14.1 Asthma Diagnosis, Control & Action Plans

Pulmonology is clinical category #7 on the CPNP-PC outline. Items sit in Assessment (Domain II) and Management (Domain III) and follow NHLBI/NAEPP, including the 2020 focused updates — not adult COPD habits and not a memorized 12-row step table. The scoring skill is naming who has asthma, who has viral wheeze, whether control is acceptable, and which controller-reliever plan is preferred.

Quick Answer: Recurrent viral wheeze is not automatically persistent asthma. Diagnose asthma from a pattern of recurrent, reversible obstruction; obtain spirometry at ≥5 years when the child can perform it. ICS is the controller backbone. SABA-only is not preferred long-term once persistent disease is present. NHLBI 2020 makes SMART (ICS-formoterol) preferred for many step 3–4 patients. Issue a written green/yellow/red action plan, teach a spacer, give annual influenza vaccine, and eliminate smoke exposure. Assess control by night wakening, SABA use, and activity. Refer severe disease, frequent wheeze under age 1, and poor control.

Recurrent wheeze is not automatically asthma

Asthma is a chronic inflammatory airway disease with variable expiratory airflow limitation, bronchial hyperresponsiveness, and recurrent symptoms: wheeze, cough (often worse at night), chest tightness, and dyspnea. Triggers include viral URI, allergen exposure, exercise, weather change, smoke, and NSAIDs in selected patients. Atopy (eczema, allergic rhinitis, food allergy, parental asthma) raises the pre-test probability but does not complete the diagnosis by itself.

Recurrent viral wheeze in toddlers is common. Many preschoolers wheeze with RSV or rhinovirus and are well between illnesses. That pattern is not a mandate for years of daily ICS. NHLBI still lets you treat the acute episode and, in selected 0–4-year-olds with recurrent wheezing, use a short ICS course at the onset of a respiratory infection plus SABA — that is not the same as labeling persistent asthma and locking the child to daily controller therapy indefinitely.

Call it asthma when the history shows recurrent symptoms between viral illnesses, exercise limitation, nocturnal cough, bronchodilator response, or a typical atopic cluster plus reversible obstruction. A single wheezy URI in a previously well infant is bronchiolitis or viral wheeze until a pattern appears.

Spirometry at ≥5 years when the child can do it

Spirometry is the office test NHLBI expects once the child is about 5 years or older and can perform acceptable, repeatable efforts. Teach FEV1, FEV1/FVC, and bronchodilator reversibility. A significant FEV1 increase after albuterol supports reversible obstruction. Normal spirometry does not exclude asthma if the history is classic — obstruction is variable. Do not wait for an FEV1 of 55% before starting a controller in a school-age child with weekly night cough and daily SABA use.

Peak-flow meters can support home monitoring in selected school-age children who already have a diagnosis; they are not a substitute for diagnostic spirometry. FeNO is an adjunct in some specialty settings; do not diagnose or step therapy on FeNO alone (NHLBI 2020). Chest x-ray is not a routine asthma diagnostic test. Image when you suspect foreign body, pneumonia, or another alternative.

Impairment, risk, and control

NHLBI splits severity and control into impairment (today's symptoms and lung function) and risk (exacerbations requiring systemic steroids, ED visits, lung-function loss, treatment side effects). A child can look “mild” between flares and still have high risk if two oral-corticosteroid courses have already been needed this year.

Assess control at every asthma visit — not once at diagnosis. Practical primary-care questions:

• Night wakening from cough or wheeze
• SABA (or SMART reliever) use more than 2 days/week for symptoms
• Activity limitation: gym, recess, sports, play
• Daytime symptom frequency
• Oral steroid bursts and unscheduled visits this year

Well controlled generally means symptoms ≤2 days/week, infrequent night waking, SABA ≤2 days/week (not counting pre-exercise doses in some schemas), no activity limitation, and FEV1 >80% predicted when measured, with at most 0–1 exacerbations/year requiring systemic steroids. Not well controlled or very poorly controlled night waking, daily SABA, and activity limits mean step up after you check adherence, inhaler technique, spacer use, and environmental triggers. Do not blindly increase the ICS dose in a child who sprays the MDI into the air without a spacer.

NHLBI 2020: ICS backbone, not SABA-only, SMART at steps 3–4

You do not need to recite every cell of the EPR-3 step table on this exam. You do need the philosophy of the 2020 focused updates.

1. ICS is the controller backbone for persistent asthma. Inhaled corticosteroid reduces impairment and the risk of severe exacerbations. Montelukast is an alternative or adjunct in selected patients, not a reflex replacement for ICS; counsel neuropsychiatric effects.
2. SABA-only is not preferred long-term once persistent disease is present. Albuterol treats acute bronchospasm; it does not treat airway inflammation. A child who needs SABA several times a week needs a controller conversation, not a bigger albuterol bottle.
3. Never prescribe a LABA without ICS. LABA monotherapy is a safety failure.
4. SMART therapy — single maintenance and reliever therapy with ICS-formoterol — is preferred for many step 3–4 patients (NHLBI 2020, generally ages 4 years and older in the focused update). The same ICS-formoterol inhaler is used daily and as-needed for symptoms. Formoterol is the LABA with onset fast enough for reliever use. Do not invent SMART with ICS-salmeterol — salmeterol is not a reliever.
5. Selected preschoolers with recurrent viral wheeze may use intermittent ICS at URI onset rather than daily ICS if they do not have persistent interval symptoms.

Stepping down is a planned, supervised move after at least 3 months of good control, not a parent stopping the orange inhaler in May because baseball season started.

Written action plan, spacer, vaccine, smoke

Every child with asthma needs a written asthma action plan with three zones:

Spacer (valved holding chamber) is not optional theater. Children using an MDI need a spacer; young children need a mask. Skipping the spacer is a classic reason “the steroid inhaler does not work.” Teach shake, seal, actuate, slow breathe or tidal breaths with mask, and rinse the mouth after ICS.

Annual influenza vaccine belongs on every asthma problem list. Inhaled ICS is not a reason to skip inactivated influenza vaccine. Live-attenuated nasal-spray decisions follow current ACIP and asthma-severity caveats — do not let a family skip all influenza immunization because someone mentioned a nasal spray.

Avoid smoking and vaping exposure. Household tobacco and e-cigarette aerosol worsen control and increase exacerbations. Ask at every visit. Wood smoke, unvented kerosene, and cockroach or rodent allergen in selected housing also matter. Dust-mite covers help selected allergic children; they do not replace ICS.

When to refer

Refer to pediatric pulmonology or allergy rather than endless primary-care step-ups:

• Severe persistent asthma or any ICU / intubation history
• Frequent symptoms in an infant <1 year
• Poor control despite correct technique, a spacer, adherence, and an appropriate NHLBI step
• Diagnostic doubt: clubbing, FTT, focal wheeze, neonatal onset, food-associated anaphylaxis plus asthma
• Consideration of biologics, allergy immunotherapy, or recurrent pneumonia

Exam traps

• Daily ICS indefinitely for isolated viral wheeze in a toddler who is well between colds.
• SABA-only for persistent asthma because “he only wheezes sometimes.”
• LABA without ICS, or SMART with salmeterol.
• Skipping the spacer and then declaring ICS a failure.
• Skipping influenza vaccine or ignoring household smoke.
• Treating unilateral wheeze as new asthma.

The CPNP-PC wants NHLBI logic: diagnose a pattern, measure when able, control with ICS, use SMART when the step calls for it, write the three-zone plan, and refer the child who is not safe in primary care.