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pulm.asthma.peds.v1PRODUCTION
pulm.asthma.peds.v1

Pediatric asthma (chronic stepwise + acute exacerbation)

pediatricschronicacutepediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm pediatric asthma diagnosis (recurrent wheeze with reversibility / Asthma Predictive Index in <5y) vs viral wheeze, foreign body, anatomic airway, CF, bronchiolitis (GINA 2026)

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Diagnosis pattern fits pediatric asthma

Patient inputs (21)

<5 vs 6-11 vs ≥12 yr defines pathway, drug formulation, and step ladder (GINA 2026)

All rescue dosing is weight-based (SABA neb 0.15 mg/kg, IV mag 25-50 mg/kg, prednisolone 1-2 mg/kg) (NAEPP EPR-4 2020)

Severity gate — admission threshold (<92%); supplemental O2 trigger (BTS/SIGN 2024)

Tachypnea by age band drives severity and respiratory failure recognition (GINA 2026)

Tachycardia by age + β2-agonist toxicity surveillance (GINA 2026)

Retractions, accessory muscle use, nasal flaring, paradoxical breathing — age-appropriate severity (BTS/SIGN 2024)

Step-up trigger; ICU admission history is a future-risk marker (GINA 2026)

Spacer required <5 yr; technique audited BEFORE step-up (GINA 2026)

Baseline controller + β-blocker/NSAID exposure; adherence (GINA 2026)

Drowsy, agitated, exhausted = life-threatening sign in a child (BTS/SIGN 2024)

Eczema / allergic rhinitis / food allergy — atopic march phenotype (GINA 2026)

Tobacco smoke, mold, pets, viral URI seasonality (NAEPP EPR-4 2020)

T2 phenotype — biologic candidacy at step 5 (≥6 yr) (GINA 2026)

T2 inflammation marker (≥5 yr can attempt) (GINA 2026)

Omalizumab eligibility (≥6 yr) (GINA 2026)

Diagnosis confirmation (≥6 yr); FEV1, FEV1/FVC, reversibility (GINA 2026)

Severe / atypical: rule out foreign body, pneumothorax, pneumonia (BTS/SIGN 2024)

Severe exac: rising / normalising PaCO2 = impending respiratory failure (BTS/SIGN 2024)

PEF % personal best (≥6 yr) — drives severity tier and zone of action plan (GINA 2026)

Hypokalemia after high-dose / continuous β2-agonist (NAEPP EPR-4 2020)

β2-agonist-mediated lactic acidosis; mimics sepsis (NAEPP EPR-4 2020)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningsilent_chest_or_drowsy_child (BTS/SIGN 2024)
    Silent chest, drowsiness, agitation, exhaustion, or cyanosis in a child (BTS/SIGN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrising_or_normalising_paco2_peds (BTS/SIGN 2024)
    PaCO2 rising or normalising in tachypnoeic severe pediatric asthma (PaCO2 should be LOW from hyperventilation) (BTS/SIGN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverespo2_under_92_pediatric (BTS/SIGN 2024)
    SpO2 <92% on room air in a child with acute asthma (BTS/SIGN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepef_under_50_after_first_hour_peds (GINA 2026)
    PEF <50% personal best after first-hour SABA + ipratropium + systemic steroid (≥6 yr) (GINA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereforeign_body_suspicion (AAP)
    Sudden onset wheeze in toddler, asymmetric breath sounds, hyperinflation on CXR (AAP)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepram_pass_disposition_mapping (Ducharme 2007)
    PRAM/PASS severity → disposition (LR-style mapping; PRAM validated 2-17 yr, post-bronchodilator PRAM r=0.5 vs admission, PMID 18346499): PRAM 0-3 (PASS 0-2) MILD → discharge if sustained ≥1 h after last neb + technique verified + action plan; PRAM 4-7 (PASS 3-4) MODERATE → SABA q20min ×3 + ipratropium ED + OCS within 1 h, reassess at 1 h; PRAM ≥8 (PASS 5-6) SEVERE → continuous SABA + IV magnesium + admit, PICU if life-threatening features
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehypokalemia_after_beta2_peds (BTS/SIGN 2024)
    K+ <3.5 after high-dose / continuous β2-agonist in a child (BTS/SIGN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatelactic_acidosis_after_beta2_peds (NAEPP EPR-4 2020)
    Unexplained AGMA / lactate >2 in severe pediatric exacerbation without sepsis (NAEPP EPR-4 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedifferential_peds_asthma_vs_mimics (GINA 2026)
    Recurrent/persistent wheeze in a child — age-conditioned discriminators: (1) viral-induced wheeze = episodic with viral URI only, well between, ≤5 yr, no atopy → episodic ICS not daily; (2) preschool MULTI-trigger wheeze = symptoms between colds + atopy → daily-ICS trial; (3) bronchiolitis = <2 yr, FIRST wheeze, viral URI, NO bronchodilator response (route peds.bronchiolitis.v1; AAP de-implements albuterol); (4) foreign body = sudden onset, asymmetric breath sounds, hyperinflation/air-trapping CXR; (5) VCD/EILO = inspiratory stridor, throat-tightness, exertional, flattened inspiratory flow-volume loop, often adolescent — does NOT respond to bronchodilator; (6) CF/PCD = failure to thrive, digital clubbing, chronic wet cough, situs/neonatal distress (PCD) — sweat chloride / nasal NO / genetics; (7) structural (vascular ring, tracheobronchomalacia) = monophonic/positional wheeze, stridor from infancy; (8) cardiac (L-R shunt, vascular sling) = murmur, hepatomegaly, failure to thrive, cardiomegaly on CXR (GINA 2026; AAP)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONrequiredDrives disposition
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Recommended regimen

GINA 2026 pediatric Track 1 (6-11 yr) — ICS-formoterol-based stepwise
axis: gina_peds_stepwise_6_to_11step 1 - Step 1 — Symptoms <2x/month
Selected step "Step 1 — Symptoms <2x/month" — 6-11 yr, infrequent symptoms, no waking, no risk factors
  • budesonide-formoterol
    first line
    ICS_formoterol_reliever
    100/6 µg (low-strength pediatric) • inhaled • 1 puff PRN for symptoms (max: 8 puffs/day total)
    triggers: symptoms_present
    GINA 2026 anti-inflammatory reliever in 6-11 yr; reduces severe exacerbations vs SABA-only
    rxcui 1246304
  • albuterol
    rescue
    SABA
    2 puffs MDI with spacer (or 0.15 mg/kg neb, min 2.5 mg, max 5 mg) • inhaled • PRN
    triggers: symptoms_present_alt_track
    Alternative reliever where ICS-formoterol PRN not available
    rxcui 435

outpatient playbook — drug actions (5)

  1. 1. budesonide-formoterol or low-dose ICS daily
    100/6 µg PRN (≥6 yr) or 50-100 µg ICS BID • inhaled • PRN or BID
    trigger: GINA Step 1-2 in 6-11 yr; or ≤5 yr with persistent symptoms
    GINA 2026 / NAEPP 2020
  2. 2. budesonide-formoterol MART
    100/6 µg or 200/6 µg • inhaled • BID + PRN reliever
    trigger: Step 3-4 in 6-11 yr
    MART reduces severe exacerbations
  3. 3. tiotropium
    2.5 µg Respimat • inhaled • 2 puffs once daily
    trigger: Step 4-5 add-on (≥6 yr)
    Approved as add-on at Step 4-5 pediatric
  4. 4. biologic referral (omalizumab / mepolizumab / dupilumab)
    Per agent • SC • q2-4 weeks
    trigger: Severe asthma at Step 5 ≥6 yr with phenotype-matching biomarker
    Specialist-led
  5. 5. prednisolone
    1-2 mg/kg (max 60 mg) • PO • daily × 3-5 days
    trigger: Outpatient exacerbation not responding to reliever increase
    GINA self-management plan

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Recurrent wheeze, cough, dyspnea in a child (GINA 2026); Exercise-induced wheeze / cough (GINA 2026); Severe acute exacerbation in child (accessory muscles, retractions, SpO2 <92%, silent chest) (BTS/SIGN 2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric asthma (chronic stepwise + acute exacerbation)** (pulm.asthma.peds.v1).
Phenotype framing: Allergic-eosinophilic / virus-induced wheeze / exercise-induced bronchoconstriction / occupational exposure (older adolescent) (GINA 2026)
Scope: Confirm pediatric asthma diagnosis (recurrent wheeze with reversibility / Asthma Predictive Index in <5y) vs viral wheeze, foreign body, anatomic airway, CF, bronchiolitis (GINA 2026)

No severity triggers fired against current inputs.

Plan

Regimen axis: **GINA 2026 pediatric Track 1 (6-11 yr) — ICS-formoterol-based stepwise** — step "Step 1 — Symptoms <2x/month".
1. budesonide-formoterol 100/6 µg (low-strength pediatric) inhaled 1 puff PRN for symptoms (ICS_formoterol_reliever, first line) — GINA 2026 anti-inflammatory reliever in 6-11 yr; reduces severe exacerbations vs SABA-only
2. albuterol 2 puffs MDI with spacer (or 0.15 mg/kg neb, min 2.5 mg, max 5 mg) inhaled PRN (SABA, rescue) — Alternative reliever where ICS-formoterol PRN not available

Setting playbook (outpatient) — Achieve and maintain symptom control with normal activity + growth + reduce future exacerbation risk via lowest effective step
3. budesonide-formoterol or low-dose ICS daily 100/6 µg PRN (≥6 yr) or 50-100 µg ICS BID inhaled PRN or BID — GINA Step 1-2 in 6-11 yr; or ≤5 yr with persistent symptoms (GINA 2026 / NAEPP 2020)
4. budesonide-formoterol MART 100/6 µg or 200/6 µg inhaled BID + PRN reliever — Step 3-4 in 6-11 yr (MART reduces severe exacerbations)
5. tiotropium 2.5 µg Respimat inhaled 2 puffs once daily — Step 4-5 add-on (≥6 yr) (Approved as add-on at Step 4-5 pediatric)
6. biologic referral (omalizumab / mepolizumab / dupilumab) Per agent SC q2-4 weeks — Severe asthma at Step 5 ≥6 yr with phenotype-matching biomarker (Specialist-led)
7. prednisolone 1-2 mg/kg (max 60 mg) PO daily × 3-5 days — Outpatient exacerbation not responding to reliever increase (GINA self-management plan)

Non-pharmacologic actions:
- Written pediatric asthma action plan personalised to PEF (≥6 yr) or symptom-based zones (<5 yr) (GINA 2026)
- School asthma action plan + reliever availability (AAP)
- Spacer + mask training, 3-month re-audit (GINA 2026)
- Tobacco smoke exposure cessation counselling for caregivers (NAEPP EPR-4 2020)
- Allergen avoidance counselling (NAEPP EPR-4 2020)
- Annual influenza vaccination (AAP)

AVOID / contraindication checks:
- Beta_blocker_avoid_nonselective_in_asthma (GINA 2026)
- LTRA_neuropsychiatric_warning_counsel (FDA 2020 boxed warning)
- High_dose_OCS_minimise_growth_glycaemia (GINA 2026)
- Tobacco_smoke_exposure_must_be_addressed (NAEPP EPR 4 2020)
- Spacer_required_under_age_5_for_MDI (GINA 2026)
- Special_pop:preschool_episodic_viral_wheeze_use_episodic_not_daily_ICS (GINA 2026 ≤5 yr)
- Special_pop:growth_velocity_monitor_annually_minimise_ICS_dose (CAMP PMID 22938716)
- Special_pop:exercise_induced_optimise_controller_before_labelling_isolated_EIB (GINA 2026)
- Special_pop:adolescent_single_inhaler_MART_for_adherence_plus_transition_plan (GINA 2026)
- Special_pop:obesity_confirm_objective_obstruction_and_T2_before_escalation (GINA 2026)
- Special_pop:dexamethasone_for_vomiting_or_adherence_risk_noninferior (Keeney PMID 24515516)

Monitoring

Regimen monitoring:
- cACT (4-11 yr) / ACT (≥12 yr) at 4-6 wk after step change then q3-6 mo when stable (GINA 2026)
- PEF q visit age >=6 and at home diary (GINA 2026)
- inhaler spacer (± mask) technique q visit — audit BEFORE any step-up (GINA 2026)
- annual height + weight percentile on ICS — flag downward percentile crossing; CAMP adult-height -1.2 cm at budesonide 400 µg/d (PMID 22938716), non-progressive, not HPA-mediated (PMID 15173493) (GINA 2026; NAEPP EPR-4 2020)
- K+ q4h during continuous neb (BTS/SIGN 2024)
- lactate if continuous neb or unexplained AGMA (BTS/SIGN 2024)
- biologic response at 4 months — ≥50% exacerbation reduction, switch class if not achieved (MUPPITS-2 mepolizumab rate ratio 0.73 PMID 35964610; VOYAGE dupilumab eos/FeNO-predictive PMID 38272375) (GINA 2026)
- blood eos + FeNO at Step 4-5 to phenotype-match biologic (eos ≥150 OR FeNO ≥20 ppb predict dupilumab response, PMID 38272375) (GINA 2026)
- SABA-overuse surveillance: >1 canister/3 mo = future-risk marker → step-up review (GINA 2026)
- attempt step-down after ≥3 months sustained control (≥6 months on biologic) (GINA 2026)

Setting (outpatient) monitoring:
- Control review at 4-6 weeks after step change (GINA 2026)
- Annual review including spirometry ≥6 yr (GINA 2026)
- Growth velocity annually on ICS (NAEPP EPR-4 2020)
- Biologic response at 4 months (≥50% exacerbation reduction) (GINA 2026)
- Attempt step-down after ≥3 months sustained control (GINA 2026)

Follow-up plan: Written pediatric asthma action plan, school plan, vaccinations (flu, pneumococcal, COVID), tobacco-smoke counselling, allergen control, growth monitoring, primary-care follow-up within 1 week of any ED/admission (GINA 2026; AAP)
- Close-out criterion: Action plan + school plan + vaccinations + 1-week follow-up complete

Monitoring phase: Acute: hourly SpO2, RR, work-of-breathing; K+/lactate after continuous neb; VBG q1-2h if hypercapnic. Chronic: control review at 4-6 weeks; growth velocity on ICS; spacer technique re-audit (GINA 2026)

Disposition

Current setting: outpatient — Achieve and maintain symptom control with normal activity + growth + reduce future exacerbation risk via lowest effective step

Disposition criteria:
- Continue current step if controlled (GINA 2026)
- Step up if uncontrolled with verified technique + adherence (GINA 2026)
- Refer to pediatric pulmonology if at Step 4-5 with ongoing exacerbations (GINA 2026)

Escalation triggers (move to higher acuity):
- Acute severe exacerbation → ED (BTS/SIGN 2024)
- Step ≥4 with ≥2 OCS courses/year → pediatric pulmonology (GINA 2026)
- Hypoxaemia (SpO2 <92%) → ED (BTS/SIGN 2024)
- Failure to thrive on ICS → specialist (GINA 2026)

Patient Action Plan

**Pediatric asthma action plan (GINA / NAEPP-aligned)**
Personalised values: weight_kg, personal_best_PEF_if_age_>=6, controller_inhaler, reliever_inhaler, OCS_dose_for_emergency_per_kg.

**Doing well — no symptoms, PEF 80-100% personal best (≥6 yr)** (green):
Triggers:
- No cough, wheeze, chest tightness, or shortness of breath
- Can play, run, sleep, attend school normally
- No night waking from asthma
- PEF ≥80% personal best (if monitoring)
Actions:
- Take controller as prescribed every day with spacer (do not skip)
- Use reliever (ICS-formoterol or SABA) only if needed before exercise or for symptoms
- Continue trigger avoidance (no smoking around child)
- Keep follow-up appointments and refill controller before it runs out

**Caution — early warning, PEF 50-79% personal best OR symptoms increasing** (yellow):
Triggers:
- Cough, wheeze, chest tightness, or breathlessness
- Waking at night with asthma
- Reliever needed more than usual (more than every 4 h)
- PEF 50-79% personal best
- Cold or viral URI starting
Actions:
- Give reliever now (SABA 4-8 puffs MDI with spacer OR ICS-formoterol 1-2 puffs PRN)
- Repeat reliever every 20 minutes for the first hour if needed
- If on MART: continue maintenance + use additional puffs as reliever
- If not improving in 24-48 h or worsening: start prednisolone 1-2 mg/kg/day (max 60 mg) PO × 3-5 days OR dexamethasone 0.6 mg/kg × 1-2 doses (per pre-prescribed action plan)
- Contact pediatrician within 24 h
Contact provider when:
- Symptoms not improving after first hour of reliever
- Any decline in PEF below 50% best
- Need to use reliever more often than every 4 h
- Child cannot speak in full sentences / drinking less

**Medical alert — PEF <50% personal best OR severe symptoms** (red):
Triggers:
- Very short of breath, cannot speak in full sentences / phrases / words
- Reliever not helping or wearing off in <2 h
- PEF <50% personal best
- Lips, tongue, or fingertips blue
- Confusion, drowsiness, or extreme agitation
- Sucking-in around the ribs or neck (severe retractions)
Actions:
- Use reliever right now: SABA 6-8 puffs MDI with spacer OR ICS-formoterol 4-6 puffs; repeat every 20 minutes while seeking help
- Give prednisolone 1-2 mg/kg PO now if available
- Call 911 / emergency services immediately
- Sit child upright; do not lie flat
- Stay with the child — go to ED now, do not wait
Contact provider when:
- Any red zone symptom — go to ED now, do not wait

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Silent chest, drowsiness, agitation, exhaustion, or cyanosis in a child (BTS/SIGN 2024)
- [LIFE_THREATENING] PaCO2 rising or normalising in tachypnoeic severe pediatric asthma (PaCO2 should be LOW from hyperventilation) (BTS/SIGN 2024)
- [SEVERE] SpO2 <92% on room air in a child with acute asthma (BTS/SIGN 2024)

Citations

- GINA 2026 Strategy Report (children ≤5 yr + 6-11 yr — distinct tracks; 4 new acute-asthma flowcharts) + NAEPP 2020 Focused Update (Cloutier JACI 2020;146:1217-1270) + AAP [PMID:33280709](https://pubmed.ncbi.nlm.nih.gov/33280709/)
- Cited evidence (PMID 24515516) [PMID:24515516](https://pubmed.ncbi.nlm.nih.gov/24515516/)
- Cited evidence (PMID 22909281) [PMID:22909281](https://pubmed.ncbi.nlm.nih.gov/22909281/)
- Cited evidence (PMID 27126744) [PMID:27126744](https://pubmed.ncbi.nlm.nih.gov/27126744/)
- Cited evidence (PMID 25080126) [PMID:25080126](https://pubmed.ncbi.nlm.nih.gov/25080126/)

Last reconciled with current guidelines: 2026-05-25.
References
  • GINA 2026 Strategy Report (children ≤5 yr + 6-11 yr — distinct tracks; 4 new acute-asthma flowcharts) + NAEPP 2020 Focused Update (Cloutier JACI 2020;146:1217-1270) + AAP — PMID:33280709
  • Cited evidence (PMID 24515516) — PMID:24515516
  • Cited evidence (PMID 22909281) — PMID:22909281
  • Cited evidence (PMID 27126744) — PMID:27126744
  • Cited evidence (PMID 25080126) — PMID:25080126