Childhood Asthma Treatment and Prevention

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It has been said that an ounce of prevention is worth a pound of cure. This adage holds more true in asthma than most conditions. Asthma is one of the most prevalent chronic illnesses in children. Millions of hospital admissions, primary care office appointments, and missed school days each year are directly related to asthma. Preventing asthma-triggering events and practicing continuous maintenance therapies can significantly reduce the amount of disruption in a child’s life due to asthma symptoms without childhood asthma treatment. In this course, we will explore the asthma disease process, triggers, and common therapeutic management with particular focus on prevention strategies for asthma exacerbation. 

Introduction 

One in 13 people are directly affected by asthma [5]. Asthma is a chronic disease of the lungs that causes wheezing, coughing, difficulty breathing, and chest tightness [12]. For clients with asthma, a common cold or allergic rhinitis can quickly escalate into a life-threatening event. Triggers in the environment can quickly initiate trouble among delicate, inflammation prone airways. 

Although asthma is one of the most prevalent chronic diseases among adults and children, it is often not well controlled. While many clients know they have asthma, many do not know how to manage it to prevent exacerbations. This can be especially devastating in children as their daily schedules, sleep, education, and activities can be significantly altered by uncontrolled asthma. 

Educating and empowering clients and their families to prevent disease exacerbation is a key component of successful asthma treatment. We will discuss asthma prevalence, common triggers, signs of asthma exacerbations, and prevention strategies in this course. 

What is Asthma? 

Asthma is a chronic disorder of the respiratory system that is characterized by four primary components: recurrent respiratory symptoms, bronchial hyper-responsiveness, airway obstruction, and inflammation [12]. 

Certain factors such as genetics, environment, socioeconomic status, smoking status, and race/ethnicity can increase the chances of developing asthma. Common triggers of asthma include allergens, pollution, cold air, stress, and exercise, among other irritants. 

Environmental factors trigger dendritic cells, which produce B and T cell lymphocytes, initiate IgE production of mast cells, eosinophil, and neutrophils. The end result of this cascade is bronchial inflammation. 

These cells also activate Th2/Th1 cytokines which amplify the response of the smooth muscle walls leading to persistent inflammation and remodeling of the tissues (long-term) [12]. 

Airway Remodeling in Asthma 

When bronchoconstriction and airway inflammation are persistent, airway edema occurs, worsening asthma symptoms. Airway edema can continue to exacerbate symptoms by promoting increased mucus production, mucous plugging, and hypertrophy and hyperplasia of the smooth muscles. 

The combination of bronchoconstriction and airway inflammation gives rise to the chronic symptoms of coughing, wheezing, and difficulty breathing. 

This is known as airway remodeling and this process makes asthma treatment more complicated as many commonly prescribed medications have limited response on altered bronchial tissues [12]. 

Importance of Early Diagnosis and Management 

While asthma cannot directly be cured, it can be managed. The earlier asthma is diagnosed, the earlier prevention education can be provided, and the earlier pharmacological management initiated, if indicated. 

The primary goal in asthma therapy is to prevent and reduce chronic inflammation (which leads to airway remodeling) and acute exacerbations. 

Proper management of asthma symptoms helps to reduce chronic damage by way of airway remodeling, (while reducing the odds of death related to an asthma attack) and increasing quality of life. 

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Prevalence and Impact of Pediatric Asthma 

Below are statistics of asthma prevalence in children [1][5][6][12][13]: 

• Most children with asthma develop symptoms before their fifth birthday. 
• Nearly 7% of children in the U.S. have asthma. 
• Asthma is more prevalent in boys than girls although girls have more asthma attacks. 
• Asthma is uncontrolled in about 50% of children, and results in frequent and severe episodes most commonly in young children (birth to 4 years). 
• 49% of children have missed one or more days of school due to asthma. 
• Asthma is more prevalent in children from low-income homes, urban areas, or those who belong to a racial/ethnic minority 
• Asthma is more prevalent in teens age 15-17 than any other childhood age group. 
• Asthma death rates among children are rare in the U.S. (2% compared to 16% in adults), most occurring between ages 5 and 11 

Presentation and Risk Factors 

Children can be diagnosed with asthma at a very young age. These children usually present with symptoms of persistent allergy, cough, and intermittent wheeze [1]. They often present to the primary care office or emergency department with asthma symptoms during periods of increased allergen exposure and/or a viral respiratory illness. 

Respiratory viruses attack airway structures causing inflammation and increased mucus production which exacerbate asthma symptoms. Children with asthma symptoms prior to the age of 3 have been seen to have significant lung growth deficits by age 6 [12]. Early diagnosis and treatments are critical in reducing such complications. 

Gender and race/ethnicity are risk factors for asthma development. Boys are more likely to have asthma, but girls have more asthma attacks [5]. Children of Black (Non-Hispanic), American Indian/ Alaska Native (Non-Hispanic), and Hispanic descent have higher risk than those of White or Asian descent [6]. 

Children with obesity are more likely to develop asthma [12]. Finally, asthma is more prevalent in households with income <100% below the poverty line [6]. 

While all children with persistent respiratory symptoms should be flagged and followed for potential asthma disease work-up, clinicians should be aware of the risk factors and be vigilant in screening and diagnosing those clients. 

Diagnosis and Treatment Disparities 

Access to healthcare, especially in many rural and poverty-stricken areas, is a national concern. Creating outreach programs in schools, primary care offices, and local hospitals may help maximize asthma screening and treatment for at-risk children. It is critical that healthcare providers recognize these care disparities and work with local and national resources to increase screening and diagnosis. 

Asthma Severity 

Asthma diagnosis and exacerbations are ranked based on of severity of symptoms, control, and responsiveness to therapies. Severity is the “intrinsic intensity of the disease process” [12]. It can be measured by incidence of symptoms without long-term therapy. 

Control is “the degree to which the manifestations of asthma are minimized and goals of therapy are met” [12]. Finally, responsiveness is how easily asthma symptoms (especially exacerbations) can be managed [12]. 

A combination of family and individual medical history, lung function testing, and history of asthma-related medication use help determine asthma diagnoses and treatment plans. 

Clients with severe symptoms and a decreased response to therapy are at an increased risk for severe, life-threatening asthma attacks. 

There are four classifications of asthma severity: 

• Intermittent 
• Persistent Mild 
• Persistent Moderate 
• Persistent Severe 

In children, components of severity are further separated by age group: 0-4 years, 5-11 years, and >12 years. Each level is described by the quantity of symptoms being experienced. 

These symptoms include nighttime awakenings, need for short-acting beta2-antagonists (SABA) for quick relief of symptoms, work/school days missed, ability to engage in normal activities, and quality of life assessments [12]. 

Lung function testing with spirometry should be performed in a healthcare office to evaluate the child’s lung compliance. This test should be attempted in all children age 5 years old or greater if asthma diagnosis is being considered [12]. Spirometry measures the child’s forced expiratory volume in 1 second and in 6 seconds (FEV1 and FEV6) and forced vital capacity (FVC). 

Spirometry should be performed before and after inhaling a SABA medication to help determine if there is airflow obstruction, its severity, and reversibility with use of a SABA (responsiveness) [12]. The resulting numbers are compared to expected values for each age group and written as percentages. 

Greater than 85% of expected lung compliance is considered normal for children up to age 19. Asthma severity and lung compliance are inversely related- the further the decrease in compliance the more severe the asthma is. 

When combined with the child’s history of symptoms and medication use, healthcare providers can determine the classification of asthma severity and appropriate treatment measures using the stepwise approach. The stepwise approach helps to standardize asthma symptoms and initiate related therapies. 

Healthcare providers use this information to determine when to move up or down a treatment level to provide the most effective management with the least number of exacerbations from this disease. Provider assessment of a child’s asthma maintenance therapy should be completed every 2-6 weeks while gaining asthma control, every 1–6 months to monitor control, and every 3 months if step down in therapy is anticipated [National Institute of Health – quick action]. 

Stepwise Approach for Classifying Asthma Severity 

The chart below outlines the evaluation of asthma utilizing a standard step-wise approach. First choose the child’s age and then ask questions pertaining to the impairment/risk. Based on the information, you will be given a “step.” The appropriate treatment for each step is outlined in a table discussed in the next main section of this course. 

Classification 1: Intermittent Asthma 

*Will discuss treatment details in next main section 

Table 1. Classifying asthma severity in children: Intermittent Asthma [11] 

Classification 2: Persistent Mild Asthma 

*Will discuss treatment details in next main section 

Table 2. Classifying asthma severity in children: Persistent Mild Asthma [11] 

Classification 3: Persistent Moderate Asthma 

*Will discuss treatment details in next main section 

Table 3. Classifying asthma severity in children: Persistent Moderate Asthma [11] 

Classification 4: Persistent Severe Asthma 

*Will discuss treatment details in next main section 

Table 4. Classifying asthma severity in children: Persistent Severe Asthma [11] 

Asthma Therapies 

Asthma is treated in a stepwise approach based on asthma symptom severity. Using the stepwise approach allows providers to prescribe appropriate medications for each child in order to optimizing symptom control. A review of common asthma medications and their escalation of prescription based on the stepwise approach is listed below. 

Table 5. The National Heart Lung and Blood Institute’s Stepwise Approach for Pharmaceutical Management of Asthma [11] 

Medications 

Inhaled Short-Acting Beta2-Agonists 

Inhaled Short-Acting Beta2-Agonists (SABA) medications are the preferred therapy in the event of acute asthma symptoms, asthma exacerbations, and in preventing exercise-induced asthma symptoms (taken before the activity). Albuterol, levalbuterol, and pirbuterol relax airway smooth muscles within minutes to allow relief of inflammation and improvement of airflow. 

Children with intermittent asthma may not require a daily, preventative medication. They may only be prescribed a SABA medication for acute symptom exacerbation. Frequency of SABA medication use can be an indicator of asthma activity and control. 

Using a SABA medication greater than two days a week for symptom relief generally indicates suboptimal control and indication to move up a treatment step. Of note, all children with asthma are prescribed a SABA medication to use as a rescue, quick-relief medication. [12] 

Inhaled Corticosteroids 

Inhaled Corticosteroids (ICS) work by suppressing cytokine involvement, decreasing the involvement of the airway’s eosinophil cells and preventing an increase in inflammatory mediators. Use of long-term ICS can prevent the need for oral systemic steroid administration by controlling asthma symptoms. Variable dosing of ICS medication is used depending on severity and persistence of asthma symptoms. 

Side effects in long-term use include impaired growth in children, decreased bone mineral density, skin thinning and bruising, and cataracts. Children on this medication should be instructed to use a spacer (if applicable) and rinse their mouths after inhalation to prevent oral thrush. Common ICS medications include fluticasone, budesonide, mometasone, beclomethasone, and ciclesonide [12]. 

Cromolyn Sodium and Nedocromil 

Cromolyn sodium and nedocromil are alternative treatment options to low-dose ICS for mild persistent asthma and exercise-induced asthma. These medications are generally not preferred in children but may be prescribed on a case-by-case basis. Studies have shown inconclusive results to the impact of effectiveness of this medication in children. [12] 

Leukotriene Modifiers 

Leukotriene modifiers (LTRA) may be used as an alternate treatment option for mild persistent asthma and step 2 of asthma management. They are not recommended over LABA medications in ages >12 years. These medications work by preventing the release of mast cells, eosinophil cells, and basophils that cause airway constriction, vascular permeability, and increased mucous. 

Medications in this class include montelukast, zafirlukast, and zileuton. Montelukast can be prescribed in children over the age of 1 and zafirlukast for children over the age of 7. While previously not approved for use in children, zileuton is now approved for use in children over the age of 12 [10][12]. 

Methylxanthines 

Theophylline is a methylxanthine that can be used as an alternative or adjunctive therapy to ICS for mild persistent asthma in children older than 5. In previous trials, theophylline was shown to have little effect on airway reactivity and produced significantly less control than the use of low-dose ICS alone [12]. Because of this and its narrow margin of safety, its use has largely fallen out of favor. 

Inhaled Long-Acting Beta2-Agonists 

Inhaled Long-Acting Beta2-Agonists (LABA) medications stimulate the beta2-receptors to relax the smooth airway muscles. They are the preferred medication to be used in adjunct with ICS medications. They are not recommended alone and not recommended to treat acute asthma symptom exacerbation. LABA therapy should be considered in children ages 5+ who are not well controlled on ICS management alone. The LABA medications on the market today are Salmeterol and Formoterol. [12] 

Oral Systemic Corticosteroids 

Oral corticosteroids are usually reserved for severe asthma flares or in the event of difficult-to-control asthma. Side effects such as adrenal suppression, growth suppression, dermal thinning, hypertension, Cushing’s syndrome, cataracts, and muscle weakness may occur and are more likely with chronic usage. If oral corticosteroids are being used more than three times a year for management of asthma exacerbations, reevaluation of long-term asthma control should be evaluated. 

Experimental Treatments 

Immunomodulators 

Immunotherapy for asthma management is a relatively new concept. Research is currently being performed to address and assess the effectiveness of immunotherapy in preventing asthma symptoms. 

Some therapy modules being studied include Omalizumab, Methotrexate, Soluble interleukin-4 receptor, anti-IL-5, recombinant IL-12, cyclosporin A, intravenous immunoglobulin (IVIG), and clarithromycin. [12] 

Complementary and Alternative Medicine 

Many complementary and alternative medicine (CAM) therapies have not been proven to statistically to reduce asthma incidence, severity, or risk. Practicing alternative medicine strategies is not recommended as a replacement to scientifically proven pharmacologic management, but they may be used as an adjunct if appropriate. 

These therapies include acupuncture, chiropractic therapy, homeopathic and herbal medicine, breathing techniques, relaxation techniques, and yoga. [12] 

Asthma Treatment and Management Guidelines for Pediatric Clinicians 

Updated recommendations for asthma treatment in children were made in 2020 by a panel of pediatric and pharmacy experts. The prior recommendations were made in 2007. The new 2020 recommendations highlight treatment guidelines for children of varying ages. While the panel has outlined several recommendations to follow, many can be considered “suggestions.” However, the following guidance is strongly recommended as a standard of care for all clinicians treating children with asthma [8]. 

Asthma Treatment Guidelines 

Updated recommendations for pharmacological treatment of asthma in children were made in 2020 by a panel of pediatric and pharmacy experts. The prior recommendations were made in 2007. The new 2020 recommendations highlight treatment guidelines for children of varying ages. While the panel has outlined several recommendations to follow, many can be considered “suggestions.” However, the following guidance is strongly recommended as a standard of care for all clinicians treating children with asthma [8]. 

• For children from birth to 4 years old with recurrent wheezing caused by respiratory tract infections (with no wheezing in between infections): 
• Begin a short course of inhaled corticosteroids (ICS) daily once the infection begins. May begin short-acting beta2-agonists (SABA) (i.e., albuterol inhaler) as needed for quick relief.  
• This recommendation changed from the previous guideline to begin with SABA as needed for quick relief without ICS. 
• For children 4 years old and older with moderate to severe persistent asthma: 
• Begin ICS-formoterol in a single inhaler used daily routinely, and as needed for quick relief. 
• This guidance is recommended over beginning a high dose corticosteroid daily routinely and SABA for quick relief. 

Asthma Management Guidelines 

The prior guidelines focused on pharmaceutical treatment of asthma; however, clinicians need guidance on how to identify and diagnose asthma as well as how to create a plan of care for treatment and follow up. The following recommendations are meant to guide clinicians in how to provide quality asthma care [11]. Asthma control focuses on reducing the impairment asthma has on individuals as well as reducing the risk of asthma attacks, progressive respiratory decline, or adverse effects of asthma medications. 

• Diagnose: perform a history and exam to determine if the client has symptoms of recurrent airway obstruction (cough, wheezing, difficulty breathing, chest tightness) or their symptoms worsen at night or with exercise, infection, stress, weather changes, allergen exposure, etc. In clients over age 5, use spirometry to determine if airway obstruction is partially reversible. Finally, make the diagnosis of asthma. 
• Assess asthma severity: as mentioned earlier, when determining severity, consider lung function, frequency of symptoms, how often the client uses SABA for quick relief, and how much symptoms interfere with sleep and activity. 
• Initiate medication and demonstrate use 
• Develop written asthma action plan (will discuss in next section) 
• Schedule follow up appointment 
• Assess & monitor asthma control 
• Review medication technique & adherence; assess side effects; review environmental control 
• Maintain, step up, or step down medication 
• Review asthma action plan, revise as needed 
• Schedule next follow-up appointment 

The guidelines also make the following recommendations for asthma urgent/emergency care [11]: 

• Assess severity by lung function measures (for ages ≥5 years), physical examination, and signs and symptoms. 
• Treat to relieve hypoxemia and airflow obstruction; reduce airway inflammation.  
• Use supplemental oxygen as appropriate to correct hypoxemia 
• Treat with repetitive or continuous SABA, with the addition of inhaled ipratropium bromide in severe exacerbations. 
• Give oral systemic corticosteroids in moderate or severe exacerbations or for clients who fail to respond promptly and completely to SABA. 
• Monitor response with repeat assessment of lung function measures, physical examination, and signs and symptoms, and, in emergency department, pulse oximetry. 
• Discharge with medication and client education: 
• Medications: SABA, oral systemic corticosteroids; consider starting ICS 
• Referral to follow-up care 
• Asthma discharge plan 
• Review of inhaler technique and, whenever possible, environmental control measure (discussed in next section) 

While the above recommendations are meant to serve as an evidence-based guide in the treatment and management of asthma in children, pediatric clinicians show follow their facility’s protocol regarding routine and emergent asthma care for children. 

Asthma Prevention Strategies 

Asthma Action Plan 

The Asthma Action Plan is a great tool for families [2]. It can improve recognition of the early signs of asthma exacerbations and facilitate appropriate treatment of asthma symptoms. If updated frequently with the child’s healthcare provider and followed in the event of asthma symptoms it may reduce exacerbation severity and duration, primary care office visits, hospital visits, and asthma-related deaths [2]. 

Asthma action plans are designed to provide families one place to collect all the child’s critical information regarding their asthma including: name, date of birth, current medications for long-term maintenance, quick-relief medications, medication dosing/instructions, and important phone numbers in case of emergency. This information helps guide caregivers to act quickly when exacerbations occur. It also identifies common asthma symptoms that might be overlooked and plans appropriate treatment steps to complete in the event these symptoms occur. 

There are three zones on the Asthma Action Plan: green, yellow, and red. Each zone indicates increasing severity of symptoms and identifies appropriate treatments or interventions. With proper control of their asthma disorder, children and adults alike should spend a majority of their days in the green zone. This zone indicates that there are no asthma symptoms, even in play or activity [2]. Prevention of trigger exposure is the key to maintaining this zone. 

The next zone, yellow, indicates that the child is not feeling well and is experiencing asthma symptoms such as coughing, wheezing, runny nose/cold symptoms, breathing harder or faster, waking at night coughing, and playing less than usual [2]. 

The final zone, red, indicates the danger zone in which the child’s symptoms worsen so drastically that in addition to giving the medications listed on the plan, taking the child immediately to the hospital or calling 9-1-1 is the necessary course of action [2]. 

Some children, even if they spend the majority of their days in the green zone, can quickly escalate to the red zone. Educating families on this plan is critical to helping them make the best decisions for their children in both preventing and managing asthma symptoms. 

Controlling Allergies and Environmental Triggers 

Children with asthma often lead normal lives until a trigger initiates the inflammatory cascade resulting in an asthma exacerbation. More than 80% of children with asthma are sensitive to at least one indoor allergen [9]. Some of the most common allergens and environmental triggers for asthma, both indoor and outdoor, include dust mites, molds, trees or pollens, cockroaches, pet dander, secondhand smoke, air pollution, and scents like perfumes, air fresheners, and household cleaners [3]. 

Exercise and stress can also be triggers for asthma symptoms [12]. While limiting exercise is not generally recommended unless prescribed by a healthcare provider, choosing less physically demanding exercises may result in better asthma control. Children with well-controlled asthma are often able to complete activities and exercise as desired [12]. 

Teaching families how to identify asthma triggers and avoid the child’s exposure, when possible, can significantly reduce asthmatic complications. Below are a few suggestions that can be offered to families to help improve environments for children with asthma. 

Avoiding Common Asthma Triggers 

Ways to avoid common asthma triggers include [3][12]: 

• Frequently wash hands to avoid spread of infection (common cold, alternate viruses, bacteria). 
• Close house windows, doors, and car windows to prevent increased exposure to pollens and other outdoor allergens 
• Use zippered mattress and pillow covers to reduce exposure to dust mites. 
• After playing outside, immediately change clothes and/or bathe to reduce prolonged exposure to outdoor allergens. 
• If possible, remove old carpeting and/or frequently vacuum when child is not around. 
• Avoid humidifiers that may harbor mold and bacteria. 
• Monitor for food allergies including but not limited to milk, eggs, peanuts, tree nuts, soy, wheat, fish, shellfish, and food additives. 
• Address pets in the home. If pets are an asthma trigger and rehoming is not an option, bathe pets weekly, keep them outside as much as possible, and avoid having them in child’s bedroom. 
• Avoid secondhand smoke. Ask those who smoke to not smoke around the child, smoke in designated rooms, or cease smoking all together. 
• It is important to note that pediatrician experts recommend against limiting contact with all allergens, but rather for specific allergens to which a child is either sensitized or symptomatic after exposure [8].  

Peak Flow Meters 

Peak flow meters are small, hand-held devices used to measure exhaled airflow [4]. In the event of an asthma exacerbation, airways become inflamed, trapping air in the lungs and increasing the difficulty of proper exhalation. The use of the peak flow meter can help identify narrowing of the airway prior to the actual presence of asthma symptoms [4]. Using the peak flow meter presents an opportunity treat early signs of asthma exacerbations with the hope of ultimately reducing the incidence of moderate to severe symptoms. 

Peak flow meter education may seem intimidating to families at first. However, it is quite simple. Just like the Asthma Action Plan, peak flow meters have three zones that indicate severity of airway inflammation. The green zone is considered the safe zone, yellow is the caution zone, and red is the emergency zone [4]. Each zone indicates a percentage of the child’s personal best exhaled air flow. 

The green zone indicates 80-100% of the child’s personal best flow; the yellow zone measures 50 to less than 80%; and the red zone measured less than 50% of the child’s personal best flow. [12] Using the results of the peak flow meter test with the asthma action plan can help families decide the appropriate course of action in asthma management. 

To use the peak flow meter, the child should move the marker on the meter to zero, sit or stand-up straight, take a deep breath, put the meter into the mouth closing the lips around the mouthpiece, and blow as hard and fast as possible [12]. The number noted on the meter should then be marked in a log and the steps repeated 5-6 more times [12]. 

The best three numbers should then be recorded in a final log to determine how well the child’s asthma is controlled. Families should be instructed to record a log over the course of a couple weeks to determine the child’s best peak flow rate as well as determine the colored zones for future asthma management. 

After the zones are created with the data collected, the child should then use the peak flow meter daily, to determine if the child is experiencing airway inflammation. The child and family should use the results to compare to the treatment plan as written on the child’s asthma action plan [12]. 

Proper Medication Administration 

Proper medication administration is crucial to asthma control. It is no longer recommended to use inhaled medications without the use of a spacer [7]. A spacer device helps deliver doses of inhaled medication in a more streamlined and coordinated movement [7]. 

However, despite being taught how to properly use a spacer upon prescription of an inhaled medication, many children and families forget to use or improperly use the device. Spacer use and proper medication administration should be reviewed with every child and their family at all asthma related healthcare appointments and/or emergency department visits. 

Ensuring that children and families are using medications correctly may reduce and even prevent serious asthma exacerbations in the future. 

Case Study 

A father and his 5-year-old son present to the primary care office: The father states that the child has been coughing at night 2-4 nights a week; coughing every morning; and has difficulty breathing with exercise or exertion. The child experienced a cold a few weeks ago and since then, the coughing has not improved. 

The father denies any fever. He describes the coughing as hoarse, hollow, dry, and sometimes barky. The child also frequently experiences rhinorrhea and increased sputum, but father denies those symptoms at present. The father mentions that they have been to the emergency department twice in the past 6 months for similar symptoms and the child has received two treatments of nebulized albuterol (2.5mg) at each visit. 

They were not sent home with any medications. Father states that while the albuterol treatments in the emergency department helped for a couple days, the coughing would return. The family has one dog in the home and the child frequently spends time at his grandparents’ house where he is exposed to secondhand smoke. 

The child appears healthy in the clinic today. His vital signs read: O2: 100%, Respiratory Rate: 13, Heart Rate: 119, Blood Pressure: 97/62, and Temperature: 98.2F. He is sitting comfortably in the office but will frequently clear this throat and have a harsh cough. Upon listening to the child’s lungs, wheezes are noted bilaterally in the bases. There are no retractions, rhonchi, or rales. 

The healthcare provider performs spirometry testing to evaluate the child’s lung compliance and level of obstruction prior to administering a SABA medication. After completing the spirometry, the child is noted to have a FEV1 75% of predicated value. A nebulized albuterol treatment is completed and the child performs the spirometry again. After the treatment, the child’s FEV1 returns to a normal range >85% of predicted value. 

Physical exam reveals improvement in wheezing and the child states he can breathe better. Based on the child’s history of persistent coughing >2 nights a week, coughing every morning, limitations on activity due to respiratory symptoms, and an initial abnormal FEV1 (though resolved after SABA administration), the healthcare provider determines that the child has Persistent Mild Asthma. 

Based on the step-wise approach of managing asthma, the child is treated as a Step 2 for symptoms aligning with mild-persistent asthma disease. The healthcare provider prescribes the child a rescue albuterol inhaler (SABA) and long-term, low-dose fluticasone inhaler (ICS). The healthcare provider recommends to the father that the child be tested for allergies to help identify possible triggers to asthma symptoms. If the child is found to have significant allergies, an additional allergy medication may be prescribed at that time. 

The father and child are educated on proper administration of the medications with use of a spacer and given a peak flow meter to measure the child’s exhaled airflow. The father is instructed on how to find the child’s best peak flow rate over the next two weeks and use that to determine critical values of expected airflow. The child should continue to record the peak flow measurements daily to assess early changes in airway obstruction. 

The healthcare provider then develops an Asthma Action Plan with the father and child to provide a guideline of therapy, write important medication and emergency information, and help to identify early asthma symptoms and emergency treatments. 

They discuss common asthma triggers to avoid. The father and child are encouraged to keep their pets out of the child’s room as much as possible and outside whenever feasible. The child should use a zippered mattress and pillow protector to prevent exposure to dust mites and flooring should be mopped or vacuumed frequently while the child is outside of the home. 

It is also recommended that secondhand smoke exposure is limited by way of having grandparents smoke outside of the home, see the child at his home where there is less smoke, and change their clothes or use a smoking jacket that can be removed after smoking before being with the child. 

With new information in hand, the father and child, while overwhelmed, feel they can start to prevent and treat the child’s asthma symptoms. The family should be encouraged to follow-up closely with their primary healthcare provider to ensure appropriate control and reduce chronic

Conclusion 

Asthma is a prevalent, chronic illness in society. Understanding the disease process, therapy options, and promoting prevention strategies can help manage this chronic disease- reducing complications and improving quality of life. 

Online resources offered through national organizations, such as the Centers for Disease Control and Prevention, American Academy of Pediatrics, Healthy People 2020, the Asthma and Allergy Foundation of America provide excellent information for both clients and healthcare members. 

It has been said that an ounce of prevention is worth a pound of cure. This holds true for asthma even more so than many other diseases. Focusing on prevention strategies, proper and prompt treatment, and appropriate use of resources are the cornerstone of asthma treatment

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