Asthma Management Handbook
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Table. Managing persistent exercise-induced respiratory symptoms in children

Clinical scenario

Action

Notes

Prior confirmed asthma diagnosis and recent asthma symptom control is assessed as partial or poor*

Consider preventer treatment based on age and pattern of symptoms§

 

Prior confirmed asthma diagnosis, recent asthma symptom control is assessed as partial or good,* and symptoms only occur with exercise

Exercise symptoms most or all days

If child 2–14, consider regular montelukast (as sole preventer or added to ICS)#

Review in 4–12 weeks

Consider alternative causes (e.g. poor cardiopulmonary fitness, upper airway dysfunction)

If symptoms do not respond to montelukast alone, consider low-dose ICS#

If child currently taking ICS/LABA combination, consider a treatment trial of ICS alone (and salbutamol taken before exercise) or ICS plus montelukast

Exercise symptoms some days but not every day

If child 6 years and over, salbutamol 15 minutes before exercise##

If child 2–5 years, consider regular montelukast

Review in 4–12 weeks

No previous history of asthma

Investigate as for asthma (history, physical examination and spirometry before and after bronchodilator if child can do test)**

If asthma confirmed, manage as for asthma

If asthma not confirmed by spirometry (in children able to perform the test), consider:

  • a trial of  salbutamol 15 minutes before exercise
  • whether regular  preventer treatment is indicated
  • exercise testing for cardiopulmonary function to rule out exercise-related dyspnoea due to poor cardiopulmonary fitness
  • indirect challenge testing

Review in 4–12 weeks

Poor cardiopulmonary fitness is a common reason for exercise-related respiratory symptoms

Some children with asthma avoid exercise

Competing athletes

Consider indirect challenge testing. (Check which tests are required to demonstrate airway hyperresponsiveness)

Check which medicines are permitted in the particular sport by consulting ASADA (www.asada.gov.au) before prescribing any medicine

Advise warm-up before planned exercise

  • Advise parents about potential adverse psychiatric effects of montelukast

* See Table. Definition of levels of recent asthma symptom control in children (regardless of current treatment regimen)

§ See Table. Initial preventer treatment for children aged 0–5 years and Table. Initial preventer treatment for children aged 6 years and over

# Before stepping up, check that inhaler technique is correct and adherence is adequate. See Figure. Stepped approach to adjusting asthma medication in children

† If exercise-induced symptoms do not resolve after adjusting medicines, and checking adherence and inhaler technique, consider alternative diagnoses, referral to an accredited respiratory function laboratory for indirect challenge testing, or referral to a respiratory physician for assessment.

** See Figure. Steps in the diagnosis of asthma in children

## Reliever should also be taken at other times as needed to manage symptoms

Notes 

For some children with asthma, exercise-related symptoms are their only asthma symptoms.

PBS status of montelukast as at March 2019: Montelukast is not subsidised for children aged 2–5 years when used in addition to another preventer, or for children of any age when used addition to a long-acting beta-agonist.

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