Management of Uncontrolled Asthma in Children

Assessment of Asthma Control

The American Academy of Allergy, Asthma, and Immunology recommends determining the level of control by evaluating symptom frequency, nighttime awakenings, interference with normal activity, short-acting β2-agonist use, lung function, and exacerbations requiring oral systemic corticosteroids 2
The National Asthma Education and Prevention Program suggests that symptom frequency (>2 days/week), nighttime awakenings (≥2 times/month), and short-acting β2-agonist use (>2 days/week) indicate not well-controlled asthma 2
The American Thoracic Society indicates that lung function (FEV1 or peak flow 60%-80% of predicted) and exacerbations requiring oral systemic corticosteroids (≥2/year) are also indicators of not well-controlled asthma 2

The American Academy of Allergy, Asthma, and Immunology recommends verifying proper inhaler technique and medication adherence as the first step in optimizing current therapy 1
The American College of Allergy, Asthma, and Immunology suggests addressing the child's concerns, preferences, and school schedule in selecting treatments 1
The National Asthma Education and Prevention Program recommends ensuring daily long-term control therapy is being used as prescribed 1
For not well-controlled asthma, the American Academy of Allergy, Asthma, and Immunology recommends increasing inhaled corticosteroid (ICS) dose to medium level 1
For very poorly controlled asthma, the American Thoracic Society suggests increasing to high-dose ICS plus a long-acting beta2-agonist (LABA) 1
The European Respiratory Society recommends considering oral systemic corticosteroids for short-term use in very poorly controlled asthma 1, 4

The American Thoracic Society recommends high-flow oxygen via face mask to maintain SaO₂ >92% for acute severe asthma symptoms 3
The British Thoracic Society suggests nebulized salbutamol 5 mg (or half dose for younger children) for acute severe asthma symptoms 3
The National Asthma Education and Prevention Program recommends intravenous hydrocortisone followed by oral prednisolone 1-2 mg/kg daily (maximum 40 mg) for acute severe asthma symptoms 3, 4
The American Academy of Allergy, Asthma, and Immunology suggests adding ipratropium 100 mg nebulized every 6 hours for acute severe asthma symptoms 3, 4

The American College of Allergy, Asthma, and Immunology recommends monitoring response to therapy closely 1
The American Academy of Allergy, Asthma, and Immunology suggests adjusting treatment if no clear positive response within 4-6 weeks 1
The European Respiratory Society recommends scheduling follow-up within 1-4 weeks after changing therapy 4
The National Asthma Education and Prevention Program suggests providing the child with a peak flow meter and written asthma action plan 4

The American Academy of Allergy, Asthma, and Immunology recommends avoiding overreliance on short-acting beta-agonists without adequate controller medications 1
The American Thoracic Society suggests avoiding failure to step up therapy when asthma is not well-controlled 1
The American College of Allergy, Asthma, and Immunology recommends avoiding inadequate assessment of inhaler technique 1
The European Respiratory Society suggests avoiding insufficient follow-up after medication changes 4