SMART Asthma Care

Educational Objectives

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

1. Identify clinical factors to determine asthma control.
2. Implement single maintenance and reliever therapy for asthma management.

Summary

Pathophysiology of asthma: asthma is a disease of small airways (bronchioles); does not affect the trachea, large airways, or alveoli; 2 characteristic features are bronchospasm and inflammation; bronchial hyperresponsiveness distinguishes asthma from normal airway function, causing excessive airway constriction in response to allergen or irritant exposure; underlying inflammatory disease involves eosinophilic infiltration, edema, and excess mucus production in airways; inadequately treated eosinophilic inflammation leads to airway remodeling, resulting in permanent lung function decline and scarring

Clinical diagnosis: diagnosis requires appropriate symptoms, identifiable triggers, and family history of atopic diseases; symptoms include cough, wheeze, shortness of breath, and/or chest tightness; any combination of symptoms is acceptable (no such entities as "cough-variant asthma" or "exercise-induced asthma"); common triggers include viral respiratory infections (most characteristic), exercise, irritant exposures, airborne allergens (if patient is allergic), and nighttime worsening; asthma is one of 4 genetically related atopic diseases (asthma, allergic rhinitis, eczema, food allergy) that cluster in families but not necessarily the same disease in each family member; patients can have asthma without having allergies, and two-thirds of children with atopic dermatitis do not have allergies despite the disease name

Asthma control vs severity classification: traditional severity classification (mild, moderate, severe) using complex criteria is impractical and unhelpful; focus instead on whether asthma is well-controlled; 4 criteria that can be used to define well-controlled asthma are normal lung function, infrequent (<2 times/wk) need for reliever medication, no activity limitations, and no exacerbations requiring corticosteroids or an unscheduled visit

Spirometry in diagnosis and monitoring: all children age ≥5 yr can perform spirometry; objective measurement is essential because significant disparity can exist between subjective assessments and actual lung function; flow-volume loop provides detailed information; normal loops appear triangular, while obstructive disease shows characteristic "scooping" on the downward limb; bronchodilator response distinguishes reversible bronchospasm from inflammation or airway remodeling; peak flow meters are inadequate substitutes because they are relatively late and crude indicators that can remain normal despite significant airway obstruction visible on full spirometry

Fractional concentration of exhaled nitric oxide (FENO) testing: FENO reflects eosinophilic airway inflammation; may assist with initial diagnosis when uncertainty exists but is not necessary or required for routine asthma monitoring

Asthma medications: controller (maintenance) medications—include inhaled corticosteroids (ICS), which treat eosinophilic inflammation (eosinophils are exquisitely sensitive to corticosteroids); long-acting beta-agonists (LABAs) provide long-acting bronchodilation; long-acting muscarinic antagonists (LAMAs) offer additional bronchodilation through different mechanisms; biologic medications are reserved for severe asthma; reliever medications—traditionally consisted of albuterol alone but now include anti-inflammatory relievers combining ICS with formoterol or albuterol

Considerations for albuterol: levalbuterol causes equivalent tachycardia and higher tremor rates compared with regular albuterol per package insert data, despite marketing suggesting otherwise; levalbuterol is acceptable if it is the least expensive option but should not be chosen for reduced side effects; albuterol should always be prescribed as needed (PRN), never on a fixed schedule (even during colds or hospitalizations), as scheduled dosing eliminates the most important indicator of asthma control, which is how often the patient actually needs symptom relief; bronchodilator effect occurs within minutes

Single maintenance and reliever therapy (SMART): preferred treatment approach uses ICS-formoterol as both maintenance and reliever medication in a single inhaler; formoterol is unique among LABAs as both quick-acting and long-acting (unlike salmeterol, which is only long-acting); maintenance dosing is 1 to 2 puffs twice daily, with additional puffs of the same inhaler for symptom relief; maximum daily doses are 8 puffs for children ≤11 yr of age and 12 puffs for children >12 yr of age; SMART therapy reduces asthma exacerbations because patients receive additional inhaled corticosteroid when experiencing symptoms that suggest increased inflammation; this is now the preferred therapy in both the 2020 Focused Updates to the Asthma Management guidelines (EPR-4) and annually updated Global Initiative for Asthma (GINA) guidelines

Alternative anti-inflammatory reliever: ICS-albuterol combination is available as an as-needed medication for patients requiring only occasional bronchodilator use; maximum 12 inhalations daily; useful when insurance does not cover ICS-formoterol but less ideal than SMART therapy

Treatment algorithms: if asthma is well-controlled—continue reliever as needed (preferably ICS-formoterol); if reliever needed >2 times/week or spirometry is abnormal—initiate or continue daily maintenance medication plus PRN reliever, titrating maintenance dose upward until control achieved; if inadequate response despite appropriate therapy—confirm diagnosis is asthma, address modifiable triggers, verify medication adherence and proper inhaler technique before increasing medications; when well-controlled for several months—trial step-down in maintenance therapy, with instructions to resume previous dose if symptoms increase

Intermittent ICS use during viral infections: for children with infrequent symptoms, ICS or ICS-LABA can be initiated at first sign of cold and continued through illness duration; critical success factor is early initiation; parents should start medication when first suspecting a cold is developing, before chest symptoms appear; if this strategy fails to prevent unscheduled visits or need for systemic corticosteroids, patient requires continuous daily maintenance therapy

LAMA therapy: may be added when ICS-formoterol maintenance therapy inadequately controls symptoms

Montelukast: not recommended for asthma management due to FDA warnings about rare but serious mental health side effects and availability of superior alternatives; notably absent from current treatment algorithms

Management of exercise-induced bronchospasm: most children achieve symptom control with pre-exercise albuterol; if insufficient, options include daily low-dose ICS or pre-exercise ICS-formoterol per GINA guidelines; treatment goal is enabling participation in any desired sport without limitations

Biologic therapies: multiple agents are available for severe asthma with different age indications and mechanisms; candidates are children on maximum conventional therapy with inadequately controlled asthma, experiencing continuous or repeated need for systemic corticosteroids; medications cost $30,000 to $40,000 annually; patients meeting criteria for biologics should be referred to allergy/immunology specialists

Exacerbation management: increase reliever medication use and administer systemic corticosteroids; single-dose dexamethasone is equivalent to multi-day prednisone or prednisolone courses; following any exacerbation, intensify maintenance therapy to prevent recurrence, as current regimen was insufficient

Trigger modification: immunize children with asthma against respiratory viruses (influenza, COVID-19); avoid cigarette smoke and other irritants; implement environmental control measures for animal dander and dust mite in patients who are allergic; do not restrict exercise; treatment goal is enabling full activity participation

Patient education: explain disease pathophysiology (bronchospasm and inflammation) to help patients understand medication rationale; demonstrate proper inhaler technique in clinic using trainer devices rather than relying on pharmacy instruction; provide clear guidance on when to use medications and when to contact clinician; simplified action plan is to contact provider if reliever is needed more often or not providing adequate relief

Clinical goals and practice changes: hospitalization for asthma should be extremely rare with appropriate management; prevent unscheduled visits, systemic corticosteroid use, missed school/work, and activity limitations; enable sleeping through night without symptoms; maintain normal lung function; consider purchasing spirometer for practice because it is essential for assessing asthma control; focus on control assessment rather than severity classification; implement SMART therapy with ICS-formoterol as preferred single-inhaler approach; intensify therapy following any exacerbation to prevent recurrence

Readings

Disclosures

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

Acknowledgements

Dr. Kelso was recorded at the Aloha Update: Pediatrics 2025, held on October 25-31, 2025, in Kauai, HI, and presented by American Academy of Pediatrics, California District IX, Chapter 2. For information about upcoming CME activities from this presenter, please visit https://aapca2.org. AudioDigest thanks Dr. Kelso and American Academy of Pediatrics, California District IX, Chapter 2 for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

OT591002

Qualifies for:

ABOHNS Continuing Certification, Clinical Pharmacology

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.