Understanding and Implementing the Latest Recommendations for Asthma Management

New guidelines for the care and treatment of asthma in children were released in 2020, but implementation has been slowed by the pandemic and need for education.

An estimated 8% of children had asthma in 2020, and it continues to have a significant impact in the lives of many kids. It interferes with their sports and schooling, which often means parents are missing out on work as well. After updated guidelines for asthma management were published in 2020, there’s work to do to improve the lives of these patients and their families. Partners For Kids® recently provided an asthma management pathway tool and other resources to help providers manage this condition based on the latest guidelines.

2007 Guidelines vs. 2020 Guidelines: Treatment For Mild Intermittent Asthma in 0-4 years

Methodology for classifying asthma didn’t change in the new guidelines. Condition severity is still measured the same way. A simplified tool for interpreting the National Heart Lung and Blood Institute (NHLBI) guidelines for classifying asthma severity was also produced by Partners For Kids and is accessible for your use.

However, recommendations for intermittent inhaled corticosteroid (ICS) use for mild intermittent asthma in ages 0-4 changed with this update. Providers were used to treating intermittent asthma in step one of the asthma guidelines by prescribing short-acting beta agonists (SABA) albuterol as needed. New for the NHLBI guidelines, it’s now recommended to use PRN albuterol and a short, seven to ten-day course of daily ICS as soon as the child got sick with a respiratory tract infection (RTI). The guidelines call out a specific population for this recommendation: children 0-4 with recurrent wheezing, defined as either:

• At least 3 episodes of wheezing triggered by apparent infection in their lifetime
• 2 episodes of wheezing in the past year with no symptoms between infections and who are not on a daily asthma treatment

“The guidelines recommend 1 mg of Pulmicort twice a day for the course of this supplemental treatment, but there are pitfalls to this approach,” explains Lisa Ulrich, MD, pediatric pulmonologist at Nationwide Children’s. “The patient has to have a nebulizer – which not every patient has access to – and use it correctly, which means sitting and keeping a mask or mouthpiece in place for ten minutes. At Nationwide Children’s, we extrapolated the research for the high-dose Pulmicort for equivalent dosing. We consider Flovent 110 mcg 2 puffs twice a day with the spacer for that seven to ten-day window to be a comparable alternative.”

 A New Approach: SMART Therapy Indications and Utilization

Single Maintenance and Reliever Therapy (SMART) is a novel approach to the labor of managing asthma. There are some difficulties with this approach; it’s only for ICS in combination with Formoterol that can be used daily and as needed. There are other preparations that are in combination with ICS and long-acting beta agonists (LABA) that are not intended for this approach.

With those complications aside, there are some significant benefits to this approach – namely, decreasing exacerbation requiring oral steroids, improving asthma control and improving quality of life.

This is designed for children ages 4 and older who have moderate to severe persistent asthma. Previously, it involved daily medium-dose ICS and SABA or LABA as needed. For these patients whose asthma is not being well-controlled and need to step up in therapy, it’s now recommended:

• Daily and as-needed combination low-dose ICS-formoterol at step three
• Daily and as-needed combination medium-dose ICS-formoterol at step four

“This simplifies treatment plans with fewer medications, but it may take time to explain this new process to patients and families who have relied on SABA as rescue therapy for years. Patient re-education is incredibly important here,” says Daniel Evans, MD, division chief of pulmonology at Dayton Children’s Hospital. “You do not need to institute this if the patient’s asthma is well-controlled on their current treatment plan.”

Recommendations from Partners For Kids for how to structure administration and medication preferences for SMART dosing are available online.

 Where to Go for Additional Information

These recommendation highlights were provided in a Partner’s For Kids asthma webinar. For more useful updates of asthma and other conditions, tune in to future webinars and review the Partners For Kids webinar archive.