Pediatrics

Asthma

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OVERVIEW: What every practitioner needs to know

Are you sure your patient has asthma? What are the typical findings for this disease?

Diagnostic criteria for asthma include:

  1. 1. Recurrent cough, wheeze, or shortness of breath often with specific triggers that is at least partially relieved by a bronchodilator.

  2. 2. Wheezing with illnesses that responds at least partially to a bronchodilator.

  3. 3. Rule out other causes such as those listed below.

When a child presents with recurrent symptoms of airway obstruction such as chronic cough, recurrent wheeze, cough or chest tightness with exercise or other triggers, the following elements in the history and physical suggest asthma:

History of present illness: recurrent symptoms, at least partial response to bronchodilator.

Specific triggers such as exercise, exposure to allergens, or viral illness.

Past medical history: history of eczema, allergies (environmental and/or food); history of recurrent bronchiolitis, recurrent pneumonia, or wheeze with illnesses.

Family history: allergies, eczema, asthma.

Environmental history: home environment including exposure to animals, molds, tobacco smoke, and odors; attendance of daycare/school.

Physical exam is usually normal. Children may also wheeze or have a prolonged expiratory phase. Consider alternate diagnoses in a child with clubbing, failure to thrive, rhonchi, or rales in a child who is not currently ill; oxygen saturations chronically below 90% in a child who is not ill are not consistent with asthma.

What other disease/condition shares some of these symptoms?

Diseases and conditions that share some symptoms with asthma

  • Chronic lung disease: bronchopulmonary dysplasia, cystic fibrosis, aspiration pneumonia

  • Pulmonary edema

  • Recurrent bronchiolitis

  • Immunodeficiency leading to recurrent pulmonary infections

  • Airway anomalies such as laryngomalacia, tracheomalacia, bronchomalacia

  • Airway compression due to: mediastinal mass, vascular ring (e.g. a double aortic arch), or pulmonary artery sling, lymphadenopathy

  • Airway foreign body

  • Vocal cord dysfunction

Guidelines to the diagnosis of asthma

The Global Initiative for Asthma (GINA) Guidelines was updated in 2014 and The National Heart Lung and Blood Institute (NHLBI) and the National Asthma Education and Prevention Program (NAEPP) published "Guidelines for the Diagnosis and Management of Asthma (Expert Panel Report-3)" in 2007. In 2012, Colorado put together a document that is much shorter and simplifies the guidelines while preserving all of the key elements. This guideline is available at: www.healthteamworks.org/guidelines/asthma.html.

What caused asthma to develop at this time?

The cause of asthma in every patient is multifactorial. In pediatric asthma, 80-90% of children have allergies and the asthma symptoms are often triggered by allergen exposure. Nevertheless, not all children with allergies develop asthma. Therefore there are probably genetic and environmental factors that influence the development of asthma in certain children with allergies.

In children who do not have allergies, the cause may be genetic and/or epigenetic. In other words, the development of asthma and the severity of the disease may be the result of exposures to respiratory illness, tobacco smoke, air pollution, or other sources of stress before or after birth that alter the expression of genes. Many investigators and multiple cohort studies are endeavoring to find the cause for asthma in allergic and non-allergic children.

What causes exacerbation of asthma?

In a child with a diagnosis of asthma, the following questions in the history might help discern the cause of an asthma exacerbation while also providing information about the severity of the disease at baseline:

History

Current severity of symptoms of airway obstruction, timing of symptoms, response to bronchodilator, recent frequency of use of the bronchodilator and other asthma medications including a daily controller, if applicable (see below), and recent viral illness or environmental exposures or exposure to any food allergens.

Past medical history

History and frequency of severe asthma exacerbations requring hospitalization or intensive care, baseline frequency of bronchodilator use per week and number of bronchodilator refills in the last 6-12 months, compliance with controller medications if applicable (see below).

Environmental history

Home environment including exposure to animals, molds, tobacco smoke, and odors; attendance of daycare/school.

Physical exam

Check vital signs including oxygen saturation; listen for wheeze or prolonged expiratory phase or decreased aeration. Evaluate the level of respiratory distress. Evaluate for signs of allergic reaction including hives or swelling of the face that might indicate anaphylaxis.

What laboratory studies should you request to help confirm the diagnosis of asthma? How should you interpret the results?

Asthma causes obstructive lung disease due to airway inflammation and bronchospasm. The flow of air during exhalation will be slower if airways are inflamed or obstructed by bronchospasm. Spirometry can be used to evaluate obstruction by measuring flow rate in children over the age of six. Even basic spirometry can be difficult to perform. Refer to the American Thoracic Society criteria for a comprehensive description of procedures and interpretation.

Spirometry involves a deep inhalation to total lung capacity and a strong, sustained exhalation of the whole vital capacity for at least 3 seconds. The measure needs to be repeated 3 times and should be reproducible within 5% of the forced vital capacity (FVC) liter value. The total amount exhaled, or FVC, on a pulmonary function test report (PFT) will show the best of three liter values and the percent predicted. The percent predicted is generated by comparing results to a group of children of similar age, height, gender, and ethnicity. The amount of air forcefully exhaled in one second is the FEV1.

The last value to consider in asthma is the FEV1/FVC ratio. The normal value for the FVC and FEV1 on a PFT is greater than 80% predicted. The normal value for the ratio is 0.85 for children up to 18 years old.

The amount of air forced out in one second (FEV1) will be decreased in a patient with obstructive lung disease.

Another value to consider in the diagnosis of asthma is the FEV1/FVC ratio. The normal value for the FVC and FEV1 on a PFT is greater than 80% of predicted. The normal value for the ratio is 0.85 for children up to 18 years of age. In obstructive disease, the volume of air inhaled should be normal. As a result, the FVC should be normal even if it takes the child longer to exhale. The FEV1 will be low and the ratio will be low. If a child responds clinically to a bronchodilator and has PFT results showing a low FEV1 and FEV1/FVC ratio in the presence of normal FVC, the diagnosis of asthma is confirmed.

Asthma can be diagnosed in the absence of a history of bronchodilator use. Since the error of the FEV1 is approximately 12%, 15% improvement in FEV1 15 minutes after three puffs of a bronchodilator represents a positive bronchodilator response and confirms the diagnosis of asthma.

If spirometry is not available or the child is unable to perform spirometry, the diagnosis of asthma may be made clinically. The caregiver can be given a bronchodilator to use at home. The medication can be used during an illness when the child is wheezing or to prevent wheezing before exposure to a known trigger such as a trip to the park. If the child at least partially responds to the bronchodilator and no other diagnosis is suspected, asthma may be the diagnosis.

Would imaging studies be helpful in the diagnosis of asthma? If so, which ones?

Imaging studies can be useful in a child where the diagnosis of asthma is unclear. Children with asthma who are not sick often have a normal chest x-ray. In children with very poorly controlled asthma, the chest x-ray may show hyperinflation.

An argument for a chest x-ray in all children who may have asthma is that a mediastinal mass must be ruled out before corticosteroids are administered. However, routine chest x-rays thereafter are not cost effective.

If you are able to confirm that the patient has asthma, what treatment should be initiated?

Guidelines to the management of asthma can be found in the Global Initiative for Asthma (GINA) Guidelines updated in 2014 and in the National Heart Lung and Blood Institute's (NHLBI) and the National Asthma Education and Prevention Program's (NAEPP) "Guidelines for the Diagnosis and Management of Asthma (Expert Panel Report-3)", published in 2007. In 2012, Colorado put together a document that is much shorter and simplifies the guidelines while preserving all of the key elements. This guideline is available at www.healthteamworks.org/guidelines/asthma.html.

The first step in the treatment and management of asthma is diagnosis.

The next step is to rate the asthma severity in order to understand the degree of disease activity using the guidelines listed above. The most important distinction to be made is between intermittent and persistent asthma. A simple algorithm to use to decide intermittent versus persistent is as follows: Any child who displays ANY of the following has persistent asthma:

  1. Daytime symptoms more than 2 times a week, OR

  2. Nighttime symptoms more than 2 times a month, OR

  3. Quick-relief medication use more than 2 times a week, OR

  4. Any exercise limitation, OR

  5. Abnormal pulmonary function tests showing airway obstruction.

  6. If the child has been treated with oral corticosteroids more than 2 times in 12 months, the child may also have persistent asthma.

  7. If a child needs to take a daily medication to prevent the symptoms listed above, that child has persistent asthma.

Treatment and education

All children and families with a child who has asthma should understand that asthma is a chronic disease that can be controlled. Children with asthma should be able to play and exercise without limitation, sleep through the night, and attend school every day when they are well.

In order to maintain control, all children with asthma need a quick-relief or bronchodilator medication to relieve acute symptoms. Short acting beta-agonists (SABA) are used for quick-relief in asthma. All children with persistent asthma need to be treated with a "controller medication" to control the airway inflammation that is causing the persistent symptoms. The dose of controller medication depends upon the severity of the disease and is described in detail in the algorithms mentioned above.

The first choice for all levels of severity will be an inhaled corticosteroid. Inhaled corticosteroids (ICS) are always listed as the first choice because studies show that ICS control symptoms and decrease the risk of exacerbation better than available alternate medications.

Asthma education should include information about the disease including the pathophysiology, information about triggers, and a complete description of the medications, including why to use them, which medications to use and when, and how to deliver the medications correctly. Medication device technique should be reviewed at every visit. Patients of all ages should use a spacer with a metered dose inhaler to ensure adequate delivery of the medication.

Children should be seen within 4-6 weeks of the initiation of chronic therapy for asthma. At that visit, the asthma control should be rated according to the algorithms mentioned above. If the child is well controlled, management will be continued. If the child is poorly controlled, the provider should evaluate environmental control, medication compliance, medication device technique, and comorbidities before adjusting medications.

Children should be followed every 3-6 months depending on the level of control. Medications can be stepped down after 3-6 months of good control. Well controlled asthma criteria are listed below.

In the management of exacerbations for a child who has increased symptoms, the first line treatment is always a bronchodilator. The bronchodilator can be delivered as a nebulized solution or through a metered dose inhaler and valved holding chamber. In the emergency room setting, three doses of albuterol combined with ipratropium bromide has been shown to decrease the likelihood of hospital admission in the setting of a moderate to severe asthma exacerbation.

If the child's symptoms continue or do not resolve with a bronchodilator, systemic corticosteroids will be necessary. Early use of systemic corticosteroids decreases the risk for hospitalization for an asthma exacerbation, ameliorates the symptoms, and may shorten the course of the illness. There is an algorithm for the care of acute asthma exacerbations available on p. 55 of the 2007 summary report. Evidence does not support doubling the dose of inhaled corticosteroids in the setting of an asthma exacerbation.

Interventions to avoid intubation or treat impending acute respiratory failure include intravenous magnesium and inhaled heliox (please refer to the guideline for dosing). Other possibilities (equivocal recommendation due to insufficient evidence) include intravenous beta-agonist, and noninvasive ventilation.

Interventions not recommended are theophylline, antibiotics, aggressive hydrations, chest physiotherapy, mucolytics and sedation.

What are the adverse effects associated with each treatment option?

Short Acting Beta Agonists (SABA) medications can cause the patient to be jittery and to have tachycardia. High doses can cause nausea and hypokalemia.

Locally, Inhaled Corticosteroids (ICS) medications can lead to thrush if not well rinsed off of the mucous membranes. Systemically, at low doses, these medications have been associated with decreased height velocity and a possible decrease in adult height of approximately 1 cm. At high doses, systemic side effects include many of the systemic side effects seen with oral corticosteroids.

Multiple anecdotal reports of altered behavior are reported in the literature and in the package insert for Leukotriene receptor antagonists (LTRA). However, large, multicenter studies of children and adults reveal no significant differences between LTRA and placebo in behavioral change. It is possible that the problem is that the reported types of psychiatric and behavior changes are common and LTRA use is common and the relationship suggested by the anecdotes is circumstantial.

There are multiple side effects of systemic oral corticosteroids including (but not limited to) cortisol suppression, immunosuppression, decreased bone growth, behavior change, increased appetite, elevated blood pressure and blood sugar.

Several large studies evaluated the safety of long-acting beta agonists (LABA). The results of some show an increased risk of severe respiratory events and even death. It is not clear how that risk changes when the medication is given in combination with an ICS, but it may be decreased. All combination agents have a black box warning in the package insert due to these study results.

The data for or against LABA in children is limited. There is significant debate in the literature about their use in children. In 2010, the Food and Drug Administration released a statement recommending that children and adolescents only use LABA in combination with an ICS and that they use these medications only if the symptoms cannot be controlled on ICS alone. Long-acting beta agonists are only available in combination in most pharmacies in the United States.

What are the possible outcomes of asthma?

Prognosis (or the probability that any child will "outgrow" asthma)

Asthma can present at any age. Several large birth cohort studies describe "wheezing pheynotypes" that may be useful in predicting the natural history of wheezing/asthma in children. In the Tucson birth cohort, children were classified as having "transient wheeze," "persistent wheeze," and "late onset wheeze."

The natural history is described as:

  • Transient wheeze: children who wheeze only with illness. Wheezing can begin in infancy and peaks at around 2 years. 75% of these children stop wheezing around age 3 years. Future episodes are infrequent.

  • Persistent wheeze/asthma: children who wheeze with illness and outside of illness starting before 3 years old and persist past 6 years old. This cohort is more likely to be allergic.

  • Late onset wheeze/asthma: children who wheeze with illness and outside of illness starting after 6 years old. This cohort of children is also more likely to be allergic.

Based upon this study, the Tucson group created an "asthma predictive index". This has been modified and used widely. This tool has been shown most effective to predict who will not have asthma (negative predictive index). The positive predictive index is low. No studies have found a tool that successfully predicts which children will have asthma later in life. Risk factors for asthma in school age children include positive aeroallergen tests or symptoms, male gender, and tobacco smoke exposure.

Possible outcomes in a child with asthma

Children with asthma will continue to have symptoms if they are not well controlled as described above. Risk factors for persistent symptoms include poor compliance with controller medications and repeated exposure to asthma triggers such as allergens and tobacco smoke.

Asthma exacerbations leading to an emergency department visit or hospitalization are described in children of every age and children at every level of disease severity. The biggest risk factor for a serious exacerbation is history of a previous exacerbation. Therefore, any child who has received prednisone more than twice in 12 months or who has been to the emergency department or hospital for asthma should be considered high risk for a future exacerbation.

Death due to asthma is rare in children. The CDC reports 0.3 deaths per 1000 children under the age of 18 from 2005-2007. Children at risk for death include those with a previous asthma exacerbation leading to respiratory failure, seizure, or loss of consciousness; previous exacerbations with rapid deterioration; food-associated asthma exacerbation, psychosocial factors including failure to perceive symptoms or severity, noncompliance, depression, and dysfunctional family unit; and demographics such as inner-city residence and race/ethnicity.

Long-term complications include loss of lung function; recurrent, severe, exacerbations; and even death. Risk factors for progression of the disease are not entirely clear. Children with a history of severe asthma exacerbations are at risk for future exacerbations.

What causes asthma and how frequent is it?

Epidemiology

Asthma is the most common acquired, chronic disease of childhood. Prevalence is rising. As of 2011, the CDC reported asthma prevalence in children to be 9.6%. In children under the age of 18, asthma is more common in boys than girls (11.3% versus 7.9%), non-Hispanic black children versus non-Hispanic white children (17.0% versus 8.5%), and poor versus not poor (13.5% versus 8.3%).

Etiology

The etiology of asthma is unclear. Most theories include a double hit phenomenon with predisposing genetics and exposures triggering inflammatory cascades. It is likely that there is genetic predisposition and triggering exposures such as upper respiratory illnesses, allergens, airway irritants, such as tobacco smoke and pollution, and stress.

Pathophysiology

Airway inflammation consists of increased inflammatory cells such as lymphocytes, macrophages, mast cells and eosinophils. Bronchial and lung biopsies of school age children show increased eosinophils and lymphocytes (See Figure 1). In children with allergic inflammation, the degranulation of eosinophils and mast cells causes acute airway swelling. Chronic inflammation is also IgE-mediated and includes processes involving increased numbers of mast cells and eosinophils, increased levels of cytokines such as IL-4 and IL-13, and impaired regulation of inflammation. In children with non-allergic inflammation, the etiology of the inflammation is not clear.

Figure 1.

Increased mucous production further drives inflammation and leads to airway obstruction and atelectasis. Increased inflammation and mucous plugging causes hypoxemia due to ventilation/perfusion mismatch.

Bronchial hyperreactivity (bronchospasm) is most likely due to inflammation since bronchial hyperreactivity decreases when airway inflammation decreases. Bronchial hyperreactivity can be partially relieved by inhaled beta-agonists which lead to muscle relaxation. Reponse to beta-agonists is a key component in the diagnosis of asthma.

Children over age 6 and beyond may develop airway muscle hypertrophy. Over time, persistent airway inflammation can lead to airway remodeling and decline in lung function.

What are the triggers for asthma symptoms and exacerbations?

Many children have more than one trigger for asthma. Triggers may include:

Environmental

  • Exposure to environmental allergens in sensitized individuals. Common allergens include: Alternaria (a mold), dust mites, cockroach, mice, animals (cats, dogs, horses), grasses, trees, weeds, and other molds.

  • Air pollutants including tobacco smoke, particulate matter, and ozone.

  • Noxious exposure such as inhalants, fumes, and even strong smells for some children.

  • Cold air.

  • Weather changes are often reported by families as a trigger although studies do not confirm this.

Activity

Physical activity may cause an asthma exacerbation.

Food and other allergies

Nuts, shellfish, insect venom and medications are common triggers.

The reaction of each child to an allergen will be unique and may not include any respiratory symptoms. However, some children with asthma have severe respiratory manifestations when exposed to allergens to which they are sensitized. For example, children with nut allergies may be at risk for more severe asthma exacerbations than children without nut allergies.

Infectious

Several viral infections are linked to exacerbations; the most common are rhinovirus, respiratory syncytial virus and human metapneumovirus.

Behavioral

Laughing, crying, and anxiety/stress can trigger asthma exacerbation.

Other diagnoses that may complicate asthma (comorbidities)

  • Allergies

  • Allergic rhinitis

  • Sinusitis

  • GERD

  • Obesity

  • Vocal cord dysfunction

  • Depression (maternal and patient)

  • Social stress/chaos

What complications might you expect from the disease?

Long-term complications can include loss of lung function, recurrent, severe, exacerbations, and even death. Risk factors for progression of the disease are not entirely clear. Children with history of severe asthma exacerbations are at risk for future exacerbations.

Other risks for severe exacerbations and death are listed in the national guidelines for asthma management. They include severe airway obstruction, frequent SABA use (more than 3 refills in 12 months), patients and families frightened by asthma, demographic factors such as race/ethnicity, lower socioeconomic status and psychosocial factors such as depression, denial, dysfunctional family units and noncompliance.

Death due to asthma is rare in children. The CDC reports 0.3 deaths per 1000 children under the age of 18 from 2005-2007. Children at risk for death include those with a previous asthma exacerbation leading to respiratory failure, seizure, or loss of consciousness; previous exacerbations with rapid deterioration; food-associated asthma exacerbation; psychosocial factors including failure to perceive symptoms or severity, noncompliance, depression, and dysfunctional family unit; and demographics such as inner-city residence and race/ethnicity.

Long-term complications can include loss of lung function; recurrent, severe, exacerbations; and even death. Risk factors for progression of the disease are not entirely clear. Children with a history of severe asthma exacerbations are at risk for future exacerbations.

Are additional laboratory studies available; even some that are not widely available?

Exercise induced bronchospasm testing can be done on a treadmill. There are specific criteria for conducting these tests that are available from the American Thoracic Society. Some have employed stair stepping and outdoor running applying heart rate criteria from the American Thoracic Society.

Methacholine challenge: Methacholine is an inhaled agent that causes acute bronchospasm in patients with asthma at doses below 8mg/ml of inhaled methacholine. Other agents include histamine and cold air. Tests can be performed in a pulmonary function laboratory and should be supervised by a specialist. Guidelines are provided listed by the American Thoracic Society.

Exhaled Nitric Oxide may be useful. Its use for ongoing management is unclear. Several review articles listed below detail use of exhaled nitric oxide in adults and children.

Can asthma be prevented?

Asthma cannot be prevented. The genetics of asthma are complicated. There are probably genetic factors that predispose children and adults to asthma, many linked to allergy. There may also be epigenetic factors, for example, if the child is born with a certain gene, environmental factors such as allergen exposure or possibly early infectious exposure or disease may affect the way the gene is expressed. At this point, it is not possible to avoid environmental factors because it is not clear which genes or combination of genes are affected or how to test for them.

What is the evidence?

Asthma predictive index

Guilbert, TW. "Long-term inhaled corticosteroids in preschool children at high risk for asthma". vol. 354. 2006. pp. 1985-97.

(The original paper describing the modified predictive index was part of a large randomized controlled trial in preschool children. The results of that trial and the modified predictive index are available through this reference.)

Huffaker, MF, Phipatanakul, W. "Utility of the Asthma Predictive Index in predicting childhood asthma and identifying disease-modifying interventions". Ann Allergy Asthma Immunol. vol. 112. 2014. pp. 188-90.

(An evaluation of the predictive value of the index in a preschool age children.)

Asthma pathophysiology and natural history

Lemanske, RF, Busse, WW. "Asthma: clinical expression and molecular mechanisms". JACI. vol. 125. 2010. pp. S95-102.

(Thorough review of clinical presentations and asthma pathophysiology including diagnosis and chronic progression.)

Gelfand, EW. "Pediatric asthma: a different disease". Proc AM Thorac Soc. vol. 6. 2009. pp. 278-82.

(A review of pediatric asthma, possible pathophysiology, and what we know about the natural history.)

Covar, RA, Spahn, JD, Murphy, JR. "Progression of asthma measured by lung function in the Childhood Asthma Management Program". Am J Respir Crit Care Med. vol. 170. 2004. pp. 234-241.

(A study of the progression of lung function in children with asthma.)

Guidelines and consensus statements

www.nhlbi.nih.gov/guidelines/asthma/.

Boulet, LP, FitzGerald, JM, Reddel, HK. "The revised 2014 GINA strategy report: opportunities for change". Curr Opin Pulm Med. vol. 21. 2015. pp. 1-7. http://ginasthma.org/.

(This includes a description of how to perform lung function testing and spirometry, how to interpret lung function tests, and guidelines for methacholine and exercise challenge testing.)

Medications

Please refer to the NHLBI and GINA guidelines for medication use and dosing.

Griffiths, B, Ducharme, FM. "Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. The Cochrane database of systematic reviews". 2013. pp. 8-Cd000060.

(This meta-analysis provides evidence for the use of atrovent with acute exacerbations and provides many more references including randomized controlled trials of albuterol or salbuterol alone versus albuterol or salbuterol with ipratropium bromide.)

Exhaled nitric oxide

Szefler, SJ. "Adding exhaled nitric oxide to guideline-based asthma treatment in inner-city adolescents and young adults: a randomized controlled trial". Lancet. vol. 372. 2008. pp. 1065-72.

(One of the most recent and largest randomized controlled trials evaluating the addition of exhaled nitric oxide to guidelines-based asthma management for ongoing asthma control. This study showed similar results to previous studies, that the additional information provided by exhaled nitric oxide does not improve asthma control or outcomes such as hospitalizations or emergency department visits.)

Baraldi, E, de Jongste, JC. "European Respiratory Society; American Thoracic Society. Measurement of exhaled nitric oxide in children 2001". Eur Resp J. vol. 20. 2002. pp. 223-37.

(Guidelines for measuring nitric oxide.)

Barnes, PJ. "Exhaled nitric oxide in pulmonary diseases: a comprehensive review". Chest. vol. 138. 2010. pp. 682-92.

(Review of exhaled nitric oxide pathophysiology and overview of how it might be used in pulmonary disease including asthma.)

Treatment of wheeze in children under 4 years

Ducharme, FM, Tse, SM, Chauhan, B. "Diagnosis, management, and prognosis of preschool wheeze". Lancet. vol. 383. 2014. pp. 1593-604.

(A review article of studies evaluating the diagnosis and treatment of asthma in preschool children.)

Ongoing controversies regarding etiology, diagnosis, treatment

Treating children under 4 years

According to the national guidelines, asthma can be diagnosed in any child who meets the criteria for diagnosis. The risk for chronic asthma symptoms beyond the age of 6 years is discussed in the outcomes section above. However, children under 4 years old who wheeze only with illness and who do not have any symptoms in between their respiratory illnesses are a difficult population to diagnose and to treat.

The diagnosis of asthma is difficult because although the children respond to asthma medications (short acting beta-agonists), the risk for chronic, long-term symptoms or even symptoms between illnesses is unclear. Studies looking at the kind of inflammation seen in these patients show variable results and suggest that the pathophysiology in this population may be different.

Several studies recently have investigated the best way to treat children ages 2-4 who wheeze with illness. Unfortunately, the treatment is not yet clear. Children who have a positive asthma predictive index (see outcomes above), and who have had severe episodes requiring hospitalization, may benefit from low-dose, daily inhaled corticosteroids.

Treating exercise induced asthma/bronchospasm

Exercise induced bronchospasm (EIB) or exercise induced asthma: recurrent symptoms of airway obstruction with exercise that improve with albuterol is a form of asthma. The question in the literature is whether or not EIB would be classified as persistent asthma. The literature suggests that children who report symptoms with exercise only will usually reveal more frequent symptoms if appropriately interviewed. These studies suggest that EIB is most likely a symptom of persistent asthma. Primary care pediatricians report significant numbers of children with EIB alone in their practices.

Future studies are needed to evaluate EIB and clearly define the relationship between EIB and persistent asthma.

Guidelines for diagnosis and treatment from the American Thoracic Society can be found at: http://www.atsjournals.org/doi/pdf/10.1164/rccm.201303-0437ST.

Reactive airway disease

Reactive Airway Disease or "RAD" is descriptive and used frequently. Many providers report that they use RAD in children where the diagnosis of asthma is unclear or when the family is not ready for the diagnosis. RAD is a separate diagnosis under the International Statistical Classification of Diseases and Related Health Problems (ICD 10).

The problem with treating RAD as an alternate diagnosis in the text of the chart or in the diagnosis section of a chart is that RAD is confusing for families and caregivers who do not know what it means or how to treat it. Therefore, if the diagnosis of asthma is unclear, other diagnoses such as "wheeze", "cough", or "viral pneumonia" can be used as alternate diagnoses if the provider does not believe that the diagnosis is asthma. The treatment of wheeze, cough, or other symptoms in these children should also be clear to the families.

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