Asthma | Outpatient Pediatrics Atlas

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Asthma, follow-up

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Counseling

Use the rescue inhaler as needed for cough, wheeze, or shortness of breath; needing it more than 2 days a week, other than before exercise, means asthma is not well controlled. If on a daily controller, use it every day, even when well. Recommended supportive care with an emphasis on avoiding smoke, vape, and known triggers. Seek urgent care for trouble breathing, trouble speaking, blue color, or symptoms not responding to the rescue inhaler. Return precautions given including needing the rescue inhaler more often, night cough, missed school or activities, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Asthma, follow-up
November 2026: Doing great!
• Asthma well controlled based on daytime and nighttime symptoms, activity, rescue inhaler use, and exacerbations
• No ED visits, hospitalizations, or oral steroid courses since the last visit
• Continue current asthma medications without changes
• Reviewed inhaler and spacer technique and daily adherence
• Asthma action plan reviewed and updated
• Discussed trigger avoidance and avoiding smoke and vape exposure
• Follow up in 3 months

Use the rescue inhaler as needed for cough, wheeze, or shortness of breath; needing it more than 2 days a week, other than before exercise, means asthma is not well controlled. If on a daily controller, use it every day, even when well. Recommended supportive care with an emphasis on avoiding smoke, vape, and known triggers. Seek urgent care for trouble breathing, trouble speaking, blue color, or symptoms not responding to the rescue inhaler. Return precautions given including needing the rescue inhaler more often, night cough, missed school or activities, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Month-year lead and status
Well controlled (symptoms, night, activity, rescue use, exacerbations)
Not well controlled
Very poorly controlled
No ED, hospitalization or oral steroids since last visit
Oral steroid course or ED visit or hospitalization since last visit
Continue current medications
Step up (adherence and technique checked first)
SMART with ICS-formoterol
Step down after ≥ 3 months controlled

Show 13 more

Start daily controller for persistent asthma
Intermittent: Albuterol as needed only
0–4: short daily ICS course at onset of colds
Medication names (Flovent, QVAR, Pulmicort, Symbicort, Dulera, Advair, Montelukast…)
Reviewed technique, spacer, adherence
Written action plan reviewed/updated
Triggers and smoke/vape exposure
Annual influenza vaccine
Spirometry reviewed
Allergy testing or allergen mitigation
Referral to pulmonology or allergy
Follow-up 3 months or 2–6 weeks after step up or 1 or 6 months or next well check
Rescue use > 2 days/week: call; urgent care for distress

Used to decide, kept out of the note

Don't briefly double ICS for symptoms

Return precautions in the template

needing the rescue inhaler more oftennight coughmissed school or activities

Sources

NHLBI. 2020 Focused Updates to the Asthma Management Guidelines: Clinician's Guide (NIH Pub 20-HL-8141)
NHLBI. Asthma Care Quick Reference (EPR-3, 2007/2012)
Cribsiders #8, Mastering Outpatient Asthma (September 16, 2020; David Stukus, MD)
Global Strategy for Asthma Management and Prevention 2026