Asthma continues to be a major health concern, both here in the United States and throughout the world, and there is a growing emphasis on young patients. As a result, research in pediatric asthma continues to grow, and recently released guidelines have changed the approach for managing asthma within the pediatric population. (An overview1 of the studies in pediatric asthma that are being funded by the National Institutes of Health is available with the online version of this article.) In this paper, we will take a brief look at the changes in the asthma guidelines and we’ll examine some of the recently published asthma research that relates to pediatric patients.

EPR-3—New Approaches and Changing Emphasis

After a long wait for its release, those who deal with asthma on a regular basis finally received the “Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma—Full Report 2007” (EPR-3).2 This guideline is from the National Asthma Education and Prevention Program (NAEPP), which commissioned a panel of experts to perform an organized literature review and produce recommendations for managing asthma. The EPR-3 guidelines, released in August 2007, introduced several new concepts to the management of asthma and have five major changes to the EPR-2 guidelines that came out in 1997 and were updated in 2002:

  1. Control and Severity. Making asthma control the goal for therapy and making a distinction between severity and control. Severity refers to the intensity of the disease, and it should be assessed before initiating therapy. Control relates to how well therapy is minimizing the symptoms and meeting its goals. For all age categories, control is divided into three levels: well-controlled, not well-controlled, and very poorly controlled. Assessing and monitoring the control of asthma guides the choices of therapy. This is a new emphasis—the older guidelines tracked severity and titrated therapy based on the classification of severity. A useful way to look at the new EPR-3 approach is to describe a patient using terms such as “moderately severe asthma that is well-controlled.”
  2. Impairment and Risk. Impairment and risk are the two main components of severity and control. They may not correlate and may have separate and distinct responses to therapy. Impairment refers to the frequency and intensity of symptoms and the patient’s limitations due to asthma. Risk refers to the chances of having exacerbations, decreases in lung function (or lung growth for children), or adverse effects from the medications being used.
  3. Changes in the Step-wise Approach. The new EPR-3 divides treatment plans into three groups: 0-4 years of age, 5 to 11 years of age, and ≥12 years of age through adults. The actions in each of the steps have been simplified and the medications have been repositioned. Also, omalizumab has been added as a consideration for the oldest age group.
  4. Patient Education and Environmental Control. Patient education has gained a new emphasis and expanded into all aspects of the health care arena (including clinic, emergency department, hospital, pharmacy, school, and home). Environmental control is now incorporating a multifaceted approach and not just a single action. Immunotherapy, “asthma shots,” is given more emphasis as well as treating comorbid conditions that affect asthma (including esophageal reflux, obesity, rhinitis/sinusitis, and chronic stress/depression).
  5. Managing Exacerbations. EPR-3 has simplified classifying asthma in the urgent and/or emergency care setting. It is encouraging development of prehospital protocols to allow for more treatment options and has modified the recommendations regarding several medications such as levalbuterol, magnesium sulfate, oral corticosteroids, and anticholinergics. Finally, it has also added a consideration for starting inhaled steroid drugs at discharge from the urgent and/or emergency care setting.

The Global Guidelines

The National Heart, Lung, and Blood Institute teamed up with the World Health Organization to issue new guidelines for the Global Initiative for Asthma (GINA) in November 2006 and has released an update to this text as of June 2007.3 The terminology is a little different from that of the EPR-3, but the new GINA guidelines have moved in much the same direction: They are also adding a focus on asthma in the very young (0 to 5 years of age), emphasizing asthma control (as opposed to tracking severity) and striving to minimize the effects of the disease.4

Inhaled Medications Are the Key

Inhaled medications are the primary treatment for all steps in the treatment plans for both pediatric age groups (0-4 and 5-11 years of age). According to the research cited in the EPR-3, the inhaled route of administration offers the advantages of delivering higher concentrations of medication to the airways, more effective delivery, and less problematic side effects compared to systemic routes (oral or parenteral). Short-acting β2-agonists (SABAs) are included in the care of intermittent and persistent asthma on an as-needed basis for symptoms and are the only preferred medication listed for step 1 Intermittent Asthma. SABAs specifically cited by the EPR-3 are albuterol, levalbuterol, and pirbuterol. At step 2 through step 6, varying doses of inhaled corticosteroids (ICS) are the preferred foundational drug for treatment. The doses are divided into low, medium, and high dose. (See Figures 1 and 2 in the online version of this article for the stepwise approach.) Beyond the inhaled medications, the recommendations mention adding other allergy and asthma medications such as leukotriene receptor antagonists, cromolyn sodium, montelukast, nedocromil, theophylline, and oral systemic corticosteroids.

Aerosol Delivery Devices for Children

The EPR-3 includes a very informative table listing the aerosol delivery devices. This table is available online at the NAEPP Web site in the Full Report of EPR-3 document, Figure 3-24 (or in the Summary Report, Figure 10, pages 31-32). The table lists the devices and drugs available in those particular devices, the population that is appropriate for using the device, the optimal technique for administering the drugs using the particular device, and the therapeutic issues related to the device and technique. Five different groups of devices are described in these details, including metered-dose inhaler (MDI), breath-actuated MDI, dry powder inhaler, spacer or valved holding chamber, and nebulizer (sometimes referred to as a handheld or a jet nebulizer). The information given in the table on devices/drugs recognizes the challenges that arise when administering inhaled medications to children; each group of devices lists the age cut-off in the column labeled “population,” and all but the last one deals with a break-point at either 4 or 5 years of age.

Metered Dose Inhalers

Metered dose inhalers are recommended for use in children ≥5 years old (or <5 with a spacer or valved holding chamber). The EPR-3 guidelines include four drugs in this category: β2-agonists, steroids, cromolyn sodium, and anticholinergics. Technique is critical for proper administration of these drugs using an MDI (particularly having a slow inhalation and coordination of actuation), and the guidelines warn that young children may have difficulty using this device. In the American Association for Respiratory Care (AARC) Clinical Practice Guideline (CPG) on aerosol delivery devices for neonatal and pediatric patients, an MDI with spacer device and face mask is described as appropriate for patients under 3 years of age.5

Breath-Actuated MDIs

Breath-actuated MDIs are recommended for use in children ≥5 years old. According to the American Thoracic Society, this category of inhalers includes the Airmax GOLD, with budesonide; Autohaler GOLD, with albuterol/salbutamol, beclomethasone, fenoterol/ipratropium combination, and pirbuterol; and the Easi-breathe GOLD with albuterol/salbutamol, beclomethasone.6 At this time, only the inhalers containing β2-agonists are approved in the EPR-3 guidelines, according to the devices/drugs table. This device may be most useful for patients who have difficulty coordinating inhalation and actuation with the standard MDI. There is an accessory device available by prescription called the MD Turbo (Respirics Inc, Raleigh, NC) that can accommodate most MDIs and allows the administration of the medication to be breath actuated. The device also includes a dose counter. The MDI is loaded into the device and the device is cocked to administer a dose. At an inspiratory flow of around 45 L/min (or 0.75 L/sec), the triggering mechanism actuates the MDI.7,8

Dry Powder Inhalers

Dry powder inhalers (DPIs) are recommended for use in children ≥4 years old. The EPR-3 lists three drugs in this category: β2-agonists, steroids, and anticholinergics. Using DPIs with children may be ineffective if they are not able to generate sufficient inspiratory flow to administer the drug (60 L/min or 1 L/sec is given as a minimum flow). Note that the AARC CPG on aerosol delivery devices for neonatal and pediatric patients recommends that the more appropriate age for using a DPI would be for children >6 years of age.5 For children in severe asthma attacks with greatly reduced flow rates, DPI administration should not be used, since they cannot generate a suitable inspiratory flow to inhale the drug into the lower airway.

Spacer Devices and Valved Holding Chambers

Spacer devices and valved holding chambers (VHCs) are recommended for use in children ≥4 years old (or <4 with a VHC with a face mask). Note that this is the only recommended system to deliver inhaled medications to children less than 4 years of age other than using a nebulizer. The EPR-3 table states that spacers and VHCs are “as effective as nebulizer for delivering SABAs and anticholinergics in mild-to moderate-exacerbations.” The recommendation given for using a face mask specifies that it should be a tight fit, and, during administration, the child should take three to five inhalations. These devices are noted to reduce deposition in the oropharynx, which decreases the risk of fungal infection. However, the table also mentions that delivery to the lungs can be reduced up to 50% when using a mask. Several sources have included discussion related to electrostatic charge associated with plastic spacer and VHC devices. When present, this charge tends to attract the aerosol inside the device and reduce the lung deposition of the medication. It is recommended that these devices be washed in liquid dishwashing soap to reduce static build-up for up to 30 days. Metal and nonconductive plastic devices do not have the problem of static build-up.7,9


Nebulizers are another group of devices in the EPR-3 table for aerosol administration. The population for these devices is described as “Patients of any age who cannot use MDI with VHC and face mask.” The technique of directing the nebulizer output toward the patient’s nose and mouth (referred to as “blow-by”) is considered to be inappropriate and should not be used. The AARC CPG on aerosol delivery devices recommends that a nebulizer with a mouthpiece and an extension reservoir be used in children >3 years of age if they are cooperative, are spontaneously breathing, and do not have an artificial airway in place. For children who are unable to use a mouthpiece, the CPG recommends using a face mask. Nebulizing some medications requires the use of a special, dedicated nebulizer system that specifies the nebulizer (and sometimes includes a specific compressor as well). These drugs (rhDNase—Pulmozyme, and tobramycin—TOBI) are primarily used in treating children with cystic fibrosis, but therapists should be aware of these restrictions.

Other Considerations

Researchers looked at deposition of nebulized budesonide on the face and in the eyes in an in vitro study published in Chest (February 2008). They compared the mask design that has the nebulizer connection at the bottom of the mask with the aerosol flowing vertically up the mask (referred to as “bottom-loaded”) versus prototype mask design with the nebulizer connection on the front of the mask with the aerosol flowing horizontally into the face (referred to as “front-loaded”). They found that the bottom-loaded design had significantly higher facial and ocular deposition compared to the front-loaded design.10

The breathing pattern is another consideration in using a nebulizer or inhaler with a child. Quiet tidal breathing is the best pattern for drug delivery. Crying is a problem during a nebulizer treatment due to high inspiratory flow during the short, rapid inspirations and prolonged expiration that result in a significant decrease in medication deposition in the lung. In severe asthma attacks, continuous bronchodilator therapy is often used to administer a β2-agonist for up to 1 hour. Administration of inhaled medications is another consideration if an asthmatic child is also receiving positive pressure therapy (CPAP or bilevel ventilation) or mechanical ventilation. Heliox is sometimes used in severe attacks to administer medication due to its reduced density, the thought being that heliox would decrease resistance to airflow through the bronchial tree, thus allowing for better deposition of inhaled medications and reduction in work of breathing. Although there are some published data examining many of these other considerations, there is a need for more research to be done in these areas to provide evidence-based practice for administering inhaled medications to children with asthma.


Consideration of many components when administering inhaled medications to children with asthma is crucial: the age of the child, the child’s cooperation, the delivery device specifications (MDI, DPI, or nebulizer), the inspiratory flow pattern, particular requirements that link a drug to a specific nebulizer system, mask fit, direction of aerosol flow, and the choice of drug based on the severity and control of the child’s asthma. The arsenal of inhaled medications used in treating asthma is expanding and bringing more complexity. Therapists are the front-line educators for patients and family members. We need to be aware of the guidelines and know the specifics about the drugs, the delivery devices, and the technique needed with various systems. The EPR-3 and GINA guidelines are excellent resources for therapists to achieve a high level of knowledge and understanding of asthma. Our expertise is critical as we partner with asthmatic children to control their asthma symptoms with the most appropriate and effective medications.

Bill Pruitt, RRT, AE-C, CPFT, is a senior instructor, Department of Cardiorespiratory Sciences, University of South Alabama, and PRN respiratory therapist at Springhill Medical Center and Mobile Infirmary Medical Center, Mobile.


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