Comprehensive Chart Note for Pediatric Asthma Review (GINA 2025-Aligned)
Patient Identification & Visit Information
- Date of Visit:
- Patient Name/MRN:
- Age: [specify if 0-4 years, 5-11 years, or ≥12 years]
- Chief Concern: Asthma follow-up/review
Assessment of Current Asthma Control
Impairment Domain (Past 2-4 Weeks)
For Children 0-4 Years:
- Daytime symptoms: ≤2 days/week = well-controlled; >2 days/week = not well-controlled; throughout the day = very poorly controlled 1
- Nighttime awakenings: ≤1 time/month = well-controlled; >1 time/month = not well-controlled; >1 time/week = very poorly controlled 1
- Interference with normal activity: None = well-controlled; some limitation = not well-controlled; extreme limitation = very poorly controlled 1
- Short-acting β2-agonist use: ≤2 days/week = well-controlled; >2 days/week = not well-controlled; several times per day = very poorly controlled 1
For Children 5-11 Years:
- Daytime symptoms: ≤2 days/week (not more than once daily) = well-controlled; >2 days/week or multiple times on ≤2 days/week = not well-controlled; throughout the day = very poorly controlled 1
- Nighttime awakenings: ≤1 time/month = well-controlled; ≥2 times/month = not well-controlled; ≥2 times/week = very poorly controlled 1
- Interference with normal activity: None = well-controlled; some limitation = not well-controlled; extreme limitation = very poorly controlled 1
- Short-acting β2-agonist use: ≤2 days/week = well-controlled; >2 days/week = not well-controlled; several times per day = very poorly controlled 1
- Lung function (FEV1 or peak flow): >80% predicted/personal best = well-controlled; 60-80% = not well-controlled; <60% = very poorly controlled 1
- FEV1/FVC ratio: >80% = well-controlled; 75-80% = not well-controlled; <75% = very poorly controlled 1
Risk Domain
- Exacerbations requiring oral corticosteroids in past year: 0-1/year = well-controlled; 2-3/year = not well-controlled; >3/year = very poorly controlled 1
- Reduction in lung growth: Document serial height measurements for children 5-11 years 1
- Adverse medication effects: Document intensity (none to very troublesome) 1
Overall Control Level: [Well-controlled / Not well-controlled / Very poorly controlled] - Based on the most severe impairment or risk category 1
Current Medication Regimen
Controller Medications
- Inhaled corticosteroid (ICS): [Drug name, dose, frequency, delivery device]
- Long-acting β2-agonist (LABA): [If applicable - only in combination with ICS] 2
- Leukotriene receptor antagonist: [If applicable]
- Other: [Cromolyn, nedocromil, theophylline if applicable]
Reliever Medications
- Short-acting β2-agonist: [Drug name, dose, frequency of use]
Inhaler Technique Assessment
- Device type: [MDI with spacer/holding chamber, DPI, nebulizer]
- Technique observed: [Adequate / Needs improvement]
- Specific deficiencies noted: [Document any errors in technique]
- Re-education provided: [Yes/No]
- For MDI users: Large volume spacer use confirmed (required for all children on inhaled steroids to enhance lung deposition) 1
Medication Adherence Assessment
- Parent/caregiver report of missed doses: [Frequency]
- Barriers to adherence identified: [Cost, complexity, side effects, misunderstanding]
- Pharmacy refill history reviewed: [Yes/No]
Environmental Triggers & Comorbidities
Trigger Identification
- Allergen exposures: [Dust mites, pets, mold, pollen]
- Irritant exposures: [Tobacco smoke, air pollution, strong odors]
- Viral respiratory infections: [Frequency in past year]
- Exercise-induced symptoms: [Present/Absent]
- Weather changes: [Relevant/Not relevant]
Comorbidities Assessed
- Allergic rhinitis: [Present/Absent, controlled/uncontrolled]
- Gastroesophageal reflux: [Present/Absent]
- Obesity: [BMI percentile documented]
- Anxiety/depression: [Screened]
Physical Examination
- Respiratory rate: [Document value; >50/min concerning for severe exacerbation] 3, 4
- Heart rate: [Document value; >140/min concerning for severe exacerbation] 3, 4
- Oxygen saturation: [Document value; maintain >92%] 4
- Work of breathing: [Normal / Increased - specify retractions, nasal flaring]
- Auscultation: [Clear / Wheezing / Decreased air entry / Silent chest]
- Ability to speak: [Full sentences / Short phrases / Single words] 3
- Growth parameters: [Height, weight, BMI percentile - monitor for growth suppression with ICS use] 1
Spirometry (For Children ≥5 Years)
- FEV1: [Value, % predicted]
- FVC: [Value]
- FEV1/FVC ratio: [Value, % predicted]
- Bronchodilator response: [If performed - % improvement]
- Peak flow: [Value, % personal best]
Treatment Plan Based on Control Assessment
If Well-Controlled (Continue Current Step)
- Maintain current controller therapy for at least 3 months before considering step-down 5
- Continue monitoring at 3-month intervals 5
If Not Well-Controlled (Step Up Therapy)
For Children ≥5 Years with Mild Persistent Asthma:
- Preferred therapy: Low-dose inhaled corticosteroids (fluticasone 100 mcg or budesonide equivalent) 1, 2
- Alternative therapies: Cromolyn, leukotriene receptor antagonists, nedocromil, or sustained-release theophylline 1, 2
For Children <5 Years with Mild Persistent Asthma:
- Preferred therapy: Low-dose inhaled corticosteroids via nebulizer, DPI, or MDI with holding chamber (with or without face mask) 1
- Alternative therapies: Cromolyn or leukotriene receptor antagonist 1
For Children ≥12 Years Inadequately Controlled on Low-Dose ICS:
- Add LABA: Combination ICS/LABA (e.g., fluticasone/salmeterol 100/50 mcg, 250/50 mcg, or 500/50 mcg twice daily) 2, 6
- Warning: Never use LABA as monotherapy; always combined with ICS 6
For Children 4-11 Years Inadequately Controlled on Low-Dose ICS:
- Option 1: Increase to medium-dose ICS
- Option 2: Add LABA (fluticasone/salmeterol 100/50 mcg twice daily for ages 4-11 years) 6
If Very Poorly Controlled
- Consider short course of oral corticosteroids: Prednisolone 1-2 mg/kg body weight (maximum 40 mg daily) for 3-5 days 3, 4
- Refer to asthma specialist if persistent symptoms despite Step 4 therapies with confirmed good technique and adherence 7
Acute Exacerbation Management (If Presenting with Worsening Symptoms)
Severity Assessment
Life-Threatening Features (Immediate Hospital Transfer):
- Too breathless to talk or feed 2
- Respiratory rate >50 breaths/min 3, 4, 2
- Heart rate >140 beats/min 3, 4, 2
- Peak flow <50% predicted 2
- Silent chest, cyanosis, fatigue, altered consciousness 4, 2
Immediate Treatment Protocol
Three simultaneous interventions:
- High-flow oxygen via face mask to maintain SaO2 >92% 3, 4, 2
- Nebulized albuterol (salbutamol): 5 mg (or 0.15 mg/kg) every 30 minutes initially if not improving, then every 4-6 hours once improving 3, 2
- Add ipratropium bromide: 250 mcg combined with albuterol for moderate-severe exacerbations, every 30 minutes initially, then every 6 hours 3, 2
- Oral prednisolone: 1-2 mg/kg body weight (maximum 40 mg daily) to speed resolution and reduce relapse 3, 4, 2
Monitoring Response
- Reassess at 15-30 minutes after initial treatment 3
- If improving: Continue nebulized treatments every 4-6 hours, monitor for decreased work of breathing, improved air entry, decreased wheezing 3
- If not improving: Increase frequency to every 15-30 minutes and consider hospital referral 3, 4
Hospital Admission Criteria
- No improvement after initial combination therapy 3
- Deteriorating clinical status despite treatment 3
- Presentation in afternoon/evening or inability of parents to administer treatment at home 3
Self-Management Education Provided
Inhaler Technique Training
- Proper use demonstrated and return demonstration observed 1, 2
- For MDI users: Actuate one puff into spacer, breathe in, repeat until appropriate number of puffs inhaled 1
- Mouth rinsing after ICS use to reduce oral candidiasis risk 6
Medication Understanding
- "Relievers" (bronchodilators): Short-acting β2-agonists for quick symptom relief 1, 2
- "Preventers" (anti-inflammatory): Inhaled corticosteroids for long-term control 1, 2
- Difference explained and understood by parent/caregiver 1, 2
Recognition of Worsening Asthma
- Increased nighttime symptoms 1, 2
- Increased reliever use (>2 days/week) 1, 2
- Decreased ability to participate in activities 1, 2
- Peak flow dropping below 80% personal best (for children ≥5 years) 1, 2
Written Asthma Action Plan Provided
Green Zone (Doing Well):
- Peak flow >80% personal best 2
- No symptoms or symptoms ≤2 days/week 2
- Continue controller medications as prescribed 2
Yellow Zone (Asthma Getting Worse):
- Peak flow 50-80% personal best 2
- Increased symptoms or reliever use 2
- Action: Increase ICS dose or add oral prednisolone as pre-arranged 2
Red Zone (Medical Emergency):
- Peak flow <50% personal best 2
- Severe symptoms, difficulty breathing, no improvement with reliever 2
- Action: Take reliever immediately, start oral steroids, seek urgent medical care 2
Monitoring Plan for ICS Side Effects
Short-Term Monitoring
- Oral candidiasis: Examine mouth periodically; advise rinsing after each use 6
- Dysphonia: Document if present 6
Long-Term Monitoring
- Growth velocity: Serial height measurements every 3-6 months (short-term reductions in tibial growth rate shown with doses >400 mcg/day, but long-term impact unclear) 1
- Bone mineral density: Assess initially and periodically for children on chronic high-dose ICS 6
- Ocular effects: Consider ophthalmology referral for children on long-term ICS who develop visual symptoms 6
- Adrenal suppression: Monitor for signs of hypercorticism with very high dosages 6
Follow-Up Plan
Routine Follow-Up
- Next appointment: [3 months if well-controlled; 1 month if adjusting therapy] 5
- Step-down consideration: After 3 months of good control 5
Post-Exacerbation Follow-Up
- Primary care follow-up: Within 48 hours if treated at home; within 1 week if hospitalized 3, 2
- Specialist follow-up: Within 4 weeks if hospitalized 3, 2
Specialist Referral Indicated If:
- Persistent symptoms despite Step 4 therapy with confirmed good technique and adherence 7
- Life-threatening exacerbation 7
- Diagnostic uncertainty 7
Goals of Successful Management
- Minimal daytime symptoms 1
- No nighttime awakening 1
- No missed school days 1
- Full participation in activities and sports 1
- Infrequent reliever medication use 1
- Normal or near-normal lung function 1
Assessment & Plan Discussed With: [Parent/caregiver name]
Understanding Confirmed: [Yes/No]
Questions Addressed: [Yes/No]