Asthma

Overview

Asthma is a complex, recurrent disease of the small airways that causes shortness of breath, wheezing, and cough. Asthma is episodic in nature and usually reversible, either spontaneously or with treatment; however, chronic inflammation, associated with persistent symptoms, may contribute to airway remodeling that may not be completely reversible. [National: 2007]
A baby using a spacer with an inhaler.
Airflow limitation occurs as a result of airway hyper-responsiveness, airway edema, and bronchoconstriction. Asthma symptoms are often "triggered" by environmental stimuli (smoke, perfumes, dust mites, animals, fungi/molds, cold air) and aggravating conditions (viral upper respiratory infections, rhinitis, sinusitis, gastroesophageal reflux, stress, exercise). The importance of such triggers, as well as patterns of inflammation and treatment response, may vary across differing phenotypes (see Causes of Asthma).

Clinicians should follow published guidelines for asthma care. The Asthma Care Quick Reference - Diagnosing and Controlling Asthma (PDF Document 719 KB) is a 12-page summary (primarily charts) of the 2007 National Heart, Lung, and Blood Institute Guidelines. The 2019 Global Initiative for Asthma (GINA) guidelines are controversial because their recommendations for treatment of intermittent and mild persistent asthma diverge substantially from prior guidelines and conflict with medication coverage policies of some insurers.

Other Names & Coding

Reactive airways disease
ICD-10 coding

J45.2x, Mild intermittent asthma

J45.3x, Mild persistent asthma

J45.4x, Moderate persistent asthma

J45.5x, Severe persistent asthma

J45.9xx, Other and unspecified asthma

The x indicates that an additional digit is required. ICD-10 Asthma Coding Reference provides details.

Prevalence

The most recent national asthma data (CDC, at the time of writing, from 2017) shows that asthma prevalence in the US was 8.4% in children and 7.7% in adults. Adult asthma prevalence varies by state, ranging from 7.3% to 13.2% [2017: 2019]; rates in children likely vary similarly. [National: 2017]
Asthma Prevalence by Age and Sex in the US (2017)
Source: Asthma Prevalence and Health Care Resource Utilization Estimates, United States, 2001-2017 (CDC) (Word Document 4.1 MB), a slide set from the Centers for Disease Control & Prevention (CDC)

Racial and ethnic differences in asthma prevalence, morbidity, and mortality are highly correlated with poverty, urban air quality, indoor allergens, lack of patient education, and inadequate medical care. [Asthma: 2013] Puerto Rican and Non-Hispanic black children are more likely to have ever been diagnosed with asthma (11.3% and 12.6%, respectively, compared to 7.7% of non-Hispanic whites). Through age 17, males have a higher rate of asthma than females. In adulthood, asthma rates for females are higher.
Asthma Prevalence by Age, Sex, Race/Ethnicity (2017)
Asthma is the second most common cause of hospitalization for children (after pneumonia and before bronchiolitis). [Leyenaar: 2016] Total direct costs of pediatric asthma were $5.92 billion in 2013. Average annual costs per child ranged from $3,076 to $13,612. [Perry: 2019] Sixty percent of annual school absences are attributed to asthma. Children with severe asthma may miss >30 school days per year. [Celeste: 2012]

Genetics

Asthma is 1 of 3 atopic conditions (asthma, hay fever, eczema) that appears to result from a combination of environmental and heritable factors. If 1 parent has asthma, chances are 1:3 that the child will have asthma. If both parents have asthma, chances are 7:10. [Asthma: 2013] A 2017 review by Yang et al. noted that heritability ranged from 0.40 to 0.85, though variants at the genetic risk loci identified to date predict only 10% of heritability. Yang’s review also discusses findings that suggest a role for epigenetics and the effects of exposures to pollution, allergens, and the environmental microbiome. [Yang: 2017]

Prognosis

Approximately 1/3 of children with asthma (usually those with milder symptoms) will "outgrow" the condition by the time they are adults. Children who develop asthma after age 5 are less likely to have long-term residual effects than those who developed asthma before age 3. Although there is a risk of severe disease and death with asthma, this is increasingly unusual, and the majority of children with appropriately treated asthma function as well as those without asthma. [National: 2007] Children most at risk of dying from asthma are those with severe and uncontrolled disease, a near fatal attack of asthma, a history of recurrent hospitalization, or intubation for asthma. [Akinbami: 2006]

Practice Guidelines

Two comprehensive practice guidelines are cited below. As mentioned in the Overview, the second guideline includes recommendations for management of intermittent and mild persistent asthma that differ from long-standing practice in the US and employ medication approaches that may not be covered by some insurers.

National Asthma Education and Prevention Program Expert Panel.
Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma.
National Heart Lung and Blood Institute, NIH; (2007) https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-manag.... Accessed on 12/16/2019.
For the full 440-page report, click the Download PDF 4 MB button; from the National Heart Lung and Blood Institute, National Institutes of Health. A 60-page Summary Report and a 12-page Asthma Care Quick Reference are also downloadable from the same web page.

Reddel HK et al.
Global Strategy for Asthma Management and Prevention.
Global Initiative for Asthma. 2019. / https://ginasthma.org/gina-reports/
A downloadable 199-page report with guidelines for the care of children (and adults) with asthma; from the World Health Organization. The guidelines are also available as a Pocket Guide for Asthma Management and Prevention (see GINA REPORTS drop-down at the link above).

Roles of the Medical Home

The medical home should ensure continuity of asthma care by collaborating on the Asthma Action Plans with family, other providers, and relevant community services (daycare, school nurses, sports programs, asthma education resources). Understanding and addressing the impact of the child’s environment and lifestyle on asthma symptoms and control may require engagement of extended family or social services. Managing the practice’s asthma population often requires using a registry (free-standing or as a component of the electronic health record) to track visit frequency, symptom scores, flu shots, emergency or hospital visits, asthma education and technique verification, and other parameters to guide management and, when needed, outreach. Collaboration with health care delivery systems and/or insurance companies may allow timely notification of urgent/emergent visits to other settings, overuse of rescue medications, or underuse of controller medications.

Clinical Assessment

Overview

The initial diagnosis of asthma is based on history, physical exam findings, and exclusion of other diagnoses. Pulmonary function testing may be helpful; however, asthma is a clinical diagnosis. Normal pulmonary function test results do not rule out the diagnosis of asthma.

Pearls & Alerts for Assessment

Spirometry in children

Obtaining accurate spirometry in children, especially those under 5 years of age, can be difficult. Seek the most experienced available resource when spirometry is needed for younger patients. If performing spirometry in a primary care setting, assure reliable flow-volume loops. Spirometry360 provides a training program for office staff that involves distance verification of reliability.

Peak flow monitoring

Peak flow meters may be helpful for children ages 6 and older with moderate to severe persistent asthma who require daily asthma medications. It is most helpful when used and tracked daily around the same time of the day. Daily readings help families to recognize early drops in airflow (peak expiratory flow (PEF) < 80% of personal best). Of note, children’s personal best improves with growth.

Short-acting beta-agonists (SABAs)

Frequent use of short-acting beta-agonists (SABAs), particularly SABA nebulizer, in the past 3 months is associated with poor asthma outcomes, such as asthma-related Emergency Department visits and asthma-related hospitalizations. [Paris: 2008]

Screening

No asthma screening in children is recommended.

Presentations

Signs and symptoms at presentation vary by age, severity, and the individual’s trigger(s). Wheezing may occur in young children who do not have asthma, and some children with asthma do not wheeze.

Typical symptoms include:
  • History of:
    • Cough, particularly at night or after activities/exercise, with or without wheezing
    • Recurrent wheezing
    • Recurrent difficulty in breathing or chest tightness
  • Triggered or worsening with:
    • Sleep, awakening patient (and family)
    • Exercise/activities
    • Viral infection
    • Inhalant allergens (e.g., animals with fur or hair, house-dust mites, mold, pollen)
    • Irritants (tobacco or wood smoke, airborne chemicals)
    • Changes in weather
    • Strong emotional expression (laughing or crying hard)
    • Stress
    • Menstrual cycles
Atypical symptoms may include:
  • Rapid breathing
  • Sighing
  • Fatigue, inability to exercise properly
  • Difficulty sleeping
  • Anxiety, difficulty concentrating
  • Upper airway noises, such as stertor, stridor, or snoring
In some children, exercise-induced bronchospasm (EIB) may be the only manifestation of asthma. EIB may begin during or after vigorous exercise; typically, it takes 20-30 minutes to resolve after peak symptoms.

Cough variant asthma (CVA) occurs in all ages but may be over-diagnosed in children. Probably no more than 5% of asthmatic children have cough as the only or primary symptom, and the cough should resolve with appropriate asthma medications and recur when the medications are stopped. [Kercsmar: 2019]

Diagnostic Criteria

Three general criteria for the diagnosis of asthma:
  • Symptoms of recurrent airway obstruction or airway hyperresponsiveness, which can be usually linked to a trigger (e.g., viral infection)
  • Airway obstruction that is at least partially reversible
  • Alternative diagnoses have been excluded, which may require additional studies
These criteria are determined by a detailed history and physical exam. Spirometry can be a helpful tool in patients ≥5 years of age. In children with asthma, airflow obstruction should be reversible within 15-20 minutes after inhalation of a short-acting bronchodilator. Airflow obstruction is detected when the forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio is below expected for age. Reversibility is demonstrated by an increase in FEV1 by ≥12% or by 200 ml or more. However, it is important to note that normal spirometry results do not rule out a diagnosis of asthma or preclude a clinical response to bronchodilator therapy

Clinical Classification

Severity of asthma, which is used to determine initial therapy, is classified as:
  • Intermittent
  • Mild persistent
  • Moderate persistent
  • Severe persistent
Asthma control is classified as:
  • Well-controlled
  • Not well-controlled
  • Very poorly controlled
Levels of severity and control are based on assessment of impairment and risk as described by the NHLBI Guidelines. For details, see the chart on page 5 of the Asthma Care Quick Reference (NHLBI) (PDF Document 719 KB). The 2019 Global Initiative for Asthma (GINA) guidelines differentiate only mild and severe/difficult-to-treat asthma, but they recommend a stepwise approach to treatment similar to that in the NHLBI Guidelines.

Differential Diagnosis

Symptoms of asthma do not necessarily mean a diagnosis of asthma. Wheezing, especially, may occur due to other conditions, such as bronchiolitis (although children who experience bronchiolitis as infants may be more likely to develop asthma later in life). [Cassimos: 2008] If wheezing does not respond to treatment to reverse airflow obstruction, additional studies may be needed to identify other causes (e.g., additional pulmonary function studies, laboratory studies to assess for alternative diagnoses, such as cystic fibrosis or immunodeficiency, and/or chest imaging).

The following differential diagnoses are from the NHLBI Guidelines. [National: 2007]
  • Vascular rings or laryngeal webs
  • Upper airway disease
  • Allergic rhinitis and sinusitis
  • Foreign body in trachea or bronchus
  • Obstruction involving large airways
  • Vocal cord dysfunction (VCD)
  • Laryngotracheomalacia, tracheal stenosis, or bronchostenosis
  • Enlarged lymph nodes or tumor
  • Obstructions involving small airways
  • Viral bronchiolitis
  • Cystic fibrosis
  • Bronchopulmonary dysplasia
  • Heart disease
  • Other causes
    • Recurrent cough, not due to asthma
    • Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux

Comorbid & Secondary Conditions

Gastroesophageal reflux disease (GERD) should be suspected when the child with asthma is not responding well to asthma medications. Acid from reflux may cause injury to the lining of the throat, airways, and lungs causing a persistent cough. Children with reflux may have shortness of breath when acid enters the esophagus, triggering airway narrowing to prevent the acid from entering. Furthermore, reflux can induce “reflex bronchospasm due to irritation of vagus nerve endings in the lower esophagus. Gastroesophageal Reflux Disease has treatment details.

Rhinosinusitis, relatively common in children with atopy, may trigger and/or exacerbate asthma symptoms. Patients with nasal polyposis and asthma are likely to have aspirin-exacerbated respiratory disease (AERD). Those patients may have sudden, life-threatening flares of asthma after ingestion of aspirin or non-steroidal anti-inflammatory drugs (NSAIDs).

Vocal cord dysfunction (VCD), can exist by itself (in the differential diagnosis for exercise-induced asthma) or coexist with asthma. VCD is more common in female adolescents participating in competitive sports, especially those who have a history of anxiety. VCD symptoms can be triggered by uncontrolled rhinosinusitis and/or GERD.

Depression, anxiety, behavioral problems, and learning disabilities have been identified by the CDC as comorbidities common among children with asthma. [University: 2013] An association among asthma and internalizing disorders in children, such as panic disorder, social phobia, separation anxiety, and generalized anxiety, has been observed. [Carrera-Bojorges: 2013] See Depression and Anxiety Disorders for treatment details.

Obstructive sleep apnea and asthma are highly prevalent respiratory disorders and are frequently comorbid. Risk factors common to the 2 diseases include obesity, rhinitis, and gastroesophageal reflux. [Prasad: 2013]

Children who are obese or overweight are 1.16 to 1.37 times more likely to develop asthma than normal-weight kids; the risk grows as their body-mass index increases. Obese children also experience more frequent and severe episodes of asthma, requiring more medical attention and drug therapy. [Oxford: 2013] See Childhood Obesity for treatment details.

History & Examination

Goals include:
  • Assessment of asthma severity/control to guide therapeutic decisions
  • Understanding the impact of asthma on the child and family to guide the accessing of needed resources and/or accommodations in the school or community
An Initial Asthma History Questions for Children (NHLBI) (PDF Document 57 KB) offers a comprehensive list.

Current & Past Medical History

Current symptoms: Cough, wheezing, shortness of breath, chest tightness, nighttime cough/awakening

Pattern of symptoms: Perennial, seasonal, or both; continual, episodic, or both; onset, duration, frequency, diurnal variations, especially nocturnal, upon awakening, or with exercise

Precipitating and/or aggravating factors: Symptoms of comorbid conditions, such as reflux, viral exposures, allergens, home characteristics

Disease course: Age at onset, progression, current management, frequency of using short-acting beta2-agonist (SABA), oral corticosteroids, current Asthma Action Plan

History of exacerbations: Usual prodromal signs and symptoms, rapidity of onset, duration, frequency, need for urgent or emergent care, hospitalization, intensive care unit admission, limitations to physical activity, exertion, play, exercise, sleep

Comorbid conditions: Gastroesophageal reflux, obesity, obstructive sleep apnea, rhinitis or sinusitis, stress, and depression, or Allergic Bronchopulmonary Aspergillosis

Current medications: Frequency and technique, complementary and alternative medications, reasons for not using prescribed medications (inadequate technique and/or adherence are very common)

Medication side effects: Headache, sleeplessness, nausea, nervousness/tremors, thrush, and behavioral changes

The Asthma Control Test (ACT) is a validated assessment tool that provides a score for recent asthma symptoms. Scores of 19 or below suggest suboptimal control.

Family History

History of asthma, allergy, sinusitis, rhinitis, eczema, or nasal polyps

Pregnancy/Perinatal History

Premature delivery and subsequent respiratory complications may be relevant

Developmental & Educational Progress

How much school has been missed due to asthma-related issues?

How is school performance affected by asthma symptoms or medications? Is the child able to fully participate in sports and physical education?

Does the student have an active health plan at school and rescue medications available?

Does the student have or need a 504 Plan or other accommodations?

Social & Family Functioning

Ask about social situations that may interfere with adherence (e.g., daycare or school) and social support/social networks. How has asthma affected the child's social interactions and recreation?

Ask about the impact of asthma on the patient and family, including the episodes of unscheduled care (emergency department, urgent care, hospitalization); number of days missed from school/work; limitations of activity, especially sports and strenuous work; history of nocturnal awakening; effect on growth, development, behavior, school or work performance, and lifestyle; impacts on family routines, activities, or dynamics; and economic impact. Have there been problems with family adjustment to asthma?

Enquire about the patient's and family's perceptions of disease, including knowledge of asthma and treatment and beliefs or concerns regarding the use and long-term effects of medications; the ability of the patient and parents to cope with disease and recognize severity of an exacerbation; the level of family support; economic resources; and sociocultural beliefs.

Physical Exam

Vital Signs

RR | HR | BP (medications may cause elevation) | SpO2 (especially if any current symptoms)

Growth Parameters

Height and weight (current and patterns of gain) for evidence of other chronic underlying diseases (e.g., cystic fibrosis), effect of medications, obesity (might complicate asthma)

Skin

Evidence of atopy/eczema

HEENT/Oral

Evidence of allergy (periorbital swelling, conjunctival injection or edema, nasal discharge, nasal polyps, pale or swollen nasal turbinates, Dennie-Morgan lines, mouth breathing), sinusitis, otitis media or effusion

Chest

Evidence of accessory muscle use (tracheal tugging, intercostal retractions, nostril flaring, increased abdominal movement), sounds of expiratory wheezing with normal breathing or with forced expiration, diminished breath sounds, hyper-expansion of the thorax (barrel chest), hunched shoulders

Extremities/Musculoskeletal

Cyanosis, clubbing (may suggest other diagnoses, particularly cystic fibrosis)

Testing

Laboratory Testing

Allergy testing may be helpful to confirm allergies as an asthma trigger or as a cause of related symptoms. It can also help guide avoidance or immunotherapy.

Imaging

Chest X-rays or other imaging may be useful to rule out other diagnoses, such as aspirated foreign body, tracheal ring, pneumonia, or congestive heart failure. Though chest X-ray cannot be relied upon to make or rule out the diagnosis, findings associated with asthma (when symptomatic) include hyperinflation, flattened diaphragms, and bronchiolar thickening. Sinus imaging may be helpful if chronic sinusitis is suspected.

Genetic Testing

Although there is a genetic susceptibility to asthma, specific genetic causes have not been identified, and testing is not currently readily available (see Causes of Asthma).

Other Testing

Spirometry: Spirometry should be performed in children ≥5 years to assess airflow obstruction and reversibility with treatment. Spirometry should be repeated 1) after treatment has resulted in symptom control to document attainment of (near) normal airway function, 2) when symptoms seem poorly controlled, to evaluate causes, and 3) every 1-2 years to detect decreasing control or decline in pulmonary function over time. [National: 2007] In children, optimal technique is crucial for obtaining accurate results. One study found more than 3/4 of spirometries in primary care pediatric clinics were unacceptable. [Gillette: 2011] For children <5 years, spirometry may be attempted, but it may not be reliable.

Peak flow: Although there is less emphasis on peak expiratory flow measurement in the most recent guidelines, these measurements are still in widespread use. Taking peak flow measurements is quick, easy, inexpensive, and, with practice, it can be sufficiently reliable to guide daily therapy or in-office assessment. After initial diagnosis, peak flow measurements can be used to monitor response to treatment.

Understanding the intricacies of peak flow use helps achieve more accurate readings:
  • They are extremely effort dependent.
  • Personal best, rather than predicted value, should be used as the 100% value.
  • Many children cannot perform an adequate peak flow maneuver.
  • Personal best increases with height (as do predicted values).
  • They are not as sensitive in children as FEV1 or FEF 25-75% (mean forced expiratory flow between the 25% to 75% of the FVC) for assessing airflow obstruction.
Peak Flow Meter Information (ALA) provides how-to information for taking peak flow measurements. The Peak Flow Chart (NACA) allows recording of peak flow measurements, and the Peak Flow Meter Guide (Children's Minnesota) offers expected peak flow rates by height.

Exercise challenge: If necessary for diagnosis, an exercise challenge with PEF or FEV1 measurements before, at 5-minute intervals during, and following a 20- to 30-minute exercise period may be performed. The test is considered positive if either measure declines by 15% or more.

Specialty Collaborations & Other Services

Pulmonary Function Testing (see NV providers [0])

Spirometry, challenge testing, and full pulmonary function testing may be available, depending on the laboratory. Education regarding symptoms, how to use a peak flow meter and inhaler, etc. is also offered in many labs. Ask about experience and comfort in testing children.

Pediatric Pulmonology (see NV providers [5])

Referral to a specialist in asthma care is recommended if:

  • Patient has a history of hospitalization or ICU stay for asthma exacerbation
  • Asthma is uncontrolled after 3-5 months of treatment; patient required >2 OCS courses in 1 year
  • Asthma signs and symptoms are atypical, and other diagnoses are considered (e.g., sinusitis, nasal polyps, allergic bronchopulmonary aspergillosis (ABPA), vocal cord dysfunction (VCD), gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD)).
  • Additional testing is considered, such as allergy skin prick testing, lung function testing, imaging, or evaluation via bronchoscopy
  • Patient requires additional education and guidance about the complications of therapy, problems with adherence, or allergen avoidance.
  • Patient is being considered for immunotherapy.
  • Patient has at least moderate persistent asthma (Step 3 for children 0-4 years of age, Step 4 for 5+ years; consider referral for Step 2 in children 0-4 years of age).
Programs that focus on comprehensive asthma care have been shown to significantly reduce emergency department visits, hospitalizations, and missed school days. [Weinberger: 2016]

Pediatric Allergy (see NV providers [8])

Consider referral for evaluation of allergies, particularly if environmental exposures are triggers for asthma symptoms or seem related to poor asthma control.

Treatment & Management

Overview

Two broad guidelines exist for the management of asthma:
  1. 2007 National Heart, Lung, and Blood Institute (NHLBI) Guidelines [National: 2007]
  2. Global Initiative for Asthma (GINA), last updated 2019
Similarities between the 2 guidelines include:
  • Emphasis on benefit of low-dose inhaled corticosteroids for the prevention of asthma flares
  • Stepwise approach to the assessment and management of asthma
Differences between them include:
  • GINA no longer recommends treatment with short-acting beta-agonists (SABA) alone.
  • The new GINA guidelines recommend that all adults and adolescents with asthma should receive either symptom-driven (in mild asthma) or daily (if more severe) low-dose ICS-containing controller treatment to reduce risk of serious exacerbations.
Because of the divergence of the GINA guidelines from long-standing practice and the coverage of controller medications by insurers is largely based on the NHLBI guidelines, the former have not been widely adopted in the US. This module will focus on the NHLBI guidelines, which are available as an Asthma Care Quick Reference (NHLBI) (PDF Document 719 KB) . The GINA offers a Pocket Guide for Asthma Management and Prevention (GINA) (PDF Document 1.7 MB) .

The NHLBI Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma Summary Report 2007 breaks asthma care into 3 different age groups:
  • 0-4 years of age, 5-11 years, and >12 years
Goals of treatment
  1. Reduce impairment by:
    • Preventing chronic and troublesome symptoms (e.g., cough, breathlessness)
    • Decreasing symptoms enough that only infrequent use (2 days a week or less) of inhaled short-acting beta2-agonists (SABA) for quick relief is required
    • Maintaining (near) normal pulmonary function
    • Maintaining normal activity levels, including exercise and school/work attendance
    • Meeting family and patient expectations of and satisfaction with asthma care
  2. Reduce risk by:
    • Preventing exacerbations of asthma and minimizing the need for Emergency Department visits or hospitalizations
    • Preventing loss of lung function (maximizing lung growth in children)
    • Providing optimal pharmacotherapy with minimal or no adverse effects
If the child with asthma is not responding well to treatment, consider an alternative diagnosis and referral to an asthma specialist. Monitor for, evaluate, and potentially treat comorbid conditions, such as gastroesophageal reflux disease, obesity, sinusitis, stress, depression, and obstructive sleep apnea.
The image below from the NHLBI guidelines depicts the flow of asthma care from the initial visit through ongoing treatment.

Flow of Asthma Care
Flow of Asthma Care 1
Flow of Asthma Care 2
Image adapted from Asthma Care Quick Reference (NHLBI) (PDF Document 719 KB)

Pearls & Alerts for Treatment & Management

Inhaler skills and adherence

Most patients (up to 80%) cannot use their inhaler correctly. At least 50% of adults and children do not take controller medications as prescribed (Global Initiative for Asthma (GINA)).

Allergies

Treatment of allergic rhinitis and chronic rhinosinusitis reduces nasal symptoms but does not improve asthma control (Global Initiative for Asthma (GINA)).

Food allergies

Confirmed food allergy is a risk factor for asthma-related death. Patients with asthma and food allergies should have an anaphylaxis plan and be trained in avoidance strategies and use of injectable epinephrine (Global Initiative for Asthma (GINA)).

Obesity

Patients with obesity and asthma have more difficult-to-control asthma due to comorbid pro-inflammatory conditions. Asthma complicates obesity care; asthma flares often require patients to take oral corticosteroids, which may lead to increased appetite and weight gain. Weight reduction, even by 5-10%, can improve asthma control (Global Initiative for Asthma (GINA)).

Surgery

Well-managed asthma reduces potential complications of surgery. Optimize control prior to surgery, including using a short course of oral corticosteroids if needed. [National: 2007]

Pregnancy

One-third of women during pregnancy have asthma worsen, and 1/3 of pregnant women have asthma improve - medications should be adjusted accordingly. Maintaining lung function helps ensure oxygen supply to the fetus. Inhaled corticosteroids (ICS) are preferred for long-term control. [National: 2007] Budesonide is the preferred ICS because more data are available on this medication during pregnancy. [National: 2007]

Depression

For children with asthma, treatment for comorbid depression increases compliance and improves outcomes. Early recognition may allow intervention before significant symptoms develop. In cases of severe asthma, treatment of depression may also decrease mortality. [Galil: 2000]

Neuropsychiatric complications

Neuropsychiatric events have been reported in some patients taking montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo and Zyflo CR). The Food and Drug Administration has requested that manufacturers include a precaution in the drug prescribing information. Reported neuropsychiatric events include post-market cases of agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor.

How should common problems be managed differently in children with Asthma?

Growth or Weight Gain

Carefully measure and plot height/weight at every encounter. If there is a slowing of height velocity that is felt to be related to ICS use, consider if modification of the medication regimen may be needed.

Viral Infections

Viral infections play a key role in triggering many asthma exacerbations; for example, the “September epidemic” of asthma exacerbations is likely related to viral illnesses, particularly rhinovirus. [Sears: 2007]

Over the Counter Medications

Antihistamines do not play a central role as a controller therapy in asthma. They are not considered an alternative to ICS or leukotriene receptor antagonists (e.g., montelukast).

Systems

Respiratory

Initial visit: After the initial diagnosis or for children who are not currently on treatment, asthma should be classified by severity, age, and risk of exacerbation. The classification then guides the level of initial treatment, which usually involves medication, an action plan, and family education. Consider a return visit in 2 weeks to assess response to treatment and the family’s ability to accurately assess and respond to symptoms.

The table below summarizes the age-based classification of asthma severity and initiation of treatment. Components of severity include impairment (reduction in lung function, frequency of symptoms, daily activity limitations, frequency of night awakenings, and medication use if pertinent) and risk (frequency and intensity of exacerbations).

Classifying Asthma Severity and Initiating Therapy
Initial Visit: Classifying Asthma Severity and Initiating Therapy
Click on the image to download a PDF of the table from the Asthma Care Quick Reference (NHLBI) (PDF Document 719 KB).
Follow-up visits: After initial treatment, patients should be seen again within a few weeks to check medication technique, compliance, and side effects. Frequency of further visits should be determined by level of control, anticipated seasonal or other changes in triggers, and confidence in their adherence to the Asthma Action Plan. At each visit, assess asthma control and adjust therapy and the Asthma Action Plan as needed. If symptoms have been in excellent control for 3 months or more, a step-down from 1 treatment level to another may be considered.

The table below can be used to guide the assessment of asthma control and changes in treatment during follow-up visits. Assessment of control is based on impairment and risk. Components of impairment include frequency of nighttime awakenings, SABA use, normal activity interruptions, lung function, and validated questionnaire scores (e.g., the Asthma Control Test - questionnaires for various ages can be found at Asthma, Services & Other Resources). Components of risk include exacerbations, corticosteroid use, lung health, and side-effects of treatment.

Assessing Asthma Control & Adjusting Therapy
Assessing Control & Adjusting Therapy
Click on the image to download a PDF of the table from the Asthma Care Quick Reference (NHLBI) (PDF Document 719 KB).

Treatment: The 2007 NHLBI Guidelines describe “Six Steps” in treatment for asthma. Recommended treatment varies by age; the appropriate Step for a given patient is based on their asthma severity or control. In a child with poorly controlled asthma, stepping up to the next treatment level should be considered after assessing adherence to medication, knowledge of inhaler technique, and control of comorbid conditions and environmental factors. Stepping down may be appropriate for the child whose asthma has been well-controlled for several months and if no new or increased exposures to triggers are anticipated. The previous 2 tables outline recommended Steps for various ages and levels of severity/control. The following tables detail the medications and dosages recommended for each Step.

Stepwise Management
Stepwise Approach for Managing Asthma Long Term
from Asthma Care Quick Reference (NHLBI) (PDF Document 719 KB)
Usual dosages quick-relief meds
Usual Dosages for Quick-Relief Medications
from Guidelines for Diagnosis & Management of Asthma - Summary (NHLBI) (PDF Document)
Comparative Doses ICS
Comparative Dosages of Inhaled Corticosteroids
from Asthma Care Quick Reference (NHLBI) (PDF Document 719 KB)
Usual Doses Other
Usual Dosages of Other Long-Term Control Medications
from Asthma Care Quick Reference (NHLBI) (PDF Document 719 KB)

Click on images to download PDFs of the tables.

Exercise-induced bronchospasm: In some children, exercise-induced bronchospasm (EIB) may be the only manifestation of asthma, and children with known asthma may experience worsening of symptoms during physical exertion. EIB may begin during or after vigorous exercise and takes about 20 to 30 minutes to resolve after peak symptoms are experienced. EIB should be controlled so that it does not limit participation in sports. The severity of EIB will depend on the duration and vigor of exercise, dryness/coolness of the air, and factors intrinsic to the child.

Pre-treatment with inhaled beta2-agonists before exercise is successful in more than 80% of patients. In children with frequent symptoms, additional long-term control medications or stepping up treatment for children who have asthma in addition to EIB is indicated. Simple remedies, including warming-up before exercise and wearing a mask or scarf over the mouth when exercising in cold weather may be helpful. Being physically fit helps postpone the onset of EIB in susceptible patients. Children with EIB alone should be monitored periodically by pulmonary function tests (PFTs) to ensure that they continue to have no evidence of asthma without exercise. [National: 2007] [Randolph: 2008]

Chronic cough: Chronic cough is a common presentation of asthma in children; if the cough is mainly nocturnal and has been present for greater than 2 weeks, response to a trial of asthma medication may raise suspicion of cough-variant asthma (CVA). [Johnson: 1991] This is particularly likely if there is a personal history of allergy and a family history of allergy and/or asthma. Medications may consist of bronchodilators, inhaled or oral corticosteroids, or leukotriene modifiers; no controlled studies to favor one class over the other have been performed. [Antoniu: 2007] [Todokoro: 2003]

Ongoing education: Education begins with in-office demonstrations for the patient and family on how to administer medication (see Administering Asthma Medication Video). The clinician also involves patients and their families in developing strategies for self-assessment, avoidance of triggers, and Asthma Action Plans for home and school. Ongoing education involves patient/family education (health literacy), school support, and referrals to local asthma resources, such as asthma camps or parent organizations. See Educational Goals for Asthma (2007 NHLBI Guidelines) (PDF Document 97 KB) for more information on how to discuss asthma with patients and families.

Printable and online fillable Asthma Action Plans and other tools for educational purposes can be found under Asthma, Services & Other Resources.

Specialty Collaborations & Other Services

A referral for specialty consultation and/or management should be considered if control has been erratic.

Pediatric Pulmonology (see NV providers [5])

Consider referral when asthma is moderate to severe, 2 or more bursts of oral steroids are needed within 6 months, an exacerbation requires hospitalization, care is at Step 4 or higher (Step 3 or higher for children 0-4 years), additional testing or asthma education is needed, or comorbid conditions present management challenges.

Pediatric Allergy (see NV providers [8])

Consider referral for evaluation and immunotherapy if there is a relationship between persistent symptoms and exposure to particular allergens, if asthma is difficult to manage and there is personal or family history of allergy, or for management of refractory cases of asthma. Allergists are more numerous than pediatric pulmonologists and, in some geographic areas, may be the specialists with the most experience.

Departments of Health, State (see NV providers [4])

Consider referring if the state has an asthma home-visiting program. Such programs can provide home trigger education, assessment, and referral for remediation.

Immunology/Infectious Disease

A child with atopy produces IgE antibodies after exposure to common environmental allergens. 60-80% of children with asthma have allergies (see Have Asthma? You Likely Have an Allergy As Well (ACAAI) and [Samuel: 2008]). The individual risk of developing asthma or other atopic diseases results from the interaction of hereditary factors and environmental stimuli.

Common allergens include dust mites, mold, cockroach feces, pollens, and exposure to animals. Dust mites, mold, and cockroach allergy are very rare in children and adults that grow up in the arid west because the humidity is generally too low to support those organisms. [Nelson: 1995] In children with seasonal allergies, asthma symptoms may worsen during certain pollen seasons. Symptoms can also flare as a result of mold exposure (e.g., during rainy seasons or in damp areas). While uncommon, food allergies can be a factor in asthma. Common food allergies in the US are eggs, cow's milk, wheat, soybean products, tree nuts, and peanuts. Food additive allergy is extremely rare but may include sodium bisulfite, potassium bisulfite, sodium metabisulfite, potassium metabisulfite, and sodium sulfite, which are commonly used in food processing or preparation and can be found in foods such as dried fruits or vegetables, potatoes (packaged and some prepared), bottled lime or lemon juice, shrimp (fresh, frozen, or prepared), and pickled foods. Food allergies that trigger symptoms of an asthma attack likely produce allergy symptoms (hives, rash, nausea, vomiting, and diarrhea) followed by coughing and wheezing. If not caught quickly, anaphylaxis may result.

The presence of specific IgE antibodies to environmental allergens is determined with skin-prick or in-vitro testing, such as ImmunoCAP. ImmunoCAP has replaced radioallergosorbent testing (RAST) as the standard for quantitative specific IgE testing.

Management of allergens includes rational environmental avoidance strategies for at-risk populations. When this is not possible, consider allergy immunotherapy. Antihistamines, while helpful for allergies, are not effective for asthma. Studies suggest that immunotherapy may be appropriate when a causative allergen has been demonstrated. [Cox: 2011] Biologics, such as anti-IgE monoclonal antibody (omalizumab) or anti-IL-5 monoclonal antibody (mepolizumab), may be useful as add-on therapy in patients with severe persistent asthma who are inadequately controlled by optimal pharmacological therapy.

Viral upper respiratory infections commonly trigger asthma exacerbations and may warrant a change in management of asthma symptoms. Limit infections through routine immunizations and teach preventive skills such as proper hand-washing. Some studies suggest that certain childhood viral infections, like rhinovirus, respiratory syncytial virus (RSV), and parainfluenza virus, can predispose children to developing asthma later in life. Consultation with an asthma specialist is recommended for patients with severe persistent asthma.

Specialty Collaborations & Other Services

Pediatric Allergy (see NV providers [8])

Consider referral for evaluation if there is a relationship between persistent symptoms and exposure to particular allergens, if asthma is difficult to manage and there is personal or family history of allergy, or for management of refractory cases of asthma. Allergists are more numerous than pediatric pulmonologists and, in some geographic areas, may be the specialists with the most experience.

Pharmacy & Medications

Evaluation and Treatment/Management

The recommended medications to manage asthma are found in the 2007 NHLBI Guidelines (Asthma Care Quick Reference (NHLBI) (PDF Document 719 KB)).

Some considerations regarding long-term controller medications:
  • Inhaled corticosteroids (ICS) vary in terms of pharmacokinetic/pharmacodynamic properties, delivery, incidence of adverse effects, and cost to patient. Decisions regarding which ICS to use should take these into consideration. [Kelly: 2009] A comparison of recommended doses for different ICS based on age and Step can be found in Asthma Care Quick Reference - Diagnosing and Controlling Asthma (PDF Document 719 KB).
  • Leukotriene receptor antagonists (LTRA) may be considered as an alternative to ICS in mild persistent asthma or in step-up therapy along with ICS in patients who are not well-controlled with ICS alone. In mild persistent asthma, controlled trials have shown that ICS have greater efficacy and are more cost-effective than LTRA. However, montelukast has some advantages, including ease of administration, benefit in treating allergic rhinitis and exercise-induced bronchoconstriction, lack of demonstrated adverse effect on growth, and availability as a generic formulation. Of note, neuropsychiatric events have been reported in adult, adolescent, and pediatric patients taking montelukast, and the clinical details of some post-marketing reports appear consistent with a drug-induced effect.
  • Long-acting beta-2 agonists (LABA) should only be used in combination medications with inhaled corticosteroids.
  • Step-up therapy for children with uncontrolled asthma already receiving ICS: A study comparing increasing the dose of ICS vs. adding LABA vs. adding LTRA (i.e., Step 3 therapy) demonstrated that while adding LABA to ICS was more likely to provide the best response, many children had a best response to LTRA or ICS step-up therapy. The authors felt that this study underscored the need to routinely monitor and appropriately adjust a child’s asthma treatment individually within Step 3 care. [Lemanske: 2010]

Complementary & Alternative Medicine

Many families use complementary and alternative medicine (CAM) for asthma, whether out of frustration with lack of effectiveness of standard therapies, in seeking safer or more natural approaches, or trying to manage symptoms not addressed by medical treatment. [Philp: 2012] Examples of CAM include breathing exercises, herbal remedies, vitamins, acupuncture, and other treatments. Given the uncertain benefits and potential side effects of some CAM and possible drug interactions, it is important for physicians to be aware of their use among their patients and understand the reasons for their use. [Chen: 2013] Probiotics may reduce the risk of atopy and asthma in children. However, results from clinical trials have been conflicting and several studies may have been underpowered. [Elazab: 2013] See Integrative Medicine for CYSHCN.

Issues Related to Asthma

Ask the Specialist

Do you need lung function testing to diagnose asthma?

No, asthma can be diagnosed with clinical history. Lung function testing, such as spirometry with bronchodilator, or methacholine challenge testing, can be used to confirm or rule out asthma.

Can younger patients use breath-actuated inhalers?

No, breath-actuated or dry-powder inhalers are not ideal for young patients due to lack of inspiratory pressure and suboptimal technique. Younger patients with asthma (ages 7 or less) should always be prescribed metered-dose inhalers with valved holding chambers for use.

Can infants be prescribed a metered-dose inhaler instead of nebulizer?

Yes, infants less than 12 months of age can be prescribed albuterol MDI. If the administration of the medication is correct, albuterol MDI has been shown to be as effective as nebulized albuterol.

Can you suggest an online education program to help me best care for my patients with asthma?

The American Academy of Pediatrics' Education in Quality Improvement in Pediatric Practice (EQIPP) offers a program (for a fee) on diagnosing and managing asthma.

What ICD-10 coding would you use for a child with viral-induced asthma severe enough to need controllers or hospitalizations?

ICD-10 provides codes specific for severity, as detailed in the NHLBI guidelines, and for exercise-induced, cough variant, and "other" asthma; the need for controllers and hospitalization would suggest at least moderate persistent asthma (J45.4) with a fifth digit to specify whether uncomplicated (0), with exacerbation (1), or with status asthmaticus (2). ICD10Data.com provides more detail (search for "asthma").

Where can I learn more about the role of office-based spirometry and asthma?

A very helpful article on this topic and other objective measures used in childhood asthma, such as peak flow, is [Spahn: 2006]. Spirometry360 is a program of the University of Washington that offers web-based training for office staff performing spirometry.

Resources for Clinicians

On the Web

Asthma Care Quick Reference (NHLBI) (PDF Document 719 KB)
A 12-page summary of the 2007 Guidelines for Diagnosis and Management of Asthma from the National Heart, Lung, and Blood Institute; provides condensed charts and bulleted lists, along with practical tips for educating patients; link will download a pdf.

Guidelines for Diagnosis & Management of Asthma - Summary (NHLBI) (PDF Document)
A 74-page summary of the 2007 Guidelines for Diagnosis and Management of Asthma from the National Heart, Lung, and Blood Institute; link will download a pdf.

National Asthma Education and Prevention Program (NHLBI)
Offers links to information about asthma for providers, families, and schools; a program of the National Heart, Lung, and Blood Institute.

Physician Asthma Care Education (PACE)
A two-part interactive, multi-media educational seminar to improve clinicians' awareness, ability, and use of communication and therapeutic techniques for reducing the effects of asthma on children and their families. It also provides instruction on how to document, code, and improve asthma counseling reimbursement; offered by the National Heart, Lung, and Blood Institute.

Asthma Provider Manual - Pediatrics (UDOH) (PDF Document 3.4 MB)
Links to a 31-page manual, a medication guide, and patient education materials; Utah Department of Health Asthma Program.

Global Initiative for Asthma (GINA)
The GINA global strategy for asthma management and prevention is presented in its strategy documents, which are freely available on the GINA Website.

Helpful Articles

Loughlin CE, Muston HN, Pena MA, Ren CL, Yilmaz O, Noah TL.
Pediatric Pulmonology year in review 2018: Asthma, physiology/pulmonary function testing, and respiratory infections.
Pediatr Pulmonol. 2019;54(10):1508-1515. PubMed abstract

Patel SJ, Teach SJ.
Asthma.
Pediatr Rev. 2019;40(11):549-567. PubMed abstract / Full Text

Clinical Tools

Assessment Tools/Scales

Initial Asthma History Questions for Children (NHLBI) (PDF Document 57 KB)
Comprehensive list of questions for the initial assessment of a child with asthma; from the 2007 NHLBI Guidelines for Asthma Diagnosis and Management.

Asthma Control Test for Children 4-11 Years Old (GlaxoSmithKline) (PDF Document)
A downloadable PDF version of the 7-question ACT to determine if a child’s asthma treatment plan is working.

Asthma Control Test for People 12 Years or Older (GlaxoSmithKline) (PDF Document)
A self-administered, downloadable PDF version of the 5-question ACT to determine if the asthma treatment plan is working.

Asthma Control Test for Children
Easy to use, online, asthma control test based on recent symptoms; allows for printing the results of the test.

Asthma Control Test for Adults
An easy to use, online asthma control test for evaluating control based on recent symptoms. Site is sponsored by a pharmaceutical company but appears to be free of advertising.

Care, Action, & Self-Care Plans

Asthma Action Plan (Intermountain Healthcare)
Sample of a 1-page plan in downloadable PDF.

Asthma Action Plans in Spanish, Chinese, Vietnamese, English (RAMP)
Asthma plans in printable and fillable PDF formats; Regional Asthma Management and Prevention program.

Care Processes & Protocols

Initial Visit - Classifying Asthma Severity and Initiating Treatment (NHLBI) (PDF Document 59 KB)
Table guides age-based classification of asthma severity and initiation of treatment, from the 2012 Asthma Care Quick Reference summary of the 2007 NHLBI Guidelines.

Follow-Up Visits: Assessing Asthma Control & Adjusting Therapy (NHLBI) (PDF Document 56 KB)
A table of age-based classification of asthma control and steps in treatment; from the 2012 Asthma Care Quick Reference summary of the 2007 NHLBI Guidelines.

Stepwise Approach for Managing Asthma Long Term (NHLBI) (PDF Document 4.6 MB)
A table of age-based medication treatment of asthma in 6 Steps; from the 2012 Asthma Care Quick Reference summary of the 2007 NHLBI Guidelines.

Medication Guides

Usual Dosages of Quick-Relief Medications for Asthma (NHLBI) (PDF Document 41 KB)
Details about the available choices of quick-relief (rescue) medications for asthma; from the Asthma Care Quick Reference by the National Heart, Lung, and Blood Institute.

Comparative Dosages of Inhaled Corticosteroids (NHLBI) (PDF Document 63 KB)
Detailed comparisons; from the Asthma Care Quick Reference; National Heart, Lung, and Blood Institute.

Usual Dosages of Other Long-Term Control Agents (NHLBI) (PDF Document 51 KB)
Details on choices for long-term medications for asthma control other than inhaled corticosteroids, from the Asthma Care Quick Reference by the National Heart, Lung, and Blood Institute.

Asthma Inhaler Poster (AAN/MoA)
A poster ($3 each) with pictures of available inhalers. Useful for learning and verifying with parents/patients the various brands; Allergy & Asthma Network/Mothers of Asthmatics.

Questionnaires/Diaries/Data Tools

Patient Self-Assessment Record (NHLBI) (PDF Document 54 KB)
A sample record for patients to track asthma symptoms and medication use; from the 2007 National Heart, Lung, and Blood Institute Guidelines.

Peak Flow Chart (NACA)
A downloadable peak flow recording chart; National Asthma Council of Australia.

Toolkits

Asthma Care Process Model (Intermountain Healthcare) (PDF Document)
Summarizes diagnosis and management information for asthma in pediatric and adult patients. Includes an algorithm, a model for assessment of control, and a list of medications by age group and severity of symptoms; Intermountain Healthcare’s Primary Care and Pediatric Specialty, 2016.

Other

Tools for Schools

Is the Asthma Action Plan Working? A Tool for School Nurse Assessment (NHLBI)
A brief checklist to determine how well an asthma action plan is working for a student. This tool can also be used by asthma educators, primary care providers, and asthma specialists; National Heart, Lung, and Blood Institute.

Students with Chronic Illnesses: Guidance for Families, Schools, and Students (NHLBI)
Two-page guidance sheet presenting positive actions schools and families can take to address multiple chronic diseases. Facilitates compliance with applicable Federal laws; National Heart, Lung, and Blood Institute.

How Asthma Friendly is Your Childcare Setting? (NAEPP)
Seven-item list that can be used by parents and child-care providers to help pinpoint specific areas that may cause problems for children with asthma; National Asthma Education and Prevention Program.

Management of Asthma Exacerbations when a School Nurse is Not Available (NHLBI)
Offers a sample protocol for non-nursing staff, such as classroom teachers, who may need to help manage a child's asthma episode; National Heart, Lung, and Blood Institute.

Management of Asthma Exacerbations – Emergency Nursing Protocol (NHLBI)
The 2-page document suggests emergency nursing protocol for students with asthma symptoms who don’t have a personal asthma action plan; National Heart, Lung, and Blood Institute.

Winning with Asthma for Coaches Booklet (UDOH)
A 24-page downloadable booklet with additional resources that educates coaches at all levels about asthma, asthma and exercise, asthma symptoms, appropriate precautions, and medications and action plans; Utah Department of Health.

Online Course for Coaches and Asthma (Minnesota Department of Health)
A 35-minute online course for coaches that furthers understanding of asthma and provides training for working with athletes who suffer from asthma.

Patient Education & Instructions

Asthma Education Resources (EPA)
A number of educational resources for learning about asthma, managing triggers, and community action; Environmental Protection Agency.

Peak Flow Meter Information (ALA)
Patient information regarding the use of peak flow meters for asthma control assessment; American Lung Association.

Breathing Easier with Asthma (Intermountain Healthcare) (PDF Document)
A 36-page pdf booklet to educate parents, families, and caregivers about asthma.

Breathing Easier With Asthma (Intermountain Healthcare) (Spanish) (PDF Document)
A comprehensive 36-page PDF about understanding and controlling asthma, in Spanish (Para Respirar Mas Facil Con Asma).

Peak Flow Meter Guide (Children's Minnesota)
Patient education on use of peak flow meters, includes expected results by height.

Resources for Patients & Families

Information on the Web

Asthma in Children (MedlinePlus)
A comprehensive compilation of links and information related to asthma in children, sponsored by the National Library of Medicine.

Asthma & Allergies (healthychildren.org)
Focused on helping parents understand and live with pediatric asthma and allergies. Offers links to numerous online articles and videos demonstrating use of inhalers and other devices; sponsored by the American Academy of Pediatrics.

Asthma (ALA)
Information for parents and families about asthma, asthma-friendly environments, advocacy, and more; American Lung Association.

Asthma (NHLBI)
Addresses multiple aspects of asthma, including causes, signs and symptoms, treatment, and prevention; National Heart, Lung, and Blood Institute.

National & Local Support

Allergy & Asthma Network
A nonprofit that offers support for families affected by asthma.

Allergy & Asthma Network (Spanish)
A nonprofit that offers support in Spanish for families affected by asthma.

Studies/Registries

Clinical Trials in Children with Asthma (clinicaltrials.gov)
A list of trials registered with the National Institutes of Health; some may be of interest and offer the opportunity to participate in research.

Asthma Research (ALA)
Current research projects funded by the American Lung Association. Emphasis on understanding the immune system’s role in asthma, the effect of mold on severe asthma, improving treatment of severe asthma in children, and studying genes and their role in controlling the immune response.

Services for Patients & Families in Nevada (NV)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: March 2004; last update/revision: December 2019
Current Authors and Reviewers:
Authors: Khalid Safi, MD
Khanh Lai, MD
Authoring history
2013: update: Richard W. Hendershot, MDCA; Jennifer Goldman-Luthy, MD, MRP, FAAPR; Derek A. Uchida, MDR; Chuck Norlin, MDA
2008: update: Lynne M. Kerr, MD, PhDA; Deirdre Caplin, Ph.D.R; Derek A. Uchida, MDR
2004: first version: Deirdre Caplin, Ph.D.A; Julia Rossi, RN, MSA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Bibliography

2017 Behavioral Risk Factor Surveillance System (BRFSS).
Most Recent Asthma State or Territory Data.
Centers for Disease Control and Prevention (CDC). December 2019. / https://www.cdc.gov/asthma/most_recent_data_states.htm
Page is periodically updated by the CDC.

Akinbami L.
The state of childhood asthma, United States, 1980-2005.
Adv Data. 2006(381):1-24. PubMed abstract
U.S. Department of Health and Human Services Centers for Disease Control and Prevention Advance Data's statistics on asthma in the United States from Vital and Health Statistics.

Antoniu SA, Mihaescu T, Donner CF.
Pharmacotherapy of cough-variant asthma.
Expert Opin Pharmacother. 2007;8(17):3021-8. PubMed abstract

Asthma and Allergy Foundation of America.
Asthma Facts and Figures.
Asthma and Allergy Foundation of America; (2013) http://www.aafa.org/display.cfm?id=8&sub=42.
The Asthma and Allergy Foundation of America (AAFA) is the leading patient organization for people with asthma and allergies, and the oldest asthma and allergy patient group in the world.

Carrera-Bojorges XB, Pèrez-Romero LF, Trujillo-Garcìa JU, Jimènez-Sandoval JO, Machorro-Muòoz OS.
Internalization Disorders in Children with Asthma.
Rev Alerg Mex. 2013;60(2):63-68. PubMed abstract

Cassimos DC, Tsalkidis A, Tripsianis GA, Stogiannidou A, Anthracopoulos M, Ktenidou-Kartali S, Aivazis V, Gardikis S, Chatzimichael A.
Asthma, lung function and sensitization in school children with a history of bronchiolitis.
Pediatr Int. 2008;50(1):51-6. PubMed abstract

Celeste Beck, MPH, Epidemiologist, Utah Asthma Program Kellie Baxter, BS, Health Program Specialist, Utah Asthma Program.
Asthma in Utah Burden Report.
Utah Department of Health, Utah Asthma Program. 2012.
The report assists in understanding the impact of asthma in Utah.

Chen W, Fitzgerald JM, Rousseau R, Lynd LD, Tan WC, Sadatsafavi M.
Complementary and alternative asthma treatments and their association with asthma control: a population-based study.
BMJ Open. 2013;3(9):e003360. PubMed abstract / Full Text

Cox L, Nelson H, Lockey R, Calabria C, Chacko T, Finegold I, Nelson M, Weber R, Bernstein DI, Blessing-Moore J, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles S, Wallace D.
Allergen immunotherapy: a practice parameter third update.
J Allergy Clin Immunol. 2011;127(1 Suppl):S1-55. PubMed abstract

Elazab N, Mendy A, Gasana J, Vieira ER, Quizon A, Forno E.
Probiotic Administration in Early Life, Atopy, and Asthma: A Meta-analysis of Clinical Trials.
Pediatrics. 2013;132(3):e666-76. PubMed abstract
Conclusion: Prenatal and/or early-life probiotic administration reduces the risk of atopic sensitization and decreases the total IgE level in children but may not reduce the risk of asthma/wheeze. Follow-up duration and strain significantly modified these effects. Future trials for asthma prevention should carefully select probiotic strain and consider longer follow-up.

Galil N.
Depression and asthma in children.
Curr Opin Pediatr. 2000;12(4):331-5. PubMed abstract

Gillette C, Loughlin CE, Sleath BL, Williams DM, Davis SD.
Quality of pulmonary function testing in 3 large primary care pediatric clinics in rural North Carolina.
N C Med J. 2011;72(2):105-10. PubMed abstract

Johnson D, Osborn LM.
Cough variant asthma: a review of the clinical literature.
J Asthma. 1991;28(2):85-90. PubMed abstract

Kelly HW.
Comparison of inhaled corticosteroids: an update.
Ann Pharmacother. 2009;43(3):519-27. PubMed abstract

Kercsmar C.M., Mcdowel K.M.
Kendig's Disorders of the Respiratory Tract in Children. Chapter 45: 45 - Wheezing in Older Children: Asthma.
Ninth Edition ed. Elsevier; 2019. 978-0323448871

Lemanske RF Jr, Mauger DT, Sorkness CA, Jackson DJ, Boehmer SJ, Martinez FD, Strunk RC, Szefler SJ, Zeiger RS, Bacharier LB, Covar RA, Guilbert TW, Larsen G, Morgan WJ, Moss MH, Spahn JD, Taussig LM.
Step-up therapy for children with uncontrolled asthma receiving inhaled corticosteroids.
N Engl J Med. 2010;362(11):975-85. PubMed abstract / Full Text

Leyenaar JK, Ralston SL, Shieh MS, Pekow PS, Mangione-Smith R, Lindenauer PK.
Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States.
J Hosp Med. 2016;11(11):743-749. PubMed abstract / Full Text

Loughlin CE, Muston HN, Pena MA, Ren CL, Yilmaz O, Noah TL.
Pediatric Pulmonology year in review 2018: Asthma, physiology/pulmonary function testing, and respiratory infections.
Pediatr Pulmonol. 2019;54(10):1508-1515. PubMed abstract

National Asthma Education and Prevention Program Expert Panel.
Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007.
National Institutes of Health: National Heart, Lung, and Blood Institute; (2007) https://www.nhlbi.nih.gov/sites/default/files/media/docs/asthsumm.pdf. Accessed on Dec. 2019.
A 60-page summary of the 440-page comprehensive guideline; published by the National Heart, Lung, and Blood Institute.

National Asthma Education and Prevention Program Expert Panel.
Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma.
National Heart Lung and Blood Institute, NIH; (2007) https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-manag.... Accessed on 12/16/2019.
For the full 440-page report, click the Download PDF 4 MB button; from the National Heart Lung and Blood Institute, National Institutes of Health. A 60-page Summary Report and a 12-page Asthma Care Quick Reference are also downloadable from the same web page.

National Health Interview Survey, National Center for Health Statistics.
Most recent national asthma data.
Centers for Disease Control and Prevention. 2017. / https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm
Based on 2017 NHIS data.

National Heart Lung Blood Institute.
Expert Guidelines for the Diagnosis and Management of Asthma.
NIH; (2007) http://www.nhlbi.nih.gov/guidelines/asthma/.

Nelson HS, Fernandez-Caldas E.
Prevalence of house dust mites in the Rocky Mountain states.
Ann Allergy Asthma Immunol. 1995;75(4):337-9. PubMed abstract

Oxford Journals - Oxford University Press.
Obesity and the Risk of Newly Diagnosed Asthma in School-age Children.
Journal of Epidemiology. 2013;vol. 158. / Full Text
Adjusted relative risk of new-onset asthma by percentile of body mass index and weight status, Children’s Health Study, 1993–1998*

Paris J, Peterson EL, Wells K, Pladevall M, Burchard EG, Choudhry S, Lanfear DE, Williams LK.
Relationship between recent short-acting beta-agonist use and subsequent asthma exacerbations.
Ann Allergy Asthma Immunol. 2008;101(5):482-7. PubMed abstract / Full Text

Patel SJ, Teach SJ.
Asthma.
Pediatr Rev. 2019;40(11):549-567. PubMed abstract / Full Text

Perry R, Braileanu G, Palmer T, Stevens P.
The Economic Burden of Pediatric Asthma in the United States: Literature Review of Current Evidence.
Pharmacoeconomics. 2019;37(2):155-167. PubMed abstract / Full Text

Philp JC, Maselli J, Pachter LM, Cabana MD.
Complementary and alternative medicine use and adherence with pediatric asthma treatment.
Pediatrics. 2012;129(5):e1148-54. PubMed abstract / Full Text

Prasad B, Nyenhuis SM, Weaver TE.
Obstructive sleep apnea and asthma: Associations and treatment implications.
Sleep Med Rev. 2013. PubMed abstract

Randolph C.
Exercise-induced Bronchospasm In Children.
Clin Rev Allergy Immunol. 2008;34(2):205-16. PubMed abstract

Reddel HK et al.
Global Strategy for Asthma Management and Prevention.
Global Initiative for Asthma. 2019. / https://ginasthma.org/gina-reports/
A downloadable 199-page report with guidelines for the care of children (and adults) with asthma; from the World Health Organization. The guidelines are also available as a Pocket Guide for Asthma Management and Prevention (see GINA REPORTS drop-down at the link above).

Samuel J. Arbes, Jr., DDS, MPH, PhD, Peter J. Gergen, MD, MPH, Ben Vaughn, MS,3 and Darryl C. Zeldin, MD.
US National Library of Medicine National Institutes of Health: Asthma Cases Attributable to Atopy: Results from the Third National Health and Nutrition Examination Survey.
PMC. 2008. / Full Text
Conclusion: About half of the current asthma cases in the U.S. population represented by NHANES III were attributable to atopy. Some allergen-specific skin tests were not independently associated with asthma.

Sears MR, Johnston NW.
Understanding the September asthma epidemic.
J Allergy Clin Immunol. 2007;120(3):526-9. PubMed abstract

Spahn JD, Chipps BE.
Office-based objective measures in childhood asthma.
J Pediatr. 2006;148(1):11-5. PubMed abstract

Todokoro M, Mochizuki H, Tokuyama K, Morikawa A.
Childhood cough variant asthma and its relationship to classic asthma.
Ann Allergy Asthma Immunol. 2003;90(6):652-9. PubMed abstract

University of Virginia Health System.
Children With Asthma Often Suffer Developmental And Behavioral Problems.
Science Daily; (2013) http://www.sciencedaily.com/releases/2007/04/070412163840.htm. Data for the research came from the National Survey of Children's Health 2003, which was obtained from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics.. Accessed on Dec. 2019.
Data for the research came from the National Survey of Children's Health 2003, which was obtained from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics.

Weinberger M.
Time for a New Paradigm for Asthma Management.
Mayo Clin Proc. 2016;91(4):405-7. PubMed abstract

Yang IV, Lozupone CA, Schwartz DA.
The environment, epigenome, and asthma.
J Allergy Clin Immunol. 2017;140(1):14-23. PubMed abstract / Full Text