Primary prevention
Preventing future asthma exacerbations and minimizing emergency department visits or hospitalizations are key goals of asthma care that can be achieved through appropriate treatment and adherence.[7][50] International guidelines from the Global Initiative for Asthma suggest the following steps for patients who have poor symptom control and/or exacerbations despite treatment:[7]
Check the patient’s inhaler technique and show them the correct technique
Discuss adherence to treatment and any barriers
Check that the patient has a written, personalized asthma action plan
Confirm the diagnosis of asthma, if there is any doubt
Remove or mitigate any risk factors or triggers, if possible
Manage comorbidities
Consider stepping up long-term treatment
Consider specialist referral.
Asthma management plans help parents and children to recognize when asthma is deteriorating and how to respond appropriately: for example, increasing usual reliever and maintenance treatment, starting a short course of oral corticosteroids, and determining when to seek medical help.[7] School‐based asthma self‐management interventions, engagement in the decision-making process, and even the use of digital interventions (e.g., trackers or reminders) may help.[51][52][53][54]
Tailored allergen mitigation strategies may also be beneficial in individuals who are exposed to relevant allergens (e.g., dust mites or cat dander) and have a history of associated symptoms or positive allergy testing (e.g., skin testing or a specific IgE).[55] Multicomponent allergen interventions are recommended based on experience that single-component interventions often do not work.[55][56] A suitable asthma management plan that is properly implemented can remove the need to avoid known triggers (e.g., allergens or poor air quality), although many children will continue to have viral-induced exacerbations despite otherwise good control.[7]
Refer to the topic Asthma in children for more information about how to maintain control of asthma.
The table that follows summarizes recommendations for primary prevention of acute asthma exacerbations in children ages 6 years and above, taken from the Global Initiative for Asthma (GINA) Report, Global Strategy for Asthma Management and Prevention.[7]
Note that an individual patient may fall into more than one group and so interventions might may be additive; please review all population and subpopulation groups to assess all that apply.
Child with asthma
All
Intervention
Guideline directed asthma management, including written asthma action plan
To reduce the risk of severe, life-threatening or fatal asthma exacerbations, a medication containing an inhaled corticosteroid (ICS) is recommended as part of the treatment plan for all children ages 6 and above with asthma, even those with infrequent symptoms.
Ensure every patient (and/or caregiver, as appropriate) is trained in essential skills and guided asthma self-management, with regular medical review to include:
demonstration of inhaler technique, and
advice on self-monitoring of symptoms and/or peak flow.
A written asthma action plan (e.g., printed, digital, or pictorial) is recommended for all patients. This should be appropriate for their age, level of health literacy, treatment regimen, and asthma control, so they know how to recognize and respond to worsening asthma.
The written asthma action plan should include when and how to:
change reliever and/or maintenance medications,
use oral corticosteroids (OCS) if needed, and
access medical care if symptoms fail to respond to treatment.
Advise patients who have a history of rapid deterioration and their caregivers to attend an acute care facility or see their doctor immediately if their asthma starts to worsen.
Advise children with asthma and their caregivers to follow their local immunization schedule, including for pneumococcal. pertussis, influenza, respiratory syncytial virus (RSV) and COVID-19 vaccinations.
For detailed advice on management of asthma, see Asthma in children.
Goal
Optimization of long-term symptom control and risk minimization (including risk of exacerbation)
For many patients in primary care, achieving good symptom control is a good guide to reduced risk of exacerbations. However, it is important to be aware that patients with few or intermittent symptoms may still be at risk of severe exacerbations.
Consider both symptom control and future risk when choosing asthma treatment and reviewing the response.
Long-term asthma symptom control may include the following goals:
Few/no asthma symptoms
No sleep disturbance due to asthma
Unimpaired physical activity
Long-term asthma risk minimization may include the following goals:
No exacerbations
Improved or stable personal best lung function
No requirement for maintenance corticosteroids
No medication side effects
Asthma management involves a continuous cycle to assess, adjust treatment, and review response.
With exposure to tobacco smoke or e-cigarettes
Intervention
Strongly encourage avoidance of second hand smoke and tobacco and vaping abstinence
In children with asthma, exposure to environmental tobacco smoke increases the risk of hospitalization and poor asthma control.
Advise patients/caregivers of children with asthma not to smoke and not to allow smoking in rooms or cars that their children use.
Strongly encourage people with asthma to avoid environmental smoke exposure.
At every visit, strongly encourage children with asthma who smoke or vape to quit. Provide access to counseling and smoking cessation programs (if available).
See: Smoking cessation.
Goal
Cessation of environmental tobacco exposure, smoking, and vaping; reduced risk of exacerbation
With suspected food allergy
Intervention
Specialist referral and guideline directed management of food allergy
Food allergy as an exacerbating factor for asthma is uncommon and occurs primarily in young children. Confirmed food allergy is a risk factor for asthma-related mortality.
Food avoidance is not typically recommended unless an allergy or food chemical sensitivity has been clearly demonstrated, usually by carefully supervised oral challenges.
Appropriate food avoidance is needed if there is confirmed allergy; ensure availability of injectable epinephrine (adrenaline) for anaphylaxis at all times, with appropriate patient training, as required.
Patient (and caregiver) education on appropriate food avoidance strategies is key.
It is especially important to ensure that:
asthma is well controlled,
the patient has a written action plan,
the patient (and caregiver) understands the difference between asthma and anaphylaxis, and
the patient is reviewed on a regular basis.
Goal
Reduction in risk of asthma exacerbation and risk of anaphylaxis
With obesity
Intervention
Advice on weight reduction
Asthma is more difficult to control in people with obesity, the risk of exacerbations is greater, and response to ICS may be reduced.
Dietary advice with the aim of weight reduction is recommended as part of the treatment plan for all children with asthma and obesity. Increased exercise alone appears to be insufficient.
See: Obesity in children.
Goal
Weight loss and reduced risk of exacerbation
Physically inactive
Intervention
Advice on exercise
Encourage all children with asthma to engage in regular physical activity for its general health benefits. There is little evidence to recommend one form of physical activity over another in children with asthma.
Provide children with asthma and their caregivers with advice about prevention and management of exercise-induced bronchoconstriction, including pharmacologic treatment to be taken before exercise and when required, according to the child's personalized asthma treatment plan.
Goal
Improved cardiopulmonary fitness and quality of life; reduced risk of exacerbation
With exposure to indoor or outdoor pollution
Intervention
Advice on avoidance of indoor and outdoor pollution
Indoor pollution:
Advise the patient and/or caregiver that sources of indoor air pollution include cooking and heating devices using gas and solid biomass fuels, particularly if they are not externally flued (vented).
Encourage children and their families to use non-polluting heating and cooking sources (e.g., heat pump, wood pellet burner, flued gas), and for sources of pollutants to be vented outdoors where possible.
Outdoor pollution:
Proximity to main roads at home and school is associated with greater asthma morbidity. Certain weather and atmospheric conditions (e.g., thunderstorms) may trigger asthma exacerbations.
In general, when asthma is well controlled, there is no need for children to modify their lifestyle to avoid unfavorable weather conditions (e.g., air pollutants).
At times of high air pollution, advise the patient (and/or caregiver) that it may be helpful, if feasible, to stay indoors in a climate-controlled environment and to avoid polluted environments during viral infections, if feasible.
Goal
Improved symptom control and reduced risk of exacerbation
With sensitization to indoor or outdoor allergens (house dust mites, pets, pollen, mold)
Intervention
Guideline-directed asthma management, with consideration of avoidance strategies +/- allergen immunotherapy
ICS-containing inhalers to maintain good asthma control have an important role because patients are often less affected by environmental factors when their asthma is well controlled.
Avoidance of indoor allergens:
There is limited evidence for the benefit of asthma avoidance strategies for house dust mites and/or pets in sensitized children with asthma.
Utility is limited by the fact that allergen avoidance strategies are often complicated and expensive; there are no validated measures for identifying those who are likely to benefit.
Complete avoidance of indoor allergens is usually impractical and very burdensome for the patient/family.
Avoidance of outdoor allergens: In sensitized patients, when pollen and mold counts are highest, closing windows and doors, remaining indoors, and using air conditioning may reduce exposure to outdoor allergens.
Allergen immunotherapy: For children with asthma who have clinically significant sensitization to aeroallergens, including in those with allergic rhinitis, allergen-specific immunotherapy may be considered as add-on therapy. There are two separate approaches: subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT).
Goal
Improved symptom control and reduced risk of exacerbation
With asthma made worse by emotional stress
Intervention
Consider identifying goals and strategies to deal with emotional stress
Emotional stress may lead to asthma exacerbations in children.
There is insufficient evidence to support one strategy over another, but relaxation strategies and breathing exercises may be helpful in reducing asthma symptoms.
Follow guideline-directed management for children with symptoms of psychiatric illness (e.g., depression, anxiety) meeting diagnostic criteria, following a mental health assessment.
See: Depression in children.
Goal
Reduction in asthma symptoms associated with emotional stress; reduced risk of exacerbation
With incorrect inhaler technique
Intervention
Correct inhaler technique; consider a change of device
Ask the child to show you how they use their inhaler; compare with a device-specific checklist.
A physical demonstration is key to improve inhaler technique. This may be easiest to demonstrate with placebo inhalers and a spacer.
Check the technique again following the demonstration, paying attention to problematic steps. You may need to repeat this process 2-3 times within the same session for the patient to master the correct technique.
Attaching a pictogram or list of inhaler technique steps increases retention of the correct technique at follow-up.
Pharmacists, nurses and trained lay health workers can provide effective inhaler skills training.
Consider an alternative device only if the patient cannot use the inhaler correctly after several repeats of training.
If starting an inhaler for the first time or considering a change of device, note that the choice of device for any particular medication class may be limited. Consider local availability, access and cost to the patient. Where more than one medication is needed, a single (combination) inhaler is preferable to multiple inhalers, if available.
Errors in inhaler technique are seen in up to 80% of people with asthma, and increase the risk of severe asthma exacerbations. Checking and correcting inhaler technique using a standardized checklist leads to improved asthma control in older children in particular.
Goal
Optimal inhaler technique and reduced risk of exacerbation
After training, inhaler technique deteriorates with time (typically within 4-6 weeks), so checking and retraining at regular intervals is strongly recommended.
The best inhaler for each patient is likely to be the one that they prefer and can use correctly, as this promotes adherence and reduces the risk of exacerbations and adverse effects.
With suboptimal adherence to asthma medication
Intervention
Assess and address factors contributing to suboptimal adherence
The following discussion may take place with the child and/or caregiver, as developmentally appropriate.
Identify difficulties with adherence with empathetic questioning that acknowledges the likelihood of incomplete adherence and encourages an open discussion, e.g., "Many patients don’t use their inhaler as prescribed. In the past 4 weeks, how many days a week have you (or they) been taking it - not at all, 1, 2, 3 or more days a week?"
Identify barriers to medication use, which may include:
Cost
Concerns about necessity
Concerns about adverse effects
Forgetfulness or misunderstanding about instructions
Difficulties using the inhaler device
A burdensome regimen of treatment
Examples of successful adherence interventions include:
Shared decision-making for medication/dose choice
Inhaler reminders, either given proactively or for missed doses
Prescribing low-dose ICS once daily versus twice daily
Home visits for a comprehensive asthma program by an asthma nurse
Note that strategies will need to be tailored according to the child’s age, understanding and stage of development.
Approximately 50% of children on long-term therapy for asthma do not take their medications as directed at least part of the time.
Goal
Improved adherence and reduced risk of exacerbation
Consider assessing adherence on an ongoing basis using one or more of the following strategies:
Checking the date of the last prescription
Checking the date and dose counter on the inhaler
Depending on the health system, checking frequency of dispensing using electronic checks
Secondary prevention
Patients who continue to experience asthma exacerbations despite treatment may need to have their treatment stepped up. Before this happens, clinicians need to check patients' adherence to treatment and inhaler technique, make sure patients have a written asthma action plan, confirm the diagnosis of asthma (if there is any doubt), consider specialist referral, and review any persistent allergen exposure, triggers and comorbidities.[7] See Asthma in children.
Viral infections are a significant trigger for acute asthma exacerbations and may be prevented by vaccination.[7] However, schedules vary by location; consult local guidance for recommendations. UKHSA: complete routine immunisation schedule Opens in new window CDC:child and adolescent immunization schedule by age Opens in new window
While influenza vaccination is recommended in many countries for children with asthma, studies have failed to demonstrate a beneficial effect on asthma exacerbation rates or lung function decline.[165] However, data suggest it is well tolerated and does not precipitate exacerbation.[165][166] There is insufficient evidence to support a beneficial role for pneumococcal vaccination in children with asthma.[167]
Improving control of related comorbidities, such as allergic rhinitis, may be beneficial to asthma control.[168] Relapse rates after discharge are higher in those with atopy.[169] Interventions to decrease environmental tobacco smoke exposure have been shown to benefit children at high risk of asthma exacerbations.[170][171] High efficiency particulate air (HEPA) filters reduce indoor air pollution and aeroallergens, improving asthma symptoms.[18] Public education campaigns appear to have positive effects on use or intention to use electronic nicotine delivery products.[29]
One Cochrane review showed that oral corticosteroids can reduce relapse rates, although this was based primarily on randomized controlled trials conducted in adults.[172] High-dose inhaled corticosteroid therapy has shown similar efficacy to oral corticosteroids, but is not as cost effective.[50]
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