Uncontrolled asthma: When to step up therapy

Key Points

A recent survey of pediatric patients with asthma visiting their primary care providers for any medical reason found a 46% prevalence of uncontrolled asthma.² Poorly controlled asthma has a significant cost to families and society related to doctor and emergency department visits, hospitalizations, and missed work and school. Children with poorly controlled asthma also have lower health-related quality-of-life scores than children whose asthma is well controlled.³

Goals of asthma therapy

Assessing asthma severity and control

At each asthma visit it is important to assess asthma control, medication technique, medication adherence, and patient and parent concerns.¹ Reliable assessment of symptoms is necessary to determine the optimal therapy to control a patient's asthma. The measures used to classify asthma severity and control include frequency of day and nighttime symptoms, frequency of rescue short-acting beta agonist (SABA) use, degree of activity limitation, and frequency of asthma exacerbations requiring oral steroid bursts (Table 1).¹

Assessing asthma control can be difficult, especially in young children, because much of it relies on self-report. Spirometry and validated questionnaires such as the Childhood Asthma Control Test (C-ACT) can assist in the assessment of asthma control.⁴ Following FEV1 (forced expiratory volume in the first second) and FEV1/FVC (forced vital capacity) is more reliable than following peak expiratory flows. The C-ACT is a self-administered test that assesses asthma control in children aged 4 to 11 years. A score of 19 or less has good reliability in indicating uncontrolled asthma.

Optimal asthma medication delivery is an important component of achieving good asthma control. A metered-dose inhaler (MDI) with a valved holding chamber, or spacer, and with a mouthpiece offers the most efficient means of delivering asthma medication to the lungs. For infants and uncooperative children, a spacer with a tight-sealing face mask can be used.⁵

Nebulizers are less reliable in their delivery of the medication to the lungs and less effective than an MDI with a spacer in acutely wheezy children.⁶

Breath-actuated, pressurized MDIs and dry powder inhalers require a certain degree of coordination and inspiratory force; their use should be restricted to children at least 6 years old. Because all the delivery devices have their limitations, the most important factor is addressing parent and child preferences and choosing a delivery device that they are comfortable with and will use.