What are the key components of an asthma check visit for an 11-year-old male patient with mild intermittent asthma, currently on albuterol (salbutamol)?

Asthma Check Visit for 11-Year-Old with Mild Intermittent Asthma

For an 11-year-old male with mild intermittent asthma on albuterol only, assess asthma control by evaluating symptom frequency, nighttime awakenings, activity limitation, rescue medication use, and perform spirometry to measure FEV1 and FEV1/FVC ratio. 1

History Components

Assess Current Asthma Control (Past 2-4 Weeks)

Impairment Domain:

• Daytime symptoms: Ask specifically how many days per week the child has asthma symptoms (cough, wheeze, chest tightness, shortness of breath). Well-controlled asthma should have symptoms ≤2 days/week but not more than once each day. 1
• Nighttime awakenings: Determine how many times per month the child wakes up at night due to asthma. Well-controlled asthma should have ≤1 nighttime awakening per month. 1
• Activity limitation: Ask if asthma interferes with normal activities, sports, or physical education class. Well-controlled asthma should have no interference with normal activity. 1
• Short-acting beta-agonist use: Determine how many days per week albuterol is used for symptom relief (not for prevention of exercise-induced symptoms). Well-controlled asthma should require albuterol ≤2 days/week. 1

Risk Domain:

• Exacerbations requiring oral corticosteroids: Ask how many times in the past year the child needed prednisone or prednisolone for asthma. Well-controlled asthma should have 0-1 exacerbations per year. 1
• Emergency department visits or hospitalizations: Document any urgent care visits, ED visits, or hospitalizations for asthma in the past year. 1

Additional History Elements

• Triggers: Identify specific asthma triggers including viral respiratory infections (colds), exercise, cold air, allergens (pets, dust mites, pollen, mold), tobacco smoke exposure, and strong odors. 1
• Medication technique and adherence: Ask the child to demonstrate albuterol inhaler technique. Verify they are using it correctly and that the inhaler is not expired. 1
• School impact: Ask about days missed from school due to asthma and whether the school has an asthma action plan on file. 1
• Exercise tolerance: Specifically ask if the child can participate fully in physical education and sports, or if they experience symptoms during or after exercise. 1

Physical Examination

Vital Signs

• Respiratory rate: Normal for an 11-year-old is approximately 18-25 breaths/minute at rest. 1
• Pulse: Normal resting heart rate for this age is approximately 70-110 beats/minute. 1
• Oxygen saturation: Should be ≥95% on room air in well-controlled asthma. 1

Respiratory Examination

• Inspection: Observe for use of accessory muscles, nasal flaring, or increased work of breathing (should be absent in well-controlled asthma). 1
• Auscultation: Listen for wheezing, prolonged expiratory phase, or decreased air entry. The chest should be clear with normal breath sounds in well-controlled asthma. 1
• Percussion: Should be resonant throughout; hyperresonance may suggest air trapping. 1

Associated Findings

• Nasal examination: Look for signs of allergic rhinitis (pale, boggy turbinates, clear discharge) which commonly coexists with asthma. 1
• Skin examination: Check for atopic dermatitis/eczema, which is associated with asthma. 1

Objective Testing

Spirometry (Essential for Ages 5-11 Years)

• FEV1 (forced expiratory volume in 1 second): Should be >80% of predicted for well-controlled asthma. 1
• FEV1/FVC ratio: Should be >80% for well-controlled asthma in this age group. 1
• Bronchodilator response: Administer 2-4 puffs of albuterol and repeat spirometry after 15 minutes. A ≥12% improvement in FEV1 supports the diagnosis of asthma. 1

Important caveat: Spirometry should be performed at every asthma visit for children aged 5 years and older to objectively assess lung function, as symptoms alone may not correlate with lung function impairment. 1

Classification and Management Decisions

If Well-Controlled (All Criteria Met):

• Symptoms ≤2 days/week (not daily)
• Nighttime awakenings ≤1 time/month
• No interference with normal activity
• SABA use ≤2 days/week
• FEV1 >80% predicted
• FEV1/FVC >80%
• 0-1 exacerbations requiring oral steroids in past year 1

Action: Continue current albuterol as-needed therapy. Provide written asthma action plan. Schedule follow-up in 6-12 months or sooner if control deteriorates. 1

If Not Well-Controlled:

• Symptoms >2 days/week or multiple times on ≤2 days/week
• Nighttime awakenings ≥2 times/month
• Some limitation of activity
• SABA use >2 days/week
• FEV1 60-80% predicted
• FEV1/FVC 75-80% 1

Action: This patient may actually have mild persistent asthma rather than mild intermittent asthma. For children aged 5-11 years with mild persistent asthma, initiate daily low-dose inhaled corticosteroid (ICS) therapy. 1 Note that as-needed ICS combined with albuterol is NOT recommended for ages 5-11 years due to insufficient evidence in this age group. 1

If Very Poorly Controlled:

• Symptoms throughout the day
• Nighttime awakenings ≥2 times/week
• Extreme limitation of activity
• SABA use several times per day
• FEV1 <60% predicted
• FEV1/FVC <75%
• ≥2 exacerbations requiring oral steroids in past year 1

Action: Initiate daily controller therapy with low-dose ICS and consider referral to asthma specialist. Provide oral corticosteroids if currently symptomatic. 1

Common Pitfalls to Avoid

• Relying solely on symptoms without spirometry: Children may underreport symptoms or have poor symptom perception. Objective lung function testing is essential for accurate assessment. 1
• Misclassifying severity: A patient using albuterol >2 days/week or having >1 exacerbation per year likely has persistent asthma, not intermittent asthma, and requires daily controller therapy. 1
• Not assessing inhaler technique: Poor technique is a common cause of inadequate asthma control. Always have the patient demonstrate their technique. 1
• Ignoring exercise-induced symptoms: If the child has symptoms with exercise, this indicates inadequate control and may require step-up in therapy or pre-treatment with albuterol before exercise. 1
• Failing to provide a written asthma action plan: All patients with asthma should have a written action plan that includes when to increase albuterol use and when to seek medical care. 1