managing-pediatric-asthma

# 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