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Asthma typically presents with a history of respiratory symptoms such as wheezing, shortness of breath, chest tightness, and cough and is characterized by chronic airway inflammation. In adults and older children, the diagnosis of asthma can be confirmed by spirometric evaluation, but asthma is a diagnostic challenge in younger children, typically school-aged. A careful history, exam, trigger factors, response to bronchodilator medications, and family history can help establish asthma diagnosis in this age group. This course highlights a stepwise approach to interprofessional asthma evaluation and treatment and discusses the medications used for rescue and control. Since the approach to a stepwise escalation or de-escalation of medication options differs depending on where the patient presents, these practice guidelines are highlighted. Biologics and immunotherapies are also discussed for refractory or chronic presentations, emphasizing adverse drug reactions (ADR) for all classes. Participating clinicians gain a specialized understanding of asthma medication in children, involving professionals from allied health professions such as nurses, technicians, and, in particular, pediatricians. Objectives: Interpret the signs and symptoms of asthma in the pediatric population. Identify medication classes that are used to treat children with asthma. Interpret how a stepwise treatment algorithm addresses asthma severity and control. Collaborate to provide interprofessional care for children with asthma to improve their quality of life. Access free multiple choice questions on this topic.

Asthma is the most common chronic respiratory disease of childhood, with approximately 14% of children affected worldwide. Asthma is characterized by chronic airway inflammation, mucus hypersecretion, and hyper-responsiveness.[1] A triad of wheezing, shortness of breath, and cough indicates pediatric asthma.[2] In adults, the diagnosis of asthma can be confirmed by spirometric evaluation, but managing asthma is challenging in pediatric patients. A careful history, exam, trigger factors, response to bronchodilator medications, family history, and FeNO testing can be useful in establishing asthma diagnosis in this age group.[3] Asthma should be suspected in children with a history of wheezing if the following symptoms are noted: Wheezing or coughing exacerbated by physical exercise or activity Laughing or crying in the absence of apparent respiratory infection A history of allergic disease (eczema or allergic rhinitis) or asthma in first-degree relatives Clinical improvement during 2 to 3 months of controller treatment and worsening after cessation Symptoms triggered by upper respiratory tract infections, exercise, stress, and environmental exposure to allergens and tobacco smoke.[4][5] This article primarily reflects pediatric asthma management according to NAEPPCC (National Asthma Education and Prevention Program Coordinating Committee) and NHLBI (National Heart, Lung, and Blood Institute).[6] The Global Initiative for Asthma (GINA) has recently published guidelines for asthma management.[7] Medications, Biologics, and Immunotherapy for Pediatric Asthma Short-acting beta-2 agonists (SABA): Albuterol (salbutamol), levalbuterol, and terbutaline are used as quick relief therapy or rescue therapy to ease symptoms as they reverse bronchoconstriction.[8] Long-acting beta-2 agonist (LABA): Formeterol and salmeterol are long-acting beta-2 agonists. Formoterol stimulates intracellular adenyl cyclase and increases cyclic AMP levels, causing the relaxation of bronchial smooth muscles. ICS-formoterol has also been used as a reliever or quick relief therapy in GINA guidelines.[7][9] Long-acting muscarinic antagonist (LAMA): Tiotropium is a long-acting muscarinic antagonist that inhibits M3 receptors in the lung's smooth muscle, leading to bronchodilation.[10]

Long-acting beta-2 agonist (LABA): Formeterol and salmeterol are long-acting beta-2 agonists. Formoterol stimulates intracellular adenyl cyclase and increases cyclic AMP levels, causing the relaxation of bronchial smooth muscles. ICS-formoterol has also been used as a reliever or quick relief therapy in GINA guidelines.[7][9] Long-acting muscarinic antagonist (LAMA): Tiotropium is a long-acting muscarinic antagonist that inhibits M3 receptors in the lung's smooth muscle, leading to bronchodilation.[10] Inhaled corticosteroids (ICS): Commonly used ICS are budesonide, fluticasone, and mometasone.[11] Inhaled corticosteroids suppress airway inflammation and downregulate proinflammatory mediators. Corticosteroids are also helpful in preventing airway remodeling. In addition, corticosteroids augment the expression of β-2 receptors in the lung and increase responsiveness to SABA and LABA therapy.[12] Systemic corticosteroids: Commonly used systemic corticosteroids include prednisone, dexamethasone, and methylprednisolone. Systemic glucocorticoids reduce airway hyperresponsiveness and airway inflammation, improve lung function and quality of life, and reduce mortality in acute exacerbation. In addition, they decrease capillary permeability, airway edema, and secretions.[13][14] Leukotriene receptor antagonist (LTRA): The leukotriene modifier, montelukast, is the leukotriene antagonist available in either granules or chewable tablets, depending on the age. It is an alternative option, either alone or in combination with inhaled corticosteroids, depending on the level of asthma severity and control. The leukotrienes LTC4, LTD4, and LTE4 are potent mediators of antigen-induced smooth muscle contraction. Montelukast antagonizes these compounds at their receptor, protecting against bronchoconstriction. In addition, leukotrienes bind to cysteinyl leukotriene (CysLT) receptors. Montelukast inhibits the CysLT1 receptor and downregulates inflammation.[15] Zafirlukast is also a recommended option.[16] 5-lipoxygenase inhibitor: Zileuton is an inhibitor of 5-lipoxygenase(5-LOX) and inhibits leukotriene formation, reducing airway inflammation.[17]

Leukotriene receptor antagonist (LTRA): The leukotriene modifier, montelukast, is the leukotriene antagonist available in either granules or chewable tablets, depending on the age. It is an alternative option, either alone or in combination with inhaled corticosteroids, depending on the level of asthma severity and control. The leukotrienes LTC4, LTD4, and LTE4 are potent mediators of antigen-induced smooth muscle contraction. Montelukast antagonizes these compounds at their receptor, protecting against bronchoconstriction. In addition, leukotrienes bind to cysteinyl leukotriene (CysLT) receptors. Montelukast inhibits the CysLT1 receptor and downregulates inflammation.[15] Zafirlukast is also a recommended option.[16] 5-lipoxygenase inhibitor: Zileuton is an inhibitor of 5-lipoxygenase(5-LOX) and inhibits leukotriene formation, reducing airway inflammation.[17] Mast cell stabilizers: Mast cell stabilizers used in asthma include sodium cromoglycate (cromolyn sodium) and nedocromil (off-label). Cromolyn sodium inhibits mast cell degranulation after exposure to antigens and inhibits the release of mediators from mast cells. Cromolyn also reduces bronchospasm induced by exercise, aspirin, cold air, and environmental pollutants.[18][19] Methylxanthine: Theophylline inhibits PDE III and adenosine receptors. Theophylline leads to bronchodilation mediated by smooth muscle relaxation by inhibiting the phosphodiesterase-III enzyme and has a prophylactic effect.[20] Anti-IgE antibody: Omalizumab is a monoclonal antibody that inhibits the binding of IgE to the IgE receptor on the surface of mast cells and prevents the mast cell degranulation and release of inflammatory mediators such as IL-4, IL-5, and IL-13.[21] Anti-interleukin-5 monoclonal antibody: Mepolizumab is an IL-5 antagonist. IL-5 is the primary cytokine responsible for eosinophils' maturation, recruitment, and activation. Administration of mepolizumab leads to decreased eosinophilia and reduced airway inflammation.[22] Anti-interleukin-5 receptor alpha monoclonal antibody: Benralizumab binds to the α subunit of the interleukin-5 receptor, decreasing eosinophil activation. Benralizumab also decreases antibody-dependent cell-mediated cytotoxicity.[23]

Anti-interleukin-5 monoclonal antibody: Mepolizumab is an IL-5 antagonist. IL-5 is the primary cytokine responsible for eosinophils' maturation, recruitment, and activation. Administration of mepolizumab leads to decreased eosinophilia and reduced airway inflammation.[22] Anti-interleukin-5 receptor alpha monoclonal antibody: Benralizumab binds to the α subunit of the interleukin-5 receptor, decreasing eosinophil activation. Benralizumab also decreases antibody-dependent cell-mediated cytotoxicity.[23] Anti-interleukin-4 receptor α monoclonal antibody: Dupilumab is an IgG4 antibody that inhibits IL-4 and IL-13 signaling by binding to the IL-4R α subunit, inhibiting the release of proinflammatory cytokines and chemokines.[24] Immunotherapy: Subcutaneous immunotherapy (SCIT) for asthma is the administration of specific exogenous aeroallergens with demonstrated sensitivity. Prerequisites are documented hypersensitivity to the specific allergen by skin testing (after 15 to 20 minutes) and antigen-specific IgE antibodies in a blood sample.[25]

The diagnosis and management of asthma in children are complex. Asthma management involves a multi-faceted approach, including medication, education, skills training, clinical monitoring, and environmental control measures when necessary. The goals of asthma management include enhanced quality of life, control of asthma symptoms, and minimized risks from exacerbations and medication side effects.[70] Pediatricians usually prescribe medications for asthma in children. Immunologists or asthma specialists should be consulted at the appropriate step for using novel biologic therapies. Pharmacists should verify dosing, check for interactions, and ensure medication reconciliation. Pediatric nurses should monitor growth and adverse effects at every visit. Admission to the PICU (pediatric intensive care unit) or neonatal intensive care unit (NICU) may be required for severe asthma exacerbation. Pediatric hospitalists, pulmonologists, and neonatologists are crucial in managing severe asthma exacerbation and management complications. In case of toxicity, consultation with a medical toxicologist may be essential. The interprofessional approach from clinicians (MD, DO, NP, PA), toxicologists, pediatric pharmacists, respiratory therapists, and specialty-trained nurses improves the treatment efficacy and optimizes the outcomes in the treatment of pediatric asthma.

Nursing interventions and actions Checking pulse oximetry Monitor the vitals Provide oxygen if O2 saturation is less than 90% Start at 2 liters nasal cannula Increase as needed Consult the provider and respiratory therapist if more than 6 liters of nasal cannula is required. Evaluate the patient to determine if they are receiving adequate oxygen. Learn triggers and ensure the room does not have any, ie, flowers, dust, animal dander, wool blankets, etc. Ensure proper delivery of medications by nebulization Patient education about ADR and adequate use of MDI to prevent oral candidiasis.[71] Physical therapists play an essential role in improving lung function. A study has demonstrated that physical therapy can improve forced vital capacity (FVC).[72] Respiratory therapist-guided bronchodilator weaning based on the MPIS (modified pulmonary index score) can reduce the hospital length of stay (LOS).[73]

Nursing monitoring should include the following: Auscultate lung sounds If wheezing, they may need a breathing treatment. No breath sounds (silent chest) or stridor is usually ominous signs and require immediate reporting to the team leader. Crackles may have pneumonia and may need suctioning.[74] Positioning the patient in an upright position Obtain a baseline peak flow and monitor for the decline. The smaller the number, the less amount of air they are moving. Complete prescribed breathing treatments such as albuterol for bronchodilation and tiotropium to decrease bronchospasm. Monitor the adverse drug reactions of corticosteroids. If theophylline is prescribed, consider therapeutic drug monitoring to prevent toxicity.[75] Make sure the entire medical team is aware if the patient is getting worse; know the location of the crash cart. If the nursing or allied health staff thinks the patient is deteriorating or airway closure may be imminent, it is better to be proactive than reactive. Contact the medical team immediately.[76]