Patient-Centered Care for

Childhood Asthma
Ellyn Hartman and Richard D. O’Connor

ABSTRACT
Asthma, the most common chronic disease in children, is characterized by chronic inflammation
of the respiratory system. If left uncontrolled, persistent asthma can have serious negative clinical
outcomes.Thus, the earliest possible diagnosis based on the recognition of specific clinical indica-
tors, treatment with anti-inflammatory controller medications such as an inhaled corticosteroid
(ICS) or a leukotriene receptor antagonist (LTRA), and patient-centered strategies for monitoring
disease and improving patient adherence are essential to successful asthma care. Recent clinical
studies support the efficacy of ICSs over LTRAs as daily treatment for pediatric asthma. Routine
follow-up and patient education can facilitate adherence to daily controller therapy and successful
asthma control in children.
Keywords: asthma diagnosis, childhood asthma, inhaled corticosteroids, leukotriene receptor
antagonists

284 The Journal for Nurse Practitioners - JNP April 2009

INTRODUCTION indicators of potential asthma in children and reviews the
Asthma is a chronic inflammatory disease of the respiratory effectiveness of ICSs vs LTRAs as daily therapy for persist-
system.The inflammatory response in the lungs can be trig- ent asthma based on the results of recently published com-
gered by various environmental factors, including viral parative pediatric studies. Finally, patient-centered strategies
infection, exercise, tobacco smoke, pets, dust, molds, and for achieving successful asthma care in children with
pollen.1 In susceptible children, these triggers cause swelling asthma are discussed.
and narrowing of the airways characterized by airway
hyper-responsiveness, airflow limitation, and respiratory CLINICAL INDICATORS AND RISK FACTORS FOR ASTHMA
symptoms, which are most commonly manifested as cough Initial asthma-like symptoms occur during the first sev-
or wheeze. Over time, persistent inflammation may lead to eral years of life but may easily be misdiagnosed as symp-
permanent and irreversible impairment of lung function.To toms of other childhood diseases.Additionally, even after
prevent the negative consequences of persistent asthma, periods of little or no symptoms, children with asthma
both early diagnosis of asthma and effective control with may experience exacerbations of symptoms1 or changes
anti-inflammatory therapy are essential. Early diagnosis in asthma severity.3 Thus, it is important not only that
requires that nurse practitioners (NPs) recognize and NPs are able to recognize symptoms indicating the possi-
understand the clinical indicators that identify young chil- ble presence of asthma but also that parent and caregiver
dren at high risk of developing persistent asthma. Patient education and awareness occur as early as possible during
response to treatment must be monitored carefully for a child’s life.
effective asthma control. If control is not attained or main- In addition to a family history of asthma or allergy, clin-
tained, treatment should promptly be adjusted. ical indicators include recurrent respiratory symptoms, par-
Although asthma-like symptoms are often treated with ticularly wheezing and nighttime cough; symptoms that
a bronchodilator, such short-acting ß2-adrenergic agonist occur in response to specific triggers and have a recogniza-
(SABA) or “rescue” therapy has no effect on the underlying ble pattern; and specific physical examination findings, such
inflammation and therefore is not a substitute for long- as hyperexpansion of the thorax (Table 1).1,4,5 Sample ques-
term anti-inflammatory controller therapy.1 Long-term tions to aid in the diagnosis of asthma are listed in Table 2.1
therapy with an inhaled corticosteroid (ICS) is recom- It is important to recognize that while cough is a common
mended for the treatment of persistent asthma, while symptom of asthma in children, isolated chronic cough is a
leukotriene receptor antagonists poor indicator of asthma.6
(LTRAs) are recommended as Although cough-variant asthma
alternatives or add-ons to ICS can occur, it is often associated
therapy. In situations where an
1 Although the percentage with bronchial hyper-responsives
ICS alone fails to effectively of predicted FEV1 and or reversibility of airway obstruc-
control persistent asthma, and overall quality of life tion, which can be used to aid in
patient adherence and environ- improved in both treatment the diagnosis. No single indica-
mental control are optimized, tor, either cough or wheeze,
combination therapy with a
groups, improvements compels a diagnosis of asthma;
long-acting ß2-adrenergic ago- were significantly greater the presence of multiple indica-
nist (LABA) may be appropriate. with fluticasone than tors suggests this diagnosis.
For details regarding the proper The Asthma Predictive Index
montelukast.
classification of asthma severity, is used to help identify children
recommendations for a stepwise with frequent wheezing who are
approach to treatment, and at risk of developing asthma.This
assessment of asthma control, the April 2008 issue of The tool was developed in 2000,7 based on longitudinal studies,
Journal for Nurse Practitioners2 provides a comprehensive and modified in 2004.8 The modified index requires a child
review of the 2007 guidelines for diagnosing and managing to have a history of 4 or more wheezing episodes, with at
asthma from the National Heart, Lung, and Blood Insti- least 1 episode confirmed by a physician, and either 1 major
tute/National Asthma Education and Prevention Program risk factor or 2 minor risk factors.The major risk factors
(NHLBI/NAEPP) guidelines for diagnosing and managing are parental history of asthma or physician-diagnosed atopic
asthma.1 The present article briefly summarizes the clinical dermatitis; the minor risk factors are allergic sensitization to

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Table 1. Clinical Indicators for Diagnosing Asthma in
Children1,4,5
Family History
Parental asthma
Parental allergy
Recurrent Symptoms
Cough, especially at night
Wheeze – high-pitched whistling sounds when
breathing out (may only be present or evident
during acute episodes or exercise)
Shortness of breath
Chest tightness
Symptom Triggers
Viral infection
Smoke (eg, tobacco, wood) and other irritants
(eg, strong odors, fumes)
Exercise
Allergens (eg, house dust mite, pollen, cockroach,
mold, animal dander)
Changes in weather
Laughing or crying
Psychological factors (eg, stress)
Symptom Pattern
Worsen at night, possibly waking the child and/or
parent/caregiver
Occur seasonally
Limit physical activity or plan
Recurrent pneumonia or bronchitis
Physical Findings
Hyperexpansion of the thorax
Use of accessory muscles
Tachypnea
Presence of other allergic diseases (eg, atopic
dermatitis/eczema, swelling and/or pale nasal
mucosa, clear nasal discharge)
milk, eggs, or peanuts; wheezing unrelated to colds; and
blood eosinophils at more than 4%.8
If children are old enough to cooperate (typically older
than 4 years), pulmonary function tests should be per-
formed to help establish a diagnosis of asthma. For younger
children, a diagnosis of asthma can only be reliably estab-
lished based on the practitioner’s clinical judgment and the
patient’s response to treatment.1
EFFICACY AND SAFETY OF INHALED CORTICOSTEROIDS
VERSUS LEUKOTRIENE RECEPTOR ANTAGONISTS IN
PERSISTENT ASTHMA
Anti-Inflammatory Effect
Both ICSs and LTRAs are commonly used to treat asthma-
related respiratory inflammation (Table 3), but clinical evi-
286 The Journal for Nurse Practitioners - JNP
Table 2. Sample Questions to Aid in the Diagnosis of
Asthma1
A “Yes” Answer To Any Question Suggests An Asthma
Diagnosis Is Likely
In the past 12 months...
• Have you had a sudden severe episode or recurrent
episodes of coughing, wheezing (high-pitched whistling
sounds when breathing out), chest tightness, or
shortness of breath?
• Have you had colds that “go to the chest” or take more
than 10 days to get over?
• Have you had coughing, wheezing, or shortness of
breath during a particular season or time of year?
• Have you had coughing, wheezing, or shortness of
breath in certain places or when exposed to certain
things (eg, animals, tobacco smoke, perfumes)?
• Have you used any medications that help you breathe
better? How often?
• Are your symptoms relieved when the medications
are used?
In the past 4 weeks, have you had coughing, wheezing,
or shortness of breath…
• At night that has awakened you?
• Upon awakening?
• After running, moderate exercise, or other physical
activity?
dence suggests that ICSs are more potent than LTRAs as
anti-inflammatory agents.1 Although LTRAs reduce
inflammatory markers, such as sputum eosinophils, biopsy
data confirming the anti-inflammatory effects in the air-
ways are limited.9,10 In a study of patients with mild asthma,
biopsy data revealed significantly fewer mast cells in patients
treated with fluticasone vs montelukast (P = 0.041).10
Moreover, in a study of corticosteroid-naïve patients with
asthma, reductions in sputum eosinophils obtained with the
ICS fluticasone were greater and lasted longer than those
obtained with montelukast.11 In a separate study of patients
dependent on high-dose corticosteroids, the addition of
montelukast to high-dose ICS or prednisone did not result
in a further reduction in sputum eosinophils compared
with placebo.12
Efficacy of Single-Agent Controller Therapy
A systematic review of clinical studies conducted primarily
with adult patients demonstrated that, when used as single-
agent daily therapy, ICSs are superior to LTRAs in improv-
ing exacerbation rates, pulmonary function, asthma symp-
April 2009
Table 3. Currently Available Inhaled Corticosteroid and Leukotriene Receptor Antagonist Controller Medications and
Age Indications in the United States for Asthma*
Generic Name Brand Name Age Indication
Inhaled corticosteroids
Budesonide
Inhalation suspension Pulmicort Respules 12 months – 8 years
Inhalation powder Pulmicort Flexhaler  6 years
Budesonide and formoterol† fumarate Symbicort  12 years
dihydrate inhalation aerosol
Ciclesonide inhalation aerosol Alvesco  12 years
Fluticasone propionate Flovent HFA Inhalation Aerosol  4 years
Fluticasone propionate and Advair Diskus  4 years
salmeterol† Advair, HFA  12 years
Beclomethasone dipropionate QVAR Inhalation Aerosol  5 years
Flunisolide Aerobid Inhaler System  6 years
Aerobid-M Inhaler System  6 years
Mometasone furoate inhalation powder Asmanex Twisthaler  4 years
Triamcinolone acetonide Azmacort Inhalation Suspension  6 years
Leukotriene receptor antagonists
Montelukast sodium Singulair (tablets, chewable tablets,  12 months
oral granules)
Zafirlukast Accolate tablets  5 years

*Based on manufacturers’ prescribing information; †Long-acting 2-adrenergic agonist.

HFA, hydrofluoroalkane.

toms, nocturnal awakenings, rescue medication use, symp-
tom-free days, and quality of life.13 Four recent clinical
studies (Table 4) in children and adolescents further showed
that ICSs provide better overall asthma control than
LTRAs.14-17
The 12-month, randomized, double-blind Montelukast
Study of Asthma in Children (MOSAIC) (Table 4) com-
pared montelukast (5 mg orally once daily) with fluticasone
delivered via a metered-dose inhaler (MDI) with or with-
out a spacer (2 puffs of 50 g twice daily) in 6- to 14-year-
old children with mild persistent asthma.14 The primary end
point of the study was the percentage of rescue-free days,
defined as days without any asthma rescue medication or
asthma-related resource use.Although primary efficacy was
similar between the 2 treatment groups (montelukast,
84.0% vs fluticasone, 86.7%), fluticasone provided signifi-
cantly better results for several secondary outcomes. For
example, the percentage of days with SABA rescue therapy
was significantly (P = 0.03) lower for patients treated with
fluticasone (12.8%) than those treated with montelukast
(15.4%).Also, the percentage of patients with exacerbations
requiring the use of systemic corticosteroids was signifi-
cantly lower in the fluticasone group versus the mon-
telukast group (10.5% vs 17.8%; P  0.001). Finally,
although the percentage of predicted forced expiratory vol-
ume in 1 second (FEV1) and overall quality of life improved
in both treatment groups, improvements were significantly
greater with fluticasone than montelukast.
A short-term (12-week) randomized study (Table 4,
Ostrom et al) showed that fluticasone 50 g delivered
twice daily via a dry powder inhaler (DPI; DISKUS, Glax-
oSmithKline, Research Triangle Park, NC) was superior to
montelukast 5 mg once daily, when used as first-line
monotherapy for the treatment of persistent asthma in 6- to
12-year-old children who were previously receiving only
SABAs.15 In contrast to the results of MOSAIC study, the
percentage of rescue-free days was significantly greater for
fluticasone than for montelukast (45.1% vs 35%; P =
0.002). For the primary end point of mean (± SEM) per-
centage change from baseline in morning predose FEV1,
children treated with fluticasone experienced significantly
greater increases than those treated with montelukast
(10.62% ± 1.28 vs 4.60% ± 1.19; P = 0.002). Fluticasone
also significantly improved morning and evening peak

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Table 4. Inhaled Corticosteroids vs Leukotriene Receptor Antagonists: Comparative Clinical Trials
MOSAIC14 Ostrom et al15 PACT16 Szefler et al17
Study design Double-blind, Double-blind, Double-blind, Open-label,
randomized, global randomized, U.S. randomized, U.S. randomized, U.S.
Duration of random- 12 months 12 weeks 48 weeks 52 weeks
ized treatment
Patient age, years 6 to 14 6 to 12 6 to 14 2 to 8
Inclusion criteria Asthma for  12 months Persistent asthma for Mild to moderate Mild persistent asthma
Mild persistent asthma  6 months persistent asthma or history of wheezing
FEV1  80% FEV1 60-85% FEV1  70%
Randomized 994 342 285 395
patients, N
ICS Fluticasone MDI* Fluticasone DPI Fluticasone DPI Nebulized BIS
100 μg twice daily 50 μg twice daily 100 μg twice daily† 0.5 mg once daily

LTRA Montelukast Montelukast Montelukast Montelukast

5 mg once daily 5 mg once daily 5 mg once daily 4 mg or 5 mg once
daily
Primary variable Percentage of RFDs Morning predose FEV1 Percentage of asthma Time to first additional
control days asthma medication at
week 52
Primary outcome No significant difference Fluticasone superior Fluticasone superior No significant difference
between treatment to montelukast to montelukast between treatment
groups (P = 0.002) (P = 0.004) groups
Key secondary Superiority of fluticasone Superiority of Superiority of fluticasone Superiority of BIS for
outcomes for improvements in fluticasone for improve- for improvements in improvements in
percent-predicted FEV1, ments in morning and percent-predicted FEV1, morning and evening
SABA-free days, and evening PEF, RFDs, and morning and evening PEF and caregiver and
overall quality of life as nighttime symptom PEF, and asthma control, global assessments of
well as the percentages scores measured by the asthma control as
of patients with asthma Asthma Control well as exacerbation
attacks and systemic Questionnaire rates
corticosteroid use

BIS, budesonide inhalation suspension; DPI, dry power inhaler; FEVI , forced expiratory volume in 1 second; MDI, metered-dose inhaler; MOSAIC, The
Montelukast Study of Asthma in Children; PACT, Pediatric Asthma Controller Trial; PEF, peak expiratory flow; RFDs, rescue-free days; SABA, short-
acting 2-adrenergic agonist.
*Spacer optional.
†
A third treatment arm that included patients receiving combination therapy with fluticasone 100 μg/salmeterol 50 μg is not presented in this table.

expiratory flow (PEF) (P  0.02) and nighttime asthma
symptom scores (P < 0.001) and reduced nighttime use
of the SABA albuterol (P < 0.001) compared with mon-
telukast. Unlike the MOSAIC study, results of the study
by Ostrom et al showed no significant difference between
treatment groups in the number of patients experiencing
asthma exacerbations. However, more patients in the
montelukast group (21% vs 13%) withdrew from the
study, and exacerbation of asthma was listed as the pri-
mary reason for withdrawal.
A recent randomized, double-blind study in school-
aged children with mild to moderate persistent asthma
(Table 4, Pediatric Asthma Controller Trial [PACT]) com-
pared the efficacy of fluticasone DPI and montelukast over
a period of 48 weeks.16 The fluticasone dose was twice that
dose used in the study by Ostrom et al, whereas mon-
telukast doses were the same in both studies. Fluticasone
was superior to montelukast for the primary end point effi-
cacy, the percentage of asthma control days (64.2% vs
52.5%, P = 0.004), which were defined as rescue-free days
(no albuterol, oral corticosteroids, or other asthma medica-
tions), where patients experienced no asthma-related day-
time symptoms or nighttime awakenings and required no
unscheduled healthcare, emergency department, or hospital
visits. Significantly greater efficacy of fluticasone com-
pared with montelukast was also demonstrated for all sec-

288 The Journal for Nurse Practitioners - JNP April 2009

Table 5. Factors Influencing Differential Response to children in that an ICS yielded overall better clinical out-
Asthma Controller Therapy5,20 comes than montelukast.
Response to ICS Response to LTRA
Atopy/allergy High levels of urinary Variability in Patient Response
leukotrienes An important consideration for the choice of therapy in
Poor pulmonary function Viral-induced wheezing (ages asthma control is the variability among patients in respond-
2-5 years) ing to ICSs18 and LTRAs.19,20 In a study of 782 adults and
Long duration of asthma Shorter duration of asthma adolescents with at least a 1-year history of asthma, inhaled
Higher exhaled nitric beclomethasone 200 g twice daily provided a significantly
oxide levels greater mean improvement in FEV1 compared with mon-
telukast 10 mg once daily (0.38 L vs 0.24 L; P 0.01).19
ICS, inhaled corticosteroid; LTRA, leukotriene receptor antagonist.
However, the distribution of treatment responses was gen-
ondary end points, including percentage predicted FEV1 erally similar for both agents, with an 81% overlap in the
(P < 0.001) and time to the first burst of oral corticos- distribution for improvement in FEV1. Moreover, the per-
teroids (P = 0.002). centage of asthma-control days was similar in both groups
In a recent 52-week, open-label study (Table 4, Szefler (98% overlap in frequency distribution). In a crossover
et al), montelukast was compared with budesonide inhala- study of children 6 to 17 years old with mild to moderate
tion suspension (BIS) in 2- to 8-year-old children with persistent asthma that 126 patients successfully completed,
mild asthma or recurrent wheezing (n = 395). BIS is the 17
23% responded (FEV1 improvement  7.5%) only to the
only ICS currently approved by the Food and Drug ICS fluticasone but not to the LTRA montelukast, 5% only
Administration (FDA) for use in children younger than 4 to montelukast and not to fluticasone, and 55% to neither
years. No difference in efficacy was observed between treatment.20 In this study, children with eosinophilic airway
montelukast (4 or 5 mg once each evening) and BIS (0.5 inflammation (ie, higher exhaled nitric oxide and
mg once each evening) for the primary outcome, the time eosinophil cationic protein levels) were more likely to
to the first course of ICS or oral corticosteroid therapy over respond to an ICS vs an LTRA. Considerations for the
the entire 52-week study period. However, at 12 weeks, the choice of asthma control therapy are provided in Table 5.5,20
time to the first administration In addition to allergic phenotype,
of additional asthma therapy was results of other studies suggest
longer for children treated with that responsiveness to ICSs21 and
BIS than for those treated with In adolescents and adults, LTRAs22 may be determined in
montelukast (P = 0.05), suggest- both LABA and LTRA add- part by genotype.
ing better asthma control with on therapies have been
BIS. Moreover, compared with Efficacy of ICS-Based Combina-
montelukast, BIS significantly
shown to improve tion Therapy
improved the rate of mild or outcomes in patients A study of patients 12 years and
severe asthma exacerbations (P already receiving an ICS; older with uncontrolled asthma
= 0.034) and morning (P = however, stronger evidence showed that exacerbation rates
0.007) and evening PEF (P = were lower with combination
0.005). It is noteworthy that the
supports use of add-on ICS/LABA therapy than with
results of the study may have LABA versus add-on LTRA. ICS therapy alone.23 In adoles-
been influenced by the pre- cents and adults, both LABA
school asthma phenotype and LTRA add-on therapies
because the diagnosis of asthma in some of the youngest have been shown to improve outcomes in patients
patients with recurrent wheezing may have been uncertain. already receiving an ICS; however, stronger evidence
Others may have had intermittent asthma or only viral- supports use of add-on LABA vs add-on LTRA.1 In
induced wheezing rather than persistent disease. Nonethe- studies directly comparing the efficacy of LABA and
less, the results are consistent with those of the 3 compara- LTRA add-on therapies, adolescents and adults receiving
tor studies of fluticasone and montelukast in school-aged an LABA experienced significantly greater24,25 improve-

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Table 6. Asthma Resources for Practitioners, Parents, Caregivers, and Children
American Academy of Allergy Asthma and Immunology
www.aaaai.org
American Lung Association
www.lungusa.com
American College of Allergy Asthma and Immunology
www.acaai.org
American Academy of Pediatrics
www.aap.org/healthtopics/asthma.cfm
Allergy and Asthma Network Mothers of Asthmatics, Inc.
www.aanma.org
ments in most asthma outcomes compared with patients
receiving an LTRA.Two randomized blinded studies
have compared the use of ICS/LTRA therapy and ICS
monotherapy in 6- to 14-year-old children with moder-
ate persistent asthma.26,27 In the first study, patients (N =
279) received budesonide 200 g twice daily delivered
via the Turbuhaler (AstraZeneca LP,Wilmington, DE)
during a 4-week run-in period to establish the need for
add-on therapy.26 Eligible patients were then randomized
to receive add-on therapy with montelukast 5 mg once
daily or placebo in a crossover fashion (two 4-week
treatment periods). Addition of montelukast provided
significant improvements in the change from baseline
FEV1 in the per-protocol (P = 0.010) but not the
intent-to-treat analysis (P = 0.62). Days with asthma
exacerbation were reduced 23% with ICS/LTRA vs ICS
therapy (P < 0.001).
In the more recent study, children (N = 71) received
therapy with either the combination of budesonide 100
g twice daily delivered via an MDI with a spacer plus
montelukast 5 mg once daily or budesonide 200 μg twice
daily alone for 12 weeks.27 In contrast to the results found
in the earlier study,26 the frequency of asthma exacerba-
tions was greater with low-dose ICS/LTRA therapy com-
pared with medium-dose ICS therapy alone (33.3% vs
9.1%; P < 0.01). However, no differences in pulmonary
function were observed between the treatment groups.27
Finally, results from a randomized placebo-controlled
trial of 194 asthmatic children aged 2 to 14 years showed
that the addition of montelukast to usual asthma therapy,
including ICSs, during the start of the school year resulted
in a 53% reduction in days with worse asthma symptoms
and a 78% reduction in unscheduled physician visits for
asthma compared with placebo.28 Interestingly, the treat-
ment effect was greater in boys aged 2 to 5 years than in
290 The Journal for Nurse Practitioners - JNP
Asthma and Allergy Foundation of America
www.aafa.org
Childhood Asthma Control Test
www.asthmacontrol.com/index.html
National Heart, Lung, and Blood Institute
www.nhlbi.nih.gov/about/naepp/index.htm
National Jewish Medical and Research Center
www.nationaljewish.org
older boys and in girls aged 10 to 14 years, with nonsignif-
icant effects in younger girls.
Unlike LTRAs, LABAs are not suitable for single-
agent asthma therapy and thus should only be used in
combination with ICS.1 When selecting ICS/LABA com-
bination therapy for children and adolescents, clinicians
should be aware that the FDA-approved ages for use vary
depending on the therapeutic agent (Table 3).The salme-
terol DPI and the combination of fluticasone/salmeterol in
one single DPI are both approved for use in children 4
years and older.The formoterol DPI is approved for use in
children 5 years and older.The combination of budes-
onide/formoterol in a single MDI is approved for use in
children 12 years and older.
Safety Profiles of ICSs and LTRAs
Generally, LTRAs and low to medium doses of ICSs2
have favorable safety profiles in children. However, the
word “steroid” has a negative connotation for some care-
givers. Health care practitioners need to explain the dif-
ferences between ICSs and anabolic steroids, typically
used by bodybuilders. Nonetheless, some parents, and
even health care practitioners, may have concerns about
ICS safety, particularly with regard to adverse effects
commonly associated with systemic corticosteroids.
In the previously discussed MOSAIC and Ostrom et
al studies, the frequency of drug-related adverse events
was similar among patients treated with fluticasone and
montelukast.14,15 The MOSAIC study showed that chil-
dren treated with fluticasone experienced a slower
growth rate than those treated with montelukast (differ-
ence of 0.41 cm/year; P = 0.018).14 These findings are
similar to those from placebo-controlled studies demon-
strating a slowing of growth velocity with ICS, particu-
larly during the first year of treatment.29,30 However,
April 2009
results of long-term studies (4-10 years) with inhaled reduce exposure to asthma triggers (eg, use of mattress
budesonide demonstrate that initial reductions in growth covers to protect against dust mites, removal of stuffed
velocity are transient29,30 and that final adult height is toys from sleeping areas).4 Education and documentation
achieved.31 Available evidence also suggests that ICSs do at regularly scheduled medical follow-up visits help prac-
not have significant effects on bone mineral density, the titioners determine the frequency of symptoms and
incidence of subcapsular cataracts or glaucoma, or hypo- SABA use and the patient response to current treatment.
thalamic-pituitary-adrenal axis function.1 However, to
minimize the potential for adverse events, the lowest ICS Strategies for Facilitating Medication Adherence
dose that still maintains good control of the child’s Adherence to therapy is essential for achieving and main-
asthma should be prescribed. taining treatment effectiveness.Thus, improved adherence
may play a role in reducing asthma morbidity.34 Several
PATIENT-CENTERED ASTHMA CARE techniques can be used to encourage adherence to daily
Strategies for Monitoring Asthma Control controller therapy. First, consistent communication and reg-
The importance of effective asthma control is illustrated ular follow-up visits with primary care providers afford
by the results of a recent 3-year observational cohort practitioners, patients, and caregivers an opportunity for
study of 6- to 12-year-old children with severe or diffi- feedback, questioning, assessment, education, and reinforce-
cult-to-control asthma. Despite high levels of controller ment. Second, when using ICS and inhaled SABA therapy,
therapy (94% received an ICS, 70% a LABA, and 72% a the delivery device must match the patient’s developmental
leukotriene modifier), asthma in these children remained ability and age.4 Several types of delivery devices are avail-
uncontrolled. Successful asthma
32
able.The medical provider
care requires a patient-centered should demonstrate the proper
approach that addresses the needs To minimize the potential technique using the age-appro-
of the child and caregivers at a priate delivery device.The par-
level they can understand, with a
for adverse events, the ent and child can then demon-
sensitivity toward their cultural lowest ICS dose that still strate the technique to the
beliefs.1 Patients and parents maintains good control of medical provider to help ensure
should be provided with a writ- the child’s asthma should adequate drug delivery to the
ten asthma action plan that lungs. Infants and children
enables them to recognize the
be prescribed. younger than 5 years often
signs and symptoms of worsen- require a mask attached to the
ing asthma and to know what nebulizer or to the holding
steps to take and what medications to adjust (Figure 1).1 chamber when using an MDI. Children 5 years and older
The child’s rescue medication (SABA) must be available at can use an MDI with a spacer or use a DPI.
all times; therefore, day care providers, school nurses, and Although ICSs are the most potent and effective con-
teachers should have a copy of the asthma action plan. troller agents, some children or adolescents may be unwill-
A variety of available asthma resources can be ing or unable to use ICS delivery devices; for these patients,
accessed through the Internet (Table 6). Health care prac- oral LTRA dosing may improve adherence with controller
titioners can download and use tools from these organi- therapy, potentially optimizing treatment response. For
zations to teach patients and caregivers. Importantly, sim- example, adolescents (n = 113) who were treated with oral
ple asthma control tests are freely available online (eg, the zafirlukast 20 mg twice daily or inhaled beclomethasone
Childhood Asthma Control Test; see http://www.asthma- 100 or 200 g twice daily in a crossover fashion preferred
control.com/ child.html).33 Patients or their caregivers the LTRA to the ICS.35 Similarly, an open-label uncon-
should be encouraged to complete these questionnaires trolled study in 124 children showed greater parent and
in the waiting room and then discuss the results with patient satisfaction and patient compliance with oral mon-
their clinician as part of their visit. telukast therapy vs inhaled beclomethasone therapy; how-
In children with asthma, primary care management ever, dosing with montelukast in this study was once daily
should include monitoring growth with stadiometry, and dosing with beclomethasone was 3 times daily.36 These
addressing sleep issues, and modifying the environment to data suggest that once-daily dosing is more convenient for

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patients and caregivers, which may promote better adher-
ence. Both the LTRA montelukast and the ICS BIS are
indicated for once-daily use.
CONCLUSION
In summary, available evidence indicates that LTRAs are not
as effective as ICSs in improving asthma outcomes.Accord-
ing to current recommendations, ICSs are the preferred
controller therapy for all severities of persistent asthma in
children.1 However, LTRAs may be a beneficial alternative
for children refractive to ICS therapy or those who are
unable to optimally use inhaled therapy.When adequate
control is not achieved with single-agent controller therapy,
and patient adherence to therapy has been confirmed, an
increase in the dose of ICS or ICS-based combination ther-
apy with either a LABA or an LTRA should be considered
based on the patient’s age. Routine follow-up and education
using a patient-centered approach helps promote patient
involvement and adherence to long-term controller therapy
and therefore better asthma control.
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Ellyn Hartman, RN, MSN, CPNP, is a certified pediatric nurse
practitioner and Richard D. O’Connor, MD, is chief of the divi-
sion of asthma, allergy, and clinical immunology at Sharp Rees-
Stealy Medical Group in San Diego, CA. Dr. O’Connor can
be reached at richard.oconnor@sharp.com. In compliance with
national ethical guidelines, the authors report no relationships
with business or industry that would pose a conflict of interest.
April 2009
 Asthma Action Plan
For: Doctor: Date: Figure 1.
Doctor’s Phone Number Hospital/Emergency Department Phone Number

Doing Well Take these long-term-control medicines each day (include an anti-inflammatory).
Medicine How much to take When to take it

Acknowledgments

www.npjournal.org
No cough, wheeze, chest tightness, or
shortness of breath during the day or night

GREEN ZONE
Can do usual activities
And, if a peak flow meter is used,

Peak flow: more than Identify and avoid and control the things that make your asthma worse, like (list here):
(80 percent or more of my best peak flow)

My best peak flow is:

Sample Asthma Action Plan.1

Before exercise, if prescribed, take: 2 or 4 puffs 5 to 60 minutes before exercise

writing support funded by AstraZeneca LP.

First Add: quick-relief medicine—and keep taking your GREEN ZONE medicine.
Asthma Is Getting Worse
Cough, wheeze, chest tightness, or 2 or 4 puffs, every 20 minutes for up to 1 hour
shortness of breath, or (short acting beta2-agonist) Nebulizer, once
Waking at night due to asthma, or If applicable, remove yourself from the thing that made your asthma worse.

YELLOW ZONE
Can do some, but not all, usual activities Second If your symptoms (and peak flow, if used) return to GREEN ZONE after 1 hour of above treatment:

tific Connexions, Newtown, PA), for providing medical

The authors acknowledge Marissa Buttaro, MPH (Scien-
Continue monitoring to be sure you stay in the green zone.
-Or-
-Or-
Peak flow: to If your symptoms (and peak flow, if used) do not return to GREEN ZONE after 1 hour of above treatment:
(50 to 79 percent of my best peak flow) Take: 2 or 4 puffs or Nebulizer
(short acting beta2-agonist)

Add: mg per day For (3–10) days

(oral corticosteroid)

Call the doctor, , before/ within hours after taking the oral corticosteroid.
(phone)

Medical Alert! Take this medicine:

Very short of breath, or 4 or 6 puffs or Nebulizer

Quick-relief medicines have not helped, or (short acting beta2-agonist)

RED ZONE
Cannot do usual activities, or mg

1555-4155/09/$ see front matter

doi:10.1016/j.nurpra.2008.09.007
Symptoms are same or get worse after (oral corticosteroid)
24 hours in Yellow Zone Then, call your doctor NOW. Go to the hospital or call an ambulance if:
-Or- You are still in the red zone after 15 minutes AND
You have not reached your doctor.
Peak flow: less than
(50 percent of my best peak flow)

© 2009 American College of Nurse Practitioners

DANGER SIGNS Trouble walking and talking due to shortness of breath Take 4 or 6 puffs of your quick-relief medicine AND
Lips or fingernails are blue Go to the hospital or call for an ambulance NOW!
(phone)

The Journal for Nurse Practitioners - JNP

293