 31-page manual, a medication guide, and patient education materials; Utah Department of Health Asthma Program.

Helpful Articles

Centers for Disease Control and Prevention (CDC).
Vital signs: asthma prevalence, disease characteristics, and self-management education: United States, 2001--2009.
MMWR Morb Mortal Wkly Rep. 2011;60(17):547-52. PubMed abstract

Spahn JD, Chipps BE.
Office-based objective measures in childhood asthma.
J Pediatr. 2006;148(1):11-5. PubMed abstract

Winer RA, Qin X, Harrington T, Moorman J, Zahran H.
Asthma incidence among children and adults: findings from the Behavioral Risk Factor Surveillance system asthma call-back survey--United States, 2006-2008.
J Asthma. 2012;49(1):16-22. PubMed abstract

Clinical Tools

Algorithms/Care Processes

Initial Visit - Classifying Asthma Severity and Initiating Treatment (NHLBI) (PDF Document 59 KB)
Table guides age-based classification of asthma severity and initiation of treatment, from the 2012 Asthma Care Quick Reference summary of the 2007 NHLBI Guidelines.

Follow-Up Visits: Assessing Asthma Control & Adjusting Therapy (NHLBI) (PDF Document 56 KB)
A table of age-based classification of asthma control and steps in treatment; from the 2012 Asthma Care Quick Reference summary of the 2007 NHLBI Guidelines.

Stepwise Approach for Managing Asthma Long Term (NHLBI) (PDF Document 4.6 MB)
A table of age-based medication treatment of asthma in 6 Steps; from the 2012 Asthma Care Quick Reference summary of the 2007 NHLBI Guidelines.

Assessment Tools/Scales

Initial Asthma History Questions for Children (NHLBI) (PDF Document 57 KB)
Comprehensive list of questions for the initial assessment of a child with asthma; from the 2007 NHLBI Guidelines for Asthma Diagnosis and Management.

Asthma Control Test for Children 4-11 Years Old (PDF Document)
A downloadable pdf version of the ACT; from Intermountain Healthcare and GlaxoSmithKline.

Asthma Control Test for Children
Easy to use, online, asthma control test based on recent symptoms; allows for printing the results of the test. Site is sponsored by a pharmaceutical company but appears to be free of advertising.

Asthma Control Test for People 12 Years or Older (PDF Document)
Downloadable PDF version; from Intermountain Healthcare and GlaxoSmithKline.

Asthma Control Test for Adults
An easy to use, online asthma control test for evaluating control based on recent symptoms. Site is sponsored by a pharmaceutical company but appears to be free of advertising.

Care/Action Plans

Asthma Action Plan (Intermountain Healthcare) (PDF Document 710 KB)
Sample plan in downloadable PDF.

Asthma Action Plan in Spanish (Minnesota Department of Health) (PDF Document 20 KB)
Sample plan in Spanish (Plan de Tratamiento Contra el Asma).

Asthma Action Plan in Spanish, Chinese, Vietnamese (RAMP) (PDF Document 20 KB)
Asthma plans in both printable and fillable PDF formats; Regional Asthma Management and Prevention program.

Asthma Action Plan, Medication Authorization & Self-Administration Form (UDOH/USOE) (PDF Document 340 KB)
Fillable PDF form that uses standard green, red, and yellow coding to guide treatment alternatives; complies with Utah Code 53A-11-602. Prepared in collaboration with the Utah Department of Health and Utah State Office of Education.

Medication Guides

Usual Dosages Quick-Relief Medications for Asthma (NHLBI) (PDF Document 41 KB)
Details on available choices of quick-relief (aka Rescue) medications for asthma; from the Asthma Care Quick Reference by the National Heart, Lung, and Blood Institute.

Comparative Dosages of Inhaled Corticosteroids (NHLBI) (PDF Document 63 KB)
Detailed comparisons; from the Asthma Care Quick Reference; National Heart, Lung, and Blood Institute.

Usual Dosages of Other Long-Term Control Agents (NHLBI) (PDF Document 51 KB)
Details on choices for long-term medications for asthma control other than inhaled corticosteroids, from the Asthma Care Quick Reference by the National Heart, Lung, and Blood Institute.

Asthma Inhaler Posters (AAN/MoA)
Posters ($3-$5 each) with pictures of available inhalers. Useful for learning and verifying with parents/patients the various brands; Allergy & Asthma Network/Mothers of Asthmatics.

Patient Education & Instructions


Controlling Triggers:
How-To Videos

Okay with Asthma™
Provides information for children about asthma through a story. Even if you do not have asthma, you will learn how to help friends that have asthma. After watching, you can create your own story and print it.

Help Your Child Gain Control Over Asthma (EPA) (PDF Document 1.3 MB)
Brochure with education, checklists, and asthma action plan items (36 pages); Environmental Protection Agency.

Help Your Child Gain Control Over Asthma (EPA) (Spanish) (PDF Document 656 KB)
Spanish-language brochure (Ayude a Su Niño a Controlar el Asma) with education, checklists, and asthma action-plan items (36 pages); Environmental Protection Agency.

Peak Flow Meter Information (ALA)
Patient information regarding the use of peak flow meters for asthma control assessment; American Lung Association.

Asthma (MedlinePlus)
Asthma information and tutorials in English and Spanish; from the National Library of Medicine.

Breathing Easier with Asthma (Intermountain Healthcare) (PDF Document 2.9 MB)
A comprehensive 36-page PDF about understanding and controlling asthma.

Breathing Easier (Intermountain Healthcare) (Spanish) (PDF Document 1.6 MB)
A comprehensive 36-page PDF about understanding and controlling asthma, in Spanish (Para Respirar Mas Facil Con Asma).

Patient/Family Questionnaires/Diaries/Data Tools

Patient Self-Assessment Record (NHLBI) (PDF Document 54 KB)
A sample record for patients to track asthma symptoms and medication use; from the 2007 National Heart, Lung, and Blood Institute Guidelines.

Outdoor Physical Activity During Inversions (UDOH) (PDF Document 123 KB)
Use this chart to track the PM2.5 level and your symptoms; Utah Department of Health.

Peak Flow Chart (NACA)
A downloadable peak flow recording chart; National Asthma Council of Australia.

Toolkits

Asthma Care Process Model (Intermountain Healthcare) (PDF Document)
Summarizes diagnosis and management information for asthma in pediatric and adult patients. Includes an algorithm, a model for assessment of control, and a list of medications by age group and severity of symptoms; Intermountain Healthcare’s Primary Care and Pediatric Specialty, 2016.

Other

Tools for Schools

Recess Guidance for Schools: Asthma (UDOH) (PDF Document 240 KB)
Guidance for when to schedule indoor recess rather than outdoor recess based on the air quality; Utah Department of Health released this

Asthma and Physical Activity in School (NHLBI)
A 29-page booklet (download as PDF or order hard copies) for school personnel about optimizing physical education for children with asthma and managing their symptoms; National Heart, Lung, and Blood Institute.

Is the Asthma Action Plan Working? A Tool for School Nurse Assessment (NAEPP)
A tool to assists school nurses in determining how well an asthma action plan is working for a student; National Asthma Education and Prevention Program.

Students with Chronic Illnesses: Guidance for Families, Schools, and Students (NHLBI)
Two-page guidance sheet presenting positive actions schools and families can take to address multiple chronic diseases. Facilitates compliance with applicable federal laws; National Heart, Lung, and Blood Institute.

How Asthma Friendly is your School? (NAEPP)
A 2-page resource for parents and school staff who would like to determine how well their school serves students who have asthma; National Asthma Education and Prevention Program.

How Asthma Friendly is Your Childcare Setting? (NAEPP)
Seven-item list that can be used by parents and child-care providers to help pinpoint specific areas that may cause problems for children with asthma; National Asthma Education and Prevention Program.

How Asthma Friendly is your Childcare Setting? (NAEPP) (Spanish)
Seven-item list in Spanish that can be used by parents and child-care providers to help pinpoint specific areas that may cause problems for children with asthma; National Asthma Education and Prevention Program.

Management of Asthma Exacerbations when a School Nurse is Not Available (NAEPP)
Offers a sample protocol for non-nursing staff, such as classroom teachers, who may need to help manage a child's asthma episode; National Asthma Education and Prevention Program.

Management of Asthma Exacerbations – Emergency Nursing Protocol (NAEPP)
The 2-page document suggests emergency nursing protocol for students with asthma symptoms who don’t have a personal asthma action plan; National Asthma Education and Prevention Program.

Winning with Asthma for Coaches Booklet (UDOH) (PDF Document 10 KB)
A 24-page downloadable booklet (click "Educational Booklet") with additional resources that educates coaches at all levels about asthma, asthma and exercise, asthma symptoms, appropriate precautions, and medications and action plans; Utah Department of Health.

Winning with Asthma for Coaches Video (UDOH)
A 30-minute educational video for coaches at all levels that furthers understanding of asthma and provides training for working with athletes who suffer from asthma; Utah Department of Health and Minnesota Department of Health Asthma Programs.

Utah School Integrated Pest Management (Utah State University)
A comprehensive approach to pest control that uses a combined means to reduce the status of pests to tolerable levels while maintaining a quality environment to improve environmental and human health in schools; Utah State University Extension Program.

Information & Support for Families

Family Diagnosis Page

Information on the Web

Asthma Program (UDOH)
Comprehensive information and education for patients, families, and professionals - also provides a local view of asthma prevalence. Available for download: Asthma Action Plan, General Emergency Protocol, Asthma Self- Administration Form, and much more; Utah Department of Health.

Asthma in Children (MedlinePlus)
A comprehensive compilation of links and information related to asthma in children, screened by the National Library of Medicine.

Asthma & Allergies (healthychildren.org)
Focused on helping parents understand and live with pediatric asthma and allergies. Offers links to numerous online articles and videos demonstrating use of inhalers and other device; sponsored by the American Academy of Pediatrics.

Asthma (ALA)
Information for parents and families about asthma, asthma-friendly environments, advocacy, and more; American Lung Association.

What Happens During an Asthma Flare-Up? (Movie) (KidsHealth)
A 3-minute movie for kids and parents; from Nemours, which offers more information about asthma and many other health conditions.

What is Asthma? (NHLBI)
Addresses multiple aspects of asthma, including causes, signs and symptoms, treatment, and prevention; National Heart, Lung, and Blood Institute.

Asthma Information (NJH)
Information about asthma, its causes, and treatment. Includes links to videos about use of inhalers and other devices; National Jewish Health.

FAM Allies Education
Information on a variety of asthma-related topics, including illustrated guides for using peak flow meters, inhalers, and spacers; Fighting Asthma Milwaukee program.

Lungtropolis (ALA)
Information (and a game) for children with asthma and their parents; American Lung Association.

Support National & Local

Allergy & Asthma Network Mothers of Asthmatics
A nonprofit that offers support for families affected by asthma.

Allergy & Asthma Network Mothers of Asthmatics (Spanish)
A nonprofit that offers support in Spanish for families affected by asthma.

Studies/Registries

Clinical Trials in Children with Asthma (clinicaltrials.gov)
A list of trials registered with the National Institutes of Health; some may be of interest and might offer opportunity to participate in research.

Services for Patients & Families

Camps

Camp Wyatt, more info...
1930 South 1100 East
Salt Lake City, UT 84106
Phone: 801-484-4456
Fax: 801-484-5461
http://www.lung.org/associations/states/utah/asthma/camp-wyatt.html

See all Camps services providers (101) in our database.

Departments of Health, State

Utah Asthma Home Visiting Program, more info...
288 North 1460 West
PO Box 142107
Salt Lake City, UT 84114-2107
http://www.health.utah.gov/asthma/homevisit/index.html

See all Departments of Health, State services providers (20) in our database.

Local Support Groups, General

See all Local Support Groups, General services providers (70) in our database.

National Support Groups, General

We currently have no National Support Groups, General service providers listed; search our Services database for related services.

Pediatric Allergy

See all Pediatric Allergy services providers (12) in our database.

Pediatric Pulmonology

Pediatric Asthma Program, more info...
100 N Mario Capecchi Dr
Salt Lake City, UT 84103
Phone: 801-662-1765
Fax: 801-662-1775
http://intermountainhealthcare.org/hospitals/primarychildrens/services/pages/Service.aspx?service=Pulmonology

See all Pediatric Pulmonology services providers (4) in our database.

Pulmonary Function Testing

See all Pulmonary Function Testing services providers (18) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Author: Chuck Norlin, MD - 12/2013
Contributing Author: Richard W. Hendershot, MD - 11/2013
Reviewing Authors: Derek A. Uchida, MD - 12/2013
Jennifer Goldman-Luthy, MD, MRP, FAAP - 11/2013
Content Last Updated: 12/2013

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