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Pediatric
ASTHMA A CLINICAL SUPPORT CHART
PAACSC FLIP CHART.indd 1 3/8/22 3:17 PM

Contents
1 Tab 1. Approach to Evaluation 24 Tab 13. Inhaled Corticosteroids
2 Tab 2. Diagnosis 26 Tab 14. LABAs and LTRAs
4 Tab 3. Office Pulmonary Function Testing 28 Tab 15. Inhaled Anticholinergic Agents
6 Tab 4. Exacerbation Assessment 30 Tab 16. Systemic Corticosteroids
8 Tab 5. Respiratory Scoring Tools 32 Tab 17. Anti-immunoglobulin E Therapy
10 Tab 6. Classifying Severity by Age 34 Tab 18. Other Biologics
12 Tab 7. Intervention Overview 36 Tab 19. Trigger Management
14 Tab 8. NIH/NHLBI Stepwise Approaches to Management 38 Tab 20. Exercise-Induced Bronchoconstriction
17 Tab 9. FeNO: NIH/NHLBI Recommendations 40 Tab 21. Asthma Control Test
18 Tab 10. GINA Stepped Approaches to Treatment 42 Tab 22. Tobacco Use/Vaping and Asthma
20 Tab 11. Maintenance and Control 44 Tab 23. Get Valid Spirometry Results Every Time
22 Tab 12. SABAs
The American Academy of Pediatrics is committed to principles of equity, diversity, and inclusion in its publishing program. Editorial boards, author
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are encouraged to actively seek out diverse authors and reviewers at all stages of the editorial process. Publishing staff are committed to promoting equity,
diversity, and inclusion in all aspects of publication writing, review, and production.
Thank you to the AAP Section on Pediatric Pulmonology and Sleep Medicine for their expert review.
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Tab 1
Approach to Evaluation
Asthma affects 7.1 million children and adolescents and leads to more hospitalizations than any other medical problem.
Asthma is a chronic inflammatory condition of the airways that is characterized by 3 features: (1) airway obstruction that
is at least partially reversible by bronchodilator treatment, (2) airway hyperreactivity or hyperresponsiveness to a variety of
external stimuli, and (3) chronic inflammation of the airway. In most children with asthma, the onset begins before 5 years
of age. The following diagram depicts the general approach to the evaluation of asthma in children, according to the Global
Initiative for Asthma (GINA):
Diagnosis of Asthma: Basic GINA Approach to a Child With Respiratory Symptoms Consistent With Asthma
Patient with respiratory symptoms

Are the symptoms typical of asthma?
NO
YES
Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
Clinical urgency, and other YES Alternative diagnosis confirmed?
diagnoses unlikely
Perform spirometry with

reversibility test
Results support asthma diagnosis?
NO Repeat on another occasion

or arrange other tests NO
YES Confirms asthma diagnosis?
Empiric treatment with
ICSs and as-needed SABA
NO YES
Review response YES
Diagnostic testing within
1–3 months Consider trial of treatment for
most likely diagnosis, or refer
for further investigations
Treat for ASTHMA Treat for alternative diagnosis
Bronchodilator reversibility may be lost during severe exacerbations or viral infections and in long-standing asthma. If bronchodilator reversibility is not found at initial presentation,
the next step depends on the availability of tests and the clinical urgency of need for treatment. Note that spirometry is of questionable validity in children under the age of 6, unless
the technician performing it is particularly skilled in working with young children. GINA indicates Global Initiative for Asthma; ICS, inhaled corticosteroid; and SABA, short-acting
β2 -adrenergic receptor agonist.
Adapted with permission from Patel SJ, Teach SJ. Asthma. Pediatr Rev. 2019;40(11):549–467.
1 Tab 1. Approach to Evaluation
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2 Tab 2. Diagnosis
Tab 2
Diagnosis
Diagnosing Asthma
Signs and Symptoms Triggers Additional Notes
Typical signs and symptoms Specific triggers can include Asthma is both underdiagnosed and overdiagnosed.
include Colds and viral illnesses Asthma is the most common chronic disease of children.
Polyphonic wheezes, Exercise Asthma causes more hospitalizations than any other medical problem
predominantly on expiration in children.
Exposure to cold air
Recurrent and/or chronic Intermittent asthma is most commonly a viral respiratory tract
Cough after laughing or crying
cough infection–induced phenotype in preschool-aged children but is found
Allergens, including pets, mold,
Chest tightness at all ages.
dust mites, and additional
Shortness of breath environmental exposures Persistent asthma phenotype is characterized by the absence of
Pollution (indoor or outdoor) extended symptom-free periods.
Passive exposure to smoke Seasonal allergic phenotype is characterized by allergen-specific
immunoglobulin E limited to seasonal inhalant allergens.
Strong odors
Asthma severity is indicated by
Additional Features • Interference with activity from exercise limitation
Additional allergic comorbidities (eg, allergies to dust mites, pollen, trees, • Interference with sleep from repeated nocturnal awakening
grasses, mold, cockroaches, dogs, cats) occur in most children with • Frequency of requirements for intervention measures, inhaled
asthma, including rhinitis and atopic dermatitis. bronchodilators, and oral corticosteroids
Any wheezing reported by patients and parents should be confirmed by • Urgent care visits or hospitalizations
a medical provider. Although some children will have symptoms of asthma that remit,
Additional physical examination findings include an increased chest many will have symptoms that continue well into adulthood.
anterior-posterior diameter, an expiratory abdominal push, and a Children who have symptoms of asthma that are not limited to a
prolonged expiratory phase on respiration. viral respiratory tract infection have a greater likelihood that asthma
Diagnostic Considerations symptoms will persist into adulthood.
Asthma can be difficult to diagnose in children, particularly in those Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric
<5 years of age. For children <5 years of age, a careful history of Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American
Academy of Pediatrics; 2018:201; and AAP Section on Pediatric Pulmonology.
impairment and risk is used to assess severity and control, and lung
Pediatric Pulmonology. 2nd ed. American Academy of Pediatrics; 2023.
function information is typically unavailable.
Aspiration as a cause of wheezing in children with neurological impairment
should be ruled out before a diagnosis of asthma is considered.
Many infants and toddlers wheeze during viral respiratory illnesses but
do not go on to have asthma when they are older.
Misdiagnosis of asthma as pneumonia or bronchitis can lead to
ineffective and unnecessary use of antibiotics.
Overdiagnosis of asthma can result in unnecessary use of inhaled
medications and oral steroids, as well as familial anxiety.
The 2 components of airway obstruction in

asthma: bronchospasm and inflammation
with mucosal edema and mucus secretions
are illustrated on the right. The normal airway
is illustrated on the left.
From AAP Section on Pediatric Pulmonology.
Pediatric Pulmonology. 2nd ed. American
Academy of Pediatrics; 2023.

Tab 2
Diagnosis
Asthma Predictive Index (API) Considering Alternative Diagnoses

The Asthma Predictive Index (API) was created to help forecast which
children are more likely to have asthma later in life, which removes some Alternative diagnoses should be considered when
ambiguity with this prognostic challenge. It includes frequent wheezing A patient is nonresponsive to standard asthma therapy
during the first 3 years after birth and either 1 major risk factor (parent (β2 -adrenergic receptor agonists or inhaled or oral corticosteroids).
history of asthma or child diagnosis of eczema) or 2 of 3 minor risk factors
Certain red flags are present, including digital clubbing, stridor, fixed
(blood eosinophilia, wheezing without colds, and allergic rhinitis). Children
monophonic wheeze at examination, cyanosis, or cardiac findings,
with a positive API are 4.3–9.8 times more likely to have active asthma
such as a cardiac murmur or asymmetrical peripheral pulses.
between ages 6 and 13 than children with a negative API; children without
API risk factors have a negative predictive value of 94% for the development Aspiration occurs in neurologically impaired children or in infants.
of asthma at age 6. Although rare, providers should consider a pediatric pulmonary referral
Stringent API: >3 episodes of wheezing per year during the first 3 years if a fixed airway obstruction is suspected, such as a vascular ring or
after birth and 1 major or 2 minor criteria sling, right-sided aortic arch, or endobronchial mass, and symptoms
persist despite asthma therapy.
Loose API: <3 episodes of wheezing per year and 1 major or 2 minor criteria
Once asthma is diagnosed, the patient should be reassessed 4–6 weeks
Major Criteria Minor Criteria after therapy initiation to ensure symptom improvement.
Asthma in a parent, documented Allergic rhinitis in the child,
by a physician documented by a physician
Eczema in the child, documented Wheezing apart from colds,
by a physician reported by the parents
Peripheral eosinophilia ≥4%
Reprinted with permission of the American Thoracic Society. Copyright ©2021
American Thoracic Society. All rights reserved. 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;162(4, pt 1):1403–1406.
The American Journal of Respiratory and Critical Care Medicine is an official journal
of the American Thoracic Society.
Differential Diagnosis
Diagnosis Age at Diagnosis Runny Nose Sputum Other Diagnostic Findings
Asthma Variable; typically >2 y Not a primary feature Rare Wheeze, chest tightness, shortness of breath
Cystic fibrosis <1 y Not a primary feature Frequent Clubbing, failure to thrive, pancreatic insufficiency
Gastroesophageal reflux disease <1 y Not a primary feature Frequent Emesis, back-arching, cough
Aspiration and/or dysphagia <2 y Not a primary feature Rare Coughing, faster breathing with eating and drinking
Primary ciliary dyskinesia <1 y Uniformly present Rare Neonatal respiratory distress common, recurrent
sinopulmonary infections
Tracheal and/or bronchial malacia <1 y Not a primary feature Absent Monophonic expiratory wheeze
Habit cough >8 y Unrelated Absent Absent when asleep
Postnasal drip <1 y Very common Rare Absence of wheezes
Foreign body >4 y Unrelated Occasional Unilateral physical examination findings
Vocal cord dysfunction >8 y Unrelated Rare Inspiratory stridor when symptomatic
Reprinted with permission from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds.
American Academy of Pediatrics; 2018:203. Adapted with permission from Rosenthal M. Differential diagnosis of asthma. Paediatr Respir Rev. 2002;3(2):148–153.
3 Tab 2. Diagnosis
PAACSC FLIP CHART.indd 3 5.625 page 3/8/22 3:17 PM

number
4 Tab 3. Office Pulmonary Function Testing
Tab 3
Office Pulmonary Function Testing
Spirometry is used most commonly for the diagnosis and ongoing management of pediatric asthma, and it can typically
be performed by trained personnel in developmentally appropriate children by 5 years of age. The goal of spirometry in a
general pediatrician’s office should be to identify and manage reversible airway obstruction, which defines asthma. Spirome-
try permits an objective measurement of the degree of airway obstruction (impairment and risk), which is important because
clinically significant obstruction can be present, even when the chest appears to be clear at physical examination. In primary
care, clinical symptoms alone will lead to underestimation of asthma severity about 30% of the time. Peak flow testing alone
is highly variable, is not very sensitive as a measure of obstruction, and is no longer recommended for diagnosis. However,
it may have a role in monitoring. See Tab 23, Get Valid Spirometry Results Every Time, for the appropriate performance
of spirometry maneuvers.
Pediatric Spirometry Algorithm
Perform
maneuver
No Check both the VT and FV

Curves
curves visually for common
Discard OK?
problems. (See examples.)
maneuver
Yes
No Sufficient Was the VT plateau at least

plateau? 1 second?
Yes Acceptability
Minimum
Age
No FET
Minimum
Discard FET? Does the FET value 2−3 s,
3−6 yrs
maneuver meet the minimum if possible
duration?
7−9 yrs ≥3 s
Yes 10+ yrs ≥6 s
Are there at least 3 acceptable

No Enough
maneuvers (that meet both the visual
maneuvers?
Perform another and plateau/FET requirements)?
Reproducibility
maneuver
Yes FVC & FEV1
Variances
Are the variances
No Reproducible between the 2 Within 150 mL
test? best maneuvers or
Perform another
within range? Within 5%
maneuver
Yes
Save and
interpret
FET indicates forced expiratory time; FEV1, forced expiratory volume in 1 second; FV, flow volume; FVC, forced vital
capacity; and VT, volume-time.
From AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine.
Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; 2018:24. Reproduced with permission from Spirometry 360.
Spirometry test algorithm. Accessed January 7, 2022. https://www.spirometry360.org/spiro360resources.

Tab 3
Office Pulmonary Function Testing
Once a diagnosis of asthma is established, the severity of lung Indications for Spirometry
function impairment is largely based on percentage of predicted Spirometry has several indications in primary care pediatrics.
forced expiratory volume in 1 second, as follows: These include
 Mild persistent (≥80%) Diagnosis and severity assessment of asthma in patients
≥5 years of age
 Moderate persistent (60%–79%) Follow-up of asthma control (especially when changing
medications)
 Severe persistent (<60%)
Evaluation of chronic cough
Evaluation of shortness of breath and other chronic
Spirometry and Asthma, Patients 5 Years and Older respiratory concerns
Spirometric Measurements Evaluation of baseline lung function in a patient with EIB
FEV1 FEV1: FVC (Absolute Ratios)a by Age Goal of Spirometry
(Percentage
Asthma Predicted), The goal is for the patient to have normal or near-normal lung
Severity % 5–11 y 12–19 y 20–39 y function during wellness. First and most importantly, assess
whether the predicted-FEV1 percentage and/or the FEV1:FVC
Normal ≥0.80 ≥0.85 ≥0.85 ≥0.80 ratio represents obstruction for the patient.
Mild ≥0.80 0.80–0.84 ≥0.85 ≥0.80 Additional Notes
persistent
Pulmonary function testing can be used to support a diagnosis of
Moderate 0.60–0.79 0.75 ≤0.80 0.80 ≤0.85 0.75 ≤0.80 asthma; however, most children with asthma will have normal
persistent lung function.
Severe <0.60 <0.75 <0.80 <0.75 Spirometry is used to measure how much air the patient breathes
persistent in and out and how fast the air is exhaled.
FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity. Spirometric findings of obstructive lung disease include the
a
Use actual ratios, not percentage of predicted values.
ratio of FEV1:FVC in the <5th percentile when compared to
predicted values.
Adapted from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology,
Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; More typically, an FEV1:FVC ratio of <80% is used to denote an
2018:253. obstructive process consistent with asthma in children.
A change in absolute value of predicted-FEV1 percentage of
≥12% within 15 minutes after bronchodilator administration
is considered a positive response and supports the diagnosis
of asthma; a predicted-FEV1 percentage change of <8% is
considered a negative response.
Consistent predicted-FEV1 values <60% typically warrant
subspecialty consultation.
A concomitant decrease in FEV1 and FVC is most commonly
caused by poor patient effort but may rarely reflect airflow
obstruction that can be better assessed with body
plethysmography.
A normal ratio of FEV1 to vital capacity, coupled with a
predicted–vital capacity percentage <80%, could be consistent
with a restrictive pulmonary defect; subspecialty consultation
(along with additional lung function testing, including body
plethysmography) should be sought.
Spirometric values should be assessed over time as a marker
of improvement and adherence to therapy.
EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second;
FVC, forced vital capacity.
Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine.
Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds.
American Academy of Pediatrics; 2018:202–204,253.
5 Tab 3. Office Pulmonary Function Testing

number
6 Tab 4. Exacerbation Assessment
Tab 4
Exacerbation Assessment
Formal Evaluation of Asthma Exacerbation Severity

Subset: Respiratory
Symptom Mild Moderate Severe Arrest Imminent
Symptoms
Breathlessness While walking While at rest (In an infant, a softer, shorter While at rest
cry is indicative, with difficulty feeding.) (An infant will stop feeding.)
Can lie down Prefers sitting Sits upright
Speech difficulty Speaks in sentences Speaks in phrases Speaks in words
Alertness May be agitated Usually agitated Usually agitated Drowsy or confused
Signs
Respiratory rate Increased Increased Often >30 breaths/min
Guide to rates of breathing in awake children:
Age Normal rate
<2 mo <60 breaths/min
2–12 mo <50 breaths/min
1–5 y <40 breaths/min
6–8 y <30 breaths/min
Use of accessory muscles; Usually not Commonly Usually Paradoxical thoracoabdominal
suprasternal retractions movement
Wheeze Moderate, wheeze often Loud, wheeze throughout Usually loud, wheeze throughout Absence
only end expiratory exhalation inhalation and exhalation of wheeze
Pulse rate <100 beats/min 100–200 beats/min >120 beats/min Bradycardia
Guide to normal pulse rates in children:
Age Normal rate
2–12 mo <160 beats/min
1–2 y <120 beats/min
3–8 y <110 beats/min
Pulsus paradoxus Absent at May be present at Often present at Absence suggests
<10 mm Hg 10–25 mm Hg >25 mm Hg in an adult and respiratory muscle
20–40 mm Hg in a child fatigue.
Functional Assessment
a
PEF (percentage predicted or ≥70% Approximately 40%–69% <40% <25%
percentage personal best) or response lasts <2 h
Pao2 (on air) Normal (test not ≥60 mm Hg <60 mm Hg:
usually necessary) (test not usually necessary) possible cyanosis
and/or Pco2 <42 mm Hg (test not <42 mm Hg ≥42 mm Hg: possible
usually necessary) (test not usually necessary) respiratory failure
Sao2 percentage (on air) >95% (test not 90%–95% <90%
at sea level usually necessary) (test not usually necessary)
Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents.
PEF, peak expiratory flow; Sao2, arterial oxygen saturation. The presence of several but not necessarily all parameters indicates the general classification of the exacerbation. Many of these
parameters have not been systematically studied, especially as they correlate with each other. Thus, they serve only as general guides. The emotional effect of asthma symptoms on the
patient and family is variable but must be recognized and addressed and can affect approaches to treatment and follow-up.
a
PEF testing may not be needed in very severe attacks.
From AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics;
2018:244–245; and National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management
of Asthma. U.S. Department of Health and Human Services; 2007.

Tab 4
Exacerbation Assessment
Factors That Can Exacerbate Asthma Not All Wheezing Indicates Asthma Exacerbation
Factor Description
It is important to note that not all wheezing represents an asthma
Viral respiratory tract infections Viral respiratory tract infections are exacerbation. The following conditions may need to be ruled out, when
by far the most common trigger of addressing an apparent exacerbation:
asthma exacerbations.
Pneumonia
Environmental allergens in Outdoor allergens
sensitized individuals (eg, seasonal allergens such Bronchiolitis in younger children
as tree pollen, grass pollen, Bacterial tracheitis
weed pollen, and molds)
Anaphylaxis
Indoor allergens
(eg, animal dander, dust mites, Foreign-body aspiration
cockroaches, indoor molds, mice) Esophageal foreign body
Irritants Environmental tobacco smoke Bronchitis
Air pollutants Vocal cord dysfunction
(eg, ozone, sulfur dioxide)
Chest radiography is not routinely necessary at the onset of asthma
Particulate matter (eg, wood- exacerbation. However, consider obtaining a chest radiograph to rule
or coal-burning smoke) out pneumonia in the presence of focal lung examination findings,
Mycotoxins fevers, continued tachypnea, hypoxemia, or chest pain after initial
asthma therapy is administered.
Endotoxins
Dust
Strong odors or fumes
(eg, perfumes, hair sprays,
cleaning agents, incense sticks,
scented candles)
Occupational exposure Farm and barn exposure
Formaldehyde
Cedar
Paint fumes
Others
Cold, dry air
Exercise
Emotions Crying
Laughter
Emotions that can cause
hyperventilation
Comorbid conditions Rhinitis
Sinusitis
Gastroesophageal reflux
Nasal polyps
Adapted from Dinakar C. Asthma. Pediatric Care Online. Accessed January 10, 2022.
https://publications.aap.org/pediatriccare/book/348/chapter/5776728/
Asthma#aap-tpc2-2016_ch218.box1.
7 Tab 4. Exacerbation Assessment

number
8 Tab 5. Respiratory Scoring Tools
Tab 5
Respiratory Scoring Tools
Asthma severity scores can be used to help establish whether an asthma exacerbation is mild, moderate, or severe (see the
Table below). The scores are generally based on a variety of signs and symptoms, including respiratory rate; work of breathing;
lung examination (ie, air entry, wheezing); degree of dyspnea; oxygen saturation; inspiratory-to-expiratory time ratio; respira-
tory rate; and peak expiratory flow rate. Although several validated asthma severity scores have been developed, no single
score has been adopted universally. This tab includes some pediatric scoring systems that may be used to assess the severity
of asthma.
Grading Asthma Severity

The general grading scale for asthma severity is as follows (for a formal evaluation of asthma exacerbation severity, see Tab 4):
Mild Dyspnea with activity, end-expiratory wheeze, mild work of breathing, tachypnea
Moderate Dyspnea at rest that interferes with usual activity, wheezing, moderate work of breathing, tachypnea. Mild to moderate exacerbations may
be managed in the office setting.
Severe Dyspnea at rest, wheezing or diminished lung sounds, clinically significant work of breathing, tachypnea, possible hypoxia. For severe
exacerbations, initiate treatment while arranging for transfer of the patient to an emergency department.
Adapted from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of
Pediatrics; 2018:243.
Pediatric Respiratory Assessment Measure (PRAM)

The 12-point Pediatric Respiratory Assessment Measure (PRAM) is a validated composite score that can be used to assess
the severity of asthma events in children 2 to 17 years of age, on the basis of 5 parameters: suprasternal retractions, scalene
muscle contraction, air entry, wheezing, and oxygen saturation. The PRAM can be used to guide therapy and apply acute
asthma guidelines based on event severity. It can also be applied after the initiation of therapy to adjust therapy.
PRAM for Use in Children 2 to 17 Years of Age

Signs 0 1 2 3
Suprasternal retractions Absent — Present —
Scalene muscle contraction Absent — Present —
a
Air entry Normal Decreased at bases Widespread decrease Absent/minimal
a
Wheezing Absent Expiratory only Inspiratory and expiratory Audible without stethoscope/silent chest with minimal air entry
O2 saturation ≥95% 92%–94% <92% —
A score of 0–3 is considered to indicate a low risk of hospital admission; a score of 4–7 indicates a moderate risk for admission; and a score of 8–12 indicates a high risk for admission.
a
If findings between the right and left lungs are asymmetrical, the most severe side is rated.
Reproduced with permission from Chalut DS, Ducharme FM, Davis GM. The Preschool Respiratory Assessment Measure (PRAM): a responsive index of acute asthma severity. J Pediatr.
2000;137(6):762–768.

Tab 5
Respiratory Scoring Tools
Pulmonary Index Score (PIS)

The Pulmonary Index Score (PIS) is a simple clinical asthma score that can be used to assess children and adolescents. It is
derived from the assessment of 5 parameters: respiratory rate, wheezing, inspiratory-respiratory ratio, accessory muscle use,
and oxygen saturation. A high PIS denotes severe asthma. Here, we present 2 PISs: one for young children, 1 to 5 years of age,
and a score for older children and adolescents, 6 to 18 years of age.
PIS for Young Children, 1 to 5 Years of Age

Respiratory Rate, Inspiratory- Accessory Oxygen
Score breaths/min Wheezinga Respiratory Ratio Muscle Use Saturation, %
0 ≤30 None 2:1 None 99–100
1 31–45 End expiration 1:1 + 96–98
2 46–60 Entire expiration 1:2 ++ 93–95
3 >60 Inspiration and expiration without stethoscope 1:3 +++ <93
a
If no wheezing because of minimal air entry, score 3.
Adapted with permission from Scarfone RJ, Fuchs SM, Nager AL, Shane SA. Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma.
Pediatrics. 1993;92(4):513–518.
PIS for Older Children and Adolescents, 6 to 18 Years of Age

Respiratory Rate, Inspiratory- Accessory Oxygen
Score breaths/mina Wheezinga Respiratory Ratio Muscle Use Saturation, %
0 ≤20 None 2:1 None 99–100
1 21–35 End expiration 1:1 + 96–98
2 36–50 Entire expiration 1:2 ++ 93–95
3 >50 Inspiration and expiration without stethoscope 1:3 +++ <93
a
If no wheezing because of minimal air entry, score 3.
Adapted with permission from Scarfone RJ, Fuchs SM, Nager AL, Shane SA. Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma.
Pediatrics. 1993;92(4):513–518.
Respiratory Rate, Accessory Muscle Use, Decreased Breath Sounds (RAD) Score
The Respiratory rate, Accessory muscle use, Decreased breath sounds (RAD) score is an easy-to-use pediatric asthma
assessment tool for acute exacerbations, based on these 3 parameters. The RAD score may facilitate efficient treatment and
triage of pediatric patients with an acute asthma exacerbation.
RAD Score to Determine Acute Asthma Severity in Patients 5 to 17 Years of Age
Score Component Operational Definition Scoringa
Respiratory rate Respiratory rate, at rest, on room airb ≤24 = 0
>24 = 1
Accessory muscle use Any visible use of accessory muscles Present = 1
Not present = 0
Decreased breath sounds Any decreased breath sounds on auscultation Normal = 0
Any decrease = 1
RAD score Sum of 3 components 0–3
a
Summary score value range: 0–3.
b
Based on 97.5 percentiles for children ages 5–17 years of age.
Reproduced with permission from Arnold DH, Gebretsadik T, Abramo TJ, Moons KG, Sheller JR, Hartert TV. The RAD score: a simple acute asthma severity score compares favorably to
more complex scores. Ann Allergy Asthma Immunol. 2011;107(1):22–28.
9 Tab 5. Respiratory Scoring Tools

number
10 Tab 6. Classifying Severity by Age
Tab 6
Classifying Severity by Age
Classifying Asthma Severity and Initiating Therapy in Children Ages 0 to 11

Persistent
Intermittent Mild Moderate Severe
Ages Ages Ages Ages Ages Ages Ages Ages
Components of Severity 0–4 5–11 0–4 5–11 0–4 5–11 0–4 5–11
Impairment Symptoms ≤2 days/week >2 days/week but not daily Daily Throughout the day
Nighttime 0 ≤2×/month 1–2×/month 3–4×/month 3–4×/month >1×/week but >1×/week Often 7×/week
awakenings not nightly
Short-acting ≤2 days/week >2 days/week but not daily Daily Several times per day
β2 -agonist use for
symptom control
Interference with None Minor limitation Some limitation Extremely limited
normal activity
Lung Function N/A Normal FEV1 N/A N/A N/A
between
exacerbations
FEV1 (predicted) >80% >80% 60%–80% <60%
or peak flow
(personal best)
FEV1/FVC >85% >80% 75%–80% <75%
Risk Exacerbations 0–1/year ≥2 exacerbations in 
requiring oral (see notes) 6 months requiring
systemic oral systemic ≥2×/year 
corticosteroids corticosteroids, (see notes)
(consider severity or ≥4 wheezing Relative annual
and interval since episodes/1 year risk may
last exacerbation) lasting >1 day be related
AND risk factors for to FEV1
persistent asthma
Recommended NIH/NHLBI Step 1 Step 2 Step 3 and Step 3: Step 3 and Step 3:
step for initiating therapy (for both age groups) (for both age groups) consider short medium-dose consider short medium-dose
(see Tab 8) course of oral ICS option and course of oral ICS option
systemic consider short systemic OR step 4 and
corticosteroids course of oral corticosteroids consider short
systemic course of oral
corticosteroids systemic
corticosteroids
In 2–6 weeks, depending on severity, evaluate level of asthma control that is achieved.
• Children 0–4 years old: If no clear benefit is observed in 4–6 weeks, stop treatment and consider alternative diagnoses or
adjusting therapy.
• Children 5–11 years old: Adjust therapy accordingly.
FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroids; ICU, intensive care unit; N/A, not applicable; NHLBI, National Heart, Lung, and Blood Institute;
NIH, National Institutes of Health. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Level of severity is determined
by both impairment and risk. Assess impairment domain by caregiver’s recall of previous 2–4 weeks. Assign severity to the most severe category in which any feature occurs. Frequency and
severity of exacerbations may fluctuate over time for patients in any severity category. At present, there are inadequate data to correspond frequencies of exacerbations with different levels
of asthma severity. In general, more frequent and severe exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity.
For treatment purposes, patients with ≥2 exacerbations described above may be considered the same as patients who have persistent asthma, even in the absence of impairment levels
consistent with persistent asthma.
From Dinakar C. Asthma. Pediatric Care Online. Accessed January 10, 2022. https://publications.aap.org/pediatriccare/book/348/chapter/5776728/Asthma. Adapted from National Heart,
Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. U.S. Department of
Health and Human Services; 2007.

Tab 6
Classifying Severity by Age
Classifying Asthma Severity and Initiating Treatment in Youths 12 Years of Age to Adults
Assessing Severity and Initiating Treatment for Patients Who Are Not Currently Taking Long-term Control Medications
Classification of Asthma Severity ≥12 Years of Age
Intermittent Persistent
Components of Severity Mild Moderate Severe
Impairment Symptoms ≤2 days/week >2 days/week but not daily Daily Throughout the day
Normal FEV1/FVC: Nighttime ≤2×/month 3–4×/month >1×/week Often 7×/week
awakenings but not nightly
8–19 yr 85%
20–39 yr 80% Short-acting β2 -agonist ≤2 days/week >2 days/week but not daily, Daily Several times
use for symptom control and not more than 1× on per day
(not prevention of EIB) any day
Interference with None Minor Some Extremely
normal activity limitation limitation limited
Lung Function Normal FEV1 between
exacerbations
FEV1 >80% FEV1 >80% FEV1 >60% but FEV1 <60%
predicted predicted <80% predicted predicted
FEV1/FVC FEV1/FVC FEV1/FVC FEV1/FVC
normal normal reduced 5% reduced 5%
Risk Exacerbations requiring oral 0–1/year ≥2/year (see note) 
systemic corticosteroids (see note)
Consider severity and Interval since last exacerbation.
Frequency and severity may fluctuate over time for patients in any severity category.
Relative annual risk of exacerbations may be related to FEV1.
Recommended NIH/NHLBI step for initiating Step 1 Step 2 Step 3 Step 4 or 5
treatment (see Tab 8)
and consider short course of
oral systemic corticosteroids
In 2–6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.
EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICU, intensive care unit; NHLBI, National Heart, Lung, and Blood
Institute; NIH, National Institutes of Health. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Level of
severity is determined by assessment of both impairment and risk. Assess impairment domain by patient’s/caregiver’s recall of previous 2–4 weeks and spirometry. Assign severity
to the most severe category in which any feature occurs. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity.
In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For
treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent
asthma, even in the absence of impairment levels consistent with persistent asthma.
From Dinakar C. Asthma. Pediatric Care Online. Accessed January 10, 2022. https://publications.aap.org/pediatriccare/book/348/chapter/5776728/Asthma. Adapted from
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma.
U.S. Department of Health and Human Services; 2007.
11 Tab 6. Classifying Severity by Age

12 Tab 7. Intervention Overview
Tab 7
Intervention Overview
Asthma Intervention Overview

Symptom Severity Intervention
Mild symptoms Give the patient 2.5–5.0 mg via nebulizer or 4–8 puffs of albuterol every 20 min for ≤3 doses.
• Reassess the patient after every dose.
Consider oral steroids if there is no improvement after 2 doses of SABA.
Provide oxygen as needed to keep the Sao2 >90%.
If the symptoms improve, send the patient home with 1.25–2.50 mg via nebulizer or 2–4 puffs every 4 h for 24 h and then
as needed.
Moderate symptoms Give the patient 2.5–5.0 mg or 4–8 puffs of albuterol every 20 min for ≤3 doses.
• Reassess after every dose.
Give the patient oral steroids.
Provide oxygen as needed to keep Sao2 >90%.
Consider administering ipratropium, especially if the patient needs to be transferred to an ED.
If symptoms are still improved 30–60 min after the most recent dose of bronchodilators, send the patient home with the
following prescriptions:
• Albuterol: 2.5 mg via nebulizer or 4 puffs every 4 h for 24 h and then as needed
• Oral corticosteroids:
– Prednisone or prednisolone: 0.5–1.0 mg/kg (maximum, 60 mg/d) administered orally twice daily for 3–5 d
or
– Dexamethasone: 0.6 mg/kg (maximum, 16 mg/d) orally for 1 dose given the following day (2 total doses)
• Consider starting inhaled glucocorticoids.
• Follow up within 1 wk.
Severe symptoms Give the patient 5 mg via nebulizer or 8 puffs of albuterol every 20 min, then switch to a continuous albuterol nebulizer,
if available.
Give the patient ipratropium.
Give the patient oral steroids or intramuscular steroids if giving the patient oral medication would be unsafe.
Provide oxygen to keep Sao2 >90%.
Expedite transfer of the patient to an ED via advanced life support.
ED, emergency department; SABA, short-acting β2 -adrenergic receptor agonist; Sao2, arterial oxygen saturation.
Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds.
American Academy of Pediatrics; 2018:247.

Tab 7
Intervention Overview
Medication Dosages and Decisions for the Usual Treatment of Acute Symptoms of Asthma
Medication Dosage When to Use
Albuterol or levalbuterol MDI 2–4 inhalations, up to 6 inhalations, can be used As needed for cough, wheezing, and labored
(at a time). breathing. Scheduled use has no advantage
over as-needed use and may be deleterious
for some patients. Repeated requirements for
bronchodilator use during exacerbations generally
warrant a short course of an oral corticosteroid.
Prednisone, prednisolone, methylprednisolone, and Dosage as prednisone or prednisolone. When bronchodilator sub-responsiveness is
dexamethasone as tablets. Liquid formulations and 1–2 mg/kg/d twice daily, maximum dose identified by incomplete resolution of symptoms
oral disintegrating tablets of prednisolone for young of 40 mg twice daily. and signs from repeated use of the bronchodilator.
children. (Parenteral forms indicated only when Reevaluate if not improving within 5 days or
concerned about oral retention.) asymptomatic within 10 days. Do not taper.
Ipratropium (Atrovent HFA) MDI; ipratropium 2–4 inhalations added to albuterol when albuterol Indicated for severe acute asthma exacerbation
solution added to albuterol solution for use in does not provide sufficient bronchodilatation or in the ED when response to a β2 -adrenergic
nebulizer 0.5 mg with 2.5–5.0 mg albuterol by nebulizer receptor agonist is inadequate for relief of
respiratory distress
Additional Decisions: When to Transfer

Most asthma attacks resolve with adequate bronchodilator and steroid therapy. However, transfer the patient to the hospital via an advanced life support
ambulance in the following situations:
Severe exacerbations
Mild or moderate exacerbations, but patient is worsening or not responding to SABA and oral glucocorticoid therapies given in the first 1–2 hours of
care in the office
Continued hypoxia after 1–2 doses of SABA therapy and supplemental oxygen therapy is needed
Risk factors for severe, uncontrolled disease, such as history of frequent ED visits, hospital and intensive care unit admissions, intubation, repeated
courses of oral glucocorticoids, history of rapid progression of exacerbations, and food allergies
Infants <1 year of age
Contributing social factors, such as patients with difficulty regarding access to care, those with medication adherence issues, and those with lack
of social supports
ED, emergency department; HFA, hydrofluoroalkane; MDI, metered-dose inhaler; SABA, short-acting β2 -adrenergic receptor agonist.
From AAP Section on Pediatric Pulmonology. Pediatric Pulmonology. 2nd ed. American Academy of Pediatrics; 2023; and AAP Section on Pediatric Pulmonology and Sleep
Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; 2018:248.
13 Tab 7. Intervention Overview

number
Tab 8. NIH/NHLBI Stepwise Approaches
14 to Management
Tab 8
NIH/NHLBI Stepwise Approaches to Management
NIH/NHLBI STEPWISE APPROACH TO ASTHMA MANAGEMENT: 0–4 YEARS
Intermittent Asthma Management of Persistent Asthma in Individuals Ages 0–4 Years
Treatment STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 STEP 6

Preferred PRN SABA Daily low-dose ICS Daily medium-dose Daily medium-dose Daily high-dose Daily high-dose ICS-
and and PRN SABA ICS and PRN SABA ICS-LABA and PRN ICS-LABA and LABA + oral systemic
SABA PRN SABA corticosteroid and
At the start of RTI: Add
PRN SABA
short course daily ICS
Alternative Daily montelukast* Daily medium-dose Daily high-dose ICS Daily high-dose ICS +
or Cromolyn,* and ICS + montelukast* + montelukast* and montelukast* + oral
PRN SABA and PRN SABA PRN SABA systemic corticosteroid
and PRN SABA
For children age 4 years only, see Step 3 and
Step 4 on Management of Persistent Asthma in
Individuals Ages 5–11 Years diagram.
Assess Control
First check adherence, inhaler technique, environmental factors, and comorbid conditions.
Step up if needed; reassess in 4–6 weeks.
Step down if possible (if asthma is well controlled for at least 3 consecutive months).
Consult with asthma specialist if Step 3 or higher is required. Consider consultation at Step 2.
Control assessment is a key element of asthma care. This involves both impairment and risk. Use of objective measures,
self-reported control, and health care utilization are complementary and should be employed on an ongoing basis, depending
on the individual’s clinical situation.
Updated based on the 2020 NIH/NHLBI guidelines. Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control
and may require a step up in treatment. If clear benefit is not observed within 4–6 weeks and the medication technique and adherence are satisfactory, the clinician should consider adjusting
therapy or alternative diagnoses.
Abbreviations: EIB, exercise-induced bronchoconstriction; FDA, Food and Drug Administration; ICS, inhaled corticosteroid; LABA, long-acting beta 2 -agonist; PRN, as needed;
RTI, respiratory tract infection; SABA, inhaled short-acting beta 2 -agonist.

Updated based on the 2020 guidelines.
* Cromolyn and montelukast were not considered for this update and/or have limited availability for use in the United States. The FDA issued a Boxed Warning for montelukast in March 2020.

Tab 8
NIH/NHLBI STEPWISE APPROACH TO ASTHMA MANAGEMENT: 5–11 YEARS
Intermittent Asthma Management of Persistent Asthma in Individuals Ages 5–11 Years
Treatment STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 STEP 6

Preferred PRN SABA Daily low-dose ICS Daily and PRN Daily and PRN Daily high-dose Daily high-dose ICS-
and PRN SABA combination low-dose combination medium- ICS-LABA and LABA + oral systemic
ICS-formoterol dose ICS-formoterol PRN SABA corticosteroid and
PRN SABA
Alternative Daily LTRA,* or Daily medium-dose Daily medium-dose Daily high-dose ICS Daily high-dose ICS +
Cromolyn,* or ICS and PRN SABA ICS-LABA and PRN + LTRA* or daily LTRA* + oral systemic
Nedocromil,* or or SABA high-dose ICS + corticosteroid or daily
Theophylline,* or Theophylline,* and high-dose ICS +
Daily low-dose ICS-
and PRN SABA PRN SABA Theophylline* + oral
LABA, or daily low- Daily medium-dose
systemic corticosteroid,
dose ICS + LTRA,* ICS + LTRA or daily
and PRN SABA
or daily low-dose medium-dose ICS +
ICS + Theophylline,* Theophylline, and
and PRN SABA PRN SABA
Steps 2–4: Conditionally recommend the use of subcutaneous Consider Omalizumab**
immunotherapy as an adjunct treatment to standard pharmacotherapy in
individuals ≥5 years of age whose asthma is controlled at the initiation,
build up, and maintenance phases of immunotherapy
Assess Control
Control assessment is a key element of asthma care. This involves both impairment and risk. Use of objective measures,
self-reported control, and health care utilization are complementary and should be employed on an ongoing basis, depending
on the individual’s clinical situation.
Updated based on the 2020 NIH/NHLBI guidelines. In Steps 3 and 4, the preferred option includes the use of ICS-formoterol 1 to 2 puffs as needed up to a maximum total daily maintenance
and rescue dose of 8 puffs (36 mcg). Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and may require
a step up in treatment. The terms ICS-LABA and ICS-formoterol indicate combination therapy with both an ICS and a LABA, usually and preferably in a single inhaler. Where formoterol is
specified in the steps, it is because the evidence is based on studies specific to formoterol. In individuals ages 5–11 years with persistent allergic asthma in which there is uncertainty in
choosing, monitoring, or adjusting anti-inflammatory therapies based on history, clinical findings, and spirometry, FeNO measurement is conditionally recommended as part of an ongoing
asthma monitoring and management strategy that includes frequent assessment.
Abbreviations: EIB, exercise-induced bronchoconstriction; FDA, Food and Drug Administration; FeNO, fractional exhaled nitric oxide; ICS, inhaled corticosteroid; LABA, long-acting
beta 2 -agonist; LTRA, leukotriene receptor antagonist; PRN, as needed; SABA, inhaled short-acting beta 2 -agonist.

* Cromolyn, Nedocromil, LTRAs including montelukast, and Theophylline were not considered for this update and/or have limited availability for use in the United States, and/or have an
increased risk of adverse consequences and need for monitoring that make their use less desirable. The FDA issued a Boxed Warning for montelukast in March 2020.
** Omalizumab is the only asthma biologic currently FDA-approved for this age range.
15 Tab 8. NIH/NHLBI Stepwise Approaches

to Management

number
Tab 8. NIH/NHLBI Stepwise Approaches
16 to Management
Tab 8
NIH/NHLBI STEPWISE APPROACH TO ASTHMA MANAGEMENT: 12+ YEARS
Intermittent Asthma Management of Persistent Asthma in Individuals Ages 12+ Years
Treatment STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 STEP 6 

Preferred PRN SABA Daily low-dose ICS Daily and PRN combination Daily and PRN Daily medium-high Daily high-dose
and PRN SABA low-dose ICS-formoterol combination medium- dose ICS-LABA + ICS-LABA +
or dose ICS-formoterol LAMA and oral systemic
PRN SABA corticosteroids +
PRN concomitant
PRN SABA
ICS and SABA
Alternative Daily LTRA* and Daily medium-dose ICS Daily medium-dose ICS- Daily medium-high
PRN SABA and PRN SABA LABA or daily medium- dose ICS-LABA or
or dose ICS + LAMA, and daily high-dose
or
PRN SABA ICS + LTRA,*
Cromolyn,* or Daily low-dose ICS-LABA, or
or and PRN SABA
Nedocromil,* daily low-dose ICS + LAMA,
or Zileuton,* or or daily low-dose ICS + LTRA,* Daily medium-dose
Theophylline,* and PRN SABA ICS + LTRA,* or daily
and PRN SABA or medium-dose ICS +
Theophylline,* or daily
Daily low-dose ICS +
medium-dose ICS +
Theophylline* or Zileuton,*
Zileuton,* and PRN SABA
and PRN SABA
Steps 2–4: Conditionally recommend the use of subcutaneous immunotherapy Consider adding Asthma Biologics
as an adjunct treatment to standard pharmacotherapy in individuals ≥5 years of (e.g., anti-IgE, anti-IL5, anti-IL5R,
age whose asthma is controlled at the initiation, build up, and maintenance anti-IL4/IL13)**
phases of immunotherapy
Assess Control
Control assessment is a key element of asthma care. This involves both impairment and risk. Use of objective measures, self-reported control,
and health care utilization are complementary and should be employed on an ongoing basis, depending on the individual’s clinical situation.
Updated based on the 2020 NIH/NHLBI guidelines. In Steps 3 and 4, the preferred option includes the use of ICS-formoterol 1 to 2 puffs as needed up to a maximum total daily maintenance and
rescue dose of 12 puffs (54 mcg). Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and may require a step
up in treatment. The terms ICS-LABA and ICS-formoterol indicate combination therapy with both an ICS and a LABA, usually and preferably in a single inhaler. Where formoterol is specified
in the steps, it is because the evidence is based on studies specific to formoterol. In individuals ages 12 years and older with persistent allergic asthma in which there is uncertainty in choosing,
monitoring, or adjusting anti-inflammatory therapies based on history, clinical findings, and spirometry, FeNO measurement is conditionally recommended as part of an ongoing asthma monitoring
and management strategy that includes frequent assessment. Bronchial thermoplasty was evaluated in Step 6. The outcome was a conditional recommendation against the therapy.
Abbreviations: AHRQ, Agency for Healthcare Research and Quality; EIB, exercise-induced bronchoconstriction; FDA, Food and Drug Administration; FeNO, fractional exhaled nitric oxide;
ICS, inhaled corticosteroid; LABA, long-acting beta2 -agonist; LAMA, long-acting muscarinic antagonist; LTRA, leukotriene receptor antagonist; PRN, as needed; SABA, inhaled short-acting
beta2 -agonist.

* Cromolyn and Nedocromil, LTRAs including Zileuton and montelukast, and Theophylline were not considered for this update and/or have limited availability for use in the United States and/or have
an increased risk of adverse consequences and need for more monitoring that make their use less desirable. The FDA issued a Boxed Warning for montelukast in March 2020.
** The AHRQ systematic reviews that informed this report did not include studies that examined the role of asthma biologics (e.g., anti-IgE, anti-IL5, anti-IL5R, anti-IL4/IL13). Thus, this report does
not contain specific recommendations for the use of biologics in asthma in Steps 5 and 6.

Data on the use of LAMA therapy in individuals with severe persistent asthma (Step 6) were not included in the AHRQ systematic review and thus no recommendation is made.
NIH/NHLBI stepwise approaches reproduced from U.S. Department of Health and Human Services, National Institutes of Health (NIH), and National Heart, Lung, and Blood Institute (NHLBI).
2020 Focused Updates to the Asthma Management Guidelines: A Report From the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. 2020.
Accessed February 2, 2022. https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines.

Tab 9
FeNO: NIH/NHLBI Recommendations
Fractional exhaled nitric oxide (FeNO) testing has a supportive role in evaluation when the diagnosis of asthma is uncertain
in patients 5 years of age and older, according to current data. The Expert Panel makes the following recommendations for
use of FeNO testing:
Recommendation 1
In individuals 5 years of age and older for whom the diagnosis of asthma is uncertain by using history, clinical findings, clinical course, and spirometry,
including bronchodilator responsiveness testing, or in whom spirometry cannot be performed, the Expert Panel conditionally recommends the addition
of FeNO measurement as an adjunct to the evaluation process. [Conditional recommendation, moderate certainty of evidence]
Clinician’s Summary: The role of an increased level of FeNO in the diagnosis of asthma is still evolving, and no definitive test exists for diagnosing
asthma. FeNO measurement may support a diagnosis of asthma in individuals for whom the diagnosis is uncertain even after a complete history, physical
examination, and spirometry testing including bronchodilator responsiveness. Recognition of allergen sensitivity is extremely important for interpreting FeNO
levels. Allergic rhinitis and atopy, which can be present in individuals with and those without asthma, are associated with increased FeNO levels, and taking
these factors into consideration is critical for accurately interpreting FeNO test results.
Recommendation 2
In individuals 5 years of age and older with persistent allergic asthma, for whom there is uncertainty in choosing, monitoring, or adjusting anti-inflammatory
therapies based on history, clinical findings, and spirometry, the Expert Panel conditionally recommends the addition of FeNO measurement as part of an
ongoing asthma monitoring and management strategy that includes frequent assessments. [Conditional recommendation, low certainty of evidence]
Clinician’s Summary: This recommendation is specific to using FeNO levels when selecting therapy for individuals with asthma and when monitoring the
response to and adjusting the dosage of anti-inflammatory therapies. This recommendation does not apply to individuals taking biologic agents, with the
exception of omalizumab, because the systematic review literature searches conducted until October 2018 did not include data on biologic agents other than
omalizumab. Clinicians must interpret FeNO levels in conjunction with other clinical data because these levels are affected by comorbid conditions, including
allergic rhinitis and atopy. The weight of the evidence suggests that when used as part of an asthma management strategy, FeNO monitoring is effective in
preventing exacerbations only when used frequently (such as every 2–3 months), but even frequent monitoring does not improve asthma control or quality
of life in individuals with asthma.
How to Use FeNO
While FeNO testing may be helpful in determining whether an individual has asthma, it cannot be used to diagnose asthma. FeNO measurements should
be performed by appropriately trained personnel who have extensive experience in interpreting the result or who consult experienced clinicians who can
interpret the findings accurately.
FeNO levels <25 ppb (or <20 ppb in children The Expert Panel offers the following suggestions Clinicians should inform individuals with
5–12 years of age) are inconsistent with T2 on how to use FeNO testing to monitor asthma: asthma who have conditions or behaviors
inflammation and suggest a diagnosis other Individuals for whom FeNO testing may be (such as smoking) that could affect the
than asthma (or that the individual has asthma useful to monitor asthma include: interpretation of the FeNO test results that
but their T2 inflammation has been managed these issues could limit the accuracy of
with corticosteroids or they have non-T2 • Individuals 5 years of age and older with diagnostic attempts.
inflammation or noneosinophilic asthma). uncontrolled persistent asthma who are
currently taking an ICS or an ICS with a FeNO test results cannot be used in isolation.
FeNO levels >50 ppb (or >35 ppb in children 5– long-acting beta2-agonist, montelukast, Their interpretation must take into account
12 years of age) are consistent with increased T2 other clinical factors and traditional measures.
or omalizumab.
inflammation and support a diagnosis of asthma. The evidence favors the use of FeNO mea-
Individuals who have T2 inflammation are more • Individuals whose symptoms indicate they
surement as an adjunct to other diagnostic
likely to respond to corticosteroid treatment. might require additional anti-inflammatory
methods (including a structured history,
therapy.
FeNO levels of 25–50 ppb (or 20–35 ppb in clinical findings, and pulmonary function
children 5–12 years of age) provide little infor- • Individuals with atopy—especially children. testing) when the results from these other
mation on the diagnosis of asthma and should • Individuals with asthma being treated by measures are not conclusive.
be interpreted with caution and attention to the providers who agree that frequent (every
clinical context. 2–3 months) assessments of asthma control
Inhaled corticosteroid treatment should not be over the course of a year are warranted.
withheld solely based on low FeNO levels.
FeNO, fractional exhaled nitric oxide; ICS, inhaled corticosteroid.

The FeNO recommendations and Expert Panel suggestions are from U.S. Department of Health and Human Services, National Institutes of Health (NIH), and National Heart, Lung,
and Blood Institute (NHLBI). 2020 Focused Updates to the Asthma Management Guidelines: A Report From the National Asthma Education and Prevention Program Coordinating
Committee Expert Panel Working Group. 2020. Accessed February 2, 2022. https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-
asthma-management-guidelines.
17 Tab 9. FeNO: NIH/NHLBI Recommendations

number
Tab 10. GINA Stepped Approaches
18 to Treatment
Tab 10
GINA Stepped Approaches to Treatment
The Global Initiative for Asthma (GINA) report is an approach to the management of asthma, rather than a guideline.
The GINA strategy involves the use of control-based asthma management, which is a continual cycle of assessing,
adjusting treatment, and reviewing the response. There are 4 steps in children younger than 6 years and 5 steps in
children 6 years and older.
GINA 4-Step Approach to Treatment in Children Younger Than 6 Years

Step 1: If symptoms are triggered by viral infections Use a SABA as needed.
or there are few or no interval symptoms Use of ICS may be considered, in addition to SABA.
Step 2: If symptoms are consistent with asthma, The preferred treatment is daily low-dose ICS.
symptoms are not well controlled, and/or there are Daily LTRA or intermittent low-dose ICS is an option.
≥3 exacerbations per year
A SABA may be used as needed.
Step 3: If symptoms are consistent with asthma Reevaluate adherence to treatment, medication and spacer skills, diagnosis, exposures,
and not well controlled with low-dose ICS and comorbidities.
Double the low dose of ICS.
Adding LTRA to low-dose ICS is an option.
Adding LABA to low-dose ICS is an option for children ≥4 years of age.
Adding SABA to low-dose ICS is an option for children <4 years of age.
Step 4: If symptoms are consistent with asthma Reevaluate adherence to treatment, medication and spacer skills, diagnosis, exposures,
and not well controlled with a double dose of ICS and comorbidities.
Refer the patient to an asthma specialist.
Add LTRA and increase ICS frequency or add intermittent ICS.
Additional Notes
Asthma control is achieved with environmental control measures and pharmacological therapy.
After step-up therapy achieves excellent symptom control, slowly step the therapy down to maintain control.
Initial accurate diagnosis, followed by continued monitoring at follow-up visits, is essential.
The following are vital to the successful management of asthma:
• Reviewing the treatment plan and correct use of medication and devices
• Maintaining a partnership with the patient and parents regarding the goals of management
• Adhering to the treatment plan
• Formulating written asthma action plans
Once an accurate diagnosis of asthma is established,
• Schedule routine, periodic follow-up visits.
• Reevaluate the patient at every visit to ascertain whether asthma control is being achieved.
• Review environmental control measures to reduce patient exposure to allergens and pollutants, both indoors and outdoors.
• Encourage and devise strategies at every visit to facilitate adherence to the treatment plan.
• At every visit, review the proper use of metered-dose inhalers with a spacer, dry-powder inhalers, and nebulizers.
• Listen to the parents and the patient and include them in the management plan.
GINA, Global Initiative for Asthma; ICS, inhaled corticosteroid; LABA, long-acting β2 -adrenergic receptor agonist; LTRA, leukotriene receptor antagonist;
SABA, short-acting β2 -adrenergic receptor agonist.
Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of
Pediatrics. 2018; and Global Initiative for Asthma. 2021 GINA Report, Global Strategy for Asthma Management and Prevention. 2021:158–160. Accessed January 11, 2022.
https://ginasthma.org/gina-reports/.

Tab 10
GINA Stepped Approaches to Treatment
GINA 5-Step Approach to Treatment in Children 6 Years and Older

Step 1: Use of a SABA as needed Infrequent symptoms (eg, <2 times per month) and no risk factors for exacerbations.
(6–11 years) or low-dose ICS- In patients 6–11 years, low-dose ICS may be added.
formoterol as needed (12+ years)
Step 2: Regular low-dose ICS with A daily LTRA is a less effective alternative to ICS.
SABA as needed
Step 3: Regular low-dose Other options are the following:
ICS-LABA maintenance plus • Medium-dose ICS
SABA as needed
• Very low-dose ICS-formoterol MART
• ICS-formoterol, used as a preventive and reliever medication if the patient is 12+ years of age
Step 4: Medium- or high-dose An option is to use high-dose ICS and LTRA.

ICS-LABA as maintenance plus If asthma is not well controlled with medium-dose ICS, refer children <12 years of age to an asthma specialist.
SABA as needed
In children >12 years of age, an option is to use medium-dose ICS-formoterol as maintenance and reliever.
If the patient is 6+ years of age, may add tiotropium.
Step 5: Refer the patient to an Additional treatment with tiotropium in patients 6+ years of age.
asthma specialist for expert Additional treatment with omalizumab for patients 6+ years of age with uncontrolled moderate or severe
assessment, phenotyping, allergic asthma.
and add-on therapy
Additional treatment with mepolizumab for patients 6+ years of age with severe uncontrolled eosinophilic asthma.
May consider low-dose systemic corticosteroids, but these will likely cause systemic side effects.
Review and adjust At follow-up visits, adjustments depend on the patient’s level of asthma control, response to prior treatment,
risk factors and occurrence of exacerbations, and capability and motivation to follow the action plan.
Consider adjustments initially 1–3 months after starting treatment, then every 3–12 months afterward.
Consider adjustments within 1 week after an exacerbation.
Stepping treatment up Sustained step-up (2–3 months) should be used for difficult-to-control symptoms or a breakthrough exacerbation.
• Review the technique used with the medication and spacer.
• Review the treatment administration for poor adherence.
• Review the treatment plan for modifiable risk factors like environmental tobacco smoke.
• Evaluate the patient for comorbidities.
Short-term step-up (1–2 weeks) should be used with concomitant viral infection or allergen exposure.
Make day-to-day adjustments if needed.
Stepping treatment down Consider stepping treatment down when good asthma control is achieved for 3 months.
Use a minimal treatment dose to achieve control of symptoms and exacerbations and minimize side effects.
Additional Notes
The severity of asthma is assessed retrospectively, from the level of management required to control symptoms.
The severity is classified as mild, moderate, or severe.
Determine if the asthma is well controlled, partly controlled, or uncontrolled.
Identify and reduce exposure to risk factors, which include indoor and outdoor allergens, indoor pollutants, viral infections, and drugs.
GINA, Global Initiative for Asthma; ICS, inhaled corticosteroid; LABA, long-acting β2 -adrenergic receptor agonist; LTRA, leukotriene receptor antagonist;
MART, maintenance and reliever therapy; SABA, short-acting β2 -adrenergic receptor agonist.
Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of
Pediatrics. 2018; and Global Initiative for Asthma. 2021 GINA Report, Global Strategy for Asthma Management and Prevention. 2021:56–72. Accessed January 11, 2022.
https://ginasthma.org/gina-reports/.
19 Tab 10. GINA Stepped Approaches

to Treatment

number
20 Tab 11. Maintenance and Control
Tab 11
Maintenance and Control
Maintenance Medications for Asthma: Overview

Medication Formulation Medication Formulation
Type (brand name in italics) When to Use Type (brand name in italics) When to Use
ICSs MDIs: First-line medication for Biologics Anti-IgE: Omalizumab is used
Fluticasone propionate persistent symptoms; Omalizumab (Xolair) for poorly controlled
(Flovent 44, 110, 220) use the MDI devices asthma that is related
Anti–IL-5:
Mometasone furoate with a VHC and mask to allergen-specific
Mepolizumab (Nucala)
(Asmanex 50, 100, 200) for infants and toddlers. IgE-mediated symptoms.
Many can use a VHC Reslizumab (Cinqair)
Ciclesonide Other biologics are used
without a mask by the age Benralizumab (Fasenra) for poorly controlled
(Alvesco 80, 160)
of 4 years; the Redihaler Anti–IL-4/IL-13: asthma with an
Redihaler: and DPI formulations can Dupilumab (Dupixent) eosinophilic phenotype.
Beclomethasone dipropionate be used effectively in most Dupilumab is effective in
(Qvar 40, 80) by the age of 6 years. recalcitrant eczema
DPIs: along with asthma.
Budesonide See Tab 18.
(Pulmicort Flexhaler 90, 180) Mepolizumab is FDA
Fluticasone furoate approved for ages
(Arnuity Ellipta 50, 100, 200) 6 and older.
Fluticasone propionate Additional Notes
(Flovent Diskus 50, 100, 250)
Managing asthma
Mometasone
Intervention measures for relief of acute symptoms are albuterol and
(Asmanex Twisthaler 110, 220)
oral corticosteroids.
LTRAs Montelukast (Singulair) 4-mg An alternative to an ICS for Children identified as having persistent asthma should be prescribed
sprinkle, 4- and 5-mg chewable, mild persistent symptoms; daily controller medications. The types of controller medications are
or 10-mg tablets modest additional benefit ICSs, LABAs, ICS-LABA combinations, leukotriene modifiers, mast
as add-on to ICSs. Black cell stabilizers (cromolyn and nedocromil), omalizumab, and low-dose
box warning regarding corticosteroid therapy.
mood disorders. Maintenance medications for those with chronic or extended seasonal
Combination MDIs: Use when a starting dose symptoms include ICSs, ICSs with long-acting bronchodilators, leukotriene
ICSs-LABAs Budesonide-formoterol of ICS does not maintain modifiers, immunotherapy, and anti-IgE.
(Symbicort 80/4.5, 160/4.5) control; the occasional Monitoring the clinical course of asthma
Fluticasone-salmeterol patient whose condition The patient’s awareness of symptoms is essential to early intervention to
(Advair 45/21, 115/21, 230/21) worsens from the addition prevent progression of exacerbations.
of LABA is essential.
Mometasone-formoterol Scheduled follow-up appointments for assessment and education are
Recent guidelines
(Dulera 50/5, 100/5, 200/5) required to evaluate adequacy of treatment and assess adherence to the
suggest the use of
DPIs: additional dosing of treatment plan.
Fluticasone-vilanterol ICS-formoterol Evaluating and managing difficult asthma
(Breo Ellipta 100/25, 200/25) preparations as a Distinguishing between poor adherence and incorrect diagnosis may
Fluticasone-salmeterol rescue strategy in require observation of the patient’s inhaler use technique, family education,
(Advair Diskus 100/50, patients already taking or even temporary hospitalization.
250/50, 500/50; them as maintenance
DPI, dry-powder inhaler; FDA, Food and Drug Administration; ICS, inhaled corticosteroid;
AirDuo Respiclick 55/14, medications. IgE, immunoglobulin E; IL, interleukin; LABA, long-acting β2 -adrenergic receptor agonist;
113/14, 232/14; LTRA, leukotriene receptor antagonist; MDI, metered-dose inhaler; VHC, valved holding
Wixela Inhub 100/50, chamber.
250/50, 500/50) From AAP Section on Pediatric Pulmonology. Pediatric Pulmonology. 2nd ed. American
Academy of Pediatrics; 2023.
Long-acting Tiotropium (Spiriva Respimat, Third-line drug after
muscarinic Spiriva Handihaler) step-up to ICS-LABA.
antagonists Tiotropium is FDA
approved for ages
6 and older.

Tab 11
Maintenance and Control
Asthma Management Strategies Difficult-to-Manage Disease

and Control Criteria How to Approach
Asthma Management Strategies Five issues should be assessed when dealing with a child whose asthma
Set individualized goals of does not respond to reasonable therapy.
asthma management. Is it asthma? Anatomical lesions or other medical conditions should be
ruled out.
Provide effective education. Basic facts about asthma
Is the child adherent to the medication regimen, and is their technique
Differences between normal and
for the medication delivery appropriate?
asthmatic airway, preferably by
using models Did the child run out of medication and not realize it or say so?
Links between airway inflammation, Is a continual exposure present, environmental or otherwise, that is
hyperreactivity, and bronchoconstriction causing problems for the child?
Long-term controller and quick-reliever A referral or a second opinion from a specialist should be considered if
medications (preferably by using the desired effect is not being achieved.
patient’s inhalers or color pictures) When to Refer
Teach, demonstrate, and have Inhaled medication use A child <12 years of age requires step 4 care or higher, or a child 6+ years
patient show proper technique (spacer use with MDI) of age requires step 5 care.
for… Peak flow meter (optional) A child has life-threatening asthma exacerbation or intensive care admission.
Tailor therapy to severity Goals of therapy are not met after 3–6 months of treatment.
and patient preference. Diagnosis or management is complicated by comorbid conditions
Proactively seek out and address (eg, sinusitis, nasal polyps, severe rhinitis, uncontrolled gastroesophageal
concerns about potential adverse reflux, and vocal cord dysfunction).
effects of medications. Additional diagnostic tests are needed (eg, allergy skin testing,
bronchoscopy).
Explore and manage asthma Environmental exposures
triggers. Allergen immunotherapy is a consideration.
Comorbid conditions
The asthma is difficult to control.
Provide asthma action plan. Involve patient and family. Occupational triggers are suspected.
Also provide asthma plan for school. Psychological or psychiatric issues are suspected.
Criteria for Control of Asthma When to Admit
Absence of hospitalization Moderate to severe illness on arrival and no response to β2 -adrenergic
Absence of urgent care requirements receptor agonist rescue therapy
Absence of interference with sleep Continued symptoms despite treatment
Absence of interference with activity Significant wheezing and retracting (ie, hunched posture, chest and neck
Infrequent use of inhaled β2 -adrenergic receptor agonists for pulling in); trouble speaking; gray or blue lips or fingernails
acute symptoms Altered mental status, such as drowsiness or agitation
Infrequent use of oral corticosteroids Peak flows <50% of personal best
Normal or near-normal pulmonary function by spirometry Requiring β2 -adrenergic receptor agonists every 2–3 hours
MDI, metered-dose inhaler. Continued need for supplemental oxygen despite initial therapy
From Dinakar C. Asthma. Pediatric Care Online. Accessed January 11, 2022. Additional Factors That May Influence the Hospitalization Decision
https://publications.aap.org/pediatriccare/book/348/chapter/5776728/Asthma;
and AAP Section on Pediatric Pulmonology. Pediatric Pulmonology. 2nd ed. Use of β2 -adrenergic receptor agonists/glucocorticoids before emergency
American Academy of Pediatrics; 2023. department visit
History of poor adherence to the medical regimen
Caregiver inability to provide careful medical care and supervision at home
Inadequate access to medical care
History of rapid progression of severity in past exacerbations
Adapted from Dinakar C. Asthma. Pediatric Care Online. Accessed January 11, 2022.
https://publications.aap.org/pediatriccare/book/348/chapter/5776728/Asthma.
21 Tab 11. Maintenance and Control

number
22 Tab 12. SABAs
Tab 12
SABAs
Inhaled SABA Bronchodilator Dosing Chart for Severe Acute Exacerbations

Medication Dosage Administration
and Delivery
Method Dose <5 Years of Age 5–11 Years of Age ≥12 Years of Age
Albuterol 0.63 mg/3 mL saline Home: 1.25–2.5 mg up to every 20 min with Home: 1.25–2.5 mg up to every 20 min for Home: 2.5–5 mg up to every
nebulizer 1.25 mg/3 mL saline face mask for ≤3 doses, then every 2–4 h ≤3 doses, then every 2–4 h as needed 20 min for ≤3 doses, then every
as needed ED: 0.15 mg/kg (minimum, 2.5 mg) every 2–4 h as needed
2.5 mg/3 mL saline
ED: 0.15 mg/kg (minimum, 2.5 mg) every 20 min for 3 doses, then 0.15–0.3 mg/kg ED: 2.5–5 mg every 20 min for
5.0 mg/mL saline
20 min for 3 doses, then 0.15–0.3 mg/kg up to up to 10 mg every 1–4 h as needed or 3 doses, then 2.5–10 mg every
(0.5% diluted with
10 mg every 1–4 h as needed or 0.5 mg/kg/h 0.5 mg/kg/h via continuous nebulization 1–4 h as needed or 10–15 mg/h
2–3 mL of normal
via continuous nebulization Hospital: 0.15–0.3 mg/kg up to 10 mg via continuous nebulization
[physiological]
saline solution) Hospital: 0.15–0.3 mg/kg up to 10 mg every every 1–4 h as needed or 0.5 mg/kg/h Hospital: 2.5–10 mg every
1–4 h as needed or 0.5 mg/kg/h via via continuous nebulization 1–4 h as needed or 10–15 mg/h
continuous nebulization via continuous nebulization
Bronchiolitis: 0.15 mg/kg up to 5 mg every
30 min for 3 doses, then every 2 h if patient
responds
Levalbuterol 45 mg per puff, See albuterol MDI doses in the See albuterol MDI doses in the See albuterol MDI doses in the
MDI 200 puffs per canister next table. next table. next table.
Levalbuterol 0.31 mg/3 mL Home: 0.63–1.25 mg up to every 20 min via Home: 0.63–1.25 mg up to every 20 min Home: 1.25–2.5 mg up to every
nebulizer saline face mask for ≤3 doses, then every 2–4 h for ≤3 doses, then every 2–4 h as needed 20 min for ≤3 doses, then every
0.63 mg/3 mL as needed ED: 0.075 mg/kg (minimum, 1.25 mg) 2–4 h as needed
saline ED: 0.075 mg/kg (minimum, 1.25 mg) every every 20 min for 3 doses, then 0.075– ED: 1.25–2.5 mg every 20 min for
1.25 mg/0.5 mL 20 min for 3 doses, then 0.075–0.15 mg/kg; 0.15 mg/kg up to 5 mg every 1–4 h as 3 doses, then 1.25–5 mg every
saline up to 5 mg every 1–4 h as needed or needed or 0.25 mg/kg/h via continuous 1–4 h as needed or 5–7.5 mg/h
0.25 mg/kg/h via continuous nebulization nebulization via continuous nebulization
1.25 mg/3 mL
saline Hospital: 0.075–0.15 mg/kg up to 5 mg every Hospital: 0.075–0.15 mg/kg up to 5 mg Hospital: 1.25–5 mg every
1–4 h as needed or 0.25 mg/kg/h via every 1–4 h as needed or 0.25 mg/kg/h 1–4 h as needed or 5–7.5 mg/h
continuous nebulization via continuous nebulization via continuous nebulization
Injectable 1 mg/mL saline ED: 0.01 mg/kg up to 0.3–0.5 mg ED: 0.01 mg/kg up to 0.3–0.5 mg ED: 0.25 mg subcutaneously
terbutaline subcutaneously every 20 min for 3 doses, subcutaneously every 20 min for 3 doses, every 20 min for 3 doses
then every 2–6 h as needed then every 2–6 h as needed
IV ED, PICU: 0.01 mg/kg IV over 1–2 min; ED, PICU: 0.01 mg/kg IV over
terbutaline continuous infusion starting at 1–2 min; continuous infusion
0.001 mg/kg/min, titrated to effect starting at 0.001 mg/kg/min,
and heart rate titrated to effect and heart rate
Additional Notes
SABAs are the most widely used quick-relief medications because of their rapid onset of action (within minutes) and effectiveness in reversing bronchospasm.
They promote smooth muscle relaxation, decrease vascular permeability, and enhance mucociliary clearance.
SABAs are rapid-acting bronchodilators, administered as a “rescue” medication for respiratory exacerbations that involve symptoms of cough, wheezing, dyspnea,
and shortness of breath.
The differences in response to bronchodilators between infants, children, and adults are not likely caused by differences in pharmacological response but rather
caused by other issues related to mechanism of airway obstruction, device delivery, or other patient-specific factors.
SABAs are meant to be used on an as-needed basis to relieve symptoms and not as long-term therapy.
Available SABAs include albuterol, levalbuterol, and terbutaline.
• Albuterol is available as an oral inhalation (most common in pediatrics), an injection, and a tablet.
• Levalbuterol is available only as an oral inhalation. It is mainly reserved for patients with heart disease or those who have adverse effects of tachycardia with the
administration of albuterol.
• Terbutaline is available only as an injection solution or a tablet, not as an inhalation.
ED, emergency department; IV, intravenous(ly); MDI, metered-dose inhaler; PICU, pediatric intensive care unit; SABA, short-acting β2 -adrenergic receptor agonist. All doses are for asthma,
unless otherwise indicated.
From AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; 2018.
Derived from National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma.
U.S. Department of Health and Human Services; 2007.

Tab 12
SABAs
Routine Outpatient Use of Inhaled SABAs: Dosages According to Age

Medication Dosage Administration
and Delivery
Method Dose <5 Years of Age 5–11 Years of Age ≥12 Years of Age
Albuterol
MDI 90 μg per puff, 60 or 2 puffs with VHC and mask every 2 puffs as needed every 4–6 h 2 puffs as needed every 4–6 h
200 puffs per canister 4–6 h as needed for symptoms and for symptoms and 5 min before for symptoms and 5 min before
5 min before exercise exercise exercise
Nebulizer 0.63 mg/3 mL saline 0.63–2.5 mg in 3 mL saline every 1.25–5.0 mg in 3 mL saline every 1.25–5.0 mg in 3 mL saline every
1.25 mg/3 mL saline 4–6 h as needed 4–8 h as needed 4–8 h as needed
2.5 mg/3 mL saline 0.1–0.2 mg/kg in 1–2 mL saline every
5.0 mg/mL saline (0.5%) 4–6 h for bronchopulmonary dysplasia
Levalbuterol
MDI 45 μg per puff, 200 puffs 2 puffs with VHC and mask every 2 puffs as needed every 4–6 h 2 puffs as needed every 4–6 h
per canister 4–6 h as needed for symptoms and for symptoms and 5 min before for symptoms and 5 min before
5 min before exercise exercise exercise
Nebulizer 0.31 mg/3 mL saline 0.31–1.25 mg in 3 mL saline every 0.31–0.63 mg every 8 h as needed 0.63–1.25 mg every 8 h as needed
0.63 mg/3 mL saline 4–8 h as needed
1.25 mg/0.5 mL saline
1.25 mg/3 mL saline
MDI, metered-dose inhaler; SABA, short-acting β2 -adrenergic receptor agonist; VHC, valved holding chamber.
From AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; 2018:261.
SABA Approvals for Use Additional Notes About Using SABAs

FDA-approved indications for asthma and bronchospasm follow. SABAs are the “rescue” inhaler medications used to relieve asthma symptoms. All patients
• ≥2 years of age: Nebulized inhalation solutions with asthma should be given a written asthma action plan in which details of when to
administer SABAs are properly outlined.
• ≥4 years of age: HFA MDIs
Proper instruction, including teach-back methods and demonstrations, is necessary to
• ≥6 years of age: Oral tablets
ensure proper adherence to treatment and use of the various SABA devices.
Non–FDA-approved indications for asthma and bronchospasm
Review of proper device use and indication at least yearly may be warranted.
follow.
Children and their families should receive education on the proper use and therapeutic
• Nebulized albuterol solution is commonly used in young
function of all their inhalers (controllers and rescue).
infants who present with onset of first-time wheeze and
have a history suggestive of asthma. Have patients bring asthma inhalers to outpatient visits to review the use of rescue and
controller medications. Alternatively, reviewing pharmacy dispensation records of albuterol
• MDIs with a holding chamber and face mask must be used in
inhalers can reveal possible overuse and/or lack of control of asthma symptoms.
children <4 years of age because of ease of use and a faster
response. (Valved holding chambers will increase penetration The Asthma Control Test (see Tab 21), Childhood Asthma Control Test (see Tab 21),
and effectiveness of MDI-administered medication in patients Asthma Control Questionnaire, and Asthma Therapy Assessment Questionnaire are
at any age.) validated assessment tools that can be easily implemented during an encounter to
assess current symptom control.
• Using appropriate demonstration and teach-back techniques
with patients, parents, and/or guardians can ensure Albuterol inhaler formulations are most typically covered by insurance at the lowest
appropriate use of medications. co-payment level, although some plans may prefer levalbuterol.
Terbutaline is FDA approved for children >12 years of age. Daily administration of SABAs as a preventive approach is not indicated for persistent
Typical usage of terbutaline is in the intensive care unit and asthma symptoms.
ED settings when inhaled bronchodilators are not tolerated or If a patient is using a SABA >2 days per week, except in prevention of exercise-induced
ineffective—most commonly for severe status asthmaticus. bronchoconstriction, then step-up therapy per National Heart, Lung, and Blood Institute
asthma guidelines should be considered.
ED, emergency department; FDA, Food and Drug Administration; HFA, hydrofluoroalkane;
MDI, metered-dose inhaler; SABA, short-acting β2 -adrenergic receptor agonist.
Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma,
and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; 2018:260,265.
23 Tab 12. SABAs

number
24 Tab 13. Inhaled Corticosteroids
Tab 13
Inhaled Corticosteroids
Low, Medium, and High Daily Doses of ICS Products

Steroid or Medication Type Product Strengths Age, y Low Daily Dose, μg Medium Daily Dose, μg High Daily Dose, μg Typical Dosing
Beclomethasone HFA 40 mg 5–11 80–160 >160–320 >320 Twice daily
80 mg ≥12 80–240 >240–480 >480 Twice daily
Budesonide DPI 90 mg 5–11 180–400 >400–800 >800 Twice daily
180 mg ≥12 180–600 >600–1,200 >1,200 Twice daily
Budesonide HFA 160/4.5 mga,b 5–11 NDc NDc NDc ND
80/4.5 mga,b ≥12 NDc ND c
ND c
Twice daily
c c
Ciclesonide HFA 80 mg b
6–11 ND c
ND ND ND
160 mgb ≥12 80–160 >160–320 >320 Twice daily
Flunisolide HFA 80 mg 5–11 160 320 ≥640 Twice daily
≥12 320 >320–640 >640 Twice daily
c c
Fluticasone furoate DPI 100 mg b
6–11 ND c
ND ND ND
200 mgb
≥12 100 ND 200 Once daily
100/25 mgd,e
200/25 mgd,e
Fluticasone propionate DPI 100/50 mgf 5–11 100–200 >200–400 >400 Twice daily
250/50 mgf
500/50 mgc,f ≥12 100–300 >300–500 >500 Twice daily
50 mg
100 mg
250 mg
Fluticasone propionate HFA 115/21 mgf 5–11 88–176 >176–352 >352 Twice daily
230/21 mgf
45/21 mgf ≥12 88–264 >264–440 >440 Twice daily
110 mg
220 mg
44 mg
Mometasone DPI 110 mg 6–11 110–220 220–440 >440 Once or twice daily
220 mg ≥12 110 ≥220–440 ≥440 Once daily
Mometasone HFA 100 mg b
6–11 100–200 >200–400 >400 ND
200 mgb ≥12 100–200 >200–400 >400 Twice daily
100 mga,b
200 mga,b
DPI, dry-powder inhaler; HFA, hydrofluoroalkane; ICS, inhaled corticosteroids; LABA, long-acting β2 -adrenergic agonist; ND, no data. Some of these products are a combination of
ICS and LABAs. The steroid referenced in addition to the LABA is indicated by the footnotes.
a
Product contains formoterol.
b
Product not approved for patients <12 years of age.
c
Product contains salmeterol.
d
Product contains vilanterol.
e
Product not approved for patients <18 years of age.
f
No guideline recommendations for ICS dosage form or specified age group.
Reprinted with permission from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds.
American Academy of Pediatrics; 2018:272–273.

Tab 13
Inhaled Corticosteroids
ICS Usage DPI, dry-powder inhaler; FDA,

Food and Drug Administration;
ICS, inhaled corticosteroid;
ICSs are recommended as the first-line treatment for most types of persistent asthma. They block late-phase reaction to allergens, MDI, metered-dose inhaler.
reduce airway hyperresponsiveness, and are the most potent and effective anti-inflammatory medications currently available. They
lessen asthma symptoms, improve pulmonary function, reduce the need for quick-relief medications, and halve the amount of
urgent care visits, systemic corticosteroid use, and hospitalizations for acute asthma exacerbations. There are different formulations
of ICSs approved by the FDA for use in children, available in different preparations—as an MDI, a DPI, or a nebulizer solution.
Potential Adverse Effects of ICSs and Prevention Strategies

Adverse Effect Description Adverse Effect Description
Systemic Potentially Adverse Effects Local Potentially Adverse Effectsa (continued)
Adrenal Chronic administration of ICSs may reduce cortisol secretion Perioral An erythematous, eczematoid eruption that occurs around
suppression from the adrenal gland via negative feedback inhibition of dermatitis the mouth, nostrils, or eyes has been described with ICS use,
the HPA axis. The degree of HPA suppression depends on most notably with budesonide. Perioral dermatitis is thought
the dose, duration, and frequency of ICS administration. to be caused by a direct local effect of ICSs on facial skin and
Symptoms include cushingoid features, anorexia, weight occurs infrequently in children. Wash the face after the use
loss, fatigue, growth failure, and hypoglycemia. of ICSs to avoid this adverse effect. Topical erythromycin or
metronidazole should be considered in severe cases.
Linear growth ICS therapy may be associated with an adverse effect on linear
deceleration growth in children. This adverse effect is dose dependent, Tongue A seldom-reported adverse effect thought to be caused by
occurs in the first several months of therapy, and is generally hypertrophy ICS-induced hypertrophy and local fat accumulation. This
small and not progressive. This phenomenon may be confounded phenomenon has been described in infants treated with
by the observation that poorly controlled asthma may also delay nebulized beclometasone dipropionate and in asthmatic
linear growth. The minor growth risks are considered to be children treated with nebulized budesonide. Tongue
outweighed by the respiratory benefits. hypertrophy resolves after cessation of ICS treatment.
Reduction in ICSs have mild effects on bone mineral density that typically Thirst Occurring in >20% of children using ICSs, a thirsty feeling
bone mineral do not reach clinical significance. Children at highest risk are sensation after delivery of the drug may be caused by throat irritation
density those with chronic disease, malnutrition, or use of long-term or as a manifestation of oral thrush. Combination treatment
medications that reduce bone mineral density. with a LABA may increase risk.
Local Potentially Adverse Effectsa Strategies to Minimize the Risks of Adverse Effects
Dysphonia Has been reported in 5%–50% of patients using ICSs. Although Recommend the routine use and cleaning of VHCs with all MDIs, especially
(hoarseness) the origin of dysphonia is unclear, it has been suggested that in children. For younger children who are unable to deeply inhale voluntarily,
pharyngeal deposition of steroid particles may induce myopathy spacers with face masks are available.
of vocal cord muscles, subsequently triggering bowing of the Advise patients to have the child “rinse and spit” and wash their face after
vocal folds on phonation. The risk of dysphonia may be dose administration of inhaled medications.
dependent, and symptoms can be reversed after discontinuation
Use the lowest effective dose of ICSs that maintains asthma control to reduce
of therapy.
unnecessary steroid excess.
Oropharyngeal May result from local deposition of ICS particles on the mucosal • There are few long-term head-to-head comparison studies with sufficient
candidiasis surface of the oropharyngeal cavity. Thrush is thought to be the sample sizes to determine whether growth effects might be less with
(thrush) consequence of local immunosuppression or increased levels different brands overall or whether an individual child might have
of salivary glucose, which may stimulate growth of Candida improved growth if switched from one formulation to another.
albicans. Symptoms of thrush tend to be mild, and the primary
DPI, dry-powder inhaler; HPA, hypothalamic-pituitary-adrenal; ICS, inhaled corticosteroid;
clinical manifestation is local discomfort (eg, altered taste
LABA, long-acting β2 -adrenergic receptor agonist; MDI, metered-dose inhaler;
sensation, sore throat); however, the risk of fungemia increases VHC, valved holding chamber.
in immunocompromised populations or if left untreated. Thrush a
Although not generally as serious as systemic adverse effects, local adverse effects have the
can occur in ≤70% of patients using ICSs, and risk increases at ability to affect patient quality of life and adherence to treatment and may mask symptoms
higher doses, with more frequent dosing, or with concomitant of more serious disease. The incidences of local adverse effects are highly variable and are
oral glucocorticoids and/or antibiotics. dependent on the type and/or dose of ICS used, the mode of delivery (MDI vs DPI), the use
of VHC devices, and inhaler technique.
Cough Can occur in >30% of children treated with ICSs, although cough
may be difficult to differentiate from poor asthma control. It has From AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology,
Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics;
been proposed that coughing may be caused by the exposure
2018:274,275.
to excipient ingredients (specifically oleic acid) and nonspecific
irritating properties of ICSs. DPIs typically have a lesser incidence
of coughing owing to a larger proportion of fine particles.
25 Tab 13. Inhaled Corticosteroids

number
26 Tab 14. LABAs and LTRAs
Tab 14
LABAs and LTRAs
LABAs
Drug Available Dosages Formulation Additional Notes
Fluticasone 100/50 mcg DPI LABAs are controller medications that are used to prevent symptoms of
or salmeterol 250/50 mcg asthma from becoming severe.
500/50 mcg These agents work by stimulating β2 -adrenergic receptor agonists in the
lungs to open the airways.
Fluticasone 45/21 mcg MDI
LABAs are not a first-line medication for treatment of asthma and are not
or salmeterol 115/21 mcg used for quick relief of asthma symptoms. LABAs are ineffective for acute
230/21 mcg symptoms of asthma.
Budesonide 80/4.5 mcg MDI The use of LABAs is never indicated as monotherapy; LABAs should always
or formoterol be used in combination with ICS therapy.
160/4.5 mcg
Two agents, salmeterol and formoterol, are approved by the FDA for use in
Mometasone/ 100/5 mcg MDI children ≥12 years of age.
formoterol 200/5 mcg Children <12 years of age may be prescribed LABAs by their provider on
the basis of recommendations by the National Asthma Education and
DPI, dry-powder inhaler; LABA, long-acting β2 -adrenergic receptor agonist;
MDI, metered-dose inhaler.
Prevention Program.
From AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, LABAs should be used adjunctively for maintenance control of asthma.
Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; LABAs are indicated for persistent asthma as a step-up therapy when
2018:267. patients are unable to control symptoms with ICSs alone.
LABAs are indicated for use in combination with an ICS (ie, fluticasone,
budesonide, mometasone) for long-term control and prevention of
LABA Use symptoms in patients with moderate to severe persistent asthma.
LABAs, such as salmeterol and formoterol, are not intended as treatment LABAs are not used as monotherapy because they have been shown to
of acute exacerbations or as monotherapy for persistent asthma. These increase the risk of asthma-related deaths and they carry an FDA black
medications act by relaxing bronchial smooth muscle, improving symptoms, box warning.
and reducing the need for quick-relief medication. Formoterol has a quick onset LABAs are indicated in step 3 care and higher in children ≥5 years old
of action, like that of SABA, whereas salmeterol has a longer onset of action. with poorly controlled asthma who are already taking a low to medium
Fixed-dose combination therapy for ICS-LABA (ie, fluticasone-salmeterol, dose of ICSs.
budesonide-formoterol, mometasone-formoterol) is available and is recommended
over using separate inhalers. Their major indication is as an add-on agent when The dose should not exceed 100 mg/d for salmeterol or 24 mg/d
asthma is uncontrolled by ICS therapy alone. In those children, the ICS-LABA for formoterol.
combination therapy has been shown to be synergistic and superior to increasing LABAs can be prescribed in several preparations, including an MDI and a DPI.
ICS dose, in both effectiveness and minimization of steroid-induced adverse The most commonly used preparation for young children is an MDI. For an
effects. Notably, the FDA requires all LABA-containing medications to carry a MDI, be sure to instruct the patient and caregiver on the proper use and
black box warning regarding potential for worsening asthma while on therapy. maintenance of a holding chamber, also known as a spacer.
The FDA also specifies that LABAs should be discontinued when asthma control DPIs have the advantage of not requiring a holding chamber; however, the
is achieved, and asthma should be maintained with controllers such as ICSs. child must be able to develop sufficient inspiratory flow to activate a DPI
to deliver sufficient medication. For a DPI, be sure to instruct the patient
to rinse and spit with water each time after inhaling the dose.
Although studies have shown that young children can develop sufficient
inspiratory flow to activate DPIs to deliver sufficient medication, there is
concern whether they will consistently use proper technique daily, over time.
For this reason, many specialists limit DPIs to children at least 8–12 years of
age and only after they are able to demonstrate proper technique in the office.
Frequent asthma visits with symptom assessment are important for patients
with persistent asthma, especially when it is hard to control. If improvement
is noted with an ICS-LABA combination, steps should be taken to continue
to step down the LABA treatment, if the patient tolerates it.
DPI, dry-powder inhaler; FDA, Food and Drug Administration; ICS, inhaled corticosteroid;
LABA, long-acting β2 -adrenergic receptor agonist; MDI, metered-dose inhaler;
SABA, short-acting β2 -adrenergic receptor agonist.
Derived from AAP Section on Pediatric Pulmonology. Pediatric Pulmonology. 2nd ed.
American Academy of Pediatrics; 2023; and AAP Section on Pediatric Pulmonology
and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC,
Dozor AJ, eds. American Academy of Pediatrics; 2018:268–269.

Tab 14
LABAs and LTRAs
LTRAs
Dosing of Antileukotriene Agents
Dosage Additional Notes
1–5 Years 6–14 Years Antileukotriene agents are also referred to as leukotriene modifiers.
Drug of Age of Age Adolescents Airflow obstruction in patients with asthma results from numerous
Montelukast 4 mg at bedtime 5 mg at bedtime 10 mg at bedtime pathological processes.
(6–14 y) (≥15 y) Inflammatory infiltrates and exudates not only distinguished by eosinophils
but also including other inflammatory cell types (ie, neutrophils, monocytes,
Zafirlukast NA 10 mg twice daily 40 mg daily lymphocytes, mast cells, basophils) can fill and obstruct the airways and
(5–11 y) (≥12 y) induce epithelial damage and desquamation into the airway lumen.
Zileuton NA NA 1,200 mg twice daily Leukotrienes are potent proinflammatory mediators that can induce
(≥12 y) bronchospasm, mucus secretion, altered cellular activity, and airway edema.
FDA, Food and Drug Administration; NA, not applicable. Parents should be counseled about Two classes of leukotriene modifiers exist: inhibitors of leukotriene synthesis
the FDA warning about risk of adverse effects on sleep and behavior with montelukast. (5-LOX) and LTRAs.
From AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, • Zileuton is the 5-LOX inhibitor used in the management of asthma.
Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; • Montelukast and zafirlukast are LTRAs used in the management of asthma.
2018:278.
LTRAs reduce the proinflammatory (increased microvascular permeability and
airway edema) and bronchoconstriction effects of leukotriene D4, especially
LTRA Use
from exercise, aspirin, and allergen-induced bronchoconstriction.
Leukotriene modifiers are popular because they can be administered in oral A stepwise approach, in addition to clinical decision-making, should be used to
form and have been shown to have bronchodilator and anti-inflammatory meet individual patient needs.
properties and to mitigate exercise-, allergen-, and aspirin-induced broncho- Antileukotriene agents are alternative medications used in the treatment of
spasm. Only montelukast (>6 months of age) and zafirlukast (>5 years of age) asthma and allergic rhinitis.
are FDA approved for children. As single agents, they are considered
alternative therapy for mild persistent asthma. They can also be used If alternative treatment is selected and well-controlled asthma is not achieved,
with ICSs. discontinue the therapy and use the preferred treatment or trial of a different
add-on therapy before stepping up the treatment. First assess adherence,
Indications, Administration, and Dosing technique, and environmental control.
LTRAs are suggested as alternative therapy for mild persistent asthma It is preferable to schedule daily, long-term medications so they are not taken
and as add-on medication with ICSs for moderate to severe persistent at school. However, prompt access to medication is essential to treat acute
asthma. symptoms or to prevent exercise-induced bronchoconstriction that may
If a child’s asthma is inadequately controlled with ICSs alone, an develop during physical education class, school recess, or organized sports.
antileukotriene agent or a LABA may be added. Most studies indicate Routine consideration for step-down to intermittent therapy should be given to
that overall, the addition of a LABA is more effective, but there are some those with well-controlled asthma, especially to children 0–4 years of age.
children for whom the addition of an antileukotriene agent may be the Adverse Effects
best choice.
LTRAs have been shown to help prevent EIB, although most specialists Dizziness, fever, headache
first try pretreatment with albuterol or another SABA. Increased levels of liver function enzymes
LTRAs are less effective than low-dose corticosteroids. Churg-Strauss syndrome
They are not used to treat acute exacerbations. Mood changes, including irritability, depression, and anxiety
Montelukast is administered orally as granules mixed with liquid or food • In 2009, the FDA issued an alert that children and adolescents may be
or as a chewable or regular tablet. at increased risk for neuropsychiatric events with antileukotriene agents,
Zafirlukast should be taken at least 1 hour before or 2 hours after meals including suicide. Because suicide and suicidal behavior are somewhat
because administration with meals decreases its bioavailability. common in the general adolescent population, the significance of this
association has not yet been definitively clarified.
When choosing an antileukotriene agent, montelukast is attractive because
it is prescribed once daily, and monitoring of liver function test results is Nightmares
not routinely needed. Abdominal pain and/or nausea
Cytochrome P450 system drug interactions
EIB, exercise-induced bronchospasm; FDA, Food and Drug Administration; 5-LOX, 5-lipoxygenase
inhibitor; ICS, inhaled corticosteroid; LABA, long-acting β2 -adrenergic receptor agonist;
LTRA, leukotriene receptor antagonist; SABA, short-acting β2 -adrenergic receptor agonist.
Derived from AAP Section on Pediatric Pulmonology. Pediatric Pulmonology. 2nd ed. American
Academy of Pediatrics; 2023; and AAP Section on Pediatric Pulmonology and Sleep Medicine.
Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American
Academy of Pediatrics; 2018:277–278.
27 Tab 14. LABAs and LTRAs

number
28 Tab 15. Inhaled Anticholinergic Agents
Tab 15
Inhaled Anticholinergic Agents
Anticholinergic agents in combination with albuterol have been shown to have a positive effect on reducing the rate of
hospitalizations during acute asthma exacerbations, although, singly, they are less potent than short-acting β2-adrenergic
receptor agonists. The most common anticholinergic agent in use is ipratropium bromide because it is available in both
metered-dose inhaler and nebulized forms and has limited central nervous system adverse effects. This agent decreases
vagal tone (resulting in bronchodilation) and blocks reflex bronchoconstriction to irritants.
This tab is limited to a discussion of inhaled anticholinergic (antimuscarinic) agents and their role in respiratory disease in
children. Inhaled anticholinergic agents include
 Ipratropium bromide (short acting)
 Tiotropium (long acting)
Anticholinergic Medication Dosing Chart for Management of Acute Respiratory Symptoms

Administration
Medication Dosage Form ≤12 Years of Age ≥13 Years of Age
Ipratropium bromide MDI (HFA): 4–8 puffs every 20 min 8 puffs every 20 min
17 mg per puff as needed for ≤3 h as needed for ≤3 h
(200 puffs per canister)
Nebulizer solution: 0.25–0.5 mg every 20 min 0.5 mg every 20 min
0.5 mg/2.5 mL (0.02%) for 3 doses, then as needed for 3 doses, then as needed
Ipratropium bromide with albuterol MDI: 4–8 puffs every 20 min 8 puffs every 20 min
18 mg of ipratropium bromide and as needed for ≤3 h as needed for ≤3 h
90 mg of albuterol per puff
Nebulizer solution: 1.5–3.0 mL every 20 min 3 mL every 20 min
Each 3-mL vial contains for 3 doses, then as needed for 3 doses, then as needed
0.5 mg ipratropium bromide
and 2.5 mg albuterol.
HFA, hydrofluoroalkane; MDI, metered-dose inhaler.
2018:283.

Tab 15
Inhaled Anticholinergic Agents
Approval of Anticholinergic Agents Treatment and Dosing

Currently, inhaled anticholinergic agents are approved by the FDA for the Moderate to Ipratropium bromide provides added effectiveness
treatment of COPD in adults, and tiotropium is FDA approved for the severe asthma when combined with SABAs in patients with moderate
treatment of asthma in children ≥6 years old. exacerbations to severe acute asthma exacerbations. Ipratropium
Although not all agents are FDA approved, anticholinergic agents have may be mixed with albuterol in the same nebulizer
been used off-label in children with asthma and BPD. or given as an MDI in combination with a SABA.
There are many medications with anticholinergic properties that are Ipratropium bromide does not improve outcomes in
approved for a wide variety of indications. Anticholinergic medications patients currently hospitalized.
can be classified as antimuscarinic agents that act on muscarinic Ipratropium bromide may be used as an alternative
acetylcholine receptors and antinicotinic agents that act on nicotinic quick reliever in patients who do not tolerate or
acetylcholine receptors. Inhaled anticholinergic agents are prescribed respond to a SABA.
for children with respiratory disease to decrease airway secretions
Chronic Ipratropium bromide has not shown effectiveness
and/or act as cough suppressants.
persistent as a long-term controller therapy.
Several newer inhaled LAMAs have been approved for the treatment of asthma • Tiotropium has been studied and is approved for
COPD in adults and are being studied in both adults and children for the
children with asthma.
treatment of asthma. These agents include
• Tiotropium can be helpful as add-on maintenance
• Aclidinium bromide
therapy when ICSs alone are inadequate.
• Umeclidinium bromide
Further studies need to be conducted to elucidate the
• Glycopyrrolate advantages and disadvantages of the addition of a
Mechanism/Duration of Action LAMA in childhood asthma.
Inhaled anticholinergic agents cause bronchodilation through competitive BPD Bronchodilator therapy does not improve long-term
blockade of muscarinic receptors in the airways, resulting in airway smooth outcomes in patients with BPD.
muscle relaxation. Aerosolized ipratropium bromide has been used to
Ipratropium bromide and tiotropium are poorly absorbed across treat infants with BPD; however, data are limited to
respiratory and gastrointestinal tract membranes, resulting in few case reports.
to no systemic effects. There is insufficient evidence to support
The duration of action for ipratropium is approximately 6 hours; it is anticholinergic therapy for the management of BPD.
therefore referred to as a short-acting muscarinic antagonist (SAMA). Adverse Effects
The duration of action of tiotropium is about 24 hours; it is therefore
referred to as a long-acting muscarinic antagonist (LAMA). Dry mouth
Dry respiratory secretions
Indications and Administration
Blurred vision if sprayed or nebulized in the eyes
Dosage forms include an MDI, a nebulizer solution, and an inhaled
aerosol solution. BPD, bronchopulmonary dysplasia; COPD, chronic obstructive pulmonary disease;
FDA, Food and Drug Administration; ICS, inhaled corticosteroid; LAMA, long-acting
A holding chamber may be used with an MDI, although this muscarinic antagonist; MDI, metered-dose inhaler; SABA, short-acting β2 -adrenergic
recommendation is not universal. Although most asthma specialists receptor agonist; SAMA, short-acting muscarinic antagonist.
recommend that a holding chamber be used with all MDIs, there is Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric
lack of agreement regarding clinical effectiveness. Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American
Potential benefits of a holding chamber include Academy of Pediatrics; 2018:281–283.
• Decreased need to coordinate actuation with inhalation
• Improved delivery of medication to the lungs
• Decreased amount of medication deposited in the oropharynx,
minimizing oral and systemic adverse effects
If an older child or adolescent consistently demonstrates proper inhaler
techniques, a holding chamber may be unnecessary.
29 Tab 15. Inhaled Anticholinergic Agents

number
30 Tab 16. Systemic Corticosteroids
Tab 16
Systemic Corticosteroids
Dosing of Systemic Corticosteroids

Corticosteroid Formulations Dosinga Adverse Effects
Prednisone Tablet: Doses are for prednisone, prednisolone, Short-term use:
1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mg and methylprednisolone. Hyperglycemia
Oral solution: Infants and children <12 years of age Increased appetite
5 mg/1 mL, 5 mg/5 mL (oral/IV):
1–2 mg/kg/d in divided doses 1–2 times daily Fluid retention
Prednisolone Tablet: for 5–10 d (maximum, 60 mg/d) Weight gain
5 mg Children ≥12 years of age and adolescents Mood alteration
Orally disintegrating tablets: (oral/IV):
40–60 mg/d in divided doses 1–2 times daily Hypertension
10 mg, 15 mg, 30 mg
for 5–10 d Peptic ulcer
Oral solution (as sodium phosphate): b
5 mg/5 mL, 15 mg/5 mL, 25 mg/5 mL IM methylprednisolone in children Muscle atrophy
≤4 years of age: (IM injection)
7.5 mg/kg as a 1-time dose (maximum dose,
240 mg) Long-term use:
Methylprednisolone Tablet: b
IM methylprednisolone in children Adrenal suppression
(IV formulation available) 2 mg, 4 mg, 8 mg, 16 mg, 32 mg >4 years of age and adolescents: (greater risk with
IV injection (as sodium succinate salt): 240 mg as a 1-time dose dexamethasone
80 mg/1 mL because of longer
duration of activity)
IM injection (as acetate):
40 mg/1 mL, 80 mg/1 mL Growth suppression
Dermal thinning
Dexamethasone Tablet: Infants, children, and adolescents
(IV formulation available) 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg (oral/IM/IV): Hypertension
0.6 mg/kg once daily as a single dose or once
Oral solution: Diabetes
daily for 2 d (maximum, 16 mg per dose)
0.5 mg/5 mL, 1 mg/1 mL Cushing syndrome
IV injection (as sodium phosphate salt): Muscle weakness
4 mg/1 mL, 10 mg/1 mL
IM, intramuscular; IV, intravenous.
a
Dosing recommendations are per National Asthma Education and Prevention Program Expert Panel Report 3.
b
May be used in place of a short burst of oral steroids in patients who are vomiting or whose adherence to treatment is a problem; IV administration is preferred in the
hospital setting.
2018:286.

Tab 16
Systemic Corticosteroids
Approval of Systemic Corticosteroids Treatment and Dosing

Systemic corticosteroids are an FDA approved treatment of asthma Once-daily dosing is preferred to improve adherence to treatment.
exacerbations that are most effective when started early in an exacerbation. IV methylprednisolone or dexamethasone may be used for patients who
Although childhood asthma leads all other medical causes for are unable to tolerate oral administration or whose gastrointestinal
hospitalization, its treatment, including systemic corticosteroids, absorption is a concern.
is essentially the same as that which would have prevented most Corticosteroids are generally continued until resolution of symptoms
hospitalizations had the treatment been administered earlier. or until peak expiratory flow is 70% of predicted or personal best
Mechanism of Action (on average about 5 days).
There is no evidence that tapering the dose after improvement in symptom
Asthma is characterized by hyperresponsiveness of the airways to various control and pulmonary function prevents relapse.
stimuli, which results in varying degrees of airway obstruction secondary
to bronchospasm and inflammation. Prolonged therapy with daily oral corticosteroids may be considered in
a rare number of children taking high-dose ICSs and a LABA that have
β2 -Adrenergic receptor agonists do not alter the inflammatory component failed to achieve adequate control.
of airway obstruction.
For patients who require long-term therapy with systemic corticosteroids,
Anti-inflammatory therapy is essential to relieve airway obstruction that is the lowest possible dose should be used, and children should be
subresponsive to bronchodilators. monitored for adverse effects of corticosteroid therapy.
Corticosteroids block late-phase reaction to allergen, reduce airway A gradual taper of corticosteroids over several weeks should be seriously
hyperresponsiveness, and inhibit inflammatory cell migration and considered for children who are taking systemic corticosteroid therapy
activation. at supraphysiological doses exceeding 14 days or for children who have
Indications and Administration received multiple courses totaling >3 weeks in the past 6 months to
avoid adrenal insufficiency.
Systemic corticosteroids are indicated for short-term treatment of
A morning cortisol level may be used to assess the presence of
acute exacerbations to gain prompt control of inadequately controlled
adrenal insufficiency in children who are at risk or whose symptoms
persistent asthma when repeated use of bronchodilator therapy leads
of adrenal insufficiency are present (corticosteroids should be tapered
to incomplete resolution of symptoms.
to a physiological dose for at least 1 week prior, and 1–2 doses should
Early administration of systemic corticosteroids for acute asthma permits be withheld before testing for cortisol).
earlier discharge of patients from the hospital, decreases the likelihood
of admission of patients for emergency care of asthma, and prevents ED, emergency department; FDA, Food and Drug Administration; ICS, inhaled
progression of exacerbation of asthma in ambulatory patients at risk corticosteroid; IV, intravenous; LABA, long-acting β2 -adrenergic receptor agonist.
for requiring urgent care. Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric
Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American
Standard therapy for an acute asthma exacerbation is a 5- to 10-day Academy of Pediatrics; 2018:285–286,287.
course of systemic corticosteroids without a taper.
Onset of action may begin within 1–2 hours of administration.
Therapy with systemic corticosteroids should be reevaluated if no
improvement is found within 5 days or if symptoms have not resolved
within 10 days.
Dexamethasone has been shown to be a viable alternative to prednisone
or prednisolone, particularly in the ED, and has been associated with less
nausea and vomiting; however, there are no studies in which extended
courses of dexamethasone were used for asthma therapy.
Adverse effects associated with systemically administered corticosteroids
occur at greater frequency in comparison to ICSs owing to systemic
delivery and higher doses administered.
Limited data suggest that repeated short courses of oral corticosteroids
(median of 4 courses in the preceding year) for asthma exacerbations in
young children do not seem to cause sustained adverse effects related
to bone metabolism, bone mineralization, and adrenal function.
31 Tab 16. Systemic Corticosteroids

number
32 Tab 17. Anti-immunoglobulin E Therapy
Tab 17
Anti-immunoglobulin E Therapy
Immunoglobulin E and Asthma
IgE plays an important role in the pathogenesis of asthma and allergic diseases.
Most patients are atopic, with positive findings from a skin test for common allergens
and with detectable allergen-specific IgE in the serum.
Exposure to allergens to which patients are sensitized can contribute to asthma
symptoms.
Anti-IgE therapy is a recombinant humanized immunoglobulin G1 monoclonal
antibody that binds to IgE with high affinity.
Omalizumab is the first FDA-approved biological therapy for asthma and the only
available anti-IgE therapy. It is FDA approved for the treatment of allergic asthma
and chronic urticaria.
• Decreases rates of asthma exacerbations, annualized rates of hospital admission,
total ED visits, unscheduled physician’s office visits, rescue therapy use, and
ICS dose
• Improves symptom scores, quality of life, and time to first asthma exacerbation
>200,000 patients with allergic asthma have been treated with omalizumab since
its approval in 2003 for people ≥12 years of age. It was approved in 2016 for people
≥6 years of age.
ED, emergency department; FDA, Food and Drug Administration; ICS, inhaled corticosteroid;
IgE, immunoglobulin E.
Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology,
Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; 2018:289.
Approval of Anti-immunoglobulin E Therapy Mechanism of Action

This therapy is approved for use in patients with the following characteristics: Binds to circulating IgE, forming immune complexes that are subsequently
≥6 years of age. cleared by the hepatic reticuloendothelial system.
Moderate to severe persistent asthma. Inhibits the attachment of IgE to IgE receptors on mast cells, basophils,
and other cell types, which reduces surface IgE receptor levels and the
Asthma symptoms that are inadequately controlled with an ICS.
ability of these cells to be activated by allergens.
A total serum IgE level between 30 and 700 IU/mL (0.07–1.68 mg/L);
Absorbs slowly, reaching peak serum concentrations after a mean of
dosing tables allow for total IgE level >700 IU/mL (>1.68 mg/L) in
7–8 days. Serum elimination half-life is about 26 days.
younger children 6 to <12 years of age because of their lower weights.
Some patients (≥12 years of age) with IgE levels >700 IU/mL (>1.68 mg/L)
are being treated with omalizumab, but safety and effectiveness in this
population have not been well studied, and concern has been expressed
for potential risk associated with the formation of immune complexes in
patients with very high IgE levels. Allergic sensitization is demonstrated
by positive results from a skin test or serum test for allergen-specific
IgE to a perennial allergen (dust mite, animal dander, cockroach, or mold).

Tab 17
Anti-immunoglobulin E Therapy
Indications and Administration Adverse Effects

Indicated as an additional controller medication in step 5 and 6 care Adverse effects include local injection site reactions (44%, like those of
for patients ≥6 years of age who have allergies and severe persistent placebo), urticaria (1%), and serum sickness (few case reports).
asthma (2007 National Asthma Education and Prevention Program Adverse effects in children 6–12 years of age with asthma include upper
asthma guidelines). respiratory tract infection symptoms, headache, fever, sore throat,
Should be administered via subcutaneous injection by a health care otalgia, abdominal pain, nausea, vomiting, and epistaxis.
professional in a health care setting prepared to manage anaphylaxis. Adverse effects in adults and children ≥12 years of age with asthma
• In general, this is accomplished in a specialist’s office. include musculoskeletal pain (mainly in the arms and legs), dizziness,
• A minimum of 3 months is needed to determine the effectiveness fatigue, skin rash, bone fractures, and otalgia. There is a questionable
for asthma. risk of cerebrovascular events (ie, transient ischemic attack,
ischemic stroke).
• A 3- to 6-month trial is appropriate.
FDA black box warning: Anaphylaxis and anaphylactoid reactions occur
Therapy is typically long-term because it is expected that the effects
at a rate of 1–2 per 1,000 patients. Because of the risk of anaphylaxis,
will wear off within 6–12 months.
omalizumab should be administered in a setting prepared to manage
Optimal duration of therapy has not been determined. anaphylaxis. Observe patients closely for an appropriate interval
Omalizumab is used by some allergists as adjuvant therapy to enhance after administration.
tolerance to allergy immunotherapy, including oral immunotherapy for Omalizumab should not be administered to patients who have
severe food allergies. experienced a severe hypersensitivity reaction to omalizumab.
Dosage and Availability FDA, Food and Drug Administration; ICS, inhaled corticosteroid; IgE, immunoglobulin E.
A dose of 75–375 mg is given via subcutaneous injection every Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric
2–4 weeks. Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American
Academy of Pediatrics; 2018:290–291.
Dose and dosing frequency are determined by serum total IgE level
(measured before the start of treatment) and body weight (in kilograms).
Adjust the dosing for clinically significant changes in body weight
during therapy.
The cost is about $11,000 per patient per year (in US dollars) for a
minimum dose (150 mg every 4 weeks) and about $65,000 per patient
per year for a maximum dose (375 mg every 2 weeks).
33 Tab 17. Anti-immunoglobulin E Therapy

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34 Tab 18. Other Biologics
Tab 18
Other Biologics
Biologics Approved for Treatment of Moderate to Severe Persistent Asthma

With Type 2 High Phenotype
Therapy Mechanism of Action Indication Dosing and Route Adverse Effects
Omalizumab Anti–IgE; prevents IgE People aged ≥6 years with moderate 0.016 mg/kg per IU of IgE Black box warning:
from binding to its to severe persistent asthma, positive (in a 4-wk period) administered ~0.1%–0.2% risk of
receptor on mast cells allergy testing, incomplete control with every 2–4 weeks subcutaneously anaphylaxis in clinical
and basophils an ICS, and IgE 30–1300 IU/mL (United (150–375 mg in United States; trials
States, age 6–11 years), 30–700 IU/mL 150–600 mg in European Union)a
(United States, age ≥12 years), or
30–1500 IU/mL (European Union)
Mepolizumab Anti–IL-5; binds to IL-5 People aged ≥12 years with severe 100 mg subcutaneously every Rarely causes hypersensitivity
ligand; and prevents eosinophilic asthma unresponsive 4 weeks reactions; can cause
IL-5 from binding to to other GINA steps 4–5 therapies. activation of zoster
its receptor Suggested AEC ≥150–300 cells/μl
Reslizumab Anti–IL-5; binds to IL-5 People aged ≥18 years with severe Weight-based dosing of 3 mg/kg Black box warning:
ligand; and prevents eosinophilic asthma unresponsive IV every 4 weeks ~0.3% risk of anaphylaxis
IL-5 from binding to to other GINA steps 4–5 therapies. in clinical trials
its receptor Suggested AEC ≥400 cells/μl
Benralizumab Anti–IL-5; binds to IL-5 People aged ≥12 years with severe 30 mg subcutaneously every Rarely causes hypersensitivity
receptor α; and causes eosinophilic asthma unresponsive 4 weeks for 3 doses; followed reactions
apoptosis of eosinophils to other GINA steps 4–5 therapies. by every 8 weeks subsequently
and basophils Suggested AEC ≥300 cells/μl
Dupilumab Anti–IL-4R; binds to IL-4 People aged ≥12 years with severe 200 or 300 mg subcutaneously Rarely causes hypersensitivity
receptor α; and blocks eosinophilic asthma unresponsive every 2 weeks reactions; higher incidence of
signaling of IL-4 to other GINA steps 4–5 therapies. injection site reactions (up to
and IL-13 Suggested AEC ≥150 cells/μl and/or 18%) and hypereosinophilia
FeNO level ≥25 ppb (4% to 14%)
AEC, absolute blood eosinophil count; FeNO, fractional exhaled nitric oxide; GINA, Global Initiative for Asthma; ICS, inhaled corticosteroid; IgE, immunoglobulin E; IL, interleukin;
IV, intravenously.
a
Upper limits exist for the dosing of omalizumab in patients with high IgE levels and increased weight.
Reprinted with permission of the American Thoracic Society. McGregor MC, Krings JG, Nair P, Castro M. Role of biologics in asthma. Am J Respir Crit Care Med. 2019;199(4):433–445;
and De Keyser HH, Chipps B, Dinakar C; American Academy of Pediatrics Section on Allergy and Immunology and Section on Pediatric Pulmonology and Sleep Medicine. Biologics for
asthma and allergic skin diseases in children. Pediatrics. 2021;148(5):e2021054270. Copyright © 2021 American Thoracic Society. All rights reserved. The American Journal of
Respiratory and Critical Care Medicine is an official journal of the American Thoracic Society.

Tab 18
Other Biologics
Use of Biologics: Key Recommendations

Key Recommendations for General Pediatricians Key Recommendations for Pediatric Subspecialists
Evaluate adherence to medications in patients with poorly controlled atopic Evaluate adherence to medications in patients with poorly controlled
diseases, such as asthma, urticaria, and atopic dermatitis. atopic diseases, such as asthma, urticaria, and atopic dermatitis.
Refer to a pediatric subspecialist (allergist, dermatologist, or pulmonologist) Partner with general pediatricians to identify appropriate patients for
for determination of whether a patient is an appropriate candidate for biological therapy.
biological therapy, as well as for determination of which therapy best
fits the patient’s phenotype.
Be familiar with adverse effects of biological therapy, particularly the risk Monitor for adverse effects that are particular to the particular therapy.
of anaphylaxis with omalizumab, benralizumab, dupilumab, and reslizumab
(if ever approved in the pediatric population).
The home administration is approved for dupilumab, mepolizumab, and Monitor for clinical improvement in symptoms with therapy.
omalizumab. Further opportunities for home administration are likely in
the future.
Continue to work to identify new biomarkers and means to identify
candidates for therapy, as well as monitor response to therapy.
Reprinted with permission from De Keyser HH, Chipps B, Dinakar C; American Academy of Pediatrics Section on Allergy and Immunology and Section on Pediatric Pulmonology
and Sleep Medicine. Biologics for asthma and allergic skin diseases in children. Pediatrics. 2021;148(5):e2021054270.
Pediatricians and pediatric subspecialists should be aware of the current range of biological medications available to children
with severe asthma. In addition, general pediatricians should monitor patients for evidence of poor response to traditional
therapies and consider referring to pediatric subspecialists for evaluation of eligibility for these types of medications. Finally,
those who administer this type of care for children with asthma should be aware of the potential for anaphylaxis for many
biologics, especially omalizumab and reslizumab, and be prepared to treat and evaluate anaphylaxis and other potential
treatment-related adverse effects.
35 Tab 18. Other Biologics

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36 Tab 19. Trigger Management
Tab 19
Trigger Management
Asthma Trigger Control Tips

Air Pollution
Asthma problems are worsened by air pollution, including ozone, fine particulate matter, oxides of nitrogen, volatile organic compounds,
and diesel smoke. Avoid these triggers whenever possible.
Check the air quality index (AQI) forecast daily at AirNow (www.airnow.gov). Limit or avoid exercise and strenuous activities outdoors
when air pollution levels are unhealthy.
Avoid living near a high-traffic road and exercising around high-traffic areas.
Dust Mites
Cover mattresses and pillows with dustproof zippered cases.
Wash bedding in hot water weekly. Wash curtains often.
Use washable rugs in the home, instead of carpet or wall-to-wall area rugs.
Apply acaricide (a house dust mite pesticide) to carpets/rugs, mattresses, and furniture.
Use air-filtration systems and air purifiers in the home, including those with HEPA filters.
Maintain indoor humidity between 30% and 50%. Use an air conditioner or dehumidifier to lower the humidity level in the child’s bedroom
and the home (and clean humidifiers regularly).
Vacuum twice per week, and use a vacuum cleaner with a HEPA filter. Dust the home frequently.
Avoid having upholstered furniture, especially in the bedroom.
Put out-of-season clothes in storage.
Wear a protective face mask in dusty areas.
Indoor Pets
Avoid animals with fur or feathers. Do not let pets inside the home.
Keep any pets out of the child’s bedroom.
Mold and Mildew
Seek professional removal, cleaning, sanitization, demolition, or other treatment to remove or prevent mold in the home.
Keep the home well ventilated and free of dampness. Fix any leaks right away.
Clean mildew from tiles and shower curtains.
Use an exhaust fan or open a window to remove moisture in bathrooms and kitchens.
Clean the water basins of air conditioners, humidifiers, and refrigerators often.
Mold grows in soil, so limit or remove plants from the home and work area.
Vent the clothes dryer outside the home.
Pollen
Keep doors and windows closed during pollen season, and limit outdoor activities when pollen levels are high.
Run the air conditioner one half-hour before the child plans to use a room.
Do not bring fresh flowers into the home.
After being outside on days with a high pollen or mold count, take a shower and change clothes.
Strong Odors
Avoid the use of air fresheners, strong-smelling cleaning agents, hair sprays, perfumes, and strong chemicals and paints used for hobbies.
Identify unscented or less toxic products that can be used.
Avoid areas with strong smells. Ask people living or working around the child not to use scented products.
Use a fan when the child must be near a strong odor.
Keep smells from spreading by closing off areas where the odor is located.
Avoid bringing formaldehyde-emitting products (eg, glues, paints, finishes) into the home. If they are used indoors, open the windows
for ventilation.

Tab 19
Trigger Management
Asthma Trigger Control Tips

Respiratory Tract Infections
Wash hands frequently to prevent infections.
Call a health care professional if you think your child has a respiratory tract infection.
Get a flu shot every year.
Exercise
Ask a health care professional about taking medicine before exercising or physical exertion.
Warm up slowly, and take breaks as needed.
Stress and Strong Emotions
Practice good general health habits to reduce stress. Avoid stressful situations.
Use relaxation exercises and techniques.
Take advantage of breaks and lunchtimes.
Cold and Heat
Avoid being outside when the weather is too cold or too hot.
When it’s cold outside, cover the child’s mouth and nose with a scarf.
Wood Smoke, Fires, and Cooking Smoke
Avoid the use of incense, fireplaces, and other burned substances in the home. Avoid burning wood indoors.
Ventilate exhaust from gas heaters outside the home.
Allow for airflow around fireplaces or vented appliances.
Check air quality forecasts during wildfires. Avoid going outside if air pollution levels are unhealthy.
Avoid outdoor leaf burning, wood fires, bonfires, and charcoal fires.
Ensure ventilation when cooking indoors (use an exhaust fan and/or open a window).
Cockroaches
Take out the trash every day. Clean up spills and crumbs right away.
Keep food in sealed containers.
Prevent standing water in dish racks, sinks, showers, and plant saucers.
Don’t leave pet food out.
Use roach baits (but not sprays or foggers).
Seal openings where bugs can get in (eg, outside faucets, holes, spaces around window seals).
Smoking and Secondhand Smoke (See Tab 22)
Don’t smoke around a child with asthma, and ask others not to as well. Do not allow anyone to smoke in the home, car, or work area.
If a smoke-free home is not an option, use HEPA filters in the home to reduce the child’s exposure to smoke particulates.
Avoid the homes and cars of people who smoke or allow smoking.
When outside the home, avoid eating or sitting in areas where smoking is allowed.
Derived from U.S. Department of Health and Human Services, National Institutes of Health, and National Heart, Lung, and Blood Institute.
2020 Focused Updates to the Asthma Management Guidelines: A Report From the National Asthma Education and Prevention Program Coordinating
Committee Expert Panel Working Group. 2020. Accessed January 13, 2022. https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/
2020-focused-updates-asthma-management-guidelines; and American Lung Association. Avoiding and controlling asthma triggers. Accessed January 13,
2022. https://www.lung.org/getmedia/d3bafd22-cb2c-48cb-9855-4d3b1d891a17/avoiding-and-controlling-triggers.pdf.pdf?ext=.pdf.
If needed, you are welcome to copy Tab 19, Trigger Management, to facilitate communication among parents, caregivers, and pediatric health professionals.
No permission is necessary to make single copies for noncommercial, educational purposes. The information contained in this publication should not be used
as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on
individual facts and circumstances. © 2022 American Academy of Pediatrics. All rights reserved.
37 Tab 19. Trigger Management

number
Tab 20. Exercise-Induced
38 Bronchoconstriction
Tab 20
Exercise-Induced Bronchoconstriction
Signs and Symptoms Triggers Additional Notes
Coughing, wheezing, Breathing dry and/or cold air causes Obtaining a history alone has been shown to lead to underdiagnosis
chest tightness, and airway narrowing via osmotic and thermal and overdiagnosis of EIB.
dyspnea. consequences of evaporative water loss • Rule out other origins, including vocal cord dysfunction, arrhythmias,
Mild impairment to from the airway surface. and pulmonary or cardiac shunt.
severe bronchospasm Dry or cold air in the distal airways causes • Obtain a complete family history, including asthma or relatives
and, rarely, respiratory hyperemia of bronchial vasculature and with atopy.
failure. airway edema, which further causes
airway narrowing. EIB, exercise-induced bronchoconstriction; FEV1, forced expiratory volume in 1 second;
Subtler symptoms FVC, forced vital capacity.
include fatigue, Airway narrowing causes cough. Diagnosis of Exercise-Induced Bronchoconstriction
a
Children may have EIB in addition to any of the disorders listed.
abdominal discomfort, Although the events that trigger EIB and
poor performance, and Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric
the role of inflammatory cells are not fully Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American
avoidance of activities. understood, a hyperosmolar environment Academy of Pediatrics; 2018:299–301.
Exercise duration for a is thought to trigger the release of
minimum of 5–8 minutes inflammatory mediators, including Diagnosis of Exercise-Induced Bronchoconstriction
at 80% of maximum histamine, tryptase, and leukotrienes
predicted oxygen from eosinophils and mast cells.
Symptoms suggestive of EIB
consumption typically Several studies have demonstrated that
generates bronchospasm. individuals who are prone to EIB have
Symptoms peak increased levels of exhaled nitric oxide,
5–10 minutes after increased airway leukotriene levels, Perform spirometry
exercise ceases and can greater expression of mast cell genes,
last 60–90 minutes. and/or peripheral eosinophilia.
Diagnostic Considerations Spirometry results Spirometry results
EIB involves acute, transient airway narrowing that occurs during and normal abnormal
after exercise.
EIB is most often defined by ≥10% decline in FEV1 at spirometry after
exercise provocation. Elite Treat for EIB
EIB occurs in 90% of individuals with asthma. athlete? and asthma
EIB can also occur in individuals without a known diagnosis of asthma.
All patients with suspected EIB should undergo spirometry. Yes No
• Assess the patient for baseline airway obstruction (ratio of FEV1:FVC Perform bronchial
up to the lower limit of reference for age). provocation testing
Differential Diagnosisa
Unrecognized or poorly controlled asthma
Anxiety
Results normal: Results abnormal:
Deconditioning consider alternative treat EIB
Vocal cord dysfunction diagnoses
Exercise-induced laryngomalacia
Exercise-induced anaphylaxis Initiate trial of short-acting
ß2 agonist 15 to 30
Exercise-induced reflux minutes before exercise
Central airway obstruction arrhythmias
Pulmonary or cardiac shunt
Adequate response: Inadequate response:
continue treatment perform bronchial
provocation testing
Reproduced with permission from AAP Section on Pediatric Pulmonology and Sleep
Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds.
American Academy of Pediatrics; 2018:300; and Krafczyk MA, Asplund CA. Exercise-
induced bronchoconstriction: diagnosis and management. Am Fam Physician.
2011;84(4):427–434.

Tab 20
EIB Management Strategies

Pharmacological Nonpharmacological Additional Notes
SABAs Adequate warm-up Identify bronchodilator responsiveness, defined as an increase of ≥12%
ICSs Avoidance of triggers in FEV1 after inhalation of a short-acting bronchodilator.
LABAs or ICSs Nasal breathing FEV1 decrease ≥10% from a pre-exercise level is diagnostic of EIB, with
an FEV1 decline of ≥50% considered to indicate severe EIB.
LTRAs Mask or face device
Indirect testing can be performed in a functional laboratory setting:
Antihistamines
Exercise, eucapnic voluntary hyperpnea, inhaled powdered mannitol,
Pretreatment before exercise. Because the degree of EIB is or nebulized hypertonic saline.
• SABAs. often related to the patient’s • Elicits inflammatory response to release mediators and provokes airway
depth and rate of breathing smooth muscle constriction
– First-line treatment of EIB
(minute ventilation), patients
– 2 puffs 15 minutes before • Measurements obtained 5, 10, 15, and 30 minutes after exercise
who are poorly conditioned
exercise may have higher rates of EIB. Direct challenges: Methacholine or histamine.
– Peak bronchodilation at • Recommend aerobic exercise • Acts directly with airway smooth muscle receptors to cause constriction
15–60 minutes, coverage for throughout the year, even independent of airway inflammation
3 hours during the off-season. EIB, exercise-induced bronchoconstriction; FEV1, forced expiratory volume in 1 second;
• LTRA: Montelukast therapy Interval or combination warm-up ICS, inhaled corticosteroid; LABA, long-acting β2 -adrenergic receptor agonist; LTRA,
offers protection against EIB exercise: Warming up before leukotriene receptor antagonist; SABA, short-acting β2 -adrenergic receptor agonist.
and improvement of decrease exercise releases catecholamines Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric
of FEV1 after exercise. such as norepinephrine and Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American
– Onset of action within epinephrine, which are Academy of Pediatrics; 2018:301,302–303.
2 hours, with continued bronchodilators.
benefit for ≤24 hours • Pre-exercise warm-up may
– Often suggested in individuals attenuate bronchoconstriction by
with allergic rhinitis inducing a “refractory period,”
• Daily ICSs should be used in which typically lasts 2 hours.
patients with refractory or daily Nose breathing warms, filters,
symptoms or asthma. and humidifies the inspired air,
– Long-term control of asthma which reduces airway cooling
with anti-inflammatory and dehydration.
medication reduces airway • Because many patients with EIB
responsiveness and also have allergic or nonallergic
frequency and severity chronic rhinitis, therapy that
of EIB. helps decrease nasal congestion
– May take 1–2 weeks after and inflammation can often help
therapy initiation to notice decrease EIB.
maximal improvement. Use of a face device, such as a
Additional therapies. mask or scarf, warms and
Antihistamine may be helpful in humidifies the inspired air.
individuals with allergies.
• LABAs are never recommended
as single-agent therapy, yet
when used in conjunction with
an ICS, they may be superior to
ICSs alone in managing EIB.
• Anticholinergics provide some
protection against EIB, yet they
are usually not as effective as
SABAs or LTRAs.
39 Tab 20. Exercise-Induced

Bronchoconstriction

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40 Tab 21. Asthma Control Test
Tab 21
Asthma Control Test
Childhood Asthma Control Test for children 4 to 11 years old.

Know the score.
This test will provide a score that may help your doctor determine if your child’s asthma treatment plan is working or if it might be time for a change.
How to take the Childhood Asthma Control Test
Step 1 Let your child respond to the first four questions (1 to 4). If your child needs help reading or understanding the question, you may
help, but let your child select the response. Complete the remaining three questions (5 to 7) on your own and without letting your
child’s response influence your answers. There are no right or wrong answers.
Step 2 Write the number of each answer in the score box provided.
Step 3 Add up each score box for the total. If your child’s score is 19 or less, it
Step 4 Take the test to the doctor to talk about your child’s total score. 19 may be a sign that your child’s
asthma is not controlled as well as
or less it could be. No matter what the
score, bring this test to your doctor
Have your child complete these questions. to talk about your child’s results.
1. How is your asthma today? SCORE
0 1 2 3
Very bad Bad Good Very good
2. How much of a problem is your asthma when you run, exercise or play sports?
0 1 2 3
It's a big problem, I can't do what I want to do. It's a problem and I don't like it. It's a little problem but it's okay. It's not a problem.
3. Do you cough because of your asthma?
0 1 2 3
Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time.
4. Do you wake up during the night because of your asthma?
0 1 2 3
Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time.
Please complete the following questions on your own.

5. During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms?
5 4 3 2 1 0
Not at all 1-3 days/mo 4-10 days/mo 11-18 days/mo 19-24 days/mo Everyday
6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma?
5 4 3 2 1 0
7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma?
5 4 3 2 1 0
TOTAL
Please turn this page over to see what your child’s total score means.

Tab 21
Asthma Control Test
Asthma Control TestTM for teens 12 years and older. Know the score.
If your teen is 12 years or older have him take the test now and discuss the results with your doctor
Step 1 Write the number of each answer in the score box provided.
Step 2 Add up each score box for the total.
Step 3 Take the test to the doctor to talk about your child’s total score.
1. In the past 4 weeks, how much of the time did your asthma keep you
from getting as much done at work, school or at home?
All of Most of Some of A little of None of
the time 1 the time 2 the time 3 the time 4 the time 5
2. During the past 4 weeks, how often have you had shortness of breath?
More than Once 3 to 6 times Once or twice Not
once a day 1 a day 2 a week 3 a week 4 at all 5
3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness,
or pain) wake you up at night or earlier than usual in the morning?
4 or more 2 or 3 nights Once Once Not
nights a week 1 a week 2 a week 3 or twice 4 at all 5
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?
3 or more 1 or 2 times 2 or 3 times Once a week Not
times per day 1 per day 2 per week 3 or less 4 at all 5
5. How would you rate your asthma control during the past 4 weeks?
Not controlled Poorly Somewhat Well Completely
at all 1 controlled 2 controlled 3 controlled 4 controlled 5
The American Lung Association

supports the Asthma Control Test Total
and wants everyone 12 years of age
and older with asthma to take it.
Copyright 2002, by QualityMetric Incorporated.

Asthma Control Test is a trademark of QualityMetric Incorporated.
What does it mean if my child scores 19 or less?
• If your child’s score is 19 or less, it may be a sign that your child’s asthma is not under control.
• Make an appointment to discuss your child’s asthma score with their doctor. Ask if you should change your child’s asthma treatment plan.
• Ask your child’s doctor about daily long-term medications that can help control airway inflammation and constriction, the two main
causes of asthma symptoms. Many children may need to treat both of these on a daily basis for the best asthma control.
©2005 The GlaxoSmithKline Group of Companies All Rights Reserved.
41 Tab 21. Asthma Control Test

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42 Tab 22. Tobacco Use/Vaping and Asthma
Tab 22
Tobacco Use/Vaping and Asthma
Tobacco dependence is a severe and chronic illness. It is associated with increased asthma prevalence and severity, worse
asthma control, increased bronchial hyperresponsiveness, increased risk for emergency department visits, and decreased
corticosteroid responsiveness. Tobacco smoke exposure accelerates decline in lung function in children with chronic
pulmonary problems, such as cystic fibrosis.
Children can be harmed from tobacco smoke by direct inhalation of exhaled and sidestream smoke (secondhand smoke)
and from the dermal absorption, ingestion, and inhalation of smoke that has been absorbed into surfaces (thirdhand smoke).
There is no safe level of tobacco smoke exposure, and children are harmed by tobacco and nicotine from gestation onward.
In the United States, the largest source of a child’s exposure to tobacco smoke is often the mother and other caregivers.
Maternal smoking increases a child’s risk for wheezing illnesses, including bronchiolitis and asthma. In utero exposure
affects lung development.
In Utero Tobacco Smoke Exposure Electronic Nicotine Delivery Systems (ENDSs)

Harms lung growth and development. Electronic nicotine delivery systems (ENDSs) (eg, e-cigarettes,
• Reduces airway size and lung function e-hookahs, vape pens) are rapidly rising in popularity among youth.
• Increases risk for wheezing as an infant and a young child Toxic and carcinogenic chemicals, including acrolein and benzene,
• Increases risk for more severe asthma as an older child as well as metallic nanoparticles, have been found in ENDS
Harms brain development. emissions.
• Increases risk for learning disabilities and attention-deficit disorder Flavoring agents can have clinically significant pulmonary toxicity,
and attention-deficit/hyperactivity disorder whose full extent is not yet known.
• Increases risk for sudden infant death syndrome The emissions of electronic nicotine delivery systems, such as
e-cigarettes, e-hookahs, and vape pens, are not safe to breathe.
Increases risk for adverse outcomes of pregnancy.
Besides nicotine, the emissions (technically an aerosol but often
• Stillbirth incorrectly called vapor) contain chemicals that are respiratory
• Lower birth weight irritants, as well as chemicals that are known toxins and carcinogens.
• Preterm birth Recent case reports have demonstrated severe lung damage
• Placental abruption associated with the use of these devices.
Is associated with other health problems. Inhaled nicotine from electronic cigarettes has been shown to cause
• Increased risk for orofacial clefts emphysema-like changes in the lungs of laboratory animals.
• Increased risk for having overweight in childhood Youth who would not otherwise be at risk for smoking are initiating
their nicotine addictions with these devices.
Although sorting out the individual effects of the nicotine versus other
toxins in tobacco smoke is difficult, it is clear that at least some of the Youth who use ENDSs are more likely to become combustible
fetal harm is caused by the nicotine component, which suggests that tobacco users and are less likely to stop smoking.
use of electronic nicotine delivery systems (ie, electronic cigarettes,
others) can lead to important fetal harms. Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine.
Postnatal Tobacco Smoke Exposure Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds.
Increases asthma prevalence and severity
Decreases effectiveness of inhaled corticosteroids for asthma control
Increases severity of viral respiratory illness, including bronchiolitis
Increases risk for pneumonia
Increases risk for cough
Lowers lung function
Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric
Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds.

Tab 22
Tobacco Use/Vaping and Asthma
Diagnostic Considerations Management: Second-Best Practices

Pediatricians should inquire about (a) tobacco product and ENDS use If parents and other caregivers are not ready to stop smoking,
and (b) emission exposure as a routine part of health supervision visits Having a smoke-free (and ENDS emission–free) home and car policy
and for illnesses or diseases that may be caused or exacerbated by can reduce a child’s exposure to tobacco smoke, although it is unlikely
exposure to tobacco smoke. to completely eliminate exposure.
Screening questions include The use of HEPA filters in the home can reduce, but not eliminate,
• Does your child live with anyone who uses tobacco or e-cigarettes the harm to a child with asthma from a household member smoking.
(vape pens)? The cost is not usually covered by health insurance. HEPA filters
• Does anyone who cares for your child smoke tobacco or use require periodic filter changes as well.
e-cigarettes? Implement office systems to identify and offer counseling, treatment,
• Does your child visit places where people smoke or use tobacco or treatment recommendations, and/or referral for parents dependent
e-cigarettes? on tobacco.
• Do you ever smell smoke from your neighbors in or near your home? • Tools provided by CEASE can facilitate screening and referral.
• Do you have a “no smoking, no e-cigarette, no vaping” policy for – Ask (“Does your child live with anyone who uses tobacco?”).
your home and car? – Assist (“As your child’s doctor [or nurse], I can help you quit using
tobacco and help you have a tobacco-free home and car”).
Management: Best Practices
– Refer (“The national smokers help line can be reached at
The best way to reduce or eliminate a child’s exposure to tobacco smoke 800/QUIT-NOW [800/784-8669]”).
is for parents, other caregivers, and close family members to become – CEASE program materials are available (www.ceasetobacco.org).
nonsmokers.
Recommend tobacco dependence treatment in parents, other caregivers, Prevention
and close family members dependent on tobacco. Parents and close Tobacco dependence starts in adolescence. Close to 90% of current adult
family members may be motivated to take action to protect the health smokers started their tobacco use before 18 years of age. Encourage
of their child and reduce their child’s need for medication. children to never smoke or use ENDSs and to avoid exposure to tobacco
The combination of counseling and medication is more effective at and nicotine products.
treating tobacco dependence than use of either strategy alone. Help the child to find personally relevant reasons to be tobacco- and
With appropriate assessment, documentation, and counseling, pediatricians nicotine-free.
can recommend or prescribe tobacco dependence treatment medications Pediatricians can be important advocates for public policies to protect
for parents. children from tobacco smoke exposure and improve children’s
The nicotine patch, nicotine gum, and nicotine lozenge are over-the- respiratory health.
counter medications that are effective for tobacco dependence treatment The following evidence-based policies protect children from tobacco
when used properly. Tobacco dependence pharmacotherapy should be smoke exposure:
initiated on the basis of readiness to change and severity of tobacco
• Comprehensive smoking bans should be enforced.
dependence. Treatment should be stepped up or stepped down, based
on control of nicotine withdrawal. – Smoking and use of tobacco products that produce an emission
should be prohibited in all workplaces, including bars, restaurants,
Telephonic tobacco use cessation support can help. Refer individuals to
and health care facilities. Smoking and use of tobacco products that
the national smokers help line: 800/QUIT-NOW (800/784-8669).
produce an emission should be banned in outdoor areas frequented
Pediatricians should be familiar with local and state resources for tobacco by children, including sidewalks, recreational and sports facilities,
dependence counseling and treatment. entertainment venues, and parks.
ENDSs should not be recommended for tobacco dependence treatment. • Smoking in multiunit housing should be prohibited.
– Smoking in 1 unit involuntarily exposes those in nearby units.
• Prohibitions on smoking and the use of tobacco products should include
prohibitions on the use of ENDSs.
The vapor emitted from ENDSs contains toxic and carcinogenic
substances, in addition to nicotine. Use of these products involuntarily
exposes others to these hazardous substances.
CEASE, Clinical Effort Against Secondhand Smoke Exposure; ENDS, electronic nicotine
delivery system.
Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine.
Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds.
43 Tab 22. Tobacco Use/Vaping and Asthma

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III
THE NEW MARQUISE
L ouis XV. had had enough of glory. Impatient to meet again the
new marquise, he left the army September 1, 1745, and returned
to Versailles, where his mistress awaited him in the apartment
once occupied by the Duchess de Châteauroux. This change of
reign was effected in an official manner. There was no more attempt
at mystery. The Marquise de Pompadour was presented September
15, conformably to the rules of etiquette. Every tongue at court was
wagging over this scandalous and ridiculous ceremony. Every one
wondered how the Queen would look. The King, his wife, and his
mistress thus exposed themselves to public view, and the ancient
ceremonial became merely a parody. The Princess de Conti, whose
debts and prodigalities seemed to condemn her to such complaisant
rôles, was the lady who presented her. The Marquise appeared at
first before the King, whose countenance betrayed an easily
comprehended embarrassment. Then she entered the salon of the
Queen and could not hide her confusion.
But Marie Leczinska, good and indulgent even to exaggeration,
reassured her by a gracious reception. Naming one of the few
aristocratic women with whom Madame de Pompadour was
connected, she said: “Have you any news of Madame de Saissac? I
have been much pleased to see her sometimes in Paris.” The
Marquise, touched and grateful, know not what to answer. She
reddened and stammered out: “Madame, I have the greatest passion
to please you.”
The Abbé de Bernis celebrated thus the new queen of Cythera:—
“Tout va changer: les crimes d’un volage
Ne seront plus érigés en exploits.
La Pudeur seul obtiendra notre hommage,
L’amour constant rentrera dans ses droits.
L’exemple en est donné par le plus grand des rois,
Et par la beauté la plus sage.”[29]
The choice of Louis XV. was thenceforward settled. The gallant
monarch was about to plume himself on fidelity.
What do you think of this modesty and this discretion? As Sainte-
Beuve says, these poets have a way of taking things which belongs
to them alone.
There was plenty of adulation, but there was also plenty of fault-
finding. The great ladies could not get used to seeing a bourgeoise
occupy the post of King’s mistress. They observed with malevolent
and ever alert attention this improvised marquise who tried to give
herself airs of nobility and grandeur. They recalled the fact that her
grandfather had been provision-contractor for the Hôtel des
Invalides. She is the granddaughter of a butcher, said they; they
jeered pitilessly about meat and fish; they found her awkward in her
part, like a grisette disguised as a marchioness. Exasperated at
seeing at Versailles a royal mistress not of his choosing, the Duke de
Richelieu tried, says Duclos, “to make the King consider her on the
footing of a bourgeoise out of place, a passing gallantry, a simple
amusement not adapted to remain worthily at court.” If anything in
her manners or her language was not perfectly well-bred, the favorite
became the butt of sarcasm as soon as her back was turned. Louis
XV. used to say: “It will amuse me to educate her.”
Madame de Pompadour had at all events the good sense to
maintain a humble and submissive attitude when she appeared
before the Queen. The rank and virtues of Marie Leczinska
intimidated her. Here is a curious passage which occurs in the
Memoirs of the Duke de Luynes: “Day before yesterday, as she was
returning from Mass, Madame de Pompadour said to Madame de
Luynes that she was in the keenest anxiety and most bitter sorrow;
that she knew somebody had frightfully aspersed her to the Queen;
and, without explaining to what she referred, said she hoped greatly
that the Queen would not believe it, and that she begged her to
speak about it to her. Madame de Luynes instantly gave an account
of this to the Queen.” Here is the letter written to Madame de
Pompadour by the Duchess de Luynes: “I have just been speaking
to the Queen, Madame, and I earnestly entreated her to tell me
frankly if she had anything against you; she answered in the kindliest
way that she had not, and that she was even very sensible of your
efforts to please her on all occasions; she even desired me to write
and tell you so.”
This is the reply of the Marquise: “You bring me to life again,
Madame; for three days I have been in unheard-of pain, as you will
believe without difficulty, knowing as you do my attachment to the
Queen. They have made frightful accusations against me to
Monsieur and to Madame the Dauphiness, who have been kind
enough to allow me to prove the falsity of the horrors they accuse
me of. I had been told some days ago that the Queen had been
prejudiced against me; think of my despair, who would give my life
for her, who find her goodness to me every day more precious. It is
certain that the kinder she is to me, the more will the jealousy of the
monsters of this place be employed in abusing me, unless she is so
good as to be on her guard against them and will kindly let me know
of what I am accused. It will not be difficult for me to justify myself;
the tranquillity of my soul on this subject assures me as much. I
hope, Madame, that your friendship for me, and still more your
knowledge of my character, will be the guarantees of what I am
writing you. Doubtless you must be annoyed by such a long story;
but my heart is so full that I cannot conceal it from you. You know my
sentiments toward you, Madame; they will end only with my life”
(February, 1746).
We read again in the Memoirs of the Duke de Luynes (March,
1746): “Madame de Pompadour, who knows the Queen loves
flowers, is so attentive as to send her bouquets as often as possible;
she continues to seek every occasion to please her.”
The Queen may have reflected that, after all, since a mistress was
inevitable, this one was better than another. Since he had been
directed by Madame de Pompadour, the King seemed in a less
sombre temper and looked a little less bored. But he lost in the
favorite’s society the needful energy to continue the successes of the
French arms, and sign a really glorious peace.
While Louis XV. was thus wasting away in futilities, Marshal Saxe
conquered all Belgium. Louis XV. never made his appearance at the
army from May 4 to the middle of June, 1746. After having made a
triumphal entry at Antwerp he hastened back to Versailles,
apparently to be present when the Dauphiness was delivered, in
reality to see Madame de Pompadour again. The Dauphiness died
prematurely in July. D’Argenson says she had become as good a
Frenchwoman as if she had been born at Versailles. She was
regretted, but the hurly-burly of festivities soon began again, and
Louis XV., after a very short mourning, resumed his accustomed
diversions and pretended pleasures.
The successes of his troops were as brilliant as they were rapid.
Never had France held better cards. It was a magnificent occasion to
complete national unity in the North. But though they had known how
to conquer they knew not how to profit by the victory. The King did
not comprehend his mission. He was thinking more about Madame
de Pompadour than about the war, and while his soldiers were
fighting so bravely, he, wholly given up to frivolous trifles, was
amusing himself, or, better, he was trying to do so. This nonchalance
became fatal. All the fruits of the war were lost by the treaty of Aix-la-
Chapelle (October 18, 1748).
People had believed that Louis XV., who was master of all
Belgium, of two Dutch provinces, of Savoy, and the county of Nice,
would claim to retain at least a part of his conquests. But, to the
general surprise, he declared he would not treat as a merchant, but
as a king. This more than amazing phrase signified that France
would demand nothing, nothing for so many dearly bought victories,
nothing for the five hundred thousand men she had sacrificed,
nothing for the twelve hundred millions added to the national debt.
Louis XV. restored all the conquered cities and territories. He
engaged not to rebuild the fortresses of Dunkirk; he recognized the
English succession in the Protestant line and carried complaisance
toward the vanquished of Fontenoy to the point of expelling the
Pretender, the heroic Charles Edward, from France. Add to this that
the French navy, like that of Spain, was half ruined, and that the time
was not far distant when the sailor might salute the ocean as
Britannic. It is true that the Infant Philip, married to the eldest
daughter of Louis XV., obtained the duchies of Parma and Plaisance.
But this was but a petty advantage considered as a recompense for
so many sacrifices of men and money.
As might have been expected, the peace of Aix-la-Chapelle was
profoundly unpopular. “As stupid as the peace,” people said in Paris.
The odium of it was cast upon the woman who, to play her part as
queen of the left hand, had meddled with diplomacy, finances, and
the army.
In 1746 Voltaire had written to Louis XV.:—
“Grand roi, Londres gémit, Vienne pleure et t’admire.
Ton bras va décider du destin de l’Empire.
La Sardaigne balance et Munich se répent,
Le Batave, indécis, au remords est en proie;
Et la France s’écrie au milieu de sa joie:
‘Le plus aimé des rois est aussi le plus grand!’”[30]
Everything was greatly changed in 1748; London no longer

groaned, and Vienna did not admire. There was neither repentance
at Munich nor remorse at Batavia, and very little was said about the
greatness of the best beloved of Kings. The situation already
contained in germ the disasters of the future Seven Years’ War.
France, which loves success, no longer compared Madame de
Pompadour to la belle Gabrielle. But the favorite had one grand
consolation under the rain of sarcasms and satires; her theatre of the
little Cabinets of Versailles was succeeding very well; and if she was
hissed as a political woman, she was warmly applauded as an
actress.
IV
MADAME DE POMPADOUR’S THEATRE
“I have seen all that is done under the sun, and beheld that all is
vanity and vexation of spirit. I have said within myself: Let us take
all manner of delights and let us enjoy our possessions; and I
have recognized that this too is vanity. I have condemned the
laughter of folly and I have cried unto joy: Why dost thou deceive us
vainly?”
What the Preacher thought, Louis XV. thought also. Like Solomon,
he was bored. His ennui was the terror of Madame de Pompadour.
The problem she had to solve was how to entertain a man who could
no longer be amused. The favorite trembled. Here was her favor
barely begun, and already she beheld symptoms of indifference and
lassitude in her royal lover. D’Argenson writes in 1747: “The
Pompadour is about to be dismissed. The King will live with his
family.” The Marquise was afraid lest the sovereign, who really had a
badly understood but sincere religion at bottom, might some day
conclude to be truly devout. Hence she desired at any cost to divert
him from serious ideas and plunge him, in his own despite, into the
vortex of false pleasures whose emptiness and poverty he knew so
well.
Even amid the splendors of Versailles, the new Marquise
regretted her successes as a private actress. The echo of the
applause she had become accustomed to in the parlor theatres of M.
Lenormand de Tournehem, at Étioles, and of Madame de Villemur, at
Chantemerle, still resounded in her flattered ears. Those who are
habituated to the emotions and vanities of the stage cannot easily do
without them. Madame de Pompadour was homesick for the
footlights and the boards. To play in comedy is such a fine occasion
for a pretty woman to shine! To see all eyes fixed on her; to put
beauty and her toilettes in the best lights; to be greeted when she
appears by a murmur of admiration; to receive when the play is
ended the rain of flowers and garlands that tumble at her feet; and at
last, when the actress resumes the grande dame and re-enters the
drawing-room, to glean compliments, madrigals, and enthusiastic
plaudits afresh,—what a triumph for a fashionable woman, what
exquisite joy for a coquette!
Women of the highest social rank are often jealous of actresses. It
annoys them to perceive that they have not that order of charms
which comediennes possess. They envy them the privilege of
attracting the attention of a whole theatre, of being the object of all
regards, the subject of all eulogies, and the ability to say to a lover
after a triumph: “I have played only for you, I have thought of you
alone; these flowers that have been thrown to me I give to you.”
They envy them the excitement of those noisy ovations, in
comparison with which all the flatteries of society seem tame. They
envy them above all that faculty of metamorphosis which transforms
the same woman into a shepherdess or a queen, a nymph or a
goddess, so that a man while adoring a single beauty, but a beauty
incessantly changed and transfigured, finds himself at once faithful
and inconstant.
This is why Madame de Pompadour wanted to play comedy at
Versailles. Little by little she accustomed Louis XV. to this idea. Holy
Week was always a sad time for the monarch, who was tortured by
remorse and ashamed of playing so badly his part as eldest son of
the Church. The favorite conceived the notion of enlivening this
dreaded week by interludes, half religious, half profane.
Accompanied by actors and amateurs, she sang pieces of sacred
music. This Lent à la Pompadour, this mixture of church and opera,
this exchange of religions for chamber, not to say alcove, music, was
very acceptable to such a character as Louis XV. and a devotion as
inconsistent and spurious as his. The courtiers, of course, went into
ecstasies over the charming voice of the Marquise. They reminded
the King of the triumphs of the little theatres at Étioles and
Chantemerle, and pitied him for not having seen comedy played by
so remarkable an actress. Sacred music had served its time; another
sort was now in order.
Madame de Pompadour achieved her purpose. A theatre was
constructed for her at Versailles,—a miniature theatre, an elegant
little place, a perfect gem.[31] The spot chosen was the gallery
contiguous to the former Cabinet of Medals, a dependence of the
King’s small apartments (room No. 137 of the Notice du Musée de
Versailles, by M. Eudore Soulié). Nearly one-third of the orchestra
was composed of amateurs belonging to the most illustrious families,
the other two-thirds being professional artists. The chorus singers
were selected among the King’s musicians. The dancers were boys
and girls from nine to thirteen years at most, who, on reaching the
latter age, were to enter the ballet corps of the opera, the Théâtre
Français, or the Comédie-Italienne (the little girls distinguished
themselves later on in choregraphic shows and gallantry).
Celebrated painters, Boucher at their head, supplied the decorations.
The mise en scène and the costumes were of incomparable
elegance. As to the actors and actresses, they bore such names as
the Duke de Chartres, the Duke d’Ayen, the Duke de Duras, the
Duke de Nivernais, the Duke de Coigny, the Marquis d’Entraigues,
the Count de Maillebois, the Duchess de Brancas, the Marquise
Livry, the Countess d’Estrades, Madame de Marchais, and finally,
the principal actress, the Armida of all these enchantments, the
Marquise de Pompadour. The Duke de La Vallière was chosen as
director of the troupe; as sub-director l’historiogriffe of cats, Moncrif,
academician and reader to the Queen; as secretary and prompter,
the Abbé de La Garde, librarian to the Marquise. Madame de
Pompadour drew up the regulations for the players. As approved by
the King, they contained ten articles:—
“1. In order to be admitted as an associate, it will be necessary to
prove that this is not the first time that one has acted, so as not to
make one’s novitiate in the troupe.
“2. Every one shall choose his own line of characters.
“3. No one may choose a different line from that for which he has
been accepted, without obtaining the consent of all the associates.
“4. One cannot, in case of absence, appoint his substitute (a right
expressly reserved to the Society which will appoint by an absolute
majority).
“5. On his return, the person replaced will resume his own line.
“6. No associate can refuse a part appropriate to his line under
pretext that such a part is unsuitable to his manner of acting or too
fatiguing.
“7. The actresses alone have the right to select the pieces to be
represented by the troupe.
“8. They shall also have the right to fix the day of representation,
the number of rehearsals, and the days and hours when they shall
occur.
“9. Each actor is bound to be present at the precise hour
appointed for the rehearsal under penalty of a fine which the
actresses alone shall determine among themselves.
“10. To the actresses alone a half-hour’s grace is accorded, after
which the fine they will have incurred shall be decided by themselves
only.
“A copy of these statutes will be given to each secretary, who shall
be bound to fetch it to each rehearsal.”
Madame de Pompadour was quite right in drawing up a severe
code of regulations, for it is not an easy thing to establish discipline
in a troupe composed of society people, where the intrigues of the
courtier are added to the vanity of the actor. What petty jealousies,
what mean vanities! What manœuvres to obtain this or that part,
what solicitations and cabals to ensure merely a spectator’s place in
the cœnaculum!
Louis XV. occupied himself seriously with such trifles. The
direction of this miniature theatre gave him no fewer cares than the
government of France. He reserved to himself the right of selecting
the spectators, and it was a signal favor to have been thus chosen.
Notwithstanding their ardent desire to be among the privileged
persons, neither Marshal de Noailles, the Duke de Gesores, nor the
Prince de Conti were admitted to the opening of the theatre. It took
place January 17, 1747. Tartuffe was given. Madame de Pompadour
played Dorine. The first theatrical season of the little cabinets lasted
until March 17.
After having secured applause as an actress in Tartuffe, Les Trois
Cousines, and Le Préjugé à la Mode, the Marquise triumphed as a
cantatrice in Erigone: “Madame de Pompadour sang very well,” says
the Duke de Luynes; “her voice has not much volume, but a very
agreeable sound; she knows music well and sings with much taste.”
The second theatrical season lasted from December 20, 1747, to
March 30, 1748. The first representation comprised a comedy, Le
Mariage fait et rompu, and a pastoral, Ismène, the words by Moncrif.
Voltaire’s Enfant prodigue was given December 20, to the author’s
great joy. Madame de Pompadour had promised Gresset to produce
Le Merchant. She kept her word. The play required two months of
study. It was given February 6, 1748, Madame de Pompadour
playing Lisette. The Duke de Nivernais was excellent as Valère, and
the Duke de Chartres took the part of Géronte. The grateful Gresset
thanked the Marquise thus:—
“On ne trace que sur le sable
La parole vague et peu stable
De tous les seigneurs de la cour;
Mais sur le bronze inaltérable
Les Muses ont tracé le nom de Pompadour
Et sa parole invariable.”[32]
Pastorals, opera ballets, comedies, succeeded each other quickly.

(The complete list may be found in the opuscule of M. Adolphe
Julien.) The usual spectators were those of the actors and actresses
who were not playing, Marshal Saxe, Marshal de Duras, all the
ministers, President Hénault, the Abbé de Bernis. The King did not
have a fauteuil. He sat in an ordinary chair and, according to the
Duke de Luynes, he seemed to be amused.
The Marquise was charming in the ballet of Almases. She had a
splendid costume: a low-cut corsage of pink taffeta trimmed with
silver wire, a petticoat of the same, pinked out with silver, opening
over a second petticoat of white taffeta pinked out and embroidered
in rose color; the mantle draping the whole was of white taffeta
glazed with silver and embroidered in flowers of their natural color.
The first dancer of the troupe was the Marquis de Courtenvaux;
the second, Count de Langeron. Others were the Duke de Beuvron
and Count de Melfort, to whom were adjoined a ballet corps
composed of young boys and little girls. Mesdemoiselles Gaussin
and Dumesnil, of the Comédie-Française, gave advice to the
actresses.
Under the title of Comédies et ballets des petites apartements, a
collection was published, bearing on its title-page a notice that it was
“Printed by express command of His Majesty.” Many were
displeased by this, especially the courtiers who were not admitted to
the much-envied entertainments. The Marquis d’Argenson, who for
some time had ceased to be minister of foreign affairs, wrote March
1, 1748, in his Danubian peasant style: “They have just published a
very ridiculous collection of the divertisements of the theatre of the
cabinets or small apartments of His Majesty,—wretched and
flattering lyrics; one finds in it dancing and singing actors, general
officers and buffoons, great court ladies and theatre girls. In fact, the
King spends his time nowadays in seeing the Marquise and the other
personages trained by all these professional actors, who familiarize
themselves with the monarch in an impious and sacrilegious
fashion.”
In October, 1748, France had lost, by the treaty of Aix-la-
Chapelle, an opportunity to enlarge its dominions. Louis XV.
consoled himself by enlarging, if not the realm, at least the theatre of
the little cabinets. A new hall was constructed in the space
containing the great staircase of the Ambassadors,[33] care being
taken to injure neither the marble nor the pictures. The new theatre
was movable. Fourteen hours were necessary to strip it, and twenty-
four to set it up again. It was opened November 27, 1748, by the
Surprises de l’amour, a play due to the collaboration of Gentil-
Beniard, Moncrif, and De Rameau. The hall was a masterpiece of
elegance. But Louis XV. was not amused. He yawned. The grand
opera of Tancred was given December 10, Madame de Pompadour
singing the part of Herminie. Two days later Quinault’s Mère
coquette was played. The really indefatigable Marquise took the part
of Laurette. She made a success, even according to D’Argenson,
her implacable enemy, who wrote, not without vexation: “The King,
who was said to be tired of the favorite sultana, is more insane than
ever about her. She has sung and played so well in the last ballets at
Versailles that the King praised her publicly, and caressing her
before everybody, said to her that she was the most charming
woman in France.”
The beginning of 1749 was signalized by the great quarrel
between the dukes of Richelieu and La Vallière. The Duke de
Richelieu was one of the four first gentlemen of the chamber who, in
virtue of their charge, had the grand apartments of the King under
their jurisdiction. Now the new theatre was constructed in the space
occupied by the great stairway of the Ambassadors, which was
considered an integral part of the grand apartments. Consequently,
the first gentlemen of the chamber claimed that the right to direct the
theatre appertained to that one of themselves who was on duty, and
that the Duke de La Vallière infringed upon this right. The Duke
d’Aumont, who was on duty in 1748, raised the question, but
somewhat timidly. Madame de Pompadour mentioned the matter to
Louis XV., who contented himself with replying: “Let His Excellency”
(the title he gave Richelieu) “come. You will see something quite
different.”
His Excellency made his appearance at the beginning of 1749,
and as soon as he took up his functions he began a desperate
struggle against the Duke de La Vallière.
“He made nothing of thwarting little Pompadour,” wrote
D’Argenson, “and treating her like an opera girl, having had great
experience with that sort of women and with all women. Mistress as
she is of the King and the court, he will torment and tire her out.”
But Richelieu went too far. Some days later, D’Argenson wrote in
his journal: “M. de Richelieu is too much attached to the trifles of the
ballet theatre. They say he has behaved like a fool; he was too open
in his antagonism to the mistress, and she has regained the upper
hand. People consider her to count for as much or more than
Cardinal Fleury in the government. Woe to any one who dares to pit
himself against her at present! She unites pleasure to decision, and
the suffrages of the principal ministers to the force of habit which is
constantly gaining strength in a mild and affectionate monarch. But
woe to the state governed in this way by a coquette! People are
exclaiming on all hands. It is kicking against the pricks to revolt in
any wise against her. Richelieu has found that out; he ought to give
up this trifling business of the ballet stage in order to pursue greater,
more important, and more virtuous matters. It would have been
enough for him to absent himself from these operas and to do so
from pride, as soon as his charge was injuriously affected by them.
The instructions he gave the musicians were thus worded: ‘Such a
person will be present at such an hour to play in Madame de
Pompadour’s opera.’ He was worsted at every step. The real friends
of those who made any pretensions advised them strongly to make
their way by means of Madame the Marquise; homage must be paid
to her.”
Like the majority of men too much favored by women, Richelieu
resembled a spoiled child. He was stingy, proud, and wilful.
However, he ended by yielding. When this quarrel of etiquette was at
its height, Louis XV. carelessly asked him this simple question:
“Richelieu, how many times have you been at the Bastille?”—“Three
times,” responded the audacious courtier. But he promised himself
not to go a fourth time. He submitted, therefore, and the Duke de La
Vallière, who remained director of the troupe, was rewarded for his
patience by the blue ribbon.
The third theatrical season ended March 22, 1749; it had cost at
least a hundred thousand ecus. Louis XV., who was not always
prodigal, began to find the expenses excessive. He did not get his
money’s worth in amusement. The fourth and last theatrical season
of the little cabinets lasted from December 26, 1749, to April 27,
1750.
Madame de Pompadour had successfully attempted comedy,
opera, and ballet. She wanted to add another gem to her crown.
After Thalia, Euterpe, and Terpsichore, it was now the turn of
Melpomene. February 28, 1750, the Marquise played the part of
Alzire. Voltaire, enraptured, went to thank her for her interpretation of
his work, as she was at her toilette, and addressed her in this not
very original impromptu:—
“Cette Américaine parfaite
Trop de larmes a fait couler.
Ne pourrai-je me consoler
Et voir Venus à sa toilette?”[34]
The King began to be bored by these incessant spectacles. He

decided that there should be no more comedies, ballets, music, and
dancing at Versailles, and that hereafter the representations should
take place at the Château of Bellevue. The stage of this château was
very small, and did not admit of a brilliant mise en scène. The
number of spectators had to be greatly restricted. Accustomed to a
real theatre, splendid decorations, and a numerous audience, the
actors and actresses no longer showed the same enthusiasm. The
hour of decadence had come. However, Jean Jacques Rousseau’s
Devin du Village was very successfully played in 1753. Madame de
Pompadour took the part of Colette. The next day she sent fifty louis
to Jean Jacques, who thanked her in the following letter:—
“Paris, March 7, 1753.—Madame: In accepting this present, which
has been sent me by you, I believe I have testified my respect for the
hand from which it came, and I venture to add that of the two proofs
you have made of my moderation, interest is not the most
dangerous. I am with respect, etc.”
The Devin du Village was the Swan Song. Madame de
Pompadour no longer pleased Louis XV. as an actress. Hence she
closed the Bellevue theatre, and her ambition became, if not to
amuse, at least to interest, as a political woman, the master whose
mistress she was said to be.
V
THE GRANDEURS OF THE MARQUISE DE POMPADOUR
L ouis XV. had made his mistress what one might call a vice-queen.
She had the power, luxury, riches, and adulations of royalty;
everything, in fact, except its moral prestige. Surrounded by a
court of ministers, prelates, and nobles, she throned it in the midst of
pomp and opulence. She was the type of the woman à la mode,
elegant, coquettish, absolute, always on show, insatiable for praise
and success, thirsting for dignities, pleasures, and money; playing
not merely the great lady, but the sovereign, having her courtiers, her
creatures, her poets, reigning alike over the King and the kingdom.
M. Arsène Houssaye has said with justice: “Louis XV. had three
prime ministers: Cardinal Fleury, the Duke de Choiseul, the Marquise
de Pompadour.” But the Marquise was not an ordinary prime
minister; she was a prime minister doubled with a mistress. To a
woman invested with this exaggerated rôle, a display of power was
necessary. The favorite set herself to create around her a sort of
decorum, etiquette, and factitious grandeur. Like little women who
wear enormously high heels, she made herself a pedestal. Madame
d’Étioles had disappeared; nothing remained but the Marquise de
Pompadour. To be a marchioness did not satisfy her, and she
demanded and obtained the tabouret and the honors of a duchess.
She had a box at the court theatre with a grating behind which she
shut herself up tête-à-tête with the King. In the chapel a gallery in the
grand tribune was reserved for her and her suite. People waited on
her stairway at the hour of her toilette just as they await a ministerial
audience in an ante-chamber. She used to say to the ministers:
“Continue; I am satisfied with you,” and to the foreign ambassadors:
“Observe that on Tuesdays the King cannot see you, gentlemen, for
I think you will hardly follow us to Compiègne.”
One of the cabinets in her apartment was full of petitions.
Solicitors approached her with respectful fear. The ducal mantle and
velvet cap figured on the panels of her carriages. A nobleman
carried her mantle and awaited her coming in the ante-chamber. A
man of illustrious birth, a Chevalier d’Hénen, of the family of the
Princes de Chimay, rode at her carriage door as equerry. She was
served at table by a Chevalier of Saint Louis, her steward Colin, a
napkin under his arm. Her chambermaid was a woman of quality,
Madame du Hausset, who has left such curious Memoirs. The all-
powerful favorite had not forgotten her family. Her father was
ennobled in 1747. Her brother, Abel Poisson, became successively
Marquis de Vandières, Marquis de Marigny, Marquis de Ménars. The
marquisate not contenting him, he obtained a place created for
Colbert, that of superintendent of crown buildings. He was as a
patron of artists a Mecænas, an arbiter elegantiarum. The King, who
treated him as his brother-in-law, gave him the blue ribbon and put
him on an equality with the greatest nobles of the realm. Young
Alexandrine, the daughter of Madame de Pompadour and M. de
Étioles, was brought up at Paris in the convent of the Assumption.
The nuns showed her the greatest attention. She was addressed
by her baptismal name, as was then the custom for princesses of the
blood, and she was expected to make one of the most brilliant
marriages in France. Madame de Pompadour desired pomp even in
death. She bought a splendid sepulchre in the Capuchin convent in
the Place Vendôme, Paris, from the Trémoille family. There she built
a magnificent mausoleum, where her mother was interred and where
she reserved a place for herself.[35]
The favorite had not simply power, but beauty; beauty, that
supreme weapon. A veritable magician, she transformed herself at
will. As mobile as the clouds, as changeful as the wave, she
renewed and metamorphosed herself incessantly. No actress knew
better than she how to compose an attitude or a countenance. In her
whole person there was an exquisite grace, an exceptional charm, a
taste, an elegance which amounted to subtlety. La Tour, the pastel
painter, is he who has best reproduced her animated, spirituelle,
triumphant physiognomy, the eyes full of intelligence and audacity,
the satin skin, the supple figure, the general harmony, the charming
and coquettish whole.
All the splendors of luxury were like a frame to the picture. A new
Danaë, the Marquise disappeared under a shower of gold. It is
known exactly what she cost France from September 9, 1745, the
time when her favor began, until April 15, 1764, the day of her death.
M. Le Roy has discovered an authentic document,[36] containing an
account of the favorite’s expenses during this period of nearly twenty
years. The total is 35,924,140 livres. In this list of expenses is found
the pension granted to Madame Lebon for having predicted to the
Marquise, then only nine years old, that she would one day be the
mistress of Louis XV.
Nothing seemed fine enough for Madame de Pompadour, either in
dress, lodgings, or furniture. At Versailles she secured for herself on
the ground floor, on the terrace looking toward the parterre on the
north, the magnificent apartments occupied by the Duke and
Duchess de Penthièvre.[37] (Part of the ministry of foreign affairs is
established there at present. The minister’s study is the same as that
of Madame de Pompadour. Her bedchamber is now the thirteenth
hall of the marshals, her ante-chamber the hall of famous warriors.)
The favorite bought a superb house in the city communicating by
a passage with the apartments of the palace (it is now the hôtel des
Réservoirs). In 1748 she acquired the château of Ciécy and the
estate of Aunay, and in 1749 the château of La Celle, near
Versailles. In 1750 she inaugurated, on the hill commanding the
Seine, between Sèvres and Meudon, that enchanting abode of
Bellevue, where all the arts rivalled each other to create a magic
entity. The ante-chamber with statues by Adam and Falconnet; the
dining-room with paintings of game and fish by Oudry; the salon
decorated by Vanloo; the apartment of the Marquise, hung with
Boucher’s glowing pictures; the park with its parterres of rare
flowers, its fine trees, grottos, and fountains, its statues by Pigalle
and Coustou, its varied perspectives, its immense horizons,—all
made of Bellevue a real palace of Armida. At Versailles, the
Marquise obtained from the King a portion of the little park wherein
to construct a gem of architecture, which she called the Hermitage; it
cloaked extreme elegance under an appearance of simplicity. It had
fine Persian hangings, panelled wainscotings decorated by the most
skilful painters, thickets of myrtles, lilacs, and roses. This habitation
is no longer in existence; a part of its site is occupied by the rue de
l’Ermitage at Versailles. The Marquise had a house at Compiègne
and a lodge at Fontainebleau. At Paris she bought, for seven
hundred and thirty thousand livres, the hôtel d’Evreux, which is now
the Élysée.
At the Trianon her apartment was on the same floor with that of
Louis XV. At Clécy she received as if in a royal château. The King’s
visits to this splendid residence used to last three or four days, and
cost about one hundred thousand livres.
A woman so influential could not fail to have a swarm of flatterers.
The resources of fawning and hyperbole were exhausted in her
favor. The most exaggerated of her sycophants was Voltaire—
Voltaire to whom the republicans are nowadays raising statues. He
treated the Marquise as a superior being, a goddess, and pushed his
flattery to absurdity, to platitude. In 1745, the moment when the reign
of the favorite began, he sent her this compliment:—
“Sincère et tendre Pompadour
(Car je peux vous donner d’avance
Ce nom qui rime avec l’amour
Et qui sera bientôt le plus beau nom de France),
Ce tokai dont Votre Excellence
Dans Étioles me régala,
N’a-t-il pas quelque ressemblance
Avec le roi qui le donna?
Il est, comme lui, sans mélange;
Il unit, comme lui, la force à la douceur,
Plaît aux yeux, enchante le cœur,
Fait du bien et jamais ne change.”[38]
In 1746, when Marshal de Lowendal had just taken Berg-Op-

Zoom, it was Madame de Pompadour whom Voltaire felicitated on
the victory, in strains like these:—

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Pediatric Asthma A Clinical Support

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PAACSC FLIP CHART.indd 1 3/8/22 3:17 PM

PAACSC FLIP CHART.indd 1 3/8/22 3:17 PM

Patient with respiratory symptoms

Perform spirometry with

NO Repeat on another occasion

Treat for ASTHMA Treat for alternative diagnosis

1 Tab 1. Approach to Evaluation

PAACSC FLIP5.625 page1

The 2 components of airway obstruction in

PAACSC FLIP CHART.indd 2 3/8/22 3:17 PM

Asthma Predictive Index (API) Considering Alternative Diagnoses

PAACSC FLIP CHART.indd 3 5.625 page 3/8/22 3:17 PM

Pediatric Spirometry Algorithm

No Check both the VT and FV

No Sufficient Was the VT plateau at least

Are there at least 3 acceptable

PAACSC FLIP CHART.indd 4 3/8/22 3:17 PM

5 Tab 3. Office Pulmonary Function Testing

PAACSC FLIP CHART.indd 5 5.625 page 3/8/22 3:17 PM

Formal Evaluation of Asthma Exacerbation Severity

PAACSC FLIP CHART.indd 6 3/8/22 3:17 PM

7 Tab 4. Exacerbation Assessment

PAACSC FLIP5.625 page7

Grading Asthma Severity

Pediatric Respiratory Assessment Measure (PRAM)

PRAM for Use in Children 2 to 17 Years of Age

PAACSC FLIP CHART.indd 8 3/8/22 3:17 PM

Pulmonary Index Score (PIS)

PIS for Young Children, 1 to 5 Years of Age

PIS for Older Children and Adolescents, 6 to 18 Years of Age

9 Tab 5. Respiratory Scoring Tools

PAACSC FLIP CHART.indd 9 5.625 page 3/8/22 3:17 PM

Classifying Asthma Severity and Initiating Therapy in Children Ages 0 to 11

PAACSC FLIP CHART.indd 10 3/8/22 3:17 PM

11 Tab 6. Classifying Severity by Age

PAACSC FLIP CHART.indd 11 3/8/22 3:17 PM

Asthma Intervention Overview

PAACSC FLIP CHART.indd 12 3/8/22 3:17 PM

Additional Decisions: When to Transfer

13 Tab 7. Intervention Overview

PAACSC FLIP5.625 page13

NIH/NHLBI STEPWISE APPROACH TO ASTHMA MANAGEMENT: 0–4 YEARS

Intermittent Asthma Management of Persistent Asthma in Individuals Ages 0–4 Years

Treatment STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 STEP 6

PAACSC FLIP CHART.indd 14 3/8/22 3:17 PM

NIH/NHLBI STEPWISE APPROACH TO ASTHMA MANAGEMENT: 5–11 YEARS

Intermittent Asthma Management of Persistent Asthma in Individuals Ages 5–11 Years

Treatment STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 STEP 6

15 Tab 8. NIH/NHLBI Stepwise Approaches

PAACSC FLIP CHART.indd 15 5.625 page 3/8/22 3:17 PM

NIH/NHLBI STEPWISE APPROACH TO ASTHMA MANAGEMENT: 12+ YEARS

Intermittent Asthma Management of Persistent Asthma in Individuals Ages 12+ Years

Treatment STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 STEP 6 

Step 4: Medium- or high-dose An option is to use high-dose ICS and LTRA.