Pediatric Asthma Management

Chronic Asthma Management

The American Thoracic Society recommends low-dose inhaled corticosteroids as the cornerstone of treatment for children with persistent asthma, using the lowest dose that provides acceptable symptom control 1, 3
For children ≥5 years with mild persistent asthma, the American Academy of Pediatrics suggests starting with low-dose ICS such as fluticasone 100 mcg or budesonide equivalent 3
Alternative therapies, including leukotriene receptor antagonists, cromolyn, nedocromil, or sustained-release theophylline, are less preferred and should be considered only when ICS is not effective 3
Combination ICS/LABA should be reserved for children inadequately controlled on ICS monotherapy, as recommended by the Global Initiative for Asthma 3
The goal of treatment is to achieve minimal daytime symptoms and no nocturnal awakening, full participation in activities and sports without limitation, no missed school days, infrequent need for relief medications, and peak flow >75% predicted with diurnal variability <25% 1, 4

The American College of Emergency Physicians recommends immediate administration of high-flow oxygen, nebulized salbutamol, and systemic corticosteroids simultaneously for acute exacerbations 1, 2
The British Thoracic Society suggests recognizing severe exacerbation by features such as too breathless to talk or feed, respiratory rate >50 breaths/minute, pulse >140 beats/minute, peak expiratory flow <50% predicted, and use of accessory muscles 2, 5
Life-threatening features requiring immediate escalation include peak flow <33% predicted or poor respiratory effort, silent chest, cyanosis, or exhaustion, altered level of consciousness or agitation, and oxygen saturation <92% despite supplemental oxygen 2, 3, 5
The American Academy of Pediatrics recommends adding ipratropium bromide 100 mcg to nebulizer immediately for moderate to severe exacerbations, repeated every 6 hours until improvement starts 1, 2, 5

Children may be discharged when all of the following are met: on discharge medications for 24 hours with proper inhaler technique verified and documented, peak flow >75% of predicted or best with diurnal variability <25%, prescribed oral steroids, inhaled steroids, and bronchodilators, own peak flow meter provided, written self-management plan or instructions for parents provided, and GP follow-up arranged within 1 week 1, 3, 5
Families must understand proper inhaler technique and peak flow meter use, difference between reliever and preventer medications, how and when to vary medications according to symptoms or peak flow, recognition of worsening asthma signs, and when to call for help or seek urgent care 3, 4

Proper device selection is critical for treatment success, and most children cannot achieve coordination for unmodified MDI, which should not be used unless technique is verified 4
Large volume spacers should be used with MDI for all children receiving inhaled steroids to enhance lung deposition, and nebulizers are often overused and can be replaced by MDI with large volume spacer 4