Pediatric Asthma

For children aged 5 years or older with recurrent wheeze, cough, dyspnea, or exercise-related respiratory symptoms, obtain quality spirometry before committing to long-term asthma treatment when the child can perform acceptable maneuvers. Pediatric guidelines consistently recommend spirometry and reversibility testing from age 5 years. Oxford AcademicOxford AcademicThe quality of paediatric asthma guidelines: evidence ... A reduced FEV1/FVC ratio supports obstruction; interpret the ratio with FVC and age-appropriate reference values rather than using FEV1 alone. PubMedPubMedOffice Spirometry: Indications and Interpretation - PubMed

Perform post-bronchodilator spirometry when baseline obstruction is present or asthma remains suspected. In children and adolescents aged 5-18 years, improvement in FEV1 or FVC of more than 12% after a short-acting bronchodilator supports reversible airflow limitation. PubMedPubMedOffice Spirometry: Indications and Interpretation - PubMed Do not use a negative bronchodilator response to exclude asthma: reversibility is neither diagnostic by itself nor required for asthma, particularly when the child is asymptomatic at testing. Wolters KluwerWolters KluwerGuidelines for diagnosis and management of... : Lung India

Normal baseline spirometry is common in symptomatic children and does not exclude asthma. Wolters Kluwer+1Wolters KluwerGuidelines for diagnosis and management of... : Lung IndiaPubMedDiagnosis of asthma in adults - PMC If pretest probability remains high, document variability with serial peak expiratory flow monitoring or refer for bronchoprovocation testing; methacholine challenge is particularly useful when normal spirometry makes an alternative diagnosis plausible. Wolters Kluwer+1Wolters KluwerGuidelines for diagnosis and management of... : Lung IndiaPubMedDiagnosis of asthma in adults - PMC Peak-flow measurements should not be treated as interchangeable with FEV1 measurements. Wolters KluwerWolters KluwerGuidelines for diagnosis and management of... : Lung India

Fractional exhaled nitric oxide can identify eosinophilic airway inflammation and may support an asthma diagnosis in the appropriate symptom context. nice org uknice org ukOmalizumab for the treatment of severe persistent allergic ... A FeNO value of 35 parts per billion or greater was incorporated into a pediatric diagnostic algorithm, although cohort data questioned the performance and sequence of the proposed thresholds. The LancetThe LancetDiagnosis of asthma in symptomatic children based on measures of lung function: an analysis of data from a population-based birth cohort study Use FeNO as one component of an objective assessment rather than as a stand-alone diagnostic test.

In children with normal spirometry in the NICE sequential algorithm, diagnosis required both FeNO of at least 35 parts per billion and peak expiratory flow variability greater than 20%. The LancetThe LancetDiagnosis of asthma in symptomatic children based on measures of lung function: an analysis of data from a population-based birth cohort study This approach is not a substitute for clinical judgment: in a multicenter assessment of children referred for diagnostic testing, many symptomatic children had normal spirometry and normal FeNO values. BMJBMJ6754 ‘Dear colleague, please perform spirometry/FeNO tests to confirm the diagnosis of asthma’ | Archives of Disease in Childhood Persistent discordance between symptoms and testing should prompt reassessment of the diagnosis and consideration of alternate causes of cough, exertional dyspnea, wheeze, or episodic respiratory distress.

For an acute exacerbation, first determine severity and risk for respiratory failure through repeated assessment of work of breathing, ventilation, oxygenation, mental status, and response to initial bronchodilator therapy. journal chestnetjournal chestnetAsthma Outcomes and Management During Pregnancy Give inhaled short-acting beta-agonist therapy as acute bronchodilator treatment and reassess after treatment rather than relying on the presenting examination alone. Combined inhaled beta-agonist and anticholinergic therapy has been evaluated for emergency management of acute asthma. Wolters KluwerWolters KluwerImplementation of a Critical Care Asthma Pathway... : Critical Care Explorations

In children with moderate or severe exacerbations, administer systemic corticosteroids early because early administration reduces hospital admission rates. Wolters KluwerWolters KluwerImplementation of a Critical Care Asthma Pathway... : Critical Care Explorations Prednisone, prednisolone, or methylprednisolone can be dosed at 1-2 mg/kg/day, given once daily or divided twice daily, with a maximum of 60 mg/day. publications aappublications aapAcute Asthma Exacerbation Triage nurse initiation of systemic corticosteroids has also been associated with improved emergency department efficiency. Wolters KluwerWolters KluwerImplementation of a Critical Care Asthma Pathway... : Critical Care Explorations

Escalate children with persistent or worsening respiratory distress, impaired ventilation, altered mental status, or inadequate response to initial therapy to an emergency or critical-care pathway. Evidence for noninvasive positive-pressure ventilation in pediatric acute asthma is limited, and ICU management has fewer validated recommendations than emergency department care. Wolters KluwerWolters KluwerImplementation of a Critical Care Asthma Pathway... : Critical Care Explorations Do not add azithromycin routinely for an asthma exacerbation; a randomized trial evaluated azithromycin in acute exacerbations without establishing it as standard exacerbation therapy. Wolters KluwerWolters KluwerImplementation of a Critical Care Asthma Pathway... : Critical Care Explorations

Use a control-based strategy: assess current impairment and future exacerbation risk, implement therapy, then monitor periodically to determine whether treatment should be maintained, stepped up, or stepped down. ScienceDirect+1ScienceDirectExpert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–Summary Report 2007ScienceDirectThe pediatric asthma yardstick: Practical recommendations for a sustained step-up in asthma therapy for children with inadequately controlled asthma Asthma severity reflects underlying disease intensity, whereas control describes the extent to which manifestations are minimized and treatment goals are met. ScienceDirectScienceDirectExpert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–Summary Report 2007 This distinction matters because an apparent need for more therapy may instead reflect poor adherence, ineffective inhaler use, exposure-related symptoms, or an incorrect diagnosis.

Daily inhaled corticosteroids remain preferred controller treatment for children of all ages. publications aappublications aapAsthma | Pediatric Care Online For children who require maintenance ICS-long-acting beta-agonist treatment, single maintenance and reliever therapy with an ICS-formoterol regimen is a candidate strategy at treatment steps corresponding to NAEPP or GINA steps 3 or 4. jaci-inpracticejaci-inpracticeA Practical Guide to Implementing SMART in Asthma ... Apply this approach only when the selected inhaler and the child's age are appropriate for the intended regimen.

For inadequately controlled asthma, do not make a sustained step-up solely from symptom report. Reconfirm the diagnosis objectively when possible, review exacerbations and reliever use, verify medication access and administration, and assess whether the child is in an age group for which the proposed treatment strategy is supported. Pediatric treatment recommendations differ among children 5 years or younger, school-age children, and adolescents. ScienceDirectScienceDirectThe pediatric asthma yardstick: Practical recommendations for a sustained step-up in asthma therapy for children with inadequately controlled asthma

At follow-up, document symptom burden, exacerbations requiring urgent care or systemic corticosteroids, reliever use, adherence, and inhaler technique; then repeat spirometry when feasible to monitor lung function and treatment response. Office spirometry can provide diagnostic information comparable to pulmonary-function laboratory testing when high quality, and it can monitor disease progression and response to therapy. PubMedPubMedOffice Spirometry: Indications and Interpretation - PubMed The treatment target is durable control with the least treatment intensity that maintains that state. ScienceDirectScienceDirectExpert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–Summary Report 2007

Refer for pediatric pulmonary or allergy evaluation when the diagnosis remains uncertain after spirometry and appropriate additional objective testing, when symptoms persist despite an optimized controller strategy, or when high-intensity treatment is being considered. Specialty evaluation is particularly important when work-related or allergen sensitization is suspected: skin-prick testing or serum specific-IgE testing may help document sensitization to high-molecular-weight occupational agents such as flour or animal dander. PubMedPubMedDiagnosis of asthma in adults - PMC

Children receiving high-dose ICS or ICS-LABA for severe persistent disease require periodic reassessment of indication and response rather than automatic continuation. High-dose ICS and long-acting bronchodilators have been described as preferred therapies for children with severe persistent asthma, but treatment intensity should follow confirmed disease, observed control, and response to therapy. pedsinreview aappublications+1pedsinreview aappublicationsNew Treatments for Asthma | Pediatrics In ReviewScienceDirectExpert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–Summary Report 2007