Pediatrics (System-Integrated)

Pediatric asthma: stepwise management

Clinical Overview and When to Suspect Pediatric Asthma

— Most common chronic disease of childhood; ~8% US prevalence

— Higher burden in Black and Puerto Rican children, urban poverty, exposure to tobacco smoke, mold, cockroach/mouse allergens

— Boys > girls before puberty; reverses after adolescence

— Recurrent wheeze, cough (especially nocturnal or exercise-induced), chest tightness, dyspnea

— Symptoms triggered by URIs, allergens, cold air, exercise, laughter, smoke

— Personal or family history of atopy: eczema, allergic rhinitis, food allergy (the atopic march)

— Improvement with bronchodilator trial

Definition: Chronic inflammatory airway disease with reversible bronchoconstriction, airway hyperresponsiveness, and variable expiratory airflow obstruction in children ≥1 year old.

Epidemiology:

When to suspect in clinic:

Asthma Predictive Index (mAPI) for kids <3 with ≥4 wheezing episodes/year — positive if ≥1 major (parental asthma, atopic dermatitis, aeroallergen sensitization) OR ≥2 minor (food sensitization, eosinophils ≥4%, wheezing apart from colds).

Diagnostic threshold: Clinical pattern + demonstration of reversible obstruction (spirometry ≥5 yo; symptom-based in younger children).

Step 3 management: In an outpatient encounter, the moment you label a child "asthma," you owe them four parallel orders — (1) controller per severity step, (2) rescue SABA + spacer, (3) written asthma action plan, and (4) trigger/environmental counseling. Missing the action plan is a recurring Step 3 distractor.

Board pearl: A child with "recurrent pneumonia" who keeps clearing without antibiotics, has nighttime cough, and a family history of eczema almost certainly has asthma — not infection. Reframe the stem before ordering chest CT.

Key distinction: Transient infant wheezing (resolves by age 3, viral-driven, no atopy) vs persistent atopic asthma (mAPI-positive, often lifelong) — only the latter benefits from early ICS.

Presentation Patterns and Key History

— Infants/toddlers: cough-predominant, tachypnea, retractions, feeding difficulty; wheeze may be absent if severely obstructed

— School-age: exercise-induced cough/wheeze, PE class avoidance, post-viral lingering cough >4 weeks

— Adolescents: nocturnal awakenings, decreased exercise tolerance, frequent albuterol use, silent chest during severe exacerbation

— Viral URIs (most common pediatric trigger)

— Aeroallergens: dust mite, cockroach, mouse, cat/dog, mold, pollen

— Tobacco/vape smoke exposure (direct and secondhand)

— Exercise, cold air, laughter, crying

— GERD, allergic rhinitis, obesity — comorbid amplifiers

— Medications: beta-blockers, NSAIDs/ASA (older kids)

— Daytime symptoms >2 days/week?

— Nighttime awakenings? (>1×/month child ≤4; >2×/month if ≥5)

— SABA use for symptoms >2 days/week?

— Activity limitation?

— Plus exacerbation history requiring oral steroids in past year

Classic symptom tetrad: wheeze, cough, chest tightness, dyspnea — episodic, variable, often worse at night or early morning.

Pattern recognition by age:

High-yield trigger history (must ask all):

Control assessment (every visit) — NAEPP/EPR-4 framework: In the past 4 weeks:

Risk-of-future-exacerbation history: ≥2 OCS bursts/year, prior ICU/intubation, low FEV1, high SABA use (>1 canister/month is a red flag).

Step 3 management: Step up therapy when either impairment OR risk domain is uncontrolled — don't wait for both. A child with normal daytime symptoms but two ED visits this year still needs a step-up.

Board pearl: Cough-variant asthma in children presents as chronic dry cough without wheeze; diagnosis is made by bronchodilator response or methacholine challenge in older children. Empiric SABA + ICS trial is appropriate before chasing zebras.

Physical Exam Findings and Severity Assessment

— Mild: SpO2 ≥95% RA, talks in sentences, mild retractions, end-expiratory wheeze, RR mildly elevated

— Moderate: SpO2 91–95%, talks in phrases, suprasternal/intercostal retractions, loud wheeze throughout expiration, accessory muscle use

— Severe: SpO2 <91%, talks in words only, marked retractions + nasal flaring, inspiratory + expiratory wheeze, prolonged expiratory phase, HR >140 (or age-elevated), agitation

— Impending respiratory failure (life-threatening): silent chest, cyanosis, somnolence/confusion, paradoxical thoracoabdominal movement, bradycardia, SpO2 <90% on O2

Interval (well) exam: Often completely normal — does not exclude asthma. Look for atopy clues: allergic shiners, Dennie-Morgan lines, transverse nasal crease ("allergic salute"), boggy turbinates, eczema, nasal polyps (think CF if present).

Acute exacerbation exam — pediatric severity grading:

Pulsus paradoxus: >20 mmHg drop suggests severe obstruction (rarely measured in pediatric ED but classic board sign).

PASS / PRAM scores: Validated pediatric asthma severity scores combining wheeze, retractions, air entry, O2 sat — guide disposition.

CCS pearl: In a CCS-style case, vitals + lung exam drive the next order. Sat 88% on RA → immediate O2, continuous pulse ox, SABA nebs every 20 min ×3, ipratropium, oral or IV corticosteroid — all in the first virtual hour. Don't sequence them one at a time.

Key distinction: A wheezing child who suddenly becomes quiet with worsening work of breathing is not improving — silent chest = airflow too low to generate wheeze. This is a pre-arrest sign and an ICU trigger.

Board pearl: Always check for clubbing — its presence essentially rules out uncomplicated asthma and points to CF, bronchiectasis, or ILD. Asthma alone does not cause clubbing.

Diagnostic Workup — Initial Studies

— Pre- and post-bronchodilator

— Obstruction: FEV1/FVC <85% predicted (pediatric cutoff; adults use 70%)

— Reversibility: FEV1 increase ≥12% post-albuterol confirms asthma

— Normal spirometry between episodes does NOT exclude asthma

— First wheezing episode in infant (rule out foreign body, vascular ring, mass)

— Asymmetric breath sounds (pneumothorax, foreign body, mucous plug atelectasis)

— Suspected pneumonia, failure to respond to therapy, severe exacerbation

— Typical findings: hyperinflation, peribronchial cuffing, atelectasis (often RML)

Spirometry (gold standard, ≥5–6 years old, cooperative):

Peak expiratory flow (PEF): Useful for home monitoring in moderate-severe asthma; >20% diurnal variability supports diagnosis. Less sensitive than spirometry — not first-line for diagnosis.

Pulse oximetry: Every acute visit; <92% on RA = moderate-severe exacerbation.

Chest X-ray — NOT routine. Indications:

CBC: Not routine. Eosinophilia (>4%) supports atopic phenotype and mAPI.

ABG: Reserved for severe exacerbation. Normal or rising PCO2 in a tachypneic asthmatic = impending respiratory failure — a classic Step 3 trap. Don't be reassured by a "normal" 40.

Allergy testing (skin prick or specific IgE): For persistent asthma to identify avoidable triggers and candidates for immunotherapy/biologics.

FeNO (fractional exhaled nitric oxide): Elevated (>20 ppb children, >35 adolescents) suggests eosinophilic inflammation; helps guide ICS responsiveness and adherence monitoring.

Step 3 management: Order spirometry at diagnosis, at 3–6 months after starting/changing therapy, then at least annually. Skipping annual spirometry is a quality-metric miss frequently tested.

Board pearl: Bronchoprovocation (methacholine, exercise, mannitol) is used when spirometry is normal but suspicion remains high — drop in FEV1 ≥10–15% confirms hyperresponsiveness.

Diagnostic Workup — Confirmatory and "Don't Miss" Studies

— Onset in first 6 months of life

— Failure to thrive, chronic diarrhea, recurrent sinopulmonary infections → CF sweat chloride test, immunoglobulins

— Focal/fixed wheeze → CT chest, bronchoscopy (foreign body, vascular ring, bronchomalacia, mass)

— Stridor or biphasic noise → laryngoscopy (vocal cord dysfunction, laryngomalacia, subglottic stenosis)

— Clubbing → CF, bronchiectasis, ILD

— Hemoptysis → bronchiectasis, AVM, pulmonary hemosiderosis

— Sweat chloride if any CF feature (≥60 mmol/L diagnostic)

— Quantitative immunoglobulins (IgG/A/M/E), vaccine titers if recurrent bacterial infections

— pH/impedance probe or empiric PPI trial for suspected GERD-driven asthma

— Sleep study in obese adolescent with poorly controlled asthma + snoring

— Bronchoscopy for fixed obstruction, suspected foreign body, recurrent same-lobe pneumonia

— CT chest (high-resolution) for suspected bronchiectasis, ILD, or congenital malformation

When asthma "doesn't fit," reconsider the diagnosis before escalating therapy. Red flags demanding further workup:

Targeted confirmatory tests:

FeNO trending: Useful to confirm adherence — a "non-responder" with low FeNO is likely not taking the ICS.

Aspergillus-specific IgE / total IgE >1000: Screen for ABPA in difficult-to-control asthma, especially with CF or central bronchiectasis.

Key distinction: Vocal cord dysfunction (paradoxical vocal fold motion) mimics asthma but features inspiratory stridor, throat tightness, normal SpO2, blunted inspiratory loop on flow-volume curve — treated with speech therapy, not ICS.

Board pearl: A toddler with sudden-onset unilateral wheeze and no atopy history has foreign body aspiration until proven otherwise — get inspiratory/expiratory or decubitus films and consult ENT/pulm for rigid bronchoscopy. Do not start ICS.

Severity Classification and Stepwise Logic (NAEPP/EPR-4 2020)

— Intermittent: symptoms ≤2 days/week, nighttime ≤2×/month (≥5 yo) or 0 (≤4 yo), SABA ≤2 days/week, no activity limit, 0–1 OCS bursts/year

— Mild persistent: symptoms >2 days/week (not daily), nighttime 3–4×/month, minor limitation

— Moderate persistent: daily symptoms, nighttime >1×/week, daily SABA, some limitation

— Severe persistent: symptoms throughout day, nighttime ≥4×/week, multiple times daily SABA, extreme limitation

— 0–4 years: 6 steps — Step 1 SABA PRN → Step 2 daily low-dose ICS → Step 3 medium ICS → Step 4 medium ICS + montelukast or LABA → Steps 5–6 high-dose ICS ± OCS + specialist

— 5–11 years: Step 2 low ICS; Step 3 low ICS-formoterol SMART (preferred) or medium ICS; Step 4 medium ICS-formoterol SMART; Steps 5–6 add LAMA/biologic/OCS

— ≥12 years: Mirrors adult GINA — Steps 3–4 ICS-formoterol SMART preferred; Step 5 add LAMA (tiotropium) and consider biologic

Initial severity classification (untreated patient) drives starting step; subsequent management is by control assessment.

Categories — based on most severe feature in either impairment or risk domain:

Age-stratified steps:

SMART (Single Maintenance And Reliever Therapy): ICS-formoterol used both as daily controller AND as reliever; reduces exacerbations vs SABA-only rescue. Preferred ≥5 yo at Steps 3–4.

Step up if not controlled after 2–6 weeks of adherence/technique check. Step down after ≥3 months of well-controlled asthma — reduce by ~25–50% of ICS dose.

Step 3 management: Before stepping up, always verify the "4 A's": Adherence, Allergens/triggers, Alternate diagnosis, Aerosol (inhaler) technique. ~50% of "uncontrolled" pediatric asthma resolves with technique correction and spacer use.

Board pearl: Children <5 cannot use formoterol-based SMART reliably — keep them on conventional ICS + SABA rescue.

Pharmacotherapy — Controllers and Relievers

— Fluticasone, budesonide (nebulized option for <4 yo), beclomethasone, mometasone, ciclesonide

— Reduce airway inflammation, decrease exacerbations, improve lung function

— Adverse effects: oral candidiasis (rinse mouth, use spacer), dysphonia, mild transient growth velocity reduction (~1 cm cumulative, no final height impact at low–medium doses), rare adrenal suppression at high doses

— Alternative controller, useful in exercise-induced bronchospasm and concomitant allergic rhinitis

— Black box (2020): neuropsychiatric effects — agitation, depression, suicidality, sleep disturbance. Counsel families and reserve for cases where ICS isn't suitable

— Omalizumab (anti-IgE) — allergic asthma, IgE 30–1300, ≥6 yo

— Mepolizumab, benralizumab (anti-IL-5/5R) — eosinophilic asthma

— Dupilumab (anti-IL-4Rα) — eosinophilic or OCS-dependent; bonus benefit in eczema

— Tezepelumab (anti-TSLP) — broad phenotype, ≥12 yo

— SABA (albuterol) PRN — but isolated SABA use is now discouraged ≥5 yo in favor of ICS-formoterol SMART

— ICS-formoterol PRN reliever in SMART

Inhaled corticosteroids (ICS) — cornerstone of controller therapy:

LABAs (salmeterol, formoterol): Never as monotherapy — black box warning for asthma death. Always combined with ICS. Formoterol's rapid onset enables SMART.

Leukotriene receptor antagonists (montelukast):

LAMA (tiotropium Respimat): Add-on ≥6 yo with uncontrolled asthma despite ICS-LABA.

Biologics (severe persistent, specialist-managed, ≥6 yo typically):

Relievers:

Step 3 management: Always prescribe a spacer with valved holding chamber (mask <4 yo, mouthpiece ≥4 yo) for MDIs — improves drug delivery from ~10% to ~40%. A prescription for an MDI without a spacer is a tested error.

Board pearl: Document inhaler technique observation at every visit; poor technique is the #1 reversible cause of "treatment failure."

Acute Exacerbation Management — ED and Inpatient

— Pulse oximetry, severity score (PRAM/PASS)

— O2 to keep SpO2 ≥92% (≥94% in young infants)

— Albuterol nebulized 2.5 mg (<20 kg) or 5 mg (≥20 kg) every 20 min ×3, or continuous neb 10–15 mg/hr for severe

— Ipratropium 250–500 mcg added to first 3 nebs for moderate-severe (reduces admission)

— Systemic corticosteroid within 1 hour: oral prednisolone/dexamethasone preferred if tolerating PO

· Dexamethasone 0.6 mg/kg (max 16 mg) ×1–2 doses — equivalent to 5-day prednisolone, better adherence, less vomiting

· Prednisolone 1–2 mg/kg/day (max 60 mg) ×5 days

· IV methylprednisolone if vomiting/severe

— Improving → space nebs to q1–2h, observe, consider discharge if stable ≥1 hour after last neb

— Not improving → escalate

— IV magnesium sulfate 25–50 mg/kg (max 2 g) over 20 min — smooth muscle relaxant

— Heliox (70:30 He:O2) — reduces work of breathing

— IV terbutaline bolus + infusion (cardiac monitoring required)

— High-flow nasal cannula or NIV (BiPAP) before intubation

Initial triage (first 60 minutes):

Reassess at 1 hour:

Second-tier therapy (severe/refractory):

Intubation indications: apnea, coma, refractory hypoxemia, rising PCO2 with fatigue. Use ketamine for induction (bronchodilator). Permissive hypercapnia; low RR, long expiratory time, watch for breath-stacking and pneumothorax.

CCS pearl: On CCS, simultaneous orders win — pulse ox, O2, albuterol-ipratropium nebs, oral dex, IV access; reassess at 60 minutes and either continue/space nebs or advance to magnesium + admit. Don't forget to continue the patient's home ICS through the exacerbation.

Avoid: routine antibiotics (no benefit unless bacterial infection), sedatives (mask respiratory failure), chest physiotherapy, mucolytics.

Special Populations — Comorbidities and Inhaler Pharmacology Considerations

— Low-medium dose ICS cause small (~1 cm) decrement in growth velocity in year 1, largely non-progressive; final adult height impact minimal

— Monitor height at every visit, plot on growth chart

— Use lowest effective dose; step down once controlled ≥3 months

— Risk rises with high-dose ICS, frequent OCS bursts, or concomitant intranasal/topical steroids

— Symptoms: fatigue, hypoglycemia, poor growth, hypotension during stress

— Stress-dose steroids for surgery/severe illness if on chronic high-dose ICS or recurrent OCS

— Allergic rhinitis — treat with intranasal steroid; improves asthma control

— Eczema — emollients, topical steroids; consider dupilumab if severe + asthma

— Food allergy — epinephrine auto-injector; food allergy + asthma = highest anaphylaxis fatality risk

— GERD — empiric PPI trial only if symptomatic; routine PPI not recommended

Pediatrics doesn't include geriatrics or renal/hepatic dose-adjusted scenarios commonly tested in adults — refocus on age-stratified physiology, growth, and comorbidity management.

Growth and ICS:

Adrenal suppression:

Atopic comorbidities (the "united airway"):

Obesity: Worsens control, lowers ICS response; weight management is a controller intervention. Screen for OSA.

Hepatic/renal: Inhaled drugs have negligible systemic exposure; montelukast metabolized hepatically — caution in severe liver disease.

Step 3 management: A child on chronic medium-high dose ICS needing surgery should receive perioperative stress-dose hydrocortisone if any signs of HPA suppression or ≥3 OCS bursts in the past year. Verify with morning cortisol if uncertain.

Board pearl: Aspirin-exacerbated respiratory disease (AERD: asthma + nasal polyps + NSAID sensitivity) is rare in young children but emerges in adolescence — avoid NSAIDs, use leukotriene modifier, consider aspirin desensitization.

Special Populations — Infants, Adolescents, Pregnancy in Teen Patients

— Distinguish viral bronchiolitis (first episode, RSV season) from early asthma

— Recurrent wheeze with positive mAPI → trial daily low-dose ICS or as-needed budesonide nebs with viral URIs (PRINCE/MIST data)

— Use nebulizer with face mask, snug fit, tidal breathing; spacer with mask acceptable

— Avoid montelukast as first-line under 2 (limited data, neuropsych warning)

— Spacer + mask MDI delivery

— Daily low-dose ICS preferred over montelukast at Step 2 (CARE Network LOOP/INFANT trials)

— Intermittent high-dose ICS at URI onset is an option for episodic viral wheezers

— Transition to spacer + mouthpiece around age 4–5

— Introduce peak flow monitoring and self-management around age 7–8

— SMART therapy ≥5 yo at Steps 3–4

— Adherence is the dominant issue — assess directly, use pharmacy refill data

— Screen for vaping, smoking, depression, vocal cord dysfunction

— Transition planning to adult care starting age 14

— Uncontrolled asthma carries greater fetal risk than medications

— Budesonide is the preferred ICS (most safety data, Category B historically)

— Continue albuterol, LABAs, montelukast as needed

— Avoid live vaccines if on biologics; otherwise routine prenatal care

Infants and toddlers (<2 years):

Preschool (2–5 years):

School-age (5–11):

Adolescents:

Pregnancy (adolescent patients):

Step 3 management: For an adolescent with poorly controlled asthma, simultaneously address inhaler technique, adherence (consider switching to once-daily regimens), mental health screen (PHQ-9), and trigger reduction including vaping cessation — this is the multi-axis Step 3 thinking.

Board pearl: A pregnant teen with worsening asthma in second trimester needs step-up of controller, not step-down — pregnancy is not a reason to lower ICS dose.

Complications and Adverse Outcomes

— Status asthmaticus — severe refractory exacerbation

— Respiratory failure requiring intubation; mortality risk

— Pneumothorax/pneumomediastinum from air-trapping and barotrauma

— Atelectasis (often RML) from mucous plugging

— Airway remodeling — chronic untreated inflammation → fixed obstruction, reduced peak adult lung function

— Growth lag from uncontrolled disease itself (separate from ICS effects)

— School absenteeism, decreased exercise tolerance, anxiety/depression

— Death — preventable; risk factors include prior intubation, ≥2 hospitalizations or ED visits in past year, OCS use, low SES, poor adherence, food allergy

— ICS: oral thrush, dysphonia, growth velocity reduction, rare cataract/glaucoma, adrenal suppression at high dose

— SABA overuse: tachycardia, tremor, hypokalemia, paradoxical bronchospasm; >1 canister/month indicates poor control

— OCS bursts: hyperglycemia, mood changes, weight gain, immunosuppression; cumulative ≥4 lifetime bursts associated with increased osteoporosis, diabetes, cataracts later in life

— LABA monotherapy: increased asthma death — always combine with ICS

— Montelukast: neuropsychiatric (black box)

— Theophylline (rare now): narrow therapeutic window, arrhythmia, seizure

— Lactic acidosis from high-dose beta-agonists (benign, self-limited)

— Hypokalemia from albuterol + steroids — monitor K+ in severe exacerbations

— Hyperglycemia from systemic steroids

From the disease:

From therapy:

From acute therapy:

Key distinction: Acute hypokalemia + tachycardia in a wheezing child receiving continuous nebs is expected pharmacology, not toxicity — don't stop the albuterol; replete potassium and continue.

Board pearl: A child with sudden unilateral chest pain and worsening dyspnea during an exacerbation has pneumothorax until imaging proves otherwise — get an immediate upright CXR or POCUS.

When to Escalate Care — Admission, PICU, and Consults

— Sustained SpO2 ≥94% on RA

— Minimal/no respiratory distress

— Nebs spaced to ≥q4h

— Adequate PO intake, reliable caregiver, action plan provided, follow-up arranged within 1–2 weeks

— Needs nebs more frequent than q4h

— Persistent O2 requirement

— Inadequate response after 4–6 hours of ED therapy

— Social concerns, transportation, prior ICU history with rapid deterioration pattern

— Comorbidity (e.g., CF, neuromuscular disease)

— Continuous albuterol nebulization needed

— Need for IV magnesium, terbutaline, heliox, or NIV

— SpO2 <90% despite high-flow O2

— Rising PCO2, altered mental status, exhaustion

— Impending or actual respiratory failure

— Pneumothorax/pneumomediastinum requiring intervention

— Pulmonology: poor control despite Step 4, diagnostic uncertainty, biologic candidates, recurrent ICU admissions, suspected alternative diagnoses

— Allergy/Immunology: atopic phenotype, immunotherapy candidate, immunodeficiency evaluation

— ENT: chronic sinusitis, polyps, vocal cord dysfunction

— GI: refractory GERD

— Behavioral health: anxiety, depression, adherence challenges, vocal cord dysfunction

Discharge from ED (after observation):

Admit to general pediatric ward:

PICU admission criteria:

Specialist consults:

CCS pearl: On a CCS case, "transfer to PICU" is itself an orderable action — don't just keep escalating on the ward. When you've ordered continuous albuterol + IV mag + steroids and the child remains in severe distress, the next move is PICU transfer + anesthesia/ICU consult before respiratory arrest.

Step 3 management: Every admitted asthmatic needs discharge planning started on day 1 — controller optimization, action plan, PCP follow-up in 1–2 weeks, school notification, vaccination review (flu, COVID, pneumococcal).

Key Differentials — Other Wheezing/Obstructive Conditions

— Viral bronchiolitis (RSV, rhinovirus): age <2, first episode, URI prodrome, diffuse crackles + wheeze, supportive care; routine bronchodilators/steroids NOT recommended

— Foreign body aspiration: toddler, sudden onset, focal/unilateral wheeze, decreased breath sounds; inspiratory/expiratory CXR shows unilateral air-trapping; rigid bronchoscopy

— Cystic fibrosis: failure to thrive, recurrent sinopulmonary infections, steatorrhea, clubbing; sweat chloride ≥60 mmol/L

— Bronchopulmonary dysplasia: preterm history, chronic O2/ventilator exposure

— Bronchiolitis obliterans: post-infectious (adenovirus), post-transplant; fixed obstruction

— Tracheomalacia/bronchomalacia: expiratory stridor or "barky" wheeze, worsens with crying, bronchoscopy diagnoses

— Vascular ring/sling: persistent wheeze + dysphagia, barium swallow + CTA

— ABPA: uncontrolled asthma, central bronchiectasis, ↑IgE, Aspergillus precipitins

— Eosinophilic granulomatosis (EGPA): rare in kids; asthma + eosinophilia + vasculitis

Same-category (lower airway obstruction) mimics:

Key distinction: First wheezing episode in a previously well infant during winter with URI = bronchiolitis; recurrent wheezing episodes with atopy and bronchodilator response = early asthma. The third wheezing episode strongly favors asthma over bronchiolitis.

Board pearl: A toddler who "developed asthma" right after a choking episode at a birthday party has aspirated a foreign body — peanut or popcorn classic. Decubitus or expiratory films show air-trapping on the affected side; CXR may be normal — bronchoscopy if clinical suspicion remains.

Step 3 management: Before labeling any child with "refractory asthma" at Step 4–5, order sweat chloride, immunoglobulins, and consider bronchoscopy/HRCT to exclude masquerading diagnoses. Mislabeling delays definitive treatment.

Key Differentials — Upper Airway and Non-Pulmonary Mimics

— Croup (laryngotracheobronchitis): 6 mo–3 yr, barky cough, inspiratory stridor, low-grade fever; dexamethasone ± racemic epinephrine

— Epiglottitis: Hib-unvaccinated child, drooling, tripoding, toxic appearance; emergent airway in OR

— Bacterial tracheitis: high fever, stridor, post-viral, thick purulent secretions

— Anaphylaxis: rapid onset stridor + wheeze + urticaria + hypotension + GI; IM epinephrine first

— Laryngomalacia: infant, inspiratory stridor worse supine, usually benign self-resolution

— Subglottic stenosis: prior intubation history, biphasic stridor

— Retropharyngeal/peritonsillar abscess: drooling, neck stiffness, muffled voice

— Vocal cord dysfunction: adolescent, athletic, inspiratory stridor, throat tightness, normal SpO2 — flow-volume loop shows blunted inspiratory limb; speech therapy

— Cardiac: CHF (cardiac asthma), congenital heart disease with pulmonary overcirculation, vascular ring

— GERD with microaspiration

— Anxiety/panic with hyperventilation

— Mediastinal mass (lymphoma) — positional dyspnea, SVC syndrome

— Aspiration syndromes in neurologically impaired children

Upper airway causes (often stridor, not true wheeze):

Non-pulmonary causes of dyspnea/wheeze:

Key distinction: Stridor is inspiratory and signals upper airway obstruction; wheeze is expiratory and signals lower airway. Biphasic noise suggests fixed obstruction (subglottic stenosis, mass). Get the location right before reaching for albuterol.

Board pearl: A teenage athlete with "exercise-induced asthma" who fails ICS-LABA, has normal spirometry, and describes throat (not chest) tightness with audible inspiratory noise has vocal cord dysfunction — refer to speech-language pathology; albuterol won't help.

Step 3 management: Anaphylaxis with wheeze gets IM epinephrine into the anterolateral thigh first, then albuterol, steroids, antihistamines — never reverse the order.

Long-Term Control, Discharge, and Secondary Prevention

— Controller medication at or above pre-exacerbation step (consider step-up if exacerbation suggests inadequate control)

— Oral corticosteroid course completion (typically dex ×1–2 doses or prednisolone 5 days)

— SABA or ICS-formoterol reliever with refills

— Spacer prescribed and demonstrated

— Written asthma action plan in caregiver's language — green/yellow/red zones with specific medication doses, peak flow thresholds (if ≥5 yo using PEF), and "when to call/go to ED"

— PCP follow-up within 1–2 weeks, pulmonology if indicated

— School/daycare notification with action plan and authorization for in-school albuterol

— Reassess control every 1–6 months depending on severity

— Step down by ~25–50% ICS dose after ≥3 months well-controlled

— Continue ICS year-round even when asymptomatic (don't stop in summer)

— Annual influenza vaccine (inactivated; LAIV avoided in poorly controlled asthma)

— COVID-19 per current schedule

— PCV15/PCV20 and PPSV23 if on chronic high-dose ICS or recurrent OCS — high-risk pneumococcal indication

— Routine RSV nirsevimab for eligible infants

— Tobacco/vape cessation in household (offer caregivers cessation resources)

— Allergen reduction: dust mite covers, cockroach/mouse extermination, pet dander mitigation, mold remediation

— Address housing quality — refer to social work for substandard housing

After exacerbation/hospital discharge — every patient gets:

Long-term controller principles:

Vaccinations (secondary prevention):

Environmental modifications:

Allergen immunotherapy: Consider for moderate persistent allergic asthma with identifiable triggers; reduces long-term medication burden.

Step 3 management: Discharge checklist is a Step 3 favorite — medications, spacer, action plan, follow-up appointment, vaccines, school plan, trigger counseling. Missing the action plan is the single most-tested omission.

Board pearl: Caregiver smoking cessation produces measurable improvement in childhood asthma control within weeks — always counsel and offer pharmacotherapy referral.

Follow-Up, Monitoring, and Counseling

— Newly diagnosed or recently stepped up: 2–6 weeks to assess response and technique

— Stable, well-controlled: every 3–6 months

— Post-exacerbation/hospitalization: 1–2 weeks

— Spirometry: at diagnosis, 3–6 months after therapy initiation/change, then at least annually ≥5 yo

— Control assessment (impairment + risk domains — use validated tools: ACT ≥12 yo, C-ACT 4–11 yo, TRACK <5 yo)

— Inhaler technique observed and corrected

— Adherence (refill history, self-report, FeNO trends)

— Growth velocity (height/weight plotted)

— Trigger review and environmental update

— Action plan reviewed and updated

— Vaccination status

— School attendance, exercise tolerance, sleep quality

— Teach symptom recognition by zone (green/yellow/red)

— Demonstrate spacer and inhaler use at every visit; teach-back method

— Peak flow monitoring for moderate-severe asthma ≥5 yo — establish personal best

— When to escalate: increasing SABA use, nighttime awakenings, PEF <80% personal best

— Adherence to controller even when feeling well — "controllers prevent, relievers rescue"

— Trigger avoidance (smoke, allergens, irritants)

— Vaping/smoking cessation in adolescents

— Physical activity is encouraged — pre-exercise SABA or ICS-formoterol if exercise-induced symptoms

— Mental health screening — anxiety and depression are common comorbidities

Visit cadence:

Monitoring at each visit:

Self-management education:

Counseling priorities:

Quality metrics (HEDIS/NCQA): Asthma medication ratio (controller:total asthma meds) >0.5 is the standard.

Step 3 management: A child filling >3 SABA canisters/year or any OCS burst in the past year is uncontrolled by definition — step up regardless of how the visit "feels." This is exactly how Step 3 distinguishes recall from clinical judgment.

Board pearl: Document inhaler technique observation in the chart at every visit — both clinically essential and audit-protective.

Ethical, Legal, and Patient Safety Considerations

— Parents/guardians consent; assent from children ≥7 is best practice for ongoing therapy and biologics

— Adolescents (variable by state, generally ≥14–18) increasingly participate in decision-making; document shared decision-making for biologics, immunotherapy

— Screen confidentially for vaping, smoking, substance use, mental health, sexual activity

— Most states allow confidential STI and contraception care to minors; asthma care typically requires parental involvement, but vaping cessation discussions can be confidential

— Recurrent severe exacerbations due to caregiver non-administration of prescribed controllers, persistent in-home smoking despite counseling, or housing-related severe asthma may warrant CPS report for medical neglect in egregious cases — usually after documented multidisciplinary attempts at support

— Document social work referral, housing referral, smoking cessation offers

— Most states have self-carry laws allowing students to carry/self-administer albuterol with physician + parent authorization — provide signed action plans

— Schools must accommodate asthma under Section 504 / IDEA for severe cases

— ED-to-home transition: ensure controller prescription filled before discharge; "meds in hand" beats "prescription sent"

— Hospital-to-PCP: schedule follow-up within 1–2 weeks; communicate discharge summary

— Adolescent-to-adult care: structured transition protocol starting age 14, transfer by 18–21

— Black and Hispanic children have 2–4× higher asthma mortality — address structural drivers: housing, air quality, access, language-concordant care, implicit bias

— Provide written action plans in family's preferred language at appropriate literacy level

Informed consent and assent:

Confidentiality with adolescents:

Mandatory reporting and safety:

School and daycare:

Transition-of-care safety:

Equity and disparities:

Patient safety pearl: Verify before discharge that the family understands the action plan via teach-back, has a working spacer, and knows the difference between controller and reliever — confusing the two is a documented cause of pediatric asthma deaths.

Step 3 management: When a 16-year-old discloses vaping during a confidential interview, address it in cessation counseling without disclosing to parents unless safety mandates — respect adolescent confidentiality while documenting the conversation.

High-Yield Associations and Rapid-Fire Facts

Atopic march: atopic dermatitis (infancy) → food allergy → allergic rhinitis → asthma (school age). Early eczema is the strongest predictor.

Samter's triad / AERD: asthma + nasal polyps + ASA/NSAID sensitivity — emerges in adolescence/adulthood.

Charcot-Leyden crystals (eosinophil-derived) and Curschmann spirals (mucus casts) on sputum — classic asthma histology.

Reid index elevated in chronic asthma — bronchial submucosal gland hypertrophy.

Pulsus paradoxus >20 mmHg — severe asthma marker.

Normalizing PCO2 in a tachypneic asthmatic = impending respiratory failure (not improvement).

Silent chest + altered mentation = pre-arrest, intubate.

ICS first-line controller at every step ≥2; LABA never as monotherapy.

SMART therapy: ICS-formoterol as both controller and reliever ≥5 yo.

Dexamethasone 0.6 mg/kg ×1–2 doses = 5-day prednisolone for pediatric exacerbations.

IV magnesium 25–50 mg/kg for severe refractory exacerbations.

Ketamine = induction agent of choice for intubating an asthmatic (bronchodilator).

Avoid: beta-blockers, NSAIDs in AERD, LAIV flu vaccine in poor control, sedatives without airway protection, routine antibiotics, chest physiotherapy in exacerbation.

Spacer improves MDI delivery 4-fold; mask <4 yo, mouthpiece ≥4 yo.

Annual flu vaccine (inactivated), PCV15/20 + PPSV23 if high-dose ICS or recurrent OCS.

Montelukast — neuropsychiatric black box (2020).

Omalizumab — anti-IgE, ≥6 yo, allergic asthma.

Tiotropium Respimat — add-on ≥6 yo.

mAPI stratifies <3-year-old wheezers for early ICS benefit.

Pediatric FEV1/FVC cutoff <85% (not 70%).

>1 SABA canister/month = poor control red flag.

≥2 OCS bursts/year = uncontrolled; step up.

First-episode wheeze in infant <1 yo with URI = bronchiolitis until proven otherwise.

Sudden focal wheeze in toddler = foreign body until proven otherwise.

Board pearl: Asthma is a clinical diagnosis confirmed by reversible obstruction — but the stepwise treatment ladder, action plan, and trigger control are what Step 3 tests, not the pathophysiology.

Board Question Stem Patterns

"4-year-old with recurrent nighttime cough and wheeze with colds, eczema, family history of asthma, mAPI positive..." → Daily low-dose ICS (Step 2), spacer with mask, action plan. Distractors: montelukast (alternative not preferred), SABA-only (inadequate for persistent).

"10-year-old on low-dose ICS using albuterol 4 days/week, waking 2×/month..." → Uncontrolled; step up to ICS-formoterol SMART (Step 3) after verifying technique and adherence. Don't jump to oral steroids or biologic.

"8-year-old in ED with SpO2 88%, retractions, talking in words only, after albuterol ×3..." → Continuous albuterol, ipratropium, IV magnesium, systemic steroids, prepare for PICU/intubation. Distractors: antibiotics, chest CT, helium-oxygen as first move.

"Tachypneic asthmatic child whose ABG now shows pH 7.36, PCO2 42..." → Impending respiratory failure; prepare to intubate. The "normal" gas is the trap.

"Toddler with sudden choking episode at a birthday party, now with unilateral wheeze..." → Foreign body aspiration; rigid bronchoscopy. Do not start ICS.

"Adolescent athlete with throat tightness, inspiratory stridor during sprints, normal spirometry, no albuterol response..." → Vocal cord dysfunction; speech therapy.

"Child on Step 4 ICS-LABA with elevated IgE, multiple allergen sensitivities, ≥2 ED visits..." → Add omalizumab; refer to pulmonology/allergy.

"Recently discharged child without follow-up scheduled, no action plan given..." → Most appropriate next step: provide written asthma action plan and schedule 1–2 week follow-up.

"Caregiver smokes indoors, child has frequent exacerbations..." → Counsel cessation, offer pharmacotherapy and referral; social work involvement; consider CPS only if persistent medical neglect after documented intervention.

"Pregnant 17-year-old with worsening asthma in second trimester..." → Step up controller (budesonide preferred); uncontrolled asthma is more dangerous to fetus than medication.

"Child on high-dose ICS needs tonsillectomy..." → Perioperative stress-dose hydrocortisone if signs of HPA suppression or recurrent OCS bursts.

Step 3 management: Step 3 stems frequently test the next best step in management — usually adherence/technique check, action plan, or stepwise adjustment — rather than diagnosis. Pick the management answer over the diagnostic one when both are offered.

Board pearl: When in doubt on an exacerbation question: oxygen, albuterol+ipratropium, systemic steroid within 1 hour. Then reassess. Then magnesium.

One-Line Recap

Pediatric asthma is a chronic, reversible inflammatory airway disease managed by stepwise controller therapy anchored on inhaled corticosteroids, paired with rescue therapy, a written action plan, trigger control, and frequent reassessment of control across both impairment and risk domains.

Stepwise ladder: SABA PRN (intermittent) → low-dose ICS (Step 2) → ICS-formoterol SMART or medium ICS (Step 3) → medium ICS-formoterol ± LAMA (Step 4) → high-dose + biologic ± OCS (Steps 5–6); age-specific protocols (0–4, 5–11, ≥12) follow NAEPP/EPR-4 2020.

Acute exacerbation algorithm: Oxygen to keep SpO2 ≥92%, albuterol-ipratropium nebs ×3 in first hour, systemic steroid (dexamethasone 0.6 mg/kg or prednisolone 1–2 mg/kg) within 60 minutes, IV magnesium 25–50 mg/kg for severe refractory cases, escalate to continuous nebs, NIV, ICU; silent chest, rising PCO2, or altered mentation = intubate.

Every visit owes the patient: observed inhaler technique with spacer, control assessment (ACT/C-ACT), updated written action plan in green/yellow/red zones, vaccinations (annual flu, COVID, pneumococcal if high-risk), trigger and tobacco-smoke counseling, and follow-up cadence matched to control (1–2 weeks post-exacerbation, 3–6 months when stable).

Step 3 management: Before stepping up, verify the 4 A's — Adherence, Allergens, Alternate diagnosis, Aerosol technique; before discharging any exacerbation, verify the 5 D's — Drug (controller + reliever), Device (spacer), Document (action plan), Doctor (follow-up), and De-trigger (environmental plan). Missing the action plan or the follow-up appointment is the single most-tested omission on Step 3 pediatric asthma stems.