SMART Asthma Care for Children

Educational Objectives

The goal of this program is to improve the management of asthma. After hearing and assimilating this program, the clinician will be better able to:

1. Describe the pathophysiology of asthma.
2. Prescribe guideline-recommended therapy for children with asthma.
3. Recognize the importance of spirometry in the diagnosis and management of pediatric asthma.

Summary

Asthma in children: good control is more important than level or severity; updated asthma guidelines were introduced in 2020, replacing those from 2007, to help develop effective management plans

Bronchospasm: asthma affects small airways, ie, the bronchioles, not the trachea or alveoli; bronchioles undergo bronchospasm (constriction of smooth muscle causing airway narrowing), which is a normal response; bronchial hyperresponsiveness causes the airways to constrict (in response to triggers) to a greater degree than in people without asthma

Inflammation: inflammation in the airways causes swelling with fluid (edema), white blood cells (specifically eosinophils), and increased mucus production; this eosinophilic inflammation can cause remodeling, or scarring, resulting in permanent airway obstruction if asthma is not properly managed

Diagnosis: involves recognizing symptoms, identifying triggers, noting any personal or family history of atopic diseases, and conducting spirometry to evaluate lung function; symptoms — include coughing, wheezing, shortness of breath, and chest tightness in any combination; there is no distinct type called “cough-variant asthma”; cough can simply be the main symptom in some patients; triggers — activate symptoms; the most common triggers are viral respiratory infections, exercise (many patients experience exercise-induced bronchospasm), exposure to cold air, fumes, and allergens (many individuals with asthma also have allergies); asthma symptoms typically worsen at night; a key diagnostic question is whether the child is woken from sleep by their symptoms

Atopic disease: asthma is part of a group of genetically linked atopic diseases that includes allergic rhinitis, atopic dermatitis, and food allergies; having one of these conditions increases the likelihood of having others; parents passing down a predisposition for atopy (“atopy gene”) does not mean their children will inherit the exact condition, ie, parents with asthma or hay fever may have a child with food allergies; likewise, specific food allergies (eg, shrimp) are not inherited; atopy is marked by the production of immunoglobulin (Ig) E antibodies, which cause, eg, allergic rhinitis, IgE-mediated food allergies; however, asthma and atopic dermatitis can occur without allergies (IgE involvement); other IgE-related conditions (eg, allergies to drugs or stinging insects) do not have a genetic inheritance pattern

2020 asthma guidelines (Larenas-Linnemann et al, 2023): sometimes referred to as the Expert Panel Report (EPR)-4; they are largely based on the 2007 EPR-3 guidelines but have been updated; these guidelines traditionally categorized asthma by severity (eg, intermittent, mild persistent, moderate persistent), which some find overly complex and not particularly useful in everyday practice; a more practical approach focuses on asthma control (well controlled, not well controlled, and very poorly controlled); severe asthma can be well controlled, but it requires more medication to achieve the same level of control as a milder case of asthma; well-controlled asthma involves minimal use of reliever medication (ideally ≤2 times/wk), normal lung function, no exacerbations resulting in unscheduled medical visits or need for systemic corticosteroids, and no activity limitations; if any of these criteria are unmet, the asthma is not well controlled

Managing asthma: involves addressing triggers and appropriate medication use; triggers — eg, viral respiratory infections can be mitigated with vaccines (eg, influenza, COVID-19, respiratory syncytial virus), including during pregnancy; sports and physical activities should not be limited; avoid cigarette smoke and other irritants, and implement environmental control measures for allergens

Asthma medications: fall into 2 main categories; controller medications — include inhaled corticosteroids (ICS), which target eosinophils to reduce inflammation; steroids are often combined with bronchodilators in the form of long-acting β-agonists (LABAs) or long-acting muscarinic antagonists (LAMAs); if asthma is not well controlled on these medications, an allergist may consider biologic medications; reliever medications — albuterol is the traditional standard; however, current guidelines specify that the preferred regimen is a low-dose ICS combined with formoterol (a LABA); levalbuterol is the active isomer of albuterol but offers no significant benefit in terms of adverse effects or efficacy; guidelines state that albuterol and levalbuterol are interchangeable (use whichever is cheaper); reliever medications should be used only as needed, not on a set schedule, even if the child is ill or hospitalized; scheduled use obscures how often medication is truly needed during an exacerbation; effectiveness should be almost immediate; key questions to ask about reliever use include the frequency of use, what prompts usage, whether it helps, nighttime awakenings requiring medication, and whether pre-exercise use prevents symptoms effectively

Spirometry: essential for diagnosing and monitoring asthma; demonstrates the presence of obstruction and its reversibility; recommended for all children ≥5 yr of age because clinical assessments alone (ie, history and physical examination) can differ significantly from objective spirometry results; baseline spirometry results are used to compare future measurements; if results are abnormal, assess the degree of obstruction and the response to bronchodilator treatment; peak flow monitoring — not an adequate substitute for spirometry and is not more effective than symptom monitoring for improving asthma outcomes; thus, it is no longer recommended; although some may find peak-flow data helpful, it is considered a late and imprecise indicator of lung function; fractional exhaled nitric oxide machines — not essential for asthma care

Asthma guidelines: are structured by age groups; for children 0 to 4 yr of age, ICS is now recommended to be used only during respiratory infections rather than continuously; children are now eligible for ICS-LABA therapy from birth; for children who experience exacerbations only with respiratory infections, the ICS or ICS-LABA must be started at the earliest signs of illness and continued for the duration of illness for the medication to be effective; relievers are then used on an as-needed basis; salmeterol is a long-acting LABA, whereas formoterol offers both long- and quick-acting relief; Single Maintenance and Reliever Therapy (SMART) uses an ICS-formoterol inhaler for daily maintenance and symptom relief, simplifying treatment to a single inhaler; the guidelines permit ≤8 puffs per day for children <11 yr of age and ≤12 puffs for older children, without risk for overdose (although clinicians should be notified if use is this high); SMART is the preferred treatment for children ≥5 yr of age; for children ≥12 of age, if ICS-formoterol therapy is insufficient, adding a LAMA (a different type of bronchodilator) is an option

Global Initiative for Asthma (Levy et al, 2023): provides simplified guidelines, updated annually; states that all patients should use an ICS-formoterol inhaler as maintenance and reliever; may be used on an as-needed basis or regularly at varying doses, escalating to higher doses or adding a LAMA if needed

Other medications: leukotriene receptor antagonists (eg, montelukast) are typically not preferred unless they are effective for specific patients; for severe asthma, biologics target eosinophils but are very expensive and should be used only after all other treatments have failed

Management: asthma is considered well-controlled if a patient uses their reliever ≤2 times/wk and has normal spirometry; if reliever use is >2 times/wk or spirometry results are abnormal, maintenance medication is needed; maintenance doses are adjusted and treatments are added as needed; providers should assess adherence and possible environmental triggers before escalating treatment; ensure patients are taking medication as prescribed by asking them to describe their routine (instead of answering “yes” to the clinician’s description); stepping down therapy — appropriate if a child with asthma has been doing well for a few months, with normal spirometry, no exacerbations, and minimal use of reliever medication; the goal is to provide enough medicine to control the disease without overmedicating; for exercise-induced symptoms, most patients can use a reliever medication (ie, albuterol, ICS-formoterol inhaler) before exercise to prevent symptoms; exacerbation — prednisone is typically prescribed for several days, but a single dose of dexamethasone can be just as effective; assess why the exacerbation occurred and adjust the treatment plan accordingly

Educating parents: involves explaining asthma, how medications work and when and how to use them, and what to do for continuing symptoms; asthma action plans are common, but there are no data to support improved outcomes; consider telling parents to contact a health care provider if reliever use increases or if reliever therapy stops working

Goal of managing asthma: is to prevent children from needing hospitalization, unscheduled visits, or systemic corticosteroids; children should not miss school or work, or have activity limitations, interrupted sleep, or abnormal lung function; key practices to improve care include using spirometry to monitor lung function and preventing exacerbations

Readings

Dinakar C, Chipps BE. Section on allergy and immunology; section on pediatric pulmonology and sleep medicine. Clinical Tools to Assess Asthma Control in Children. Pediatrics. 2017;139(1):e20163438. doi:10.1542/peds.2016-3438; Haktanir Abul M, Phipatanakul W. Severe asthma in children: Evaluation and management. Allergol Int. 2019;68(2):150-157. doi:10.1016/j.alit.2018.11.007; Hoch HE, Houin PR, Stillwell PC. Asthma in children: A brief review for primary care providers. Pediatr Ann. 2019;48(3):e103-e109. doi:10.3928/19382359-20190219-01; Larenas-Linnemann D, Romeo J, Ariue B, Oppenheimer J. American College of Allergy, Asthma and Immunology members’ preferred steps 1 to 3 asthma maintenance and reliever therapy and incomplete insurance coverage indicated as main practice hurdle. Ann Allergy Asthma Immunol. 2023;131(4):451-457. doi:10.1016/j.anai.2023.05.036; Levy ML, Bacharier LB, Bateman E, et al. Key recommendations for primary care from the 2022 Global Initiative for Asthma (GINA) update. NPJ Prim Care Respir Med. 2023;33(1):7. Published 2023 Feb 8. doi:10.1038/s41533-023-00330-1; Miller RL, Grayson MH, Strothman K. Advances in asthma: New understandings of asthma’s natural history, risk factors, underlying mechanisms, and clinical management. J Allergy Clin Immunol. 2021;148(6):1430-1441. doi:10.1016/j.jaci.2021.10.001; Miller RL, Grayson MH, Strothman K. Advances in asthma: New understandings of asthma’s natural history, risk factors, underlying mechanisms, and clinical management. J Allergy Clin Immunol. 2021;148(6):1430-1441. doi:10.1016/j.jaci.2021.10.001; Zhou X, Zhang P, Tan H, et al. Progress in diagnosis and treatment of difficult-to-treat asthma in children. Ther Adv Respir Dis. 2023;17:17534666231213637. doi:10.1177/17534666231213637.

Disclosures

For this program, members of the faculty and the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Kelso was recorded at Pediatrics in the Islands: Clinical Pearls 2024, held October 28, 2024, in Waikoloa, HI, and presented by Children’s Hospital Los Angeles Medical Group. For information about upcoming CME activities from this presenter, please visit https://www.chla.org/chla-medical-group/cme-conferences. Audio Digest thanks Dr. Kelso and Children’s Hospital Los Angeles Medical Group for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

PD710401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.