Children and their caregivers should be educated about self-monitoring and self-management of exacerbations, especially for moderate and severe persistent asthma or history of severe asthma exacerbations. A written action plan with patient-specific instructions based on clinical indicators using peak flow readings, symptoms, or both to identify the need for prompt medical care should be developed, reviewed periodically, and revised for home and school settings. peak flow meters (PFMs) should be used every morning upon awakening before medication administration. A personal best value should be identified for comparison. Alternatively, the peak flow meter (PFM) can be used in the morning and in the late afternoon or evening; a difference in the two values of greater than 20% suggests poor asthma control. Any medication regimen adjustments should be outlined in detail. Trigger avoidance or minimization of exposure should be discussed. Participation in physical activities, exercise, and sports should be promoted. Frequent use of a quick-relief bronchodilator is a sign of poor control and may indicate that the patient requires a step up in treatment if technique, adherence, and environmental control are appropriate.
After adequate control has been established and sustained for two to four months, step-down therapy is recommended. Therapy should be stopped if no clear benefit has been observed within four to six weeks. Alternative therapy or diagnosis should be considered. Consultation with an asthma specialist is recommended in infants and young children with mild persistent asthma. Older children with uncontrollable moderate or severe persistent asthma should be referred to an asthma specialist.