CLINICAL
REVIEW
Authors
Rudy Dressendorfer, BScPT, PhD
Cinahl Information Systems, Glendale, CA
Andrea Callanen, MPT
Cinahl Information Systems, Glendale, CA
Reviewers
Diane Matlick, PT
Cinahl Information Systems, Glendale, CA
Rudy Dressendorfer, BScPT, PhD
Cinahl Information Systems, Glendale, CA
Rehabilitation Operations Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Sharon Richman, MSPT
Cinahl Information Systems, Glendale, CA
June 2, 2017
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Asthma in Children
Indexing Metadata/Description
› Title/condition: Asthma in Children
› Synonyms: Childhood asthma, pediatric asthma
› Anatomical location/body part affected: Lungs/lower pulmonary airways (bronchi,
bronchioles), cardiopulmonary system
› Area(s) of specialty: Pulmonary Rehabilitation, Home Health, Pediatric Rehabilitation
› Description
• Asthma is a chronic lung disease with acute episodic exacerbations associated with a
complex of genetic and environmental triggers(1,2,3,4,5,6,33)
• Asthma is characterized by recurring episodes of dyspnea (e.g., wheezing, shortness of
breath, coughing, chest tightness) due to increased airway reactivity (bronchospasm),
persistent airway inflammation, and excess mucus production(1,2,6,7,8,9,10)
• Children with asthma who have exertional dyspnea may use an inhaler to premedicate
before planned exercise and/or use a “rescue inhaler” after strenuous physical activity(33)
› ICD-9 codes
• 493.0 extrinsic asthma
–493.00 extrinsic asthma without mention of status asthmaticus or acute exacerbation or
unspecified
–493.01 extrinsic asthma with status asthmaticus
–493.02 extrinsic asthma, with acute exacerbation
• 493.1 intrinsic asthma
–493.10 intrinsic asthma without mention of status asthmaticus or acute exacerbation or
unspecified
–493.11 intrinsic asthma with status asthmaticus
–493.12 intrinsic asthma, with acute exacerbation
• 493.2 chronic obstructive asthma
–493.20 chronic obstructive asthma without mention of status asthmaticus or acute
exacerbation or unspecified
–493.21 chronic obstructive asthma with status asthmaticus
–493.22 chronic obstructive asthma, with acute exacerbation
• 493.82 cough variant asthma
• 493.9 asthma, unspecified
–493.90 asthma, unspecified type, without mention of status asthmaticus or acute
exacerbation or unspecified
–493.91 asthma, unspecified type, with status asthmaticus
–493.92 extrinsic asthma, with acute exacerbation
› ICD-10 codes
• J45 asthma
–J45.0 predominantly allergic asthma
–J45.1 nonallergic asthma
–J45.8 mixed asthma
–J45.9 asthma, unspecified
 –ICD-10-CA modifications in Canada: J45.0, J45.1, J45.8, and J45.9 subdivided and additional digit used to indicate:
- 0 without stated status asthmaticus
- 1 with stated status asthmaticus
• J46 status asthmaticus
• J38.5 laryngeal spasm
• J44.8 other specified chronic obstructive pulmonary disease
• J82 pulmonary eosinophilia, not elsewhere classified
• I50.1 left ventricular failure
• F54 psychological and behavioral factors associated with disorders or diseases classified elsewhere
• Z82.5 family history of asthma and other chronic lower respiratory diseases
(ICD codes are provided for the reader’s reference, not for billing purposes)
› G-Codes
• Mobility G-code set
–G8978, Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8979, Mobility: walking & moving around functional limitation; projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8980, Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end
reporting
• Changing & Maintaining Body Position G-code set
–G8981, Changing & maintaining body position functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8982, Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset , at
reporting intervals, and at discharge or to end reporting
–G8983, Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end
reporting
• Carrying, Moving & Handling Objects G-code set
–G8984, Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8985, Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8986, Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end
reporting
• Self Care G-code set
–G8987, Self care functional limitation, current status, at therapy episode outset and at reporting intervals
–G8988, Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at
discharge or to end reporting
–G8989, Self care functional limitation, discharge status, at discharge from therapy or to end reporting
• Other PT/OT Primary G-code set
–G8990, Other physical or occupational primary functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8991, Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8992, Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end
reporting
• Other PT/OT Subsequent G-code set
–G8993, Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8994, Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset,
at reporting intervals, and at discharge or to end reporting
–G8995, Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to
end reporting
›.
 G-code Modifier Impairment Limitation Restriction
CH 0 percent impaired, limited or restricted
CI At least 1 percent but less than 20 percent impaired, limited or
restricted
CJ At least 20 percent but less than 40 percent impaired, limited
or restricted
CK At least 40 percent but less than 60 percent impaired, limited
or restricted
CL At least 60 percent but less than 80 percent impaired, limited
or restricted
CM At least 80 percent but less than 100 percent impaired, limited
or restricted
CN 100 percent impaired, limited or restricted
Source: https://www.cms.gov/

.
› Reimbursement: Reimbursement for therapy will depend on individual insurance contract coverage. No special agencies
are applicable for this condition. No specific issues or information regarding reimbursement have been identified
› Presentation/signs and symptoms
• Intermittent dry coughing and expiratory wheezing(9)
• Older children report associated shortness of breath and chest congestion and tightness whereas younger children report
intermittent, nonfocal chest pain(9)
• Respiratory symptoms can be worse at night when associated with respiratory infections or allergens(9)
• Daytime symptoms are often linked to physical exertion in children(9)
• Self-imposed limitation of physical activities, general fatigue and difficulty keeping up with peers(9)
• Classification of pediatric asthma is based on severity of symptoms and pulmonary function testing(11)
–Mild intermittent
- Symptoms during the day ≤ 2 x/week
- Symptoms at night < 3 x/month
- Forced expiratory volume in 1 second (FEV1) is at least 80% of predicted value
- Peak expiratory flow (PEF) is at least 80% of predicted value
- PEF variability is < 20%
–Mild persistent
- Symptoms during the day ≥2 x/week
- Symptoms at night 3-4 x/month
- FEV1 is at least 80% of predicted value
- PEF variability is 20-30%
–Moderate persistent
- Daily asthma symptoms
- Symptoms at night at least 5x/month
- FEV1 is 61-79% of predicted value
- PEF is 61 -79% of predicted value
- PEF variability is > 30%
–Severe persistent
- Asthma symptoms are daily and continuous
- Child frequently has symptoms at night
- FEV1 is ≤ 60% of predicted value
- PEF is ≤ 60% of predicted value
- PEF variability is > 30%
 –Severe persistent asthma (SPA) is associated with reduced aerobic and muscle endurance performance(12)

Causes, Pathogenesis, & Risk Factors

› Causes
• A complex interplay of genetic and environmental triggers causes asthma symptoms(11,33)
–More than 100 genetic loci have been linked to asthma but no consistent link has been found between cohorts(9)
–Exposure to environmental allergens during infancy may alter the development of the immune and respiratory systems
and increase sensitivity to triggers(10)
• Asthmatic episodes in children are strongly associated with environmental allergens or triggers such as tobacco smoke,
wood-burning stoves, pets, dust mites, and cold air. Symptoms can also be triggered by viral respiratory infections,
strenuous physical activity, hyperventilation, cold air, dry air (i.e., low humidity), allergies, chemical irritants, and some
medications, including aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), beta-blockers, and sulfites(18)
› Pathogenesis
• Increased bronchial reactivity to allergens, viral infection, environmental triggers, emotional stress, and exercise results in
periodic episodes of bronchoconstriction and wheezing that limit airflow(1,9,25,33)
• Although acute episodes of bronchoconstriction are reversible, over time the airways can become persistently inflamed and
obstructed
• Authors of a randomized controlled trial (RCT) conducted in Brazil found that children with SPA had a significantly lower
peak oxygen consumption (VO2peak; 28.2 mLkg/min) and quadriceps endurance (43.1 repetitions) than healthy controls
(34.7 mLkg/min and 80.9 repetitions, respectively). Corticosteroid use was not associated with values for VO2peak and
quadriceps endurance. In contrast, children with mild persistent asthma performed similar to the control group(12)
› Risk factors
• Factors that increase risk of asthma in children(9)
–Parental asthma
–Allergy
- Atopic dermatitis (eczema)
- Allergic rhinitis
- Food allergy
- Inhalant allergen sensitization
- Food allergen sensitization
–Severe lower respiratory tract infection
- Pneumonia
- Bronchiolitis requiring hospitalization
–Wheezing apart from colds
–Male gender
–Low birthweight
–Environmental tobacco smoke exposure
–Reduced lung function at birth
–A family history of atopy (i.e., positive skin prick test to 1 or more allergens)(1)
–NSAIDs, particularly ibuprofen, are associated with drug hypersensitivity in children(34)
–Obesity may complicate asthma attacks(13,32)

Overall Contraindications/Precautions
› Consult with referring physician for any specific treatment guidelines associated with pediatric asthma for this patient
› Obtain written consent from parent or legal caretaker and secure parental involvement with, and commitment to, the
treatment plan
› Consult with the parent and/or primary caregiver regarding asthma medications and any other treatment intervention as
prescribed by the physician. Fast-acting bronchodilators such as βeta-2 (β2) agonists are typically used as “rescue inhalers”
for severe acute attacks
› Exercise may trigger transient airway constriction. Exercise-inducedbronchospasm (EIB) is diagnosed by a drop in FEV1
of 10% or more after an exercise challenge of 5 to 10 minutes duration such as a graded exercise test or 6-minute walk for
distance test (6MWT).(14) A rescue inhaler should be available during treatment sessions and may be used before exercise to
forestall or prevent EIB. Advise patient to use a spacer on inhaler to deliver proper dose (per physician recommendation)
› Status asthmaticus is a medical emergency in which asthma symptoms (chest tightness, rapidly progressive shortness of
breath, dry cough, wheezing, nasal flaring, severe chest contractions, gasping for air, sweating, cyanosis) are refractory/not
responsive to rescue bronchodilator therapy. Seek emergency services for the patient immediately to relieve severe airflow
obstruction and hypoxemia. Status asthmaticus occurs more often after a recent viral respiratory illness, exposure to potent
allergens or irritants, or exercise in a cold environment. The primary therapies are repetitive administration of rapid-acting
inhaled bronchodilators, systemic glucocorticosteroids, and oxygen supplementation(9)
› See specific Contraindications/precautions to examination and Contraindications/precautions under Assessment/
Plan of Care

Examination
› Contraindications/precautions to examination
• Postpone exercise testing if the patient develops symptoms that do not subside after use of rescue inhaler. Contact the
referring physician. Call 911 if patient does not respond to known treatment
› History
• History of present illness/injury: Based on the patient’s medical history, physical examination, and pulmonary function
and laboratory test results
–Mechanism of injury or etiology of illness
- At what age was asthma diagnosed?
- About 80% of all patients with asthma report disease onset prior to 6 years old(9)
- When do asthma attacks occur? What are the child’s known triggers? Is the child able to feel an attack starting? How
long do symptoms last? How debilitating are symptoms? Is there any pain or tightness in the chest during an attack? Is
wheezing or cough (productive or dry) present? Does the patient have known allergies? Has the patient received allergy
shots?
- Children with a diagnosis of asthma who are age 7 or older may be dependable historians; based on a study of 414
parent-and-child duos(15)
–Course of treatment
- Medical management
- Current guidelines for the management of asthma in adults and children from the U.S. National Heart, Lung, and
Blood Institute (NHLBI), the Global Initiative for Asthma (GINA), and the British Thoracic Society (BTS) were
all developed using the same evidence database, with emphasis on their specific patient populations.(25) Canadian
Thoracic Society (CTS) guidelines describe management of asthma in preschoolers and children 6 years and older(26)
- Black children have 2-7 times more emergency department visits, hospitalizations, and deaths due to asthma than
non-Black children(9)
- Acute asthma attacks are generally managed with a short-acting β2 agonist and, if necessary, supplemental oxygen
- Chronic asthma is generally managed with inhaled corticosteroids (ICSs)(9)
- What environmental modifications have been made to minimize triggers?(9)
- Has allergen immunotherapy been tried? If so, does it appear to be effective in reducing asthma attacks?(9)
- Medications for current illness/injury: Determine what medications clinician has prescribed for this condition or
any other medical condition; are they being taken and does the patient feel they are effectively controlling his or her
symptoms?(2)
- ICSs
- Short-acting β2 agonists (e.g., albuterol, terbutaline, metaproterenol)
- Long-acting β2 agonists (salmeterol xinafoate [Serevent], formoterol fumarate [Foradil])
- Severe asthma can be treated with oral prednisolone, which in the long term may have adverse toxic effects.
Subcutaneous injections of omalizumab, a monoclonal anti-immunoglobin E antibody, may allow for a reduction in the
daily prednisolone dose(28)
- Mast cell stabilizers (e.g., cromolyn, nedocromil)
 - Antileukotrienes (montelukast [Singulair])
- Diagnostic tests completed: May include
- Pulse oximetry
- Pulmonary function tests with spirometry(16)
- Allows the clinician to diagnose asthma, the severity of airway obstruction, and assist with determining the
appropriate therapeutic intervention
- Chest x-ray(9)
- Infants may undergo fluoroscopy to rule out dynamic obstruction
- Allergy testing(9)
- Arterial blood gases (ABGs) in severe cases
- Complete blood count (CBC)
- Home remedies/complementary therapies: Document any use of home remedies or complementary therapies (e.g.,
acupuncture, herbal supplements) and whether or not they help
- Complementary therapies for the management of asthma include mind-body techniques, dietary and herbal
supplements, dietary changes, manual therapies, and acupuncture(4)
- Previous therapy: Document whether patient has had physical therapy for this or other conditions and what specific
treatments were helpful or not helpful
–Aggravating/easing factors (and length of time each item is performed before the symptoms come on or are eased):
Some of the most common aggravating factors include upper respiratory infections, noncompliance with treatment
regimen, and exposure to allergens(1)
–Nature of symptoms: Document nature of symptoms. See Presentation/signs and symptoms, above. In general, are
symptoms improving, worsening, or staying the same?
–Rating of symptoms: Use a visual analog scale (VAS) or 0-10 scale to assess symptoms at their best, at their worst, and
at the moment (specifically address if pain is present now and how much).Include Oucher scale or FACES for children
–Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (A.M., mid-day, P.M.); also
document changes in symptoms due to weather (cold vs. warm temperatures), seasonal changes, physical activity, or
other external variables. Do symptoms occur perennially/seasonally, episodically/continually, or diurnally? Number of
symptom episodes per week?
–Sleep disturbance: Document number of wakings/night. Number of nocturnal episodes per month?
–Other symptoms: Document other symptoms patient may be experiencing that could exacerbate the condition and/or
symptoms that could be indicative of a need to refer to physician (e.g., dizziness, bowel/bladder dysfunction). Infants and
children with frequent episodes of bronchitis are likely to have asthma
–Respiratory status: Inquire about corticosteroid use and previous need for intubation. Does the patient complain of
fatigue with exercise? Is patient able to keep up with peers during physical activities such as physical education and
recreational sports? Does the child feel limited in his or her activities due to asthma?
–Barriers to learning
- Are there any barriers to learning? Yes__ No__
- If Yes, describe _________________________
• Medical history
–Past medical history
- Previous history: Is there a history of asthma, eczema (urticaria), angioedema or respiratory allergies? Have there been
any recent respiratory infections, hospitalizations for asthma, or other medical issues?
- Comorbid diagnoses: Ask patient/caregiver about other problems, including diabetes, learning disabilities, attention
disorders, obesity, allergies, cancer, heart disease, psychiatric disorders, orthopedic disorders, etc. Associated medical
conditions include rhinitis, sinusitis, and gastroesophageal reflux disease (GERD)
- Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken
(including over-the-counter drugs)
- Other symptoms: Ask patient about other symptoms he or she may be experiencing
• Social/occupational history
–Patient’s goals: Document what the patient or primary caregivers hope to accomplish with therapy and in general
–Vocation/avocation and associated repetitive behaviors, if any: Does the patient participate in recreational or
competitive sports? If so, describe any limitations. Does the patient fatigue easily or seem anxious with physical activity?
 Can the patient fully participate in the school day, including physical education? Is the patient able to participate in other
desired activities? Does the patient walk to/from school or work? Is the patient able to keep up with family/peers in the
community (e.g., shopping, amusement parks)?
–Functional limitations/assistance with ADLs/adaptive equipment: Is the patient independent in functional activities?
Does the patient use assistive or adaptive devices?
–Living environment
- Are there any known risk factors or environmental triggers within the home, such as secondhand smoke, pets, or mold?
- Exposure to secondhand tobacco smoke may worsen asthma symptoms in children, based on a study (n = 523) in the
United States(17)
- Clinicians should inquire whether there is a possibility of mold in the home
- Inquire about the layout of the home (e.g., stairs, number of floors in home). Does the patient complain of fatigue with
stair negotiation within the home or school setting?
› Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be
appropriate to patient medical condition, functional status, and setting)
• Anthropometric characteristics: Document height, weight, and body mass index (BMI). Indicate if patient is overweight
or obese based on age and sex normative data
–There is an association between asthma and obesity. On average, children with asthma have higher BMI values than
children without asthma. Obese children with asthma tend to be more symptomatic than non-obese children with
asthma(32)
• Balance: Assess standing static and dynamic balance using Pediatric Balance Scale (PBS) or components of balance
(single limb stance eyes open and closed).The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)
balance subscale or Peabody Developmental Motor Scales, Second Edition (PDMS-2) can also be used
• Cardiorespiratory function and endurance
–Assess resting heart rate (HR), blood pressure (BP), respiratory rate (RR), and oxygen saturation, as indicated
- It is important to use a proper cuff size with children so that HR and BP are accurately measured. Compare with
normative data for age
–Assess breath sounds. Indicate if tachypneic or labored
–Assess aerobic endurance fitness using the 6MWT or graded exercise test on a cycle ergometer.(6,12) In some settings,
pulmonary function testing with spirometry before and after exercise is warranted to assess for EIB(6)
- Verbal dyspnea scale
- Borg Rating of Perceived Exertion (RPE) Scale
• Circulation: Assess bilateral peripheral pulses (should be intact)
• Gait/locomotion: Assess gait and note any asymmetry or abnormality that might contribute to gait inefficiency or pain,
such as decreased heel strike or excessive anterior trunk lean. Document any reports of pain
• Muscle strength: Use manual muscle testing to assess bilateral upper and lower extremity strength using myotomes in
developmentally age-appropriate children without tone or coordination issues. For those who are unable to follow manual
muscle testing commands, assess functional strength with age-appropriate gross motor skills such as squatting, tall kneel,
half-kneel, floor to stand, heel and toe raises, sit-ups, and plank(12,16)
• Observation/inspection/palpation (including skin assessment)
–Document any visible signs such as cyanosis or diaphoresis during severe asthmatic exacerbations
–Does the patient use accessory muscles for breathing?
–Note color of skin, fingernails
• Posture
–Assess posture in sitting and standing
- Assess for scapular winging, rounded shoulders, forward head, and tight pectoral muscles
- In sitting/standing, assess for slouched posture/decreased lumbar lordosis, posterior pelvic tilt
–Alterations in static posture due to labored breathing using accessory muscles in children with SPA may include
protraction of head and shoulders, reduced normal spinal curves, and changes in chest wall anatomy(18)
• Range of motion: Assess AROM and PROM for extremities and trunk. Note any asymmetry
• Reflex testing: Assess bilateral deep tendon reflexes, if indicated by comorbidity
• Sensory testing: General scan of dermatomes, if indicated by comorbidity
 • Special documentation specific to diagnosis
–Pediatric Asthma Quality of Life Questionnaire(PAQLQ)(7)
–Document any of the following symptoms observed or reported during the evaluation and note whether at rest or during
activity:
- Wheezing
- Atypical breathing patterns (e.g., labored, prolonged expiration)
- Shortness of breath, dyspnea
- Cough (if productive, document sputum color, consistency, and amount)
- Chest tightness

Assessment/Plan of Care
› Contraindications/precautions
• Only those contraindications/precautions applicable to pediatric asthma are mentioned below, including with regard to
exercise therapy. Rehabilitation professionals should always use their professional judgment in decision making and follow
the exercise guidelines of their clinic/hospital
• Obtain treatment guidelines/parameters from referring physician
• Tailor the exercise program to accommodate the patient’s functional ability, age, goals, and interests
• Ensure close supervision with instruction throughout exercise therapy and functional training sessions
• Provide a thorough orientation to patient with regards to the exercise equipment. Adequate warm-up time should be
implemented during treatment sessions to help reduce the patient’s apprehension about exercise
• In order to prevent EIB, it is important to include a light warm-up,frequent rest breaks, and enjoyable activities and to avoid
breathing cold air(14)
• Clinicians should use their professional judgment concerning the use of modalities
• Electrotherapeutic modalities are not indicated in children with asthma except when prescribed by the referring physician
for another problem (e.g., coexisting musculoskeletal condition)
› Diagnosis/need for treatment
• Asthma based on the patient’s medical history, physical examination, pulmonary function and laboratory test results
• Persistent pediatric asthma/respiratory symptoms that impair cardiopulmonary and physical functioning for
age-appropriateactivities of daily living (ADLs) and reduce health-related quality of life (HRQoL) and caregiver QoL;
postural changes related to breathing with accessory muscles
• Asthma-related symptoms can impact a child’s HRQoL and ability to perform age-appropriate ADLs in the home and
community.(1,2) For example, Canadian researchers reported that children with asthma are less likely to walk to school,
even if they live in close proximity to the school(24)
› Rule out (9)
• Allergic rhinitis
• Sinusitis
• Adenoidal or tonsillar hypertrophy
• Nasal foreign body
• Vocal cord dysfunction or paralysis
• Vascular rings
• Laryngotracheomalacia
• Laryngotracheobronchitis (e.g., pertussis)
• Laryngeal web, cyst, or stenosis
• Exercise-induced laryngeal obstruction
• Tracheoesophageal fistula
• Foreign body aspiration
• Chronic bronchitis (from environmental tobacco smoke exposure)
• Toxic inhalations
• Bronchopulmonary dysplasia
• Viral bronchiolitis
• Gastroesophageal reflux
• Causes of bronchiectasis: cystic fibrosis, immune deficiency, allergic bronchopulmonary mycosis, chronic aspiration
 • Immotile cilia syndrome
• Bronchiolitis obliterans
• Interstitial lung disease
• Hypersensitivity pneumonitis
• Pulmonary eosinophilia, Churg-Strauss vasculitis
• Pulmonary hemosiderosis
• Tuberculosis
• Pneumonia
• Pulmonary edema
• Medications associated with chronic cough (e.g., ACE inhibitors)
• Angiotensin-converting enzyme inhibitors
› Prognosis
• Authors of a pilot study (n = 45) in the United States found that children with asthma can participate safely in regular
moderate to vigorous intensity physical activity(19)
–Forty-five children 7 to 14 years of age were randomized to a 9-week vigorous-level swimming program or a
9-weekmoderate-intensity golf program
–Combined group analysis revealed that only 6 symptom exacerbations occurred during 1,125 person-sessions of golf and
swimming and all exacerbations were controlled with bronchodilator therapy
–Ninety-two percent of parents were very or extremely satisfied with the program
–Asthma symptom severity scores decreased, parental QoL increased, and the number of urgent physician visits for asthma
decreased after the 9-week trial
• ICSs can provide long-term control of chronic asthma symptoms if taken properly(2)
• Aerobic training can increase endurance capacity, improve symptom control, and improve HRQoL in children with
persistent asthma, even when pulmonary function testing does not improve(6,7,8,27)
• Adolescents with uncontrolled persistent asthma often complain of ongoing symptoms that reduce HRQoL(3)
› Referral to other disciplines: Contact referring physician for increased asthma symptoms; respiratory therapist for
breathing exercises; nutritionist or registered dietitian for dietary counseling;(4) acupuncturist for alternative care(4)
› Other considerations
• Urban, high-risk adolescents with undiagnosed asthma may be at risk for sleep disturbances that result in daytime
sleepiness during activities(35)
–Based on a study of 349 adolescents (46% Latinos and 37% African American) in the United States who reported waking
at night due to asthma-like symptoms and perceived severity of breathing problems
–Authors suggested that more aggressive interventions should be considered in this high-risk group with no asthma
diagnosis
• Educate the child in the use of a harmonica for improving pulmonary function. Harmonica playing is a fun and possibly
effective method for improving symptoms of asthma in children(21)
• Massage may improve FEV1, but not forced vital capacity (FVC), in children with asthma
–Based on an RCT (n = 60) in Egypt in which children received a daily 20-minute parent-administered massage for 5
weeks plus conventional treatment or conventional treatment only(29)
- Evidence is lacking on the mechanism by which massage may provide a benefit in pediatric asthma or other pulmonary
conditions
• Caregiver considerations
–Caregivers of patients with asthma who use denial as a coping mechanism have decreased QoL compared to caregivers
who use acceptance as a coping mechanism(36)
- Based on a Portuguese study of 182 parents of a child/adolescent with asthma
–Authors in Taiwan identified the primary sources of caregiver stress in 30 caregivers of children with asthma through
interviews and focus groups(37)
- Primary physiologic stressor – household cleaning
- Primary psychological stressor – coping with life-threatening nature of asthma attacks
- Primary intellectual stressor – drug safety
 - Authors of the study also identified the following situations that increase stress for the primary caregiver of a child with
asthma:
- Close family ties of Chinese culture
- Lack of support for children with asthma at school
- Lack of family acceptance due to negative social label of asthma
› Treatment summary
• Physical therapy treatment of children with asthma includes relaxation, endurance training, breathing, strength training and
aerobic exercise(16,22,23,24,25,26,27)
• There are no established guidelines for the individualized prescription of exercise in children with asthma. However,
studies indicate that with precautions, asthmatic children can participate in supervised submaximal exercise similar to
healthy children(6,7,8,12,20) Aerobic exercise training is associated with reduced airway reactivity during physical activity/
EIB, decreased asthma exacerbations, and improved HRQoL(7,8)
–Authors of an RCT (n = 38) in Brazil found that a supervised aerobic training program for 16 weeks decreased the
severity of EIB and the use of ICSs and improved HRQoL in children with moderate to severe persistent asthma(7)
- Spirometry, exercise challenge, and maximum incremental cardiopulmonary exercise tests were performed before and
after the 16-week training program. Daily doses of inhaled steroids and PAQLQ scores were also recorded
- Physical training was associated with significant improvements in cardiopulmonary function at peak and submaximal
exercise in the treatment group, whereas no significant changes were found in controls
- Severity of EIB and post-exercise breathlessness were significantly decreased in the treatment group; improvement in
fitness and EIB, however, were not significantly related
- PAQLQ scores improved only in the treatment group. The use of daily doses of ICSs decreased in the training group
(-52%), but remained unchanged or increased in controls
–Authors of an RCT (n = 62; mean age 10.4 years) in Turkey found that asthma symptoms decreased and HRQoL scores
increased in children with mild to moderate asthma after 8 weeks of basketball training (1 hour, 3 x/week)(6)
- The exercise and control groups participated in a home respiratory exercise program. In addition, the exercise group
participated in a moderately intensive basketball exercise training program for 8 weeks
- Although PAQLQ scores improved in both groups, the improvement in the exercise group was significantly greater.
After training, the exercise group performed better in the physical work capacity test (PWC170 test) and 6MWT,
whereas no improvement was found in the control group
- Medication scores improved in both groups, but symptom scores improved only in the exercise group
- No significant changes in pulmonary function were found for either group, except PEF increased in the exercise group
• Treatment should include patient and caregiver education about environmental triggers, promoting a healthy lifestyle,
exercise, and diet (5,13)

.
Problem
Persistent asthma
symptoms despite
medical treatment
Goal Intervention Expected Progression Home Program
Reduce asthma Patient education Reduced frequency Provide patient and
exacerbations _ and severity of asthma family/caregivers with
Minimize exposure symptoms literature on asthma
to environmental triggers and advise
triggers. Comply with them to follow medical
prescribed use of prescriptions and
asthma medications. home modifications.
Have patient/primary Encourage acceptance
caregiver keep a daily of diagnosis by
medication journal and caregiver and proactive
note any exacerbations ways to deal with
diagnosis(36)
Productive cough with Reduce frequency Chest physical Improved airway Daily repetition of
sputum and severity of excess therapy clearance breathing exercises(23)
mucus production _ _ _
Use airway clearance _ _
techniques as directed Improved ability to Parent to be
by physician demonstrate productive independent in chest
_ cough as indicated physical therapy
_ treatment techniques
Instruct primary
caregiver in proper
chest physical therapy
treatment techniques
Decreased activity Improve physical Therapeutic exercise Improved aerobic Participation in
tolerance/endurance functioning in daily and _ functional capacity pleasurable recreational
_ recreational activities Supervised aerobic _ activities
_ _ training as tolerated, _ _
Changes in posture _ including treadmill, Patient to demonstrate _
related to use of Improved posture cycle ergometer, and understanding of proper Demonstrate awareness
accessory respiratory elliptical trainer. Age- sitting and standing of posture and
muscles appropriate aerobic posture ergonomic desk/
conditioning activities _ computer set-up at
such as jumping _ home
rope, jumping jacks, Improved posture _
skipping, obstacle _ _
courses Progress strengthening Daily repetition of
_ and aerobic exercises
_ conditioning program _
Assess ergonomic set- as patient improves Ensure parent/primary
up for studying at home caregiver educated on
and using computer. any home program and
Provide patients and/ provide with written
or caregiver with guidelines/instructions
written instructions
regarding proper sitting
position for studying at
a desk and/or using a
computer
_
_
Functional training
_
Posture retraining and
exercises and stretching
to address any posture-
related deviations, chest
muscle weakness or
tightness

Desired Outcomes/Outcome Measures

› Reduced frequency and severity of asthma symptoms and exacerbations
• Asthma diary
› Improved activity tolerance and endurance
• 6MWT or graded cycling exercise test (with dyspnea and RPE assessments)
› Increased recreational activity
• Activity diary
› Improved posture (as indicated)
• Posture reassessment
› Improved standing static and dynamic balance (as indicated)
• PBS
› Improved HRQoL
• PAQLQ(7)
› Improved strength
• Strength testing (manual muscle testing, myotomal testing)

Maintenance or Prevention
› A collaborative approach to the management of pediatric asthma should include patient and caregiver education on the
importance of compliance with medical prescriptions and avoidance of environmental triggers(5,24)
› At-risk, urban adolescents having asthma-like symptoms and showing signs of sleepiness during the daytime should be
tested for asthma and interventions should be considered(35)
› Patients with persistent asthma should receive an annual influenza vaccine
› The Environmental Practice Parameter Work Group, commissioned by the U.S. Joint Task Force on Practice Parameters and
comprising members of the American Academy of Allergy, Asthma, and Immunology, the American College of Allergy,
Asthma, and Immunology, and the Joint Council of Allergy and Immunology, systematically reviewed the literature and
recommended practice parameters regarding furry animal exposure control. Exposure control guidelines can be used to
reduce exposure to a known contaminant in the environment(30)
• Source control involves the complete removal of the furry animal and abatement involves removing from the home any
contaminated material that serves as a reservoir
• Primary prevention consists of avoidance measures directed at preventing clinical manifestations of atopy by suppressing
or delaying the onset of sensitization. This can begin before birth and extend into the first few months of life
–Evidence suggests that early exposure (first 3 months of life) to animal allergens may have a protective effect in
some individuals, although the evidence is not strong enough to recommend having a furry animal for the purpose of
prevention. Therefore, the risk reduction is not sufficient to justify the decision to get a pet to avoid allergen sensitization
• Secondary prevention focuses on reducing or removing the environmental triggers, especially allergens, that lead to the
allergic disease in a sensitized individual
–One or more known dog allergens are present in all dogs
–To reduce the transport of cat allergens persons should consider changing their clothes when traveling from a
high-cat-allergen environment to a low-cat-allergenenvironment
–The use of high-efficiency particulate air cleaners that run continuously can reduce pet allergen exposure
–Nonwoven microfiber encasings cannot be washed and are not recommended. Some woven microfiber bed encasings can
block cat allergens from penetrating the fabric
–Regular, long-term use of high-efficiency or central vacuum cleaners is associated with reduced allergen exposure in
homes with pets
–Frequent washing of pets (at least weekly) can reduce airborne cat or dog allergens; however, the clinical benefit has yet
to be established
–Keeping the pet out of the child’s bedroom may help reduce exposure to allergens
–Homes with poor ventilation and wall-to-wall carpet have higher levels of cat and dust allergens
–Families generally are reluctant to get rid of a favored pet, so recommending they get rid of the pet is not advised. Instead,
control measures should be used so the pet can remain with the family
• Tertiary prevention, also known as treatment, consists of avoiding triggers. Despite major advances in drugs for the
treatment of asthma, none have shown to permanently stop disease progression
–Dogs should be excluded from rooms in which reduced exposure is desired
–Exposure to dog and cat allergens should be minimized to reduce the likelihood of an asthma exacerbation in sensitized
children
 –Avoidance is the most effective way to manage allergens
› Use rodent traps to remove rodents from an infested building. Rodenticides should be used if other interventions are
ineffective. These should be applied by a licensed professional exterminator(31)
› Continue therapeutic exercises and/or daily aerobic activity at home, as indicated
› Continue airway clearance techniques, as needed
› Dialogue with caregiver about stress of taking care of child and offer suggestions for coping strategies that include
acceptance of diagnosis(36)

Patient Education
› American Lung Association website, “Asthma & Children Fact Sheet,”
http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/learn-about-asthma/asthma-children-facts-sheet.html
› Asthma.com website has area for parents to learn about how they can help their child live with asthma at
https://www.asthma.com/for-parents.html
› General information can be found regarding symptoms, diagnosis, management, and
treatment on the American Academy of Allergy, Asthma, & Immunology website,
http://www.aaaai.org/conditions-and-treatments/asthma For information specific to children on this website, see
http://www.aaaai.org/conditions-and-treatments/conditions-a-to-z-search/Childhood-(pediatric)-Asthma

Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

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