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 Pediatric
ASTHMA A CLINICAL SUPPORT CHART

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 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

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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 ƒ Asthma is both underdiagnosed and overdiagnosed.
include ƒ Colds and viral illnesses ƒ Asthma is the most common chronic disease of children.
ƒ Polyphonic wheezes, ƒ Exercise ƒ Asthma causes more hospitalizations than any other medical problem
predominantly on expiration in children.
ƒ Exposure to cold air
ƒ Recurrent and/or chronic ƒ Intermittent asthma is most commonly a viral respiratory tract
ƒ Cough after laughing or crying
cough infection–induced phenotype in preschool-aged children but is found
ƒ Allergens, including pets, mold,
ƒ Chest tightness at all ages.
dust mites, and additional
ƒ Shortness of breath environmental exposures ƒ Persistent asthma phenotype is characterized by the absence of
ƒ Pollution (indoor or outdoor) extended symptom-free periods.
ƒ Passive exposure to smoke ƒ Seasonal allergic phenotype is characterized by allergen-specific
immunoglobulin E limited to seasonal inhalant allergens.
ƒ Strong odors
ƒ Asthma severity is indicated by
Additional Features • Interference with activity from exercise limitation
ƒ 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
ƒ Any wheezing reported by patients and parents should be confirmed by • Urgent care visits or hospitalizations
a medical provider. ƒ Although some children will have symptoms of asthma that remit,
ƒ 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 ƒ 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.
ƒ 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.
ƒ Aspiration as a cause of wheezing in children with neurological impairment
should be ruled out before a diagnosis of asthma is considered.
ƒ Many infants and toddlers wheeze during viral respiratory illnesses but
do not go on to have asthma when they are older.
ƒ Misdiagnosis of asthma as pneumonia or bronchitis can lead to
ineffective and unnecessary use of antibiotics.
ƒ 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.

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 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 ƒ 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
ƒ 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 ƒ 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

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 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.

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 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%) ƒ Diagnosis and severity assessment of asthma in patients
≥5 years of age
 Moderate persistent (60%–79%) ƒ Follow-up of asthma control (especially when changing
medications)
 Severe persistent (<60%)
ƒ Evaluation of chronic cough
ƒ Evaluation of shortness of breath and other chronic
Spirometry and Asthma, Patients 5 Years and Older respiratory concerns
Spirometric Measurements ƒ 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
ƒ 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 ƒ 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. ƒ 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; ƒ More typically, an FEV1:FVC ratio of <80% is used to denote an
2018:253. obstructive process consistent with asthma in children.
ƒ 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.
ƒ Consistent predicted-FEV1 values <60% typically warrant
subspecialty consultation.
ƒ 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.
ƒ 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.
ƒ 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

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 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.

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 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.
ƒ Pneumonia
Environmental allergens in ƒ Outdoor allergens
sensitized individuals (eg, seasonal allergens such ƒ Bronchiolitis in younger children
as tree pollen, grass pollen, ƒ Bacterial tracheitis
weed pollen, and molds)
ƒ Anaphylaxis
ƒ Indoor allergens
(eg, animal dander, dust mites, ƒ Foreign-body aspiration
cockroaches, indoor molds, mice) ƒ Esophageal foreign body
Irritants ƒ Environmental tobacco smoke ƒ Bronchitis
ƒ Air pollutants ƒ Vocal cord dysfunction
(eg, ozone, sulfur dioxide)
Chest radiography is not routinely necessary at the onset of asthma
ƒ 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,
ƒ Mycotoxins fevers, continued tachypnea, hypoxemia, or chest pain after initial
asthma therapy is administered.
ƒ Endotoxins
ƒ Dust
ƒ Strong odors or fumes
(eg, perfumes, hair sprays,
cleaning agents, incense sticks,
scented candles)
Occupational exposure ƒ Farm and barn exposure
ƒ Formaldehyde
ƒ Cedar
ƒ Paint fumes
ƒ Others
Cold, dry air
Exercise
Emotions ƒ Crying
ƒ Laughter
ƒ Emotions that can cause
hyperventilation
Comorbid conditions ƒ Rhinitis
ƒ Sinusitis
ƒ Gastroesophageal reflux
ƒ 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

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 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.

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 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

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

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.

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

 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

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

 12 Tab 7. Intervention Overview

Tab 7
Intervention Overview

Asthma Intervention Overview

Symptom Severity Intervention
Mild symptoms ƒ 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.
ƒ Consider oral steroids if there is no improvement after 2 doses of SABA.
ƒ Provide oxygen as needed to keep the Sao2 >90%.
ƒ 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 ƒ Give the patient 2.5–5.0 mg or 4–8 puffs of albuterol every 20 min for ≤3 doses.
• Reassess after every dose.
ƒ Give the patient oral steroids.
ƒ Provide oxygen as needed to keep Sao2 >90%.
ƒ Consider administering ipratropium, especially if the patient needs to be transferred to an ED.
ƒ 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 ƒ Give the patient 5 mg via nebulizer or 8 puffs of albuterol every 20 min, then switch to a continuous albuterol nebulizer,
if available.
ƒ Give the patient ipratropium.
ƒ Give the patient oral steroids or intramuscular steroids if giving the patient oral medication would be unsafe.
ƒ Provide oxygen to keep Sao2 >90%.
ƒ 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.

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

 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:
ƒ Severe exacerbations
ƒ 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
ƒ Continued hypoxia after 1–2 doses of SABA therapy and supplemental oxygen therapy is needed
ƒ 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
ƒ Infants <1 year of age
ƒ 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

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