managing-pediatric-asthma

name	managing-pediatric-asthma
language	en
description	Applies stepwise pediatric asthma management with age-appropriate device selection and action plans. Use when managing childhood asthma, selecting pediatric inhalers, or creating asthma action plans.
tags	["management","pediatrics"]
metadata	{"author":"casemark","practice_areas":["Pediatrics","Neonatology","Adolescent Medicine"],"document_types":["Management Report"],"skill_modes":["Management","Coordination"]}

Managing Pediatric Asthma

Applies NAEPP EPR-3/EPR-4 stepwise approach to pediatric asthma management with age-stratified severity classification, controller/reliever medication selection, age-appropriate delivery device matching, and written Asthma Action Plan generation. Covers ages 0-4, 5-11, and 12+ treatment tiers.

Why This Skill Exists

Asthma is the most common chronic childhood disease, affecting approximately 6 million children in the United States. Under-classification of severity leads to under-treatment and preventable ED visits and hospitalizations. The NAEPP guidelines stratify management by age group (0-4, 5-11, 12+) with different stepwise therapy ladders for each — a complexity that is easy to misapply. This skill enforces proper severity classification, step assignment, device selection, and mandatory creation of a written Asthma Action Plan at every encounter.

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Checkpoint A — Intake Verification

Required Intake Questions

1. What is the child's age (determines which stepwise pathway applies)?
2. What are the current symptoms — daytime frequency, nighttime awakenings, activity limitation?
3. What is the current medication regimen (controller and reliever, with doses and devices)?
4. How many SABA canisters has the patient used in the last 12 months?
5. How many ED visits, hospitalizations, or oral steroid courses in the last 12 months?
6. Has spirometry been performed (if ≥ 5 years old)? What were FEV1 and FEV1/FVC values?
7. What are known triggers (viral URI, exercise, allergens, tobacco smoke exposure, weather)?
8. Does the patient have comorbid allergic rhinitis, eczema, GERD, or obesity?
9. Does the patient have a current written Asthma Action Plan? When was it last updated?

Required Documents

• Previous clinic notes with asthma documentation
• Spirometry results (if age ≥ 5)
• Current medication list with doses and frequencies
• ED visit / hospitalization discharge summaries (if applicable)
• Current Asthma Action Plan (if one exists)
• Allergy testing results (if performed)

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Step 1 — Severity Classification (Initial Visit) or Control Assessment (Follow-Up)

Severity Classification (Not Yet on Controller Therapy)

Components of Severity

Component	Intermittent	Mild Persistent	Moderate Persistent	Severe Persistent
Symptom days	≤ 2/week	> 2/week (not daily)	Daily	Throughout the day
Night awakenings (0-4y)	0	1-2/month	3-4/month	> 1/week
Night awakenings (5-11y)	≤ 2/month	3-4/month	> 1/week (not nightly)	Often 7/week
SABA use	≤ 2 days/week	> 2 days/week	Daily	Several times/day
Activity limitation	None	Minor	Some	Extremely limited
FEV1 (≥ 5y)	> 80%	≥ 80%	60-80%	< 60%
Exacerbations requiring OCS	0-1/year	≥ 2 in 6 months	≥ 2 in 6 months	≥ 2 in 6 months

Classify severity by the most severe component in any category. Two or more exacerbations requiring OCS moves severity to at least persistent — regardless of interval symptoms.

Control Assessment (Already on Controller Therapy)

• Well-controlled: symptoms ≤ 2 days/week, no night awakenings, no activity limitation, SABA ≤ 2 days/week, FEV1 > 80%
• Not well-controlled: any component worse than above
• Very poorly controlled: symptoms throughout day, night awakenings ≥ 4/week (12+) or > 1/week (5-11), SABA several times/day, FEV1 < 60%

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Step 2 — Stepwise Therapy Assignment

Ages 0-4 Years

Step	Preferred Controller	Alternative
1	SABA PRN only	—
2	Low-dose ICS	Montelukast
3	Medium-dose ICS	—
4	Medium-dose ICS + montelukast or referral	—
5	High-dose ICS + referral	—
6	High-dose ICS + oral systemic corticosteroids + referral	—

Ages 5-11 Years

Step	Preferred Controller	Alternative
1	SABA PRN only	—
2	Low-dose ICS	Montelukast, cromolyn, or nedocromil
3	Low-dose ICS + LABA OR medium-dose ICS	Low-dose ICS + LTRA or theophylline
4	Medium-dose ICS + LABA	Medium-dose ICS + LTRA or theophylline
5	High-dose ICS + LABA	High-dose ICS + LTRA or theophylline
6	High-dose ICS + LABA + oral corticosteroids	—

Ages 12+ Years

• Follow adult stepwise guidelines (EPR-4 2020 focused update)
• Step 3-4: consider single maintenance and reliever therapy (SMART) with budesonide-formoterol
• Step 5: add-on options include tiotropium, anti-IgE (omalizumab), anti-IL5

Step-Up / Step-Down Rules

• Step up if not well-controlled after 2-6 weeks of adherence and correct technique
• Before stepping up: verify adherence, inhaler technique, trigger avoidance, and comorbidity management
• Step down after ≥ 3 months of well-controlled asthma; reduce by one step at a time
• Never discontinue ICS entirely in persistent asthma without a step-down trial period

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Step 3 — Device Selection by Age

Age	Preferred Device	Notes
0-3 years	MDI + valved holding chamber (VHC) + face mask	Nebulizer as alternative
4-5 years	MDI + VHC (mouthpiece, no mask)	Nebulizer as alternative
6-11 years	MDI + VHC (mouthpiece) or DPI	Assess inspiratory effort for DPI
12+ years	MDI ± spacer, DPI, or SMI	DPI requires adequate inspiratory flow

Technique Verification

• Demonstrate and observe technique at every visit (teach-back method)
• Common errors: not shaking MDI, not priming, inhaling too fast with MDI, not holding breath 10 seconds, not rinsing mouth after ICS
• Switch devices only if technique cannot be mastered after repeated instruction

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Step 4 — Written Asthma Action Plan

Every patient must have a written Asthma Action Plan. Generate or update the plan at every visit:

Green Zone (Doing Well)

• No cough, wheeze, chest tightness, or shortness of breath
• Can do usual activities
• Peak flow (if monitoring): > 80% personal best
• Action: take controller medications as prescribed daily

Yellow Zone (Getting Worse)

• Cough, wheeze, chest tightness, or shortness of breath
• Waking at night due to asthma
• Can do some but not all usual activities
• Peak flow: 50-80% personal best
• Action: add SABA every 4-6 hours; may double ICS or start OCS per physician instruction; call provider if not improving in 24 hours

Red Zone (Medical Alert)

• Very short of breath, SABA not helping, cannot do usual activities
• Symptoms getting worse, lips/fingernails blue
• Peak flow: < 50% personal best
• Action: give SABA immediately; start oral corticosteroids; call 911 or go to ED

Plan Must Include

• Specific medication names, doses, and devices for each zone
• Emergency contact numbers (provider office, after-hours, 911)
• Known triggers with avoidance strategies
• Signature of provider and date

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Step 5 — Trigger Management and Environmental Control

• Tobacco smoke: counsel all household members on cessation; no smoking in home or car
• Allergens: dust mite covers, HEPA filter, remove carpet from bedroom if dust mite allergic
• Viral URI: hand hygiene, influenza vaccine annually (≥ 6 months old)
• Exercise: pre-treat with SABA 15 minutes before exercise if exercise-induced symptoms
• Mold/pest: remediate moisture; integrated pest management for cockroach allergen
• Allergic rhinitis: treat as comorbidity — intranasal corticosteroids significantly improve asthma control

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Checkpoint B — Asthma Management Review

• Severity classified (new patients) or control assessed (established patients)
• Appropriate step assigned with preferred controller medication
• Device selected for age with technique assessed and documented
• Written Asthma Action Plan created or updated with all three zones
• SABA usage quantified (canisters in last 12 months)
• Exacerbation history documented (ED visits, hospitalizations, OCS courses)
• Spirometry reviewed or ordered (if age ≥ 5)
• Triggers identified with avoidance counseling documented
• Comorbidities addressed (allergic rhinitis, GERD, obesity)
• Follow-up interval set (2-6 weeks if step-up; 3 months if well-controlled)
• All [VERIFY] flags resolved or escalated

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Quality Audit

Item	Requirement	Pass?
Age-appropriate classification	Correct stepwise pathway used for age group
Severity vs. control	Severity for new; control assessment for established
Step assignment	Medication matches assigned step
Device match	Device appropriate for age and demonstrated
Asthma Action Plan	All three zones with specific medications and doses
Spirometry	Ordered or reviewed for age ≥ 5
Trigger assessment	At least 3 triggers assessed and documented
Exacerbation count	OCS courses, ED visits, hospitalizations in last 12 mo
Adherence check	Refill history or adherence discussion documented
No unexplained [VERIFY] tags	All flagged items resolved or escalated

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Guidelines

• Follow NAEPP EPR-3 (2007) and EPR-4 Focused Update (2020) for stepwise management
• Apply GINA guidelines as supplementary reference for global alignment
• ICS dose ranges per NAEPP: low, medium, high vary by specific medication and age group
• Montelukast (Singulair): FDA black box warning for neuropsychiatric events — discuss risk/benefit with family and document
• SMART therapy (budesonide-formoterol as both maintenance and reliever) per EPR-4 for ages 12+ at Step 3-4
• Spirometry is preferred over peak flow for children ≥ 5; perform at diagnosis, after treatment initiated, and at least every 1-2 years
• Pre-school asthma diagnosis is clinical (spirometry not reliable < 5 years); modified Asthma Predictive Index (mAPI) helps predict persistence
• Refer to pulmonology or allergy for Step 4+ disease, diagnostic uncertainty, or biologic consideration
• This skill produces clinical documentation; it does not replace clinical judgment