Management of Pediatric Asthma: Focus on the Expert Panel Report 3

Article Outline

• Definition and impact of asthma
• Risk factors for asthma development
• Pathogenesis and pathophysiology
• National asthma guidelines
• Diagnostic considerations
• Classification: severity and control
• Long-term management
• Education
  • Self-monitoring and Periodic Assessment
  • Environmental Control and Avoidance
• Pharmacotherapy recommendations
  • Step 1 Management
  • Step 2 Management
  • Step 3 Management
  • Step 4 Management
  • Step 5 and 6 Management
• Challenges with inhalation therapies
• Adjusting asthma therapies
• Acute exacerbations
• Specific considerations for pediatric patients with asthma
• Summary
• References
• Biography
• Copyright

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Definition and impact of asthma 

Asthma is a chronic inflammatory disorder of the airways involving numerous cell types and mediators. Patients with asthma exhibit variable and recurring symptoms, including recurrent episodes of cough or wheeze, breathlessness, and chest tightness (National Asthma Education and Prevention Program [NAEPP], 2007). The airflow obstruction responsible for the symptoms is largely reversible and related to bronchial smooth muscle contraction (broncho-constriction), inflammation of the airway mucosal surface leading to edema and increased mucus production, and hyperresponsiveness or increased bronchial reactivity.

Diagnosis is challenging in young children who often present with transient episodes of wheezing or reactive airways disease with or without respiratory viral infections.

Asthma is unique because it has a significant direct impact on people across the continuum of life, from the young to the very old. It is a leading diagnosis among children and is associated with significant morbidity as measured in exacerbations, missed days of school, and decreased quality of life. According to national statistics, more than 20 million people in the United States have asthma, including 9 million children and adolescents (American Lung Association, 2005; Dey, Schiller, & Tai, 2004). In other surveys, nearly 12% of children report an asthma diagnosis, and the prevalence is disproportionately higher among lower socioeconomic groups (Bloom & Dey, 2006; Cloutier, Hall, Wakefield, & Bailit, 2005). Children experience 4 million asthma attacks annually, and 44% of hospitalizations for this disease occur in children (Hall & Owings, 2002). In 2002, 14.7 million days were missed from school reportedly due to asthma. Diagnosis is challenging in young children who often present with transient episodes of wheezing or reactive airways disease with or without respiratory viral infections.

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Risk factors for asthma development 

Wheezing that occurs early in life is considered a risk factor for asthma development; however, young patients exhibit varying patterns of wheeze, ranging from transient wheeze that resolves, wheezing during viral infections in the absence of atopy, and persistent wheezing. In addition, many patients experience wheezing during childhood that resolves during adolescence. In these patients, the symptom may never occur again or may develop later in life.

The major risk factors associated with asthma development are the presence of atopy, recurrent respiratory viral illnesses, and early exposure to allergens (Stewart, 2008). Atopy refers to a genetic predisposition to allergic diseases, including atopic dermatitis and eczema. The Modified Asthma Predictive Index indicates major asthma risk factors as a parental history of asthma, clinician diagnosis of atopic dermatitis, and evidence of sensitization to at least one aero-allergen (Guilbert et al., 2004). Respiratory viral illnesses are both a risk factor and a trigger for asthma. Specifically, severe infection with respiratory syncytial virus is associated with asthma development later (Sigurs et al., 2005). The impact of early allergen exposure as a risk factor is less clear. Early exposure to dust mites and cockroach roach allergen is associated with higher asthma rates; however, data are conflicting about whether a pet in the home acts as a risk or protective factor (Hesselmar, Abert, Aberg, Eriksson, & Bjorksten, 1999; Litonjua, Carey, Burge, Weiss, & Gold, 2001).

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Pathogenesis and pathophysiology 

Pediatric asthma is characterized by episodic wheezing and reversible airflow obstruction. The concomitant presence of allergies is more prevalent in children compared with adults. Available evidence suggests that loss of lung function occurs early in life for asthma patients, even before a pattern of recurrent or persistent wheezing is evident (Taussig et al., 2003). Some patients continue to exhibit spirometric declines despite adequate long-term control therapy.

Common triggers for asthma symptoms and exacerbations include upper respiratory viral infections, exposures to allergens or irritants, exercise, and cold air. Other conditions that are often present in children with asthma and can aggravate asthma control include gastroesophageal reflux disease, allergic rhinitis, and sinusitis. Among young children, the most frequent cause of asthma symptoms is a viral respiratory infection. For infants and children who wheeze with viral upper respiratory infections, two patterns develop: either persistence of symptoms throughout childhood, or a disappearance of symptoms in the preschool years.

Bronchoconstriction, hyperresponsiveness, and airway edema are principal features attributed to underlying inflammation of asthma. The chronic effects of inflammation include changes in airway structure, exhibited as sub-basement membrane fibrosis, mucus hypersecretion, smooth muscle hypertrophy, and damage to epithelial cells. Permanent remodeling of the airway occurs in some but not all patients.

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National asthma guidelines 

Recommendations concerning asthma management are available from the NAEPP. In 2007, Guidelines for the Diagnosis and Management of Asthma's Expert Panel Report 3 was published and provides evidence-based recommendations (NAEPP, 2007). The guidelines describe three categories for management based on the patient's age: 0 to 4 years, 5 to 11 years, and 12 years and older. Each category includes a six-step approach for management, with consideration provided for age-appropriate management considerations.

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Diagnostic considerations 

Data suggest that symptoms develop in more than 50% of children with asthma before age 5 years. Under-diagnosis is a frequent problem, especially in children who exhibit wheezing with respiratory infections. Although clinicians who treat children often are reluctant to make a diagnosis of asthma, recurrent episodes of cough and wheezing most often are due to asthma in both children and adults. It is prudent, however, to consider the differential diagnoses described in Box 1.

The main components of asthma diagnosis include the patient history, physical examination, and selected diagnostic testing based on the patient's age. Diagnosis can be challenging in young patients based on the absence of objective parameters. A key feature in the history is reported wheezing with respiratory infections, although wheezing in the absence of infection may predict more persistent disease. The presence of risk factors for asthma development is important to explore. These include previous respiratory infections and environmental exposures to a variety of allergens and irritants.

Based on the episodic nature of asthma, the physical examination is often relatively normal. Because of the prevalence of allergies in childhood asthma, signs of allergic rhinitis or dermatologic allergies may be present. Lung examination is often normal during asymptomatic periods, and signs and symptoms, including wheezing, coughing, decreased air movement, and accessory muscle retractions, are only present during acute episodes.

Objective data that can be obtained in older children can facilitate a diagnosis of asthma. Spirometry testing is important for asthma diagnosis and monitoring and should be considered for children as young as age 5 or 6 years, although a child's ability to perform spirometry is highly variable at this age. Evidence for airflow obstruction on spirometry is reflected in a reduced ratio of forced expiratory volume in 1 second (FEV₁) to forced vital capacity. These results basically measure the volume of air exhaled in the first second of a maximal exhalation (FEV₁) and the total volume of air exhaled (forced vital capacity). A ratio of less than 75% is consistent with asthma in children. The actual FEV₁ result provides evidence for asthma severity (see severity classification).

A recent American Thoracic Society workshop addressed the benefit of widespread screening for asthma in children (Gerald et al., 2007). Participants concluded that, based on current evidence, a good rationale does not exist for population-based asthma screenings. The participants suggest that clinicians should be attentive to recurrent or persistent symptoms among children followed by appropriate workup and assessment.

Other objective testing in the diagnosis of asthma include peak expiratory flow rates, post-bronchodilator testing to evaluate reversibility, bronchial challenges with methacholine or histamine, and skin testing or serologic testing for the presence of atopy and allergies.

Other objective testing in the diagnosis of asthma include peak expiratory flow rates, post-bronchodilator testing to evaluate reversibility, bronchial challenges with methacholine or histamine, and skin testing or serologic testing for the presence of atopy and allergies. These tests may be useful in selected clinical situations or when the diagnosis is difficult.

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Classification: severity and control 

In the current asthma guidelines, there was a major shift in emphasis from categorizing patients based on disease severity to a new focus on asthma control. At the time of diagnosis or initial assessment, the patient can be categorized according to severity as described in Table 1, Table 2, Table 3. After therapeutic strategies are initiated, ongoing monitoring should focus on control. The categories of control are well controlled, not well controlled, and very poorly controlled, which are described in Table 4, Table 5, Table 6.

Table 1. Asthma severity classification for patients aged 0 to 4 years

SABA, Short-acting inhaled β₂ agonists.

Lung function assessments are not practical for this age group. National Asthma Education and Prevention Program, 2007.

Table 2. Asthma severity classification for patients 5 to 11 years

FEV_1, Forced expiratory volume in 1 second; SABA, Short-acting inhaled β₂ agonists. National Asthma Education and Prevention Program, 2007.

Table 3. Asthma severity classification for patients ≥12 years

FEV_1, Forced expiratory volume in 1 second; SABA, short-acting inhaled β₂ agonists. National Asthma Education and Prevention Program, 2007.

Table 4. Asthma control classification for patients aged 0 to 4 years

SABA, Short-acting inhaled β₂ agonists.

Lung function assessments are not practical for this age group.

For asthma that is not well controlled, consider one step up in therapy.

For very poorly controlled asthma, consider a short course of oral corticosteroids and a step up in therapy. National Asthma Education and Prevention Program, 2007.

Table 5. Asthma control classification for patients aged 5 to 11 years

FEV_1, Forced expiratory volume in 1 second; SABA, short-acting inhaled β₂ agonists.

For asthma that is not well controlled, consider one step up in therapy.

For very poorly controlled asthma, consider a short course of oral corticosteroids and a step up in therapy. National Asthma Education and Prevention Program, 2007.

Table 6. Asthma control classification for patients aged ≥12 years

ACQ, asthma control questionnaire; ACT, asthma control test; ATAQ, asthma therapy assessment questionnaire; FEV₁, Forced expiratory volume in 1 second; SABA, short-acting inhaled β₂ agonists.

For asthma that is not well controlled, consider one step up in therapy.

For very poorly controlled asthma, consider a short course of oral corticosteroids and a step up in therapy. National Asthma Education and Prevention Program, 2007.

Severity and control are described in two specific domains: impairment and risk. Impairment refers to the patient's current condition and how it affects his or her life. Risk is assessed based on the potential for future problems associated with their asthma. Assessment of severity or control involves the use of similar measures: nature and frequency of symptoms, use of rescue therapies (short-acting β₂ agonist [SABA]), limitations in activity because of asthma, spirometry or peak flow measurements, and exacerbation frequency. A combination of measures should be used in assessing severity or control. An emerging measure that may become more important in the near future is the use of exhaled nitric oxide measurements. Exhaled nitric oxide may be related to inflammatory activity in the airways and could become a usual monitoring parameter for asthma severity and control.

The new focus on control offers the advantage of clearly identifying patients whose asthma is not well controlled or is very poorly controlled. The clinician can use the various tools available for assessing control and, based on the results, interventions can be made to improve lung function and asthma control.

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Long-term management 

The major components of asthma management are education of the patient and family, strategies to reduce or eliminate exposure to known asthma trigger, pharmacotherapy, and an appropriate self-management plan. The clinician should give ample attention to each of these areas in an effort to optimize asthma control for the benefit of the patient.

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Education 

Educational strategies for patients with asthma and their families are based on numerous factors, including patient age and the family situation and dynamics. Sufficient evidence exists to support the value of educating children and their families about self-management skills in improving numerous asthma-related outcomes (Brown et al., 2002, Butz et al., 2005). The guidelines describe the educational process as a partnership between the clinician, patient, and the caregivers. The clinician should make an assessment of the child's ability and receptivity to receive educational messages, information about the home environment and usual routine for care of the child, and the family's involvement in the patient's illness. Key educational messages to be communicated are listed in Box 2. Education should be offered at multiple points of care.

One of the important components of education relates to the use of inhalation devices. Inhalation therapy is a common method of treating asthma, and proper use of inhalation devices is essential to achieve the therapeutic benefit. Inhalation devices differ significantly in their directions for use, and patients require initial instruction and observation, as well as periodic follow-up, to ensure proper use. This is true for all currently available inhalation devices.

Self-monitoring and Periodic Assessment 

Periodic assessment by a health professional is essential for optimal asthma management. During the visits, the extent of asthma control can be assessed through evaluation of subjective and objective information that is gathered. One important focus should be on the self-management skills used by the patients and their families to monitor asthma control and take actions when the asthma condition changes. All patients should receive a written asthma action plan that includes instructions about daily management and actions to take to manage worsening symptoms. Written action plans are especially important for patients with moderate or severe persistent asthma, patients whose asthma is poorly controlled, and those who have experienced a severe exacerbation. Written action plans can be based on peak flow results or recognition of symptoms because both approaches have been proved to be equally effective with no clear advantage of one over the other. Common strategies used for worsening symptoms include increased use of rescue therapies, initiating a short course of oral corticosteroids, and early action to seek medical care.

Environmental Control and Avoidance 

Control of environmental factors that may be asthma triggers as well as effective management of co-morbid conditions are important strategies of management. Potential allergen exposure should be evaluated during the medical history and possibly confirmed by skin testing. It is clear that a multifaceted, comprehensive approach is required for effective allergen management (Morgan et al., 2004). Common strategies to control exposure to allergens and irritants are summarized in Box 3.

The recent asthma guidelines also include a comprehensive list of co-morbid conditions that can disrupt asthma control, as listed in Box 4. Recognition and effective management of these conditions can contribute to improved asthma control. In addition, patients with asthma should receive the influenza vaccine annually. Of particular note, evidence exists that obesity increases the clinical severity of asthma and decreases quality of life (Story, 2007). With the alarming increase in obesity rates among children, this situation is likely to continue to be problematic.

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Pharmacotherapy recommendations 

Age-specific recommendations are available for asthma management in the current asthma guidelines (NAEPP, 2007). These recommendations are based on the available evidence for the individual age groups and, for each age category, there are six steps of therapy, as described in Table 7. In some cases at the younger ages, there has not been adequate research to support recommendations for some of the available therapies. In other cases, however, the recommendations are inferred through extrapolation from other age groups. The various options are available based on the heterogeneity of asthma, which suggests that no single therapy is the optimal choice for every patient in a specific severity category.

Table 7. Stepwise approach to asthma management^∗

ICS, Inhaled corticosteroid; LABA, long-acting β₂ agonist; LTRA, leukotriene receptor antagonist; SABA, short-acting β₂ agonist.

∗Patient education, environmental control, and management of co-morbidities should be considered at each step.

†Subcutaneous allergen immunotherapy should be considered at Steps 2 through 4 for patients with allergies, ages 5 years and older. National Asthma Education and Prevention Program, 2007.

Step 1 Management 

All patients with asthma should have access to a rescue therapy to use when acute symptoms develop or, in some cases, are anticipated. This therapy should be safe and convenient with a rapid onset of effect. SABAs are universally recommended as the primary quick relief agent or rescue therapy, and albuterol is the most frequently used agent. All patients should have access to a SABA for relief of acute symptoms. The frequency of use of SABA also is a common method of assessing the degree of asthma control. The use of more than one canister of a SABA every 1 to 2 months is a risk factor for asthma exacerbations (Schatz et al., 2005).

An ongoing controversy relates to the relative benefit and safety of levalbuterol compared to albuterol, particularly for the treatment of children. Levalbuterol is a single isomer product of the active component of albuterol. It is well established that the therapeutic benefit and beta agonist–related adverse effects of albuterol are associated with the R isomer, the therapeutically active component. The controversy lies in proposed safety issues related to the S isomer of albuterol. Historically, this isomer has been considered inactive, contributing neither beneficial nor detrimental effects during the use of racemic albuterol. Preclinical evidence suggests that the S isomer may exhibit some pro-inflammatory effects that can counteract the effects of the R isomer. If the S isomer is causing antagonistic effects, the use of the single isomer product should be more effective and possibly safer; however, the detrimental effect has been difficult to demonstrate in the clinical setting when albuterol and levalbuterol are compared. The cost of levalbuterol products is higher than albuterol, and it has been difficult to justify the increased cost on the basis of improved safety and efficacy.

Albuterol metered dose inhaler products are not available in formulations that contain chlorofluorocarbons as propellants. New products contain hydrofluoroalkanes as propellants. There is a worldwide effort to phase out the use of chlorofluorocarbons because of potential environmental and health effects unrelated to asthma. The hydrofluoroalkane products are equally or more effective than previous products but will have a higher unit cost.

Step 2 Management 

For mild persistent asthma, several options exist for managing asthma with a single long-term control therapy. Inhaled corticosteroids (ICS) are preferred for all patients independent of their age. Alternatives exist in this category ranging from cromolyn and nedocromil to leukotriene modifiers to theophylline. Each agent is recommended because there is evidence about its benefit as a single long-term control agent for mild persistent asthma; however, ICS are routinely more effective in head-to-head comparisons. ICS are well tolerated and safe when used in accordance with recommended doses. The use of ICS is associated with improved lung function, decreased symptoms, reduced requirements for rescue therapies, and fewer exacerbations requiring oral corticosteroids, emergency department treatment, or hospitalizations (The Childhood Asthma Management Program Research Group [CAMP], 2000). Previously, it was hoped that early intervention with ICS therapy in asthma may offer some benefit on modifying the natural course of the disease; however, available evidence suggests that while therapy can reduce exacerbations, it does not alter the natural course of asthma (Guilbert et al., 2006).

A major subject of debate for over two decades is related to the relative safety of ICS as a long-term therapy for children with asthma. Ample evidence exists to support the benefit associated with ICS use for asthma in children. In countless clinical studies, ICS consistently improve outcomes, including spirometry, requirements for rescue therapies, day and nighttime symptoms, school absences, emergency department visits, and hospitalizations. Yet many clinicians and patients continue to have concerns about the safety of chronic use of ICS.

The most frequent adverse effects of ICS occur locally and include hoarseness or dysphonia, cough, and mouth lesions associated with candida overgrowth. Other adverse effects from ICS, including decreased growth velocity, are primarily due to systemic activity that may occur at high doses, although the long-term clinical implications are not clear (Leone, Fish, Szefler, & West, 2003). This effect associated with ICS therapy appears to be small and possibly transient, yet many clinicians and parents express concerns about this adverse effect (Finkelstein et al., 2000, Gold and Fuhlbrigge, 2006, Peters, 2006).

Clearly, ICS possess a superior safety profile when compared with systemic corticosteroid therapies. The risks of chronic use have been difficult to assess based on the relatively short duration of clinical trials and the presence of numerous confounding factors. Of specific concern is the effect of corticosteroids (including inhaled therapies) on the growth velocity, or growth rate, in children with asthma. Assessment of this effect often is hampered by requirements for short courses of oral corticosteroids for asthma exacerbations, which has well-documented effects on growth suppression, and the direct effect of poorly controlled asthma on growth rate. Uncontrolled asthma also has the potential for serious consequences, and the benefit of ICS therapy outweighs those risks in most patients (CAMP, 2000; Leone et al., 2003).

Despite these concerns about ICS use in children, when patients' asthma is well controlled, normal growth and development occur in these patients. However, it is imperative that these agents be used in the safest possible fashion when treating asthma. This approach includes ensuring that the patient is taking the lowest effective dose necessary to control his or her condition, appropriate step-down strategies are used when control is maintained for at least 3 months, and inhaled products are used with mouth-rinsing procedures and holding chambers when appropriate to minimize the systemic exposure. In addition, periodic measurement of height is recommended using stadiometers in children receiving ICS therapies.

Currently, no credible evidence exists to support selecting one ICS product over another. Numerous clinical trials report potential differences in the efficacy and safety among available corticosteroid products; however, it is generally believed that the various products are equally effective when used in equipotent doses, and the risk profile among these agents are similar. Product selection should be based on clinician experience, patient preference, factors affecting adherence, such as dosing frequency and taste, and cost.

Leukotriene receptor antagonists (LTRAs) are an acceptable option for the long-term management of asthma in children. Ample evidence exists to support the benefit of LTRAs as monotherapy for mild forms of asthma, including in children. When compared with placebo, montelukast therapy improves a variety of outcome measures in children ages 2 through 5 years, as well as patients ages 6 through 14 years. In studies comparing montelukast to an ICS, the leukotriene modifier improves various asthma measures and has been judged either similar or less effective than the corticosteroid. Fewer data exist supporting the use of these agents in children with moderate or severe asthma. LTRAs often are considered as useful additions when a fixed dose of ICS alone is not adequate, but the evidence supporting this practice is either inconsistent or lacking.

Some clinicians have pointed to adherence problems that may arise due to concerns about the adverse effects of chronic ICS therapy; indeed, reported adherence rates with long-term asthma medications are generally poor (Walders, Kopel, Koinis-Mitchell, & McQuaid, 2005). Inhaled therapy presents an additional problem of adherence related to the patient's ability to use the inhalation device correctly. Many persons consider an oral therapy, such as a leukotriene modifier, to be a beneficial therapy for children having difficulty with appropriate administration of inhalation therapy. Among children with asthma, many present with mild forms of the disease, in which case, a leukotriene receptor antagonist is an acceptable alternative to ICS (Fabbri & Stoloff, 2005). Other selected situations that may benefit specifically from the use of an LTRA include patients with allergic rhinitis or aspirin sensitivity.

Regarding the other agents listed as possible therapies for mild persistent asthma, historical data exist to support the benefit of cromolyn, nedocromil, and theophylline in the long-term treatment of asthma. Each provides therapeutic benefit in selected patients. However, these therapies cannot be considered primary treatments because of a relative lack of efficacy and the risk of adverse effects. The overall efficacy of cromolyn and nedocromil is less compared with other therapies; these agents require multiple daily doses; and cost advantages are minimal. Theophylline is a difficult medication to dose accurately, and numerous challenges are associated with its use. The optimal dose of theophylline varies from patient to patient, and even within the same patient in the presence of intra-current disease and other risk factors. Theophylline exhibits a low therapeutic index with some overlap between therapeutic and toxic serum concentrations. Adverse effects and intolerance to this medication are common, affecting the gastrointestinal, cardiovascular, and central nervous system. Finally, the potential exists for numerous drug interactions associated with the use of theophylline, resulting in significant increases or decreases in the serum concentration. In total, all of these reasons explain why theophylline has been relegated to an option that is not commonly chosen for the long-term management of asthma.

Step 3 Management 

Some differences in recommendations according to age at this step of treatment are based on available evidence. For children 12 years and older, the preferred therapies are either a medium dose of ICS or low dose ICS plus a long-acting β₂ agonist (LABA). The best evidence for improved control is available for the use of combination therapy. However, concerns about the safety of LABAs resulted in a recommendation for medium-dose ICS as a primary option.

LABAs are important and valuable therapies for the management of moderate to severe asthma; however, the optimal use is as an add-on therapy to anti-inflammatory therapies, especially ICS. In asthma, LABAs should never be used alone because they are associated with an increase in adverse outcomes, including increased frequency and severity of exacerbations, and an increased risk of asthma deaths (Nelson, Weiss, Bleecker, Yancey, & Dorinsky, 2006).

Step 4 Management 

At this level, the preferred treatment for each age group is a combination of an ICS and a LABA. For the younger age groups, this recommendation is based on extrapolation of the benefit that is proven for older patients. Other combinations are potential options, but the strongest data supporting use are available for both ICS and LABAs.

Step 5 and 6 Management 

At these higher level steps, the combinations of ICS and LABAs prevail based on available clinical evidence and extrapolation from older patients. Other combinations are acceptable alternatives. At the highest level, oral corticosteroid therapy may be required, although this treatment should be avoided if at all possible because of the risk for significant toxicity. In addition, for patients who are at least 12 years old, omalizumab therapy is an option in the presence of severe allergic asthma.

Omalizumab is a monoclonal antibody against immunoglobulin E (IgE). The antibody binds to serum free circulating IgE and forms a complex that prevents binding of the IgE with receptors on mast cells and basophils. As a result, the inflammatory cascade and allergic reaction is not initiated or is lessened. Omalizumab dosing is based on patient weight and serum IgE level prior to initiating therapy. Doses are administered subcutaneously; however, a maximum dose for any single injection site is 150mg, necessitating two injections per treatment for some patients.

Omalizumab therapy is not well tolerated by some patients. Pain and bruising at the subcutaneous injection site is reported by up to 20% of patients. In addition, the risk of anaphylaxis is present and persists throughout treatment with this agent. As a result, the monthly or twice monthly subcutaneous injections should be administered in a health care setting, and the patient should be observed for 2 hours following the injection for signs and symptoms of anaphylaxis (Food and Drug Administration, 2007).

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Challenges with inhalation therapies 

Pharmacological management of asthma is largely accomplished through the use of medications delivered by inhalation. This practice presents unique challenges to the management of this condition because the proper use of inhalation delivery systems is imperative in order to receive benefit from these therapies. Improper inhalation technique is another type of adherence problem. It is well established that the clinician should spend time instructing the patient initially and then periodically evaluate the patient's use of the device.

Inhalation devices vary in the recommended technique for use, which also complicates this issue. For pediatric patients, the clinician should assess the appropriateness of specific inhalation devices based on the patient's ability and willingness to use it. Despite these challenges, inhalational therapies for asthma offer significant advantages over oral agents in terms of effectiveness and safety.

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Adjusting asthma therapies 

Strategies are available for stepping up or stepping down asthma therapies based on the degree of control. Step-up should be considered when the patient's asthma is not well controlled or very poorly controlled. Prior to a decision about step-up, however, the clinician should review the patient's adherence pattern, inhaler technique, and compliance with nonpharmacologic recommendations, including environmental control. Another recommendation that is sometimes overlooked in the asthma guidelines is related to stepping-down treatment regimens once the patient's asthma has been well controlled and he or she is symptom-free and without exacerbations for an extended period. Step-down should be considered after the patient's asthma has been well controlled for at least 3 months. There are obvious advantages to a step-down in therapy related to patient convenience, cost of therapy, and reducing the risk of adverse effects.

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Acute exacerbations 

Despite the best efforts in management, some patients will experience exacerbations of their asthma which are unavoidable. Acute exacerbations of asthma in children should be treated promptly and aggressively to ensure the best possible outcome. The general principles of management do not differ significantly among children and adults. They include intensification of short-acting bronchodilator therapy and using adequate doses of systemic corticosteroids.

Following treatment of an acute exacerbation in the primary care provider's office, emergency department, or hospital, the patient should receive instructions concerning a discharge plan. The basic premise of this plan is to continue the treatment for the acute exacerbation and to advise the patient that he or she should notice an incremental improvement each day. If there is not improvement each day, or significant improvement over a few days, the patient and family should be instructed to return for evaluation and treatment. In most cases, patients should receive follow-up care in at least 30 days following the exacerbation.

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Specific considerations for pediatric patients with asthma 

Pediatric patients with asthma have age-specific issues that should be considered in their management. Very young patients are dependent on their parents or caregivers for their management. Many decisions regarding care are outside the direct control of the patient; thus, the clinician should consider home environment and family dynamic issues when developing treatment plans. For each category of pediatric patients, key clinical activities that have been identified as being important for the various age categories are described in Table 8.

Table 8. Recommended key activities for asthma management

Modified from National Asthma Education and Prevention Program, 2007.

The presence of asthma during the adolescent years presents specific challenges to the clinician. Included among these are behavioral or attitudinal issues related to the lack of acceptance of an illness, symptom denial, carelessness about inhalational exposures, adherence problems, over-exertion without adequate pretreatment, and relational problems with family and health care providers (de Benedictis & Bush, 2007). Special techniques including peer education, networking, and careful attention to relationship building are effective strategies to maintaining control during this period of rapid changes.

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Summary 

Comprehensive asthma management involves patient education, including education about inhalation techniques, environmental control strategies, appropriate pharmacotherapy, and an effective plan for self-monitoring by the patient.

As a chronic condition with life-threatening implications, asthma has numerous unique features that should be considered in managing this disease. Asthma is one of the most common chronic conditions in children, and they present a variety of challenges in order to achieve adequate control. Comprehensive asthma management involves patient education, including education about inhalation techniques, environmental control strategies, appropriate pharmacotherapy, and an effective plan for self-monitoring by the patient. Deaths resulting from asthma are relatively uncommon among pediatric patients, but each one is preventable with effective treatment.

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