Updated Pediatric Asthma Management Guide

An interactive tool for pediatricians, based on the latest evidence and clinical guidelines such as GEMA 5.4 and GINA 2024.

Prevalence and Impact

Asthma affects approximately 10% of children in Spain and 6.5% in the US. It is one of the most common chronic diseases in childhood, with 85% of cases of allergic origin.

Main Objective of Management

Achieve and maintain total control of the disease to minimize symptoms, prevent exacerbations and allow an active and normal life, adapting treatment in an individualized and dynamic way.

The Importance of Being Updated

The guides are updated annually, reflecting rapid evolution of knowledge. This tool synthesizes the latest recommendations for optimal and safe clinical practice.

Key News GEMA 5.4 (2024)

●Incorporation of the concept of Asthma Remission (REMAS consensus).
●New risk factors identified: maternal obesity and climate change.
●Recommendation of Tezepelumab as an option in severe asthma (Step 6).
●Launch of iaGEMA, a clinical decision support AI.

Diagnostic Process

A multifaceted evaluation based on clinical and objective tests, especially in children >5 years.

Clinical Criteria and History

The initial diagnosis is based on a pattern of recurrent and variable respiratory symptoms:

  • Cough: Often at night or with exercise.
  • Wheezing: Sharp sound when exhaling.
  • Respiratory difficulty: Feeling of lack of air.
  • Chest tightness: Feeling of weight in the chest.

The history should investigate the frequency, severity, triggers (infections, allergens, exercise), and family and environmental history.

The ERS guidelines for children ages 5-16 recommend at least two abnormal objective tests to confirm the diagnosis. A normal result does not exclude asthma.

Pulmonary Function (5-16 years)

Spirometry: It is considered positive if FEV1/FVC < LLN or < 80%, or FEV1 < LLN or < 80% of predicted.

Reversibility Test (BDR): Positive with an increase in FEV1 ≥12% and/or ≥200 mL after SABA.

Biomarkers and Provocation

FeNO (Exhaled Nitric Oxide): A value ≥25 ppb is compatible with the diagnosis.

Provocation Tests: Consider whether initial tests are inconclusive (e.g. methacholine, exercise).

Key Diagnostic Thresholds

Main Differential Diagnoses

It is crucial to rule out other conditions, especially in infants and preschoolers:

  • Recurrent infections (rhinitis, sinusitis)
  • Anatomical malformations of the airway
  • bronchopulmonary dysplasia
  • foreign bodies
  • Swallowing dysfunction
  • Heart disease
  • Immunodeficiencies
  • Inducible laryngeal obstruction

Control and Severity Assessment

Management is based on achieving control, adjusting treatment according to continuous evaluation.

Asthma Control Levels (GEMA)

Severity Classification

It is classified according to the intensity of treatment necessary to maintain control. It is evaluated retrospectively.

Episodic (Mild)

Infrequent and mild crises. No symptoms between attacks and good tolerance to exercise.

Persistent (Moderate)

More frequent crises. Occasional symptoms between attacks and regular tolerance to exercise.

Serious (Difficult to Control)

Frequent crises and symptoms. Poor exercise tolerance and impaired lung function.

Escalated Pharmacological Management

A stepwise approach to adjust therapy and maintain control with minimally effective medication.

Pediatric Asthma Treatment Steps

Step 1: Mild Intermittent Asthma

IC at low doses as needed (preferred) or SABA only as needed. The use of SABA is only considered an alternative option.

Step 2: Mild Persistent Asthma

Daily maintenance treatment with low-dose IC. Alternative: Leukotriene Receptor Antagonists (LRT).

Steps 3 and 4: SMART Therapy (>4 years)

SMART Therapy (Single Maintenance And Reliever Therapy) with CI-Formoterol is the preferred option for moderate-severe asthma.

Use a single inhaler for maintenance (daily) and relief (as needed). Improves control, reduces exacerbations and simplifies treatment. It is a fundamental paradigm shift from previous guidelines.

Maximum Daily Doses (SMART):

  • 4-11 years: 8 inhalations/day (e.g. Symbicort 80/4.5).
  • 12+ years: 12 inhalations/day (e.g. Symbicort 160/4.5).

Step 5: Severe Asthma

Add LAMA (e.g. tiotropium), increase dose of IC. Consider referral to a specialized unit.

Step 6: Severe Uncontrolled Asthma

Consider biological therapies (e.g. Omalizumab, Mepolizumab, Tezepelumab) and oral corticosteroids at the lowest possible dose.

Acute Crisis Management

Quick action guide for asthma exacerbations in emergencies.

Emergency Treatment

1. Oxygen therapy

Administer if SpO₂ < 92-94% to maintain adequate saturation.

2. SABA (Salbutamol)

Preferred route: Metered dose inhaler (MDI) with spacer chamber (more efficient and fewer side effects than nebulizer). Dose: 4-10 pulses every 20 minutes depending on severity. Continuous nebulization in cases of impending respiratory failure.

3. Systemic Corticosteroids

Indicated in moderate-severe crises. Prednisone/Prednisolone oral (1-2 mg/kg/day, 3-5 days) or Dexamethasone (0.6 mg/kg/day, 1-2 days).

4. Ipratropium Bromide

Add to SABA in moderate-severe crises. 4-8 pulses (IDM+chamber) every 20 min together with salbutamol.

5. Magnesium IV Sulfate

Consider in severe crises that do not respond to initial treatment.

Severity Assessment

  • Vital signs and SpO₂
  • Respiratory difficulty (drawing, slurred speech)
  • Level of consciousness
  • Risk factors (previous hospitalizations)

Discharge Criteria

  • SpO₂ ≥ 92-94% in ambient air
  • Minimal or no respiratory distress
  • Need for SABA no > every 4 hours
  • Follow-up scheduled in 2 weeks

Resources and Education

Non-pharmacological management is as vital as medication for long-term control.

Therapeutic Education

Empowering patients and caregivers is key. It includes teaching about the disease, the correct use of devices, and how and when to adjust medication. Inhalation technique should be verified at each visit.

Written Action Plan

Essential tool that details what to do based on symptoms. It should be clear, personalized and reviewed regularly to guide self-management and know when to seek medical help.

Environmental control

Identifying and avoiding specific triggers is crucial. Includes allergens (mites, pollen, pets), tobacco smoke, viral infections and pollutants. An allergy evaluation can be very useful.

Concept of Asthma Remission (REMAS 2024)

A new objective in the management of asthma, which goes beyond symptomatic control.

Clinical Referral

Controlled asthma, without need for relief, without exacerbations and with FEV1 ≥ 80%, maintained for at least 12 months.

Complete Remission

Clinical remission criteria PLUS absence of inflammation (FeNO < 40, eosinophils < 2%) and bronchial hyperresponsiveness, maintained for ≥ 3 years.

Important: Asthma can recur after remission, so long-term follow-up is essential.