This document discusses whether escalating the dose of inhaled corticosteroids (ICS) is appropriate for acute loss of asthma control in children to reduce the need for oral corticosteroids. It presents evidence on both sides of the argument. Studies that doubled the ICS dose after asthma symptoms were established did not show benefit, but studies that substantially increased the dose early on (e.g. quadrupling the dose) found a modest reduction in need for oral steroids. However, extremely high ICS doses should be avoided due to growth suppression concerns. The definition of "loss of control" versus an actual exacerbation is also debated.

1. In Acute Loss of Asthma Control: always systemic
steroids or add/increase the dose of ICS ?
Attilio Boner
University of
Verona, Italy
attilio.boner@univr.it
The case of ICS
 Some doubts
 The case for oral steroids
 Why not ICS?
 Why not oral steroids?
 What to do in practice?

2. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? Yes
Farber HJ, Chest. 2016;150(3):488-90.
Guidelines from the National Asthma Education and Prevention Program
(2007) recommend managing mild asthma exacerbations with the addition
of a short-acting beta agonist to the treatment regimen,
and if response is incomplete, adding an oral corticosteroid.
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
problems:
•Oral corticosteroid medications, although effective, have significant
side effects, even in short bursts.
•Beta agonists relieves asthma symptoms but do not prevent a mild
exacerbation from progressing to a severe exacerbation.
•Nonadherence to the daily use of long-acting controller medication is
extremely common. Smith LA, Pediatrics. 2008;122(4):760-769.
Finkelstein JA, Arch Pediatr Adolesc Med. 2002;156(6):562-567.
corticofobia

3. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? Yes
Farber HJ, Chest. 2016;150(3):488-90.
Guidelines from the National Asthma Education and Prevention Program
(2007) recommend managing mild asthma exacerbations with the addition
of a short-acting beta agonist to the treatment regimen,
and if response is incomplete, adding an oral corticosteroid.
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
problems:
•Oral corticosteroid medications, although effective, have significant
side effects, even in short bursts.
•Beta agonists relieves asthma symptoms but do not prevent a mild
exacerbation from progressing to a severe exacerbation.
•Nonadherence to the daily use of long-acting controller medication is
extremely common. Smith LA, Pediatrics. 2008;122(4):760-769.
Finkelstein JA, Arch Pediatr Adolesc Med. 2002;156(6):562-567.
Addressing those problems a practice parameter from the American
Academy ofAllergy, Asthma, and Immunology (2014) recommends initiation
or escalation of inhaled corticosteroids for acute loss of asthma control.
Dinakar C, Ann Allergy Asthma Immunol. 2014;113(2):143-159.
corticofobia

4. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? Yes
Farber HJ, Chest. 2016;150(3):488-90.
Short-Course Oral Corticosteroids Are Not Completely Benign
Short bursts of oral corticosteroid medication :
1) have substantial adverse behavioral effects, causing anxiety, mania,
irritability, or aggressive behavior, or a combination.5,6
2) can cause transient hypothalamic-pituitary-adrenal axis suppression,
increase blood pressure, and decrease responses to neoantigens.7,8
3) can predispose the patient to infections, with severe varicella infection
and tuberculosis.9,10
4) frequent short courses of oral steroids decrease bone mineral density.11

5. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? Yes
Farber HJ, Chest. 2016;150(3):488-90.
Escalation After the Flare-Up Is Established Is Too Little Too Late.
•ICS are best at stabilizing normal airways and preventing an exacerbation
from starting.
•Initiation or escalation is likely to be most effective at the
moment that it starts to get more difficult to keep the airways normal.
•Studies that waited for symptom duration of 24 to 72 hours or a
substantial decrease in peak expiratory flow, or both, before doubling the
ICS dose showed no benefit.12-14

6. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? Yes
Farber HJ, Chest. 2016;150(3):488-90.
The Case for As-Needed Escalation of Inhaled Corticosteroid Medication
•Initiation or substantial escalation of the ICS dose at the onset of loss
of asthma control does show benefit. The challenge is that the escalation
needs to be substantial and started early. (premonitor symptoms)
•In adults on a low daily ICS dose, quadrupling the dose after the onset
of an exacerbation reduced the need for oral corticosteroids.15
Foresi A. Chest. 2000;117(2):440-446.
•In young children, an extremely high dose of fluticasone, 1,500 mg
daily, administered at the first sign of an upper respiratory tract infection
substantially decreased the need for oral corticosteroids (OR, 0.49) but at
the cost of an unacceptable decrease in growth.16
Ducharme FM, N Engl J Med. 2009;360(4):339-353.

7. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? Yes
Farber HJ, Chest. 2016;150(3):488-90.
The Case for As-Needed Escalation of Inhaled Corticosteroid Medication
Prodromal features
of asthma.
Beer S, Arch Dis Child.
1987;62(4):345-8.

8. Budesonide/formoterol maintenance plus reliever therapy:
a new strategy in pediatric asthma.
Bisgaard H. Chest. 2006;130(6):1733-1743.
budesonide/formoterol (80 µg/4.5 µg)
as maintenance + reliever
budesonide/formoterol (80 µg/4.5µg)
as maintenance + terbutaline as reliever
high-dose budesonide (320 µg)
as maintenance
+ terbutaline as reliever
% patients with severe exacerbations

9. Use of beclomethasone dipropionate as rescue treatment
for children with mild persistent asthma (TREXA)
Martinez Lancet 2011;377:650
 843 children and adolescents
with mild persistent asthma
aged 5–18 yrs.
 4 treatment groups:
twice daily beclomethasone with
beclomethasone plus albuterol
as rescue (combined group);
twice daily beclomethasone with
placebo plus albuterol as rescue
(daily beclomethasone group);
twice daily placebo with
beclomethasone plus albuterol
as rescue (rescue
beclomethasone group); and
twice daily placebo with placebo
plus albuterol as rescue
(placebo group).
Frequency of exacerbations
in 44 weeks follow-up
49%
Placebo
no BDP
Salb
28%
31%
Combined
BDPx2
BDP+Salb
60 –
50 –
40 –
30 –
20 –
10 –
0
Daily
BDPx2
Salb
Rescue
No BDP
BDP+Salb
p=0.03
p=0.07
35%
p=0.07
Regular
Rescue

10. Use of beclomethasone dipropionate as rescue treatment
for children with mild persistent asthma (TREXA)
Martinez Lancet 2011;377:650
Regular Rescue
Combined BDPx2 + BDP-Salb
Daily BDPx2 + Salb
Rescue no BDP + BDP-Salb
Placebo no BDP + Salb
Frequency of treatment failure
requiring oral steroids
23%
5.6%
2.8%
8.5%

11. Use of beclomethasone dipropionate as rescue treatment
for children with mild persistent asthma (TREXA)
Martinez Lancet 2011;377:650
Regular Rescue
Combined BDPx2 + BDP-Salb
Daily BDPx2 + Salb
Rescue no BDP + BDP-Salb
Placebo no BDP + Salb
Linear growth by treatment group

12. Use of beclomethasone dipropionate as rescue treatment
for children with mild persistent asthma (TREXA)
Martinez Lancet 2011;377:650
Interpretation:
1. Children with mild persistent asthma should not be treated with
rescue albuterol alone and the most effective treatment to
prevent exacerbations is daily ICS.
2. ICS as rescue medication with albuterol might be an effective
step-down strategy for children with well controlled, mild
asthma because it is more effective at reducing exacerbations
than is use of rescue albuterol alone.
3. Use of daily ICS treatment and related side-effects
such as growth impairment can therefore be avoided.

13. Regular vs prn nebulized treatment in wheeze preschool
children Papi Allergy 2009:64:1463
276 symptomatic children
with frequent wheeze, aged
1–4 years.
3-month nebulized treatment:
1) 400 μg beclomethasone bid
plus 2500 μg salbutamol prn;
2) placebo bid plus 2500 μg
salbutamol prn;
3) placebo bid plus 800 μg
beclomethasone/1600 μg
salbutamol combination prn.
PRN
SALBUTAMOL
REGULAR
BECLOMETHASONE
PRN
COMBINATION
69.6%
61% 64.9%
% FREE DAYS
70 –
60 –
50 –
40 –
30 –
20 –
10 –
0
p=0.034
ns

14. Regular vs prn nebulized treatment in wheeze preschool
children Papi Allergy 2009:64:1463
276 symptomatic children
with frequent wheeze, aged
1–4 years.
3-month nebulized treatment:
1) 400 μg beclomethasone bid
plus 2500 μg salbutamol prn;
2) placebo bid plus 2500 μg
salbutamol prn;
3) placebo bid plus 800 μg
beclomethasone/1600 μg
salbutamol combination prn.
PRN
SALBUTAMOL
REGULAR
BECLOMETHASONE
PRN
COMBINATION
69.6%
61% 64.9%
% FREE DAYS
70 –
60 –
50 –
40 –
30 –
20 –
10 –
0
p=0.034
ns
The effect of prn
combination was no
different from that
of regular
beclomethasone on
the primary and on
several important
secondary outcomes.

15. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? Yes
Farber HJ, Chest. 2016;150(3):488-90.
Evidence Synthesis
•Studies that focused on doubling the inhaled corticosteroid dose
after the asthma flare was established did not show benefit.
•The key factor in the studies showing benefit of as-needed inhaled
corticosteroid escalation is early initiation and substantial escalation (4X).
•Extremely high ICS doses, however, should be avoided
because of the concern about adverse effects on growth.
•Never use albuterol alone!

16. Attilio Boner
University of
Verona, Italy
attilio.boner@univr.it
The case of ICS
 Some doubts
 The case for oral steroids
 Why not ICS?
 Why not oral steroids?
 What to do in practice?
In Acute Loss of Asthma Control: always systemic
steroids or add/increase the dose of ICS ?

17. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? No/Yes ?
Weinberger M. Chest. 2016;150(3):490-2.
Some doubts
What is meant by loss of control?
Is this the same as an exacerbation?
A previously published practice
parameter summarizes the goal of
the yellow zone as “Responding to
the symptoms of acute loss of control
in the yellow zone with effective
interventions can help prevent
deterioration to the red zone,
necessitating use of systemic corticosteroids and/or urgent medical care.”
Dinakar C, Ann Allergy Asthma Immunol. 2014;113:143-159.

18. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? No/Yes ?
Weinberger M. Chest. 2016;150(3):490-2.
•So what is meant by loss of asthma control?
•Does it differ from an exacerbation?
•Is it essentially a preexacerbation?
•Symptoms requiring increased reliever medication, especially with an
increase in nocturnal symptoms, is a full-blown exacerbation by someone
standards even though that is described as still in the yellow zone and
not an actual exacerbation. Dinakar C, Ann Allergy Asthma Immunol. 2014;113:143-159.
the loss of control, if not already
an exacerbation, is considered to
be potential, pending, or
imminent but
not quite yet an exacerbation.

19. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? No/Yes ?
Weinberger M. Chest. 2016;150(3):490-2.
•So what is meant by loss of asthma control?
•Does it differ from an exacerbation?
•Is it essentially a preexacerbation?
•Symptoms requiring increased reliever medication, especially with an
increase in nocturnal symptoms, is a full-blown exacerbation by someone
standards even though that is described as still in the yellow zone and
not an actual exacerbation. Dinakar C, Ann Allergy Asthma Immunol. 2014;113:143-159.
As a parent, someone would
certainly consider that
an exacerbation,
not just loss of control.

20. Attilio Boner
University of
Verona, Italy
attilio.boner@univr.it
The case of ICS
 Some doubts
 The case for oral steroids
 Why not ICS?
 Why not oral steroids?
 What to do in practice?
In Acute Loss of Asthma Control: always systemic
steroids or add/increase the dose of ICS ?

21. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? No
Weinberger M. Chest. 2016;150(3):490-2.
•There is convincing data that early aggressive use of systemic steroids
provides impressive clinical benefit for children having an acute exacerbation
of asthma.6,11,12,13,14
•The question then is, can increasing ICS from a maintenance dose previously
associated with control prevent the need for an oral corticosteroid?
•Doubling the dose of ICS provided no therapeutic advantage.15
•Quadrupling the dose was associated with a modest but not statistically
significant decrease in subsequent requirement for oral corticosteroids. 16
= ?

22. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? No
Weinberger M. Chest. 2016;150(3):490-2.
•Is there an advantage with regard to safety for a higher dose of inhaled
corticosteroid compared with a short course of an oral corticosteroid?
•Sustained adverse effects from a short course of a corticosteroid has been
examined and found to be absent.18
•A Cochrane review of the subject concluded, “Practitioners may prescribe
systemic corticosteroids in otherwise healthy children when indicated for
the management of acute respiratory conditions (ie, infections or asthma
exacerbations) with minimal concern about short-term adverse effects.”19
Fernandes RM. Evid-Based Child Health. 2014;9(3):733-747.

23. The Cochrane Library and safety of systemic
corticosteroids for acute respiratory conditions
in children: an overview of reviews.
Fernandes RM. Evid-Based Child Health. 2014;9(3):733-747.
 7 reviews
containing 44
relevant randomized
controlled trials
with corticosteroids there were
significantly fewer admissions at day 1
(OR = 0.63, 95% confidence interval 0.52 to 0.78).
8.49 fewer hours in hospital compared
with placebo.
significantly fewer relapses leading to
hospitalization
(OR = 0.42, 95% confidence interval 0.23 to 0.76).

24. Triage nurse initiation of corticosteroids in pediatric asthma
is associated with improved emergency department efficiency.
Zemek R, Pediatrics. 2012 Apr;129(4):671-80.
644 consecutive children
aged 2 to 17 years
nurse initiation of treatment with
steroids before physician assessment
in children with Pediatric Respiratory
Assessment Measure score ≥4.
Time to clinical improvement
Physician-initiated phase(black) and
nurse-initiated phase (gray).

25. Triage nurse initiation of corticosteroids in pediatric asthma
is associated with improved emergency department efficiency.
Zemek R, Pediatrics. 2012 Apr;129(4):671-80.
644 consecutive children
aged 2 to 17 years
nurse initiation of treatment with
steroids before physician assessment
in children with Pediatric Respiratory
Assessment Measure score ≥4.
Time to clinical improvement
Physician-initiated phase(black) and
nurse-initiated phase (gray).
Nurse-initiated phase children
improved earlier compared to
physician-initiated phase (median
difference: 24 minutes; 95%
confidence interval [CI]: 1–50;
P = 0.04).
Admission was less likely if
children received steroids at
triage (odds ratio = 0.56;
95% CI: 0.36–0.87)

26. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? No/Yes
Weinberger M. Chest. 2016;150(3):490-2.
There are occasional exceptions to the use of oral corticosteroids:
1) patients with mild exacerbations that do not require urgent medical care
or hospitalizations, quadrupling the ICS dose may provide satisfactory relief
of symptoms.
2) patients who may experience acute adverse effects from oral steroids,
such as a child with diabetes requiring insulin, a trial of increasing the
inhaled corticosteroids may be justified.
•However, a short course of an oral corticosteroid is likely to provide
greater assurance of more rapid improvement.
•For most children who have experienced troublesome exacerbations, a short
course of an oral corticosteroid provides an acceptably safe and generally
assured means of preventing an exacerbation from progressing.

27. Attilio Boner
University of
Verona, Italy
attilio.boner@univr.it
The case of ICS
 Some doubts
 The case for oral steroids
 Why not ICS?
 Why not oral steroids?
 What to do in practice?
In Acute Loss of Asthma Control: always systemic
steroids or add/increase the dose of ICS ?

28. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? Rebuttal to No
Farber HJ, Chest. 2016;150(3):488-90.
•What is loss of control?
•Are symptoms that need reliever medication a “full blown exacerbation”?
•Is the “yellow zone” simply a “procrastinator’s zone”?
•Should we just cut to the chase and give oral corticosteroid
medication any time a child has symptoms of asthma?

29. Independent parental administration of prednisone
in acute asthma: a double-blind, placebo-controlled,
crossover study. Grant CC, Pediatrics. 1995;96(2 Pt 1):224-229.
78 children (2 to 14 years) who
had made ≥ 2 outpatient (ED or
primary-care clinic) visits for acute
asthma in the preceding yr.
1 dose of prednisone
(2 mg/kg up to 60 mg) or placebo
if an asthma attack had not
improved after a dose of the
child's regular acute asthma
medicine.
number of attacks resulting
in outpatient visits during
1 year follow-up
1.5 –
1.0 –
0.5 –
0.0 -
prednisone placebo
1.1
0.59
P=0.004

30. Independent parental administration of prednisone
in acute asthma: a double-blind, placebo-controlled,
crossover study. Grant CC, Pediatrics. 1995;96(2 Pt 1):224-229.
78 children (2 to 14 years) who
had made ≥ 2 outpatient (ED or
primary-care clinic) visits for acute
asthma in the preceding yr.
1 dose of prednisone
(2 mg/kg up to 60 mg) or placebo
if an asthma attack had not
improved after a dose of the
child's regular acute asthma
medicine.
number of attacks resulting
in outpatient visits during
1 year follow-up
1.5 –
1.0 –
0.5 –
0.0 -
prednisone placebo
1.1
0.59
P=0.004
The poorer outcome
in the prednisone
group was attributable
primarily to
significantly
more visits made
in the prednisone group
by children
≤5 years of age
(P = 0.009).

31. Efficacy of a short course of parent-initiated oral
prednisolone for viral wheeze in children aged 1-5 years:
randomised controlled trial.
Oommen A, Lancet. 2003;362(9394):1433-1438.
Children aged 1-5 years
admitted to hospital with
viral wheeze were
randomised to parent-
initiated prednisolone
(20 mg one daily for 5 days)
or placebo for the next
episode
51 received prednisolone
and 69 placebo.
% children admitted
to hospital
15 –
10 –
05 –
00 -
prednisone placebo
12%
3%
P=0.06

32. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? Rebuttal to No
Farber HJ, Chest. 2016;150(3):488-90.
•Although oral corticosteroid medication has definite benefits
for patients with a moderate to severe asthma exacerbation,4
these clinical trials suggest that for most patients,
early initiation by parents is not beneficial.
4. Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota GW. Early emergency department
treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev.
2001;1: CD002178.

33. Attilio Boner
University of
Verona, Italy
attilio.boner@univr.it
The case of ICS
 Some doubts
 The case for oral steroids
 Why not ICS?
 Why not oral steroids?
 What to do in practice?
In Acute Loss of Asthma Control: always systemic
steroids or add/increase the dose of ICS ?

34. Is Escalation of the Inhaled Corticosteroid Dose Appropriate
for Acute Loss of Asthma Control in an Attempt to Reduce
Need for Oral Corticosteroids in Children? Rebuttal to Yes
Weinberger M. Chest. 2016;150(3):490-2.
•A systematic review did find acute vomiting, transient behavioral
changes, and sleep disturbances in 5.4%, 4.7%, and 4.3% of children,
respectively, who were given a short course of an oral corticosteroid,
predominantly prednisolone.3
3. Aljebab F, Choonara O, Conroy S. Systematic review of the toxicity of short-course oral
corticosteroids in children. Arch Dis Child. 2016;101(4):365-370.
•However, vomiting is a formulation issue due to the extremely foul taste
of some liquid formulations of prednisolone.

35. Attilio Boner
University of
Verona, Italy
attilio.boner@univr.it
The case of ICS
 Some doubts
 The case for oral steroids
 Why not ICS?
 Why not oral steroids?
 What to do in practice?
In Acute Loss of Asthma Control: always systemic
steroids or add/increase the dose of ICS ?

36. Empowering the child and caregiver: yellow zone Asthma
Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475.
Asthma Action Plans commonly are based on the traffic signal
color-coded concept of:
- green (go)
- yellow (caution)
- red (danger)
pharmacotherapy recommendations
intervention needed
asthma exacerbation
requiring urgent treatment
no change
(http://www.nhlbi.nih.gov/health/public/lung/asthma/actionplan_text.htm

37.  Daily symptoms and
morning peak
expiratory flows
(PEFs) from two
previous studies.
 predicting
exacerbations.
The use of action points in an 8-week
peak flow chart with an exacerbation
at the half-way point
Early detection of asthma exacerbations by using
action points in self-management plans
Honkoop PJ, Eur Respir J 2013;41:53-9

38. Nonrespiratory symptoms before loss of asthma control
in children. Newton L, JACI Pract 2013;1:304
 Caregivers of children aged
2 to 11 years with asthma.
 Diary cards daily for 16 weeks
during cold and flu season.
 Likert scale from 1 to 5
(3 represented baseline or usual;
1 or 2, less than usual; and
4 or 5, more than usual).
 Multiple nonrespiratory (NR)
 Upper respiratory (UR) signs and
symptoms.
 Mood changes (MC)
 Lower respiratory tract (LR).
 Loss of asthma control (LOC)
Percentage of days with
a nonusual symptom before and
during a LOC episode
(≥2 consecutive days with LR symptoms)

39. Nonrespiratory symptoms before loss of asthma control
in children. Newton L, JACI Pract 2013;1:304
 Caregivers of children aged
2 to 11 years with asthma.
 Diary cards daily for 16 weeks
during cold and flu season.
 Likert scale from 1 to 5
(3 represented baseline or usual;
1 or 2, less than usual; and
4 or 5, more than usual).
 Multiple nonrespiratory (NR)
 Upper respiratory (UR) signs and
symptoms.
 Mood changes (MC)
 Lower respiratory tract (LR).
 Loss of asthma control (LOC)
Percentage of days with
a nonusual symptom before and
during a LOC episode
(≥2 consecutive days with LR symptoms)
changes in behavior
(moody, irritability,
tension)
and appearance
(dry skin, eye swelling,
sunken eyes)
can be present 3 days
before an
exacerbations

40. A Low-Literacy
Asthma Action
Plan to Improve
Provider Asthma
Counseling: A
Randomized Study
Yin H S, Pediatrics.
2016;137:e20150468
changes in behavior
(moody, irritability,
tension)

41. A Low-Literacy Asthma Action Plan to Improve Provider
Asthma Counseling: A Randomized Study
Yin H S, Pediatrics. 2016;137(1):e20150468
 119 providers were randomly assigned
(61 low literacy, 58 standard)
 Physicians at 2 academic centers
randomized to use a low-literacy or
standard action plan to counsel the
hypothetical parent of child with
moderate persistent asthma
(regimen:
-Flovent 110 μg 2 puffs twice daily,
-Singulair 5 mg daily,
-Albuterol 2 puffs every 4 hours as needed)
90 –
80 –
70 –
60 –
50 –
40 –
30 –
20 –
10 –
00
% providers using explicit symptoms
(eg, "ribs show when breathing," )
100 -
54.1%
p<0.001
3.4%
The low-literacy
plan
Standard plan
OR=33.0
OCS
+
ICS

42. Empowering the child and caregiver: yellow zone Asthma
Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475.
Asthma Action Plans commonly are based on the traffic signal
color-coded concept of:
- green (go)
- yellow (caution)
- red (danger)
pharmacotherapy recommendations
intervention needed
asthma exacerbation
requiring urgent treatment
no change
(http://www.nhlbi.nih.gov/health/public/lung/asthma/actionplan_text.htm
The risk of a “false” start, or
initiating YZ treatment when
not needed, should be balanced
with the risk of a “late” start,
resulting in downstream
morbidity.

43. Empowering the child and caregiver: yellow zone Asthma
Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475.
Asthma Action Plans commonly are based on the traffic signal
color-coded concept of:
- green (go)
- yellow (caution)
- red (danger)
pharmacotherapy recommendations
intervention needed
asthma exacerbation
requiring urgent treatment
no change
(http://www.nhlbi.nih.gov/health/public/lung/asthma/actionplan_text.htm
Criteria proposed to identify the YZ:
1) an increase in asthma symptoms
(two or more times per day)
2) asthma symptoms that do not
improve or recur (within 4 h or less)
after treatment with an inhaled
SABA
3) increase in nocturnal symptoms
4) Peak flow decline ≥ 15% at <80% of
personal best
Since symptoms
return to baseline
sooner than
objective measures of function,
YZ therapy should be
continued for a period of
≈ 2 weeks to ensure
full recovery

44. Empowering the child and caregiver: yellow zone Asthma
Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475.
100% lung function
Symptoms’ perception
The yellow zone
2 weeks of ICS x 2-4
OCS
ICS

45. Written action plans for asthma: an evidence-based
review of the key components.
Gibson PG, Thorax. 2004;59(2):94-9.
trials (n=26) that
evaluated asthma action
plans as part of asthma
self-management education
For individualised complete
written action plans:
the use of 2-4 action points and
the use of both inhaled (ICS) and
oral (OCS) corticosteroid
consistently improved asthma
outcomes.
Action points based on personal best
peak expiratory flow (PEF) consistently
improved health outcomes while those
based on percentage predicted PEF did
not.

46. Written action plans for asthma: an evidence-based
review of the key components.
Gibson PG, Thorax. 2004;59(2):94-9.
Comparison of the effects of
action plan components on
hospital admissions for asthma
Comparison of the effects of
action plan components on mean
peak expiratory flow (PEF) in asthma
* *

47. Empowering the child and caregiver: yellow zone Asthma
Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475.
Intervention Strategies in the Yellow Zone
A yellow zone episode
can occur in two ways:
•progresses over days after
exposure to a known trigger, such
as at the onset of a viral RTI
•rapidly after a short-term
exposure to allergens (furry
animals) or irritants (fireworks)
In such situations include scheduled dosing step-up tactics such as
quadrupling or higher doses of inhaled corticosteroids (ICS), or
supplementation of moderate- to high-dose ICS
in those not receiving daily controllers
or

48. Empowering the child and caregiver: yellow zone Asthma
Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475.
Intervention Strategies in the Yellow Zone
A yellow zone episode
can occur in two ways:
•progresses over days after
exposure to a known trigger, such
as at the onset of a viral RTI
•rapidly after a short-term
exposure to allergens (furry
animals) or irritants (fireworks)
In such situations include scheduled dosing step-up tactics such as
quadrupling or higher doses of inhaled corticosteroids (ICS), or
supplementation of moderate- to high-dose ICS
in those not receiving daily controllers
or
Use oral
corticosteroids
very early + ICS

49. Conclusions
•Increasing the dose of ICS
may prevent deterioration if
started early and with moderate-high
dose (4X) at the very onset
of deterioration.
•For children with
no prodromal symptoms,
for those with a clinical history of
severe asthma exacerbations and
particularly for those of mold allergy
the combined use of OCS and ICS
seem more appropriate.

50. Thank you for
your attention
to the story
my grandpa told you.
Mia Charlize Powell