Paeds · respiratory-sleep-and-airway
Asthma diagnosis and long-term control
Also known as Asthma diagnosis and long-term control · Childhood asthma · Paediatric asthma management · Preschool wheeze and asthma · Reactive airways disease in children
Fellowship guide to the diagnosis and long-term control of asthma in children: recognising the variable, reversible airflow obstruction that defines the disease, confirming it with spirometry, bronchodilator reversibility and exhaled nitric oxide, distinguishing the preschool wheeze phenotypes and using the Asthma Predictive Index, separating current control from future risk, and delivering the stepwise controller ladder built on the inhaled corticosteroid — including the shift to anti-inflammatory reliever therapy from the SYGMA trials, the ICS-and-growth evidence from CAMP, and the written action plan.
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Red flags
- A child labelled 'asthma' who has never responded to an adequate trial of inhaled corticosteroid, or who has a chronic wet cough, digital clubbing, failure to thrive or focal chest signs, does not have asthma until an alternative diagnosis (cystic fibrosis, bronchiectasis, an inhaled foreign body, a vascular ring) has been excluded
- Escalating reliever use — more than one salbutamol canister a month, or reliever needed several times a week — signals uncontrolled inflammation and a high risk of a severe exacerbation; step up the controller and review, do not simply supply more reliever
- Nocturnal waking with cough or wheeze, and exercise that the child can no longer keep up with, are markers of poor control that children and families under-report — ask about them specifically at every review
- A preschooler with recurrent wheeze, early allergic sensitisation and a parental history of asthma has a positive Asthma Predictive Index and a high likelihood of persistent school-age asthma — do not dismiss recurrent wheeze as 'just viral' without stratifying the risk
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- Asthma diagnosis and long-term control
- Asthma in children: diagnosis, phenotyping, and stepwise long-term control
- Asthma diagnosis and long-term control: the controller ladder and the anti-inflammatory reliever evidence
- Short case: the child with chronic cough and wheeze
- Long case: the adolescent with poorly controlled asthma and adherence issues
- Asthma in children: diagnosis, control assessment, and stepwise management
- Respiratory: the child with chronic wheeze
- Pulmonology: asthma diagnosis and long-term control
- Patient Care: asthma diagnosis and long-term control in children
- Medical Expert: asthma diagnosis and long-term control
Overview & Definition
Asthma is the commonest chronic disease of childhood, and yet it has no single confirmatory test — it is a clinical diagnosis built from a characteristic pattern of symptoms and the demonstration that airflow obstruction is both variable and reversible. The child has recurrent episodes of wheeze, cough, breathlessness and chest tightness that come and go, are worse at night and with triggers, and improve with a bronchodilator. The whole skill of paediatric asthma lies in confirming that pattern, excluding the mimics, and then keeping the airway quiet with the smallest effective treatment. [5] [10]
The reason the disease behaves this way is that the underlying lesion is chronic airway inflammation. Inflammation makes the airways twitchy, so they narrow excessively in response to triggers that a normal airway would ignore; the narrowing is intermittent, which is why symptoms are variable, and it is caused by smooth-muscle spasm and mucosal swelling that a bronchodilator and an inhaled corticosteroid can reverse, which is why the obstruction is reversible. Holding these two ideas — variable and reversible — in mind is what separates asthma from the fixed obstruction of a structural airway problem. [5]
References12ShowHide
- [1]Martinez FD; Wright AL; Taussig LM; Holberg CJ; Halonen M; Morgan WJ Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med, 1995.PMID 7800004
- [2]Castro-Rodríguez JA; Holberg CJ; Wright AL; Martinez FD A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med, 2000.PMID 11029352
- [3]Szefler S, Weiss S, Tonascia J, et al. Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med, 2000.PMID 11027739
- [4]Guilbert TW; Morgan WJ; Zeiger RS; Mauger DT; Boehmer SJ; Szefler SJ; et al Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med, 2006.PMID 16687711
- [5]Bacharier LB; Boner A; Carlsen KH; Eigenmann PA; Frischer T; Götz M; et al Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report. Allergy, 2008.PMID 18053013
- [6]Moffatt MF; Gut IG; Demenais F; Strachan DP; Bouzigon E; Heath S; et al A large-scale, consortium-based genomewide association study of asthma. N Engl J Med, 2010.PMID 20860503
- [7]Dweik RA; Boggs PB; Erzurum SC; Irvin CG; Leigh MW; Lundberg JO; et al An official ATS clinical practice guideline: interpretation of exhaled nitric oxide levels (FENO) for clinical applications. Am J Respir Crit Care Med, 2011.PMID 21885636
- [8]O'Byrne PM; FitzGerald JM; Bateman ED; Barnes PJ; Zhong N; Keen C; et al Inhaled Combined Budesonide-Formoterol as Needed in Mild Asthma. N Engl J Med, 2018.PMID 29768149
- [9]Bateman ED; Reddel HK; O'Byrne PM; Barnes PJ; Zhong N; Keen C; et al As-Needed Budesonide-Formoterol versus Maintenance Budesonide in Mild Asthma. N Engl J Med, 2018.PMID 29768147
- [10]Levy ML; Bacharier LB; Bateman E; Boulet LP; Brightling C; Buhl R; et al Key recommendations for primary care from the 2022 Global Initiative for Asthma (GINA) update. NPJ Prim Care Respir Med, 2023.PMID 36754956
- [11]Chauhan BF; Ducharme FM Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children. Cochrane Database Syst Rev, 2012.PMID 22592685
- [12]Cloutier MM; Baptist AP; Blake KV; Brooks EG; Bryant-Stephens T; et al 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol, 2020.PMID 33280709