Asthma

How to read this summary

• Canadian sources come first, US/international sources second. Each point has a source tag like ^[S1] or ^[U1]. The full list of tags is at the end.
• "WARNING" marks a conflict or an old document. "Unconfirmed" means it could not be verified in the sources used. Never trust an unconfirmed item without checking.
• PEBC follows Canada. When Canada and other guidelines differ, the Canadian answer is the exam answer.
• IMPORTANT (newest guidelines): the main Canadian guideline is the Canadian Thoracic Society (CTS) 2021 Guideline update on diagnosis and management of asthma in preschoolers, children and adults ^[S1], built on the CTS 2021 focused update on very mild and mild asthma ^[S2]. These are the newest CTS asthma guidelines found in October 2026 (CTS lists no newer full update in the library). The CTS severe-asthma position statement ^[S3] is from 2017.
• WARNING: the CTS severe-asthma statement ^[S3] is from 2017 and is older than several biologic approvals. Biologic facts in this summary come from the current Health Canada product monographs ^{[S10 to S14]}, not from ^[S3].
• WARNING: several Health Canada drug labels in the library are older than 2022 (Symbicort 2021, Flovent 2021, Spiriva Respimat 2019, Singulair 2020, Alvesco 2020, Tezspire 2022). Newer versions may exist; they were not found.
• Health Canada drug labels (product monographs) can differ from the guideline. Those points are collected in section 14 "Label vs guideline" and are NOT used in the MCQs.
• Page numbers: S1 uses the journal page (348-361). S2 and S3 use the PDF page. Drug labels use the section or page.
• Doses and numbers are for exam study, not for real patients.
• Abbreviations used: SABA = Short-Acting Beta2-Agonist; LABA = Long-Acting Beta2-Agonist; ICS = Inhaled CorticoSteroid; LAMA = Long-Acting Muscarinic Antagonist; LTRA = LeukoTriene Receptor Antagonist; bud/form = budesonide-formoterol in one inhaler; SMART = Single Maintenance And Reliever Therapy (maintenance and reliever with the same bud/form inhaler); PRN = as needed; pMDI = pressurized Metered-Dose Inhaler; VHC = Valved Holding Chamber (a spacer with a valve); DPI = Dry Powder Inhaler; FEV1 = Forced Expiratory Volume in 1 second; FVC = Forced Vital Capacity; PEF = Peak Expiratory Flow.

1. What is asthma, and how is it diagnosed? (a sensitive pipe that tightens and swells)

• Asthma is a long-term inflammatory disease of the airways. It causes on-and-off or constant cough, wheeze, chest tightness, shortness of breath and sputum, with airflow limitation that changes over time and airways that over-react to triggers ^{[S1 p349]}.
• Daily-life picture: the airways are like a sensitive garden hose. When dust, smoke, a cold or exercise touches it, the hose swells inside and squeezes tight, so air moves through a narrower tube. Between attacks the hose may look normal, but the swelling problem is still there. Asthma is chronic; only the symptoms come and go ^{[S1 p349]}.
• Diagnosis = a history that fits asthma PLUS objective proof of reversible airflow obstruction ^{[S1 p349, Table 1]}.

1.1 Confirming the diagnosis (Table 1, CTS 2021 ^{[S1 p349-350]})

• Spirometry for age 6 and over is the preferred test. It is better at ruling asthma IN than OUT: a normal spirometry does not rule out asthma ^{[S1 p350]}.
• Under age 6, the diagnosis is clinical: a fitting history, an exam and a trial of treatment. Up to 50% of children under 6 outgrow their symptoms, so a monitored trial off medicine can be tried after 3 to 6 months of good control, including no exacerbations ^{[S1 p350]}.
• Choosing Wisely Canada (Canadian Thoracic Society): do not keep asthma medicines going in people with no clear benefit and no objective confirmation of reversible airflow limitation. Up to one third of people diagnosed with asthma show no evidence of it when tested. If testing is not available quickly, treatment can start and be confirmed later; where safe, stopping controllers for 4 to 8 weeks makes lung testing more sensitive ^{[S18 item 5]}.
• Choosing Wisely Canada: do not use antibiotics for an asthma exacerbation without clear signs of bacterial infection (most triggers are viral) ^{[S18 item 6]}.
• The fraction of exhaled nitric oxide (FeNO) is not recommended as a routine measurement of asthma control (CTS 2012, restated in ^{[S1 p351]}).

Must remember for the exam: diagnosis = fitting history + proof of reversible obstruction (age 6+: spirometry with FEV1 rise of 12% or more, adults also 200 mL or more). Normal spirometry does not rule asthma out. Under 6: clinical diagnosis with a treatment trial.

Blueprint area: 1A Clinical Care.

2. Control, risk and goals

• Goal of treatment: well-controlled asthma, to prevent short- and long-term harm, illness and death. Control means more than symptoms: symptoms and quality of life, exacerbations, lung function (and inflammatory markers only in adults with moderate to severe asthma in specialist care) ^{[S1 p351]}.
• Assess BOTH control (Table 2) and risk of exacerbation (Table 3) at EVERY visit ^{[S1 p351]}.

2.1 Well-controlled asthma (Table 2 ^{[S1 p352]}). The person must meet ALL of these

• Daily-life example: a girl who needs her blue inhaler 3 times in a week, or wakes at night once a week, does NOT have well-controlled asthma (reliever use must be 2 doses a week or fewer) ^{[S1 p352]}.
• Use of a reliever more than 2 doses a week is a sign of poor control and should make the team look for the reason ^{[S1 p354]}.

2.2 Risk of a severe exacerbation (Table 3 ^{[S1 p353]})

• A person with ANY ONE of these four is at higher risk, even if well controlled: (1) any past severe exacerbation (needing systemic steroids, an ED visit or a hospital stay); (2) poorly controlled asthma by CTS criteria; (3) SABA overuse = more than 2 SABA inhalers in a year; (4) current smoker ^{[S1 p353]}.
• Table 4 lists more risk factors, for example a past severe exacerbation (greatly increased risk), low FEV1, excessive SABA use, obesity, depression, past smoking or smoke exposure, and blood eosinophils above 300/microlitre; the ranking differs by age group ^{[S1 p353]}.
• Near-fatal or fatal asthma risks (Table 5): a past ICU stay or ventilation; repeated hospital or ED visits in the past year; severe asthma; SABA overuse; poor adherence; missed appointments; depression, anxiety or other psychiatric illness; alcohol or drug use; obesity; major stress; denying the illness. These patients need careful follow-up and may benefit from a team ^{[S1 p352-353]}.

2.3 Exacerbation words and severity (CTS 2021)

• Severe exacerbation = needs systemic (oral) steroids, an ED visit or a hospitalization. Mild exacerbation = worse symptoms that do NOT need any of these ^{[S1 p348-349]}.
• Asthma severity is the amount of treatment needed to keep control. It can only be judged once control is achieved: very mild = well-controlled on PRN SABA; mild = well-controlled on low-dose ICS (or LTRA) with PRN SABA, or on PRN bud/form; moderate = needs low-dose ICS plus a second controller, or moderate-dose ICS (with or without a second controller), or low-moderate dose bud/form with PRN bud/form; severe = high-dose ICS plus a second controller for the past year (or oral steroids for half the year), or uncontrolled despite this. The "very severe" category was removed ^{[S1 p357]}. Terms like "mild intermittent" are no longer used ^{[S1 p349]}.

Must remember for the exam: well-controlled = daytime symptoms 2 days a week or fewer, reliever 2 doses a week or fewer, night symptoms under 1 night a week, normal activity, FEV1/PEF 90% or more of personal best. Higher risk = past severe exacerbation, poor control, more than 2 SABA inhalers a year, or current smoking.

Blueprint area: 1A Clinical Care.

3. Education, action plan, triggers and what to check before stepping up

• Every person with asthma gets self-management education and a WRITTEN action plan. Plans lower exacerbations in children and adults ^{[S1 p352]}.
• A symptom-based plan is as good as a peak-flow-based plan; choose by preference and judgment (a peak-flow plan can help people who do not sense their symptoms well) ^{[S1 p352]}.
• The plan must say how to keep control every day, what to change when control is lost (medicine, how much, how long), and when to seek urgent help or go to hospital ^{[S1 p352-353]}.
• Education program (Table 6): what asthma is; triggers; control and "all patients can lead a normal life"; reliever versus controller; the written plan; expected effects and side effects; teaching and CHECKING inhaler technique for each device, including how to tell when an inhaler is empty ^{[S1 p353]}.
• Daily-life example: Mia has a green card on the fridge: what to take every day, what to add if she starts wheezing, and when to call 911.
• Triggers: find the person's own triggers (allergens, viral colds, smoke, cold air, exercise, strong smells, work exposures) and avoid them if possible ^{[S1 p352]}.
• About 36% of adult-onset asthma is probably or possibly work-related, so take a work history ^{[S1 p352]}.
• Allergen-reduction at home is not recommended as a general strategy (expensive, weak evidence), but is sensible when a person reacts to an indoor allergen. Several steps together work better than one ^{[S1 p352]}.
• First- or second-hand tobacco smoke raises exacerbation risk: counsel to quit. Smoking cannabis and vaping are also growing causes of symptoms and risk ^{[S1 p352-354]}.
• Before increasing medicine for poor control, CHECK: adherence; inhaler technique; whether the inhaler is empty; environmental and work exposures; and comorbidities (rhinosinusitis, gastro-esophageal reflux, paradoxical vocal fold motion, anxiety and depression) ^{[S1 p352, p355]}.
• Adherence facts: adherence in trials is only about 56 to 75%, and is probably lower in real life; many people take a controller only when they feel they need it ^{[S2 pdf p3]}.

Must remember for the exam: written action plan for everyone; check adherence, technique, empty inhaler, exposures and comorbidities BEFORE stepping up therapy; ask about smoking and work.

Blueprint area: 1A Clinical Care.

4. Inhaler devices, spacers and technique

• Poor inhaler technique is seen in up to 70% of patients and goes with worse control and more exacerbations ^{[S1 p354]}.
• Up to 50% cannot coordinate pressing and breathing in with a pMDI. A valved holding chamber (VHC, a spacer with a valve) reduces medicine landing in the mouth and throat, increases lung delivery and fixes the coordination problem. CTS recommends a VHC for ALL ages using a pMDI, especially with an ICS ^{[S1 p354]}.
• Dry powder inhalers (DPIs) need a deep, fast breath in. That may be hard for young children, people with low FEV1 or muscle weakness, and during an exacerbation ^{[S1 p354]}.

• Daily-life example: a 7-year-old uses a spacer for the steroid puffer so most of the medicine reaches the lungs, not the throat.
• Salbutamol (Ventolin HFA) pMDI label technique: shake well; prime with 4 puffs into the air before first use or if not used for more than 5 days; breathe out; start to breathe in slowly and press once; hold the breath as long as comfortable; wait about 30 seconds between puffs; clean the plastic casing at least once a week (dry thoroughly, canister is not put in water) ^{[S5 patient section p23-25]}. A spacer is recommended for children under 5 years ^{[S5 7.1.3]}.
• Fluticasone (Flovent HFA) pMDI: prime before the first use and after more than 7 days without use (shake 5 seconds, actuate, shake and actuate again). Rinse the mouth and gargle with water after each use ^{[S6 section 4, p8]}.
• Budesonide-formoterol (Symbicort Turbuhaler) is a dry powder inhaler: twist the red grip all the way one way and back to load ONE dose (a click is normal); breathe out away from the mouthpiece; seal lips and breathe in as deeply and strongly as possible; do not breathe out into it; if you drop it, shake it or breathe out into it after loading, the dose is lost and you load again; you may not taste or feel the powder; rinse the mouth with water and do not swallow; when the "0" on the red background reaches the middle of the dose-indicator window, throw the inhaler away and start a new one; it cannot be refilled ^{[S4 patient information, pp54-56]}.
• Choosing Wisely Canada (CTS): avoid choosing a high-greenhouse-gas pMDI when an equal inhaler with a lower carbon footprint is available, the person has good technique and the person agrees. This may not suit preschool children, people with cognitive or physical limits, severe lung disease, or emergencies ^{[S18 item 8]}.

Must remember for the exam: use a spacer (valved holding chamber) with every pMDI, especially ICS; check technique every visit; a DPI needs a fast deep breath; rinse the mouth after ICS.

Blueprint area: 1A Clinical Care.

5. Relievers (rescue)

• Everyone with asthma needs a reliever. In Canada, approved relievers are SABAs (salbutamol, terbutaline) and the combination inhaler budesonide-formoterol (for age 12 and older) ^{[S1 p354]}.
• Bud/form as a reliever is studied only when the person takes no other controller, or takes bud/form for maintenance. Do not use bud/form as a reliever on top of other controller medicines ^{[S1 p354]}.
• Needing a reliever more than 2 doses a week means re-check control. Using more than 2 SABA inhalers in a year (about 200 doses each) is a risk for severe exacerbation and asthma death ^{[S1 p354]}.
• A SABA is for symptom relief only. Do NOT use it regularly "to open the airways" before the daily controller: this raises exacerbation risk ^{[S1 p354; S2 rec 5.1, pdf p12]}.
• Salbutamol (Ventolin HFA 100 mcg per puff) label doses: ages 12 and over, 1 to 2 puffs as needed; to prevent exercise-induced bronchospasm, 2 puffs 15 minutes before exercise; maximum 8 puffs (800 mcg) in 24 hours. Ages 4 to under 12: 1 puff as needed (may increase to 2); 1 puff 15 minutes before exercise (may increase to 2) ^{[S5 section 4.2]}.
• If the usual dose does not give the usual relief, or relief lasts less than 3 hours, get medical advice promptly: this is usually a sign of worsening asthma ^{[S5 section 4.1]}.
• Side effects of salbutamol: fine tremor of the hands and nervousness (often fade with use), fast heartbeat, low potassium (mainly with high doses, nebulised or by injection), and rarely paradoxical bronchospasm (wheeze or tightness right after the dose: stop it and use another treatment) ^{[S5 sections 7 and 8]}.
• Non-selective beta-blockers (for example propranolol) can block the effect of salbutamol and should usually not be prescribed together ^{[S5 section 9]}.
• Salbutamol is contraindicated as a tocolytic (to stop premature labour or threatened abortion) ^{[S5 section 2]}.

Must remember for the exam: reliever more than 2 doses/week = not controlled; more than 2 SABA inhalers/year = risk; no routine SABA before ICS; non-selective beta-blockers oppose salbutamol; salbutamol max 8 puffs/day for adults.

Blueprint area: 1A Clinical Care.

6. Controller medicines

6.1 Inhaled corticosteroids (ICS): the foundation

• ICS calm the swelling in the airways. They work best taken every day, even when the person feels well ^{[S6 p7; S2 pdf p3]}. Daily-life example: like brushing teeth every day to prevent cavities, not only when a tooth hurts.
• Improvement begins within 1 to 2 weeks of starting daily ICS; full benefit can take months ^{[S1 p355]}.
• Use the lowest dose that gives control and removes exacerbations, especially in children (growth concern) ^{[S1 p355]}. Most people respond to low to medium doses (dose equal to about 200 to 250 mcg of fluticasone propionate a day); above that the benefit flattens ^{[S1 p355]}.

• CTS table note: budesonide, ciclesonide, fluticasone furoate and mometasone are licensed for once-daily dosing in Canada. Some doses in the table are not approved in Canada (for example for the youngest children): the table says which. Max FP is 200 mcg/day in ages 1 to 4 and 400 mcg/day in ages 4 to 16 ^{[S1 p354]}.
• Side effects (ICS): throat irritation, hoarse voice (dysphonia), and oral thrush (Candida in the mouth and throat). Rinse the mouth and gargle with water after each dose (also clean dentures). Thrush can be treated with a topical antifungal while the ICS continues ^{[S6 p12 Candidiasis; S4 Warnings and Precautions, Candidiasis]}. Higher doses over time: adrenal suppression, reduced bone density, cataract, glaucoma, and slower growth in children ^{[S6 Warnings and Precautions]}. Watch the growth of children and teens on long-term ICS ^{[S4 Warnings and Precautions; S6 p14]}.
• Growth facts (CTS): in the START trial, children on daily budesonide grew about 0.43 cm per year less than the PRN SABA group. Studies suggest adult height ends up about 1.2 cm lower, or normal. Use the lowest effective dose ^{[S2 pdf p14-16]}.
• Switching from oral steroids to ICS: the body's own steroid production can stay low for a long time; patients may show signs of adrenal insufficiency during stress, surgery or a severe attack ^{[S6 p10]}.

6.2 Leukotriene receptor antagonist (LTRA): montelukast

• LTRAs are second-line to daily ICS in all ages ^{[S1 p356]}. Montelukast is taken once daily in the evening: 10 mg for ages 15 and over, 5 mg chewable for ages 6 to 14, 4 mg for ages 2 to 5 ^{[S8 Dosage and Administration]}.
• Not for acute attacks ^[S8].
• WARNING (boxed warning): serious neuropsychiatric (NP) events: agitation, aggression, depression, sleep disturbance, suicidal thoughts and behaviour, in people with or without psychiatric history. CTS reports up to 16% of children starting montelukast had such effects, typically within 2 weeks. Tell patients and caregivers to watch for behaviour changes and to stop and call if they appear ^{[S1 p356; S8 Serious Warnings]}.
• Montelukast can be used for exercise-induced bronchoconstriction (age 2 and older) and in aspirin (ASA)-sensitive asthma ^{[S8 indications]}. Rare: systemic eosinophilia with vasculitis features (EGPA, formerly Churg-Strauss), with or without steroid reduction; watch for rash, joint pain, worsening lung symptoms or nerve problems ^{[S8 Warnings and Precautions]}.

6.3 Long-acting beta2-agonists (LABA) and combinations

• LABA (salmeterol, formoterol, vilanterol) are NEVER used alone in asthma (no ICS). They are used with an ICS, ideally in the same inhaler ^{[S1 p356; S4 Warnings and Precautions]}.
• Safety: LABA alone raises the risk of asthma-related death and hospital stays. Large trials of ICS plus LABA together found no significant rise in serious asthma events compared to ICS alone, and the older black-box warning is no longer on LABA medicines ^{[S1 p356; S4 Warnings and Precautions, Table 1]}.
• Maximum daily LABA doses approved in Canada for adults: salmeterol 100 mcg, formoterol 48 mcg, vilanterol 25 mcg ^{[S1 p357]}.

6.4 Long-acting muscarinic antagonist (LAMA): tiotropium

• Add-on only. Spiriva Respimat 2.5 mcg per actuation, 2 inhalations once daily. Label: add-on for ADULTS with asthma who remain symptomatic on ICS plus LABA and had one or more severe exacerbations in the past year. Not for rescue. Use caution in narrow-angle glaucoma and urinary retention ^{[S9 indications, dosage, warnings]}.

Must remember for the exam: ICS = foundation, daily; rinse the mouth to prevent thrush; LABA never alone; LTRA is second-line with a neuropsychiatric boxed warning; tiotropium is add-on for severe uncontrolled asthma.

Blueprint area: 1A Clinical Care.

7. Stepwise treatment (CTS 2021)

7.1 Starting: people on PRN SABA or no medicine (Figure 3 ^{[S1 p355]}; recommendations ^{[S2 pdf p11-12]})

• PRN bud/form is approved as a reliever for age 12 and over. The panel cautions against using it off-label in ages 6 to 11 ^{[S1 p354; S2 pdf p16]}.
• Taking an ICS every time a SABA is used (PRN ICS-SABA with two separate inhalers) is NOT approved in Canada. It is only a harm-reduction option for people 18 and over at higher risk who cannot use daily ICS or PRN bud/form; do not exceed the maximum approved daily ICS dose ^{[S1 p355-356]}.
• A short course of very high-dose ICS at loss of control is not suggested in people on PRN SABA only ^{[S2 rec 6.1, pdf p12]}.
• An LTRA is second-line to daily ICS ^{[S1 p356]}.
• Any severe exacerbation in a person on PRN SABA alone is a reason to start a controller ^{[S1 p357]}.

7.2 Not controlled on low-dose ICS (good adherence and technique)

• People 12 and over on ICS/LABA with poor control, or who are prone to exacerbations, can be switched to SMART (bud/form for both maintenance and reliever) at the same maintenance ICS dose ^{[S1 p356]}.
• After control (including no severe exacerbation) for at least 3 to 6 months, reduce to the minimum dose that keeps control ^{[S1 p351 Figure 2 legend]}.
• Other guidelines allow adding a LABA at age 6 to 11 sooner, but Canada's limited ICS/LABA approvals in this age group stop CTS from making the same recommendation ^{[S1 p356]}.

7.3 Budesonide-formoterol (Symbicort Turbuhaler) label approaches (age 12 and over) ^{[S4 Dosage and Administration]}

• A. Anti-inflammatory reliever therapy: Symbicort 200 Turbuhaler used as needed for symptoms.
• B. SMART (reliever plus maintenance): 100 or 200 strength: 1 or 2 inhalations twice daily, or 2 inhalations once daily; plus 1 extra inhalation as needed, one more after a few minutes if symptoms persist; no more than 6 inhalations at one time; maximum 8 inhalations a day. No separate SABA is needed. Symbicort Forte is not used for SMART.
• C. Maintenance therapy (SMT): fixed daily dose (maximum 4 inhalations a day) PLUS a separate SABA for relief.
• Missed maintenance dose: take it as soon as possible, then resume the usual schedule. Never double.
• Not approved under age 12 for asthma ^{[S4 Indications and Pediatrics]}.

Must remember for the exam: higher-risk or poorly controlled patients are NOT left on SABA alone; start daily ICS (or PRN bud/form if 12+ with poor adherence). Not controlled on low ICS: age 12+ add LABA in the same inhaler; ages 6 to 11 go to medium ICS first, then add LABA or LTRA; under 6 go to medium ICS then refer.

Blueprint area: 1A Clinical Care.

8. Exacerbations and the yellow zone

• A written action plan has zones: green (well), yellow (losing control, step up now) and red (urgent help). The yellow-zone step-up depends on age and on the controller ^{[S1 p356-357, Table 9]}.
• Do NOT double the ICS dose at loss of control: no proven benefit. In children under 16, do not raise ICS 4-fold or more (a trial of 200 versus 1000 mcg/day in ages 5 to 11 did not reduce exacerbations) ^{[S1 p356]}.

• A 4-fold ICS increase in adults caused more hoarseness and oral thrush; the benefit was modest (severe exacerbations 45% versus 52% in a pragmatic trial) ^{[S1 p357]}.
• Adult prednisone: 30 to 50 mg a day for at least 5 days. Child: 1 mg/kg/day (maximum 50 mg) for at least 3 days ^{[S1 p357]}.
• Do not routinely add oral corticosteroids to an action plan, except for people with recent severe exacerbations who do not respond to the SABA ^{[S1 p357]}.
• If a person needs the step-up plan or a steroid course regularly, find out why control is poor and restart or reassess the controller. Frequent oral steroid courses mean refer to a specialist ^{[S1 p356-357]}.
• After ANY severe exacerbation, reassess all asthma management ^{[S1 p357]}.
• Daily-life example: Sam is 30, takes budesonide-formoterol daily, and catches a cold with wheeze. His yellow-zone plan tells him to use up to 4 puffs twice daily for 7 to 14 days, and to call his clinic if he does not improve.
• Red zone/urgent signs (from the plan): the plan tells the person when to go to hospital or call the clinician ^{[S1 p353 Table 6]}. The exact red-zone wording is set in the individual plan.

Must remember for the exam: never just double the ICS; the evidence-based step-up depends on the controller; adult prednisone 30 to 50 mg for at least 5 days; oral steroid courses regularly needed = refer.

Blueprint area: 1A Clinical Care.

9. Special topics: comorbidities, pregnancy, children, vaccines

9.1 Comorbidities and other drugs

• Poor control may come from comorbid conditions: rhinosinusitis, gastro-esophageal reflux, paradoxical vocal fold motion, anxiety, depression; also obesity ^{[S1 p352, p355]}. Treat them as part of asthma care.
• Beta-blockers (especially non-selective) can worsen asthma or oppose salbutamol ^{[S5 section 9]}. Aspirin and other NSAIDs can trigger asthma in ASA-sensitive people (montelukast is labelled for ASA-sensitive asthma) ^[S8]. The need for allergy testing is one reason to refer ^{[S1 p357-358]}.

9.2 Pregnancy

• WARNING: the CTS guidelines in the library ^{[S1, S2]} do not have a pregnancy section, so a Canadian pregnancy recommendation could not be confirmed.
• International GINA 2026 ^{[U1 p9, p31]}: ask all pregnant women (and those planning pregnancy) about asthma; use ICS-containing treatment during pregnancy because exacerbations raise the risk of pre-term delivery, low birth weight and perinatal death, and these risks are reduced by ICS; do not stop or reduce ICS in pregnancy; ICS and beta2-agonists are not linked to fetal abnormalities; treat exacerbations as in non-pregnant adults to avoid fetal hypoxia; monitor asthma every 4 to 6 weeks.
• Canadian labels are more cautious in wording: salbutamol and fluticasone: use in pregnancy only if the benefit outweighs the risk; inhaled budesonide: world-wide post-marketing experience shows no adverse effect on the fetus or newborn, and a Swedish register study found no link with overall malformations; the safety of formoterol in pregnancy has not been established ^{[S5 7.1.1; S6 7.1.1; S4 Warnings and Precautions]}. Salbutamol during labour only when benefits clearly outweigh risks ^{[S5 7.1.1]}.

9.3 Children

• Ages 1 to 5: diagnosis by observation and treatment trial; pMDI + VHC with mask (1 to 3 years) or mouthpiece (4 to 6 years); medium-dose ICS before referral ^{[S1 p349-350, p354, p356]}.
• Ages 6 to 11: spirometry (if able); ICS first; add LABA or LTRA only after medium-dose ICS; PRN bud/form is not approved and CTS cautions against it ^{[S1 p356; S2 pdf p16]}.
• Teens 12 to 18 are treated like adults for medicine approval but are watched for growth effects like children ^{[S2 pdf p3]}.
• Check height regularly on long-term ICS (section 6.1) ^{[S4 Warnings and Precautions; S6 p14]}.

9.4 Vaccines (Canadian Immunization Guide)

• Influenza: yearly vaccine for everyone 6 months and older. People with chronic lung disease including asthma are on the list of high-risk groups ^{[S15 Recommendations; List 1]}.
• Live attenuated influenza vaccine (LAIV, nasal spray) may be given to children with stable, non-severe asthma. LAIV is contraindicated in people with severe asthma on oral or high-dose inhaled glucocorticosteroids, with active wheezing, or with medically attended wheezing in the 7 days before vaccination; a history of stable asthma or non-active recurrent wheeze is not a contraindication. LAIV is not recommended in pregnancy or for adults with chronic health conditions: use an injectable (IIV) or recombinant (RIV) vaccine instead ^[S15].
• Egg allergy is not a reason to avoid any influenza vaccine, including LAIV ^[S15].
• Pneumococcal conjugate vaccine: adults with risk factors are recommended to be vaccinated. Chronic lung disease, including asthma requiring medical care in the preceding 12 months, is on the risk list ^{[S16 risk factors]}.
• RSV vaccine: cardiac or pulmonary disorders including asthma are on the list of chronic conditions for which RSV vaccination is particularly important in adults ^{[S17 List 2]}.
• GINA also advises people with asthma to keep respiratory vaccines up to date ^[U1].

Must remember for the exam: yearly flu shot for all with asthma; LAIV (nasal) is not for severe asthma on oral or high-dose inhaled steroids or with active wheeze; use an injectable flu vaccine instead.

Blueprint area: 1A Clinical Care.

10. Severe asthma and biologic (injection) medicines

• Severe asthma affects about 5% of people with asthma but causes a large share of costs ^{[S3 abstract]}. Before calling asthma "severe", fix adherence, technique, triggers and comorbidities ^{[S3; S1 p355]}.
• Referral for specialist care is needed for suspected or confirmed severe asthma (section 12) ^{[S1 p357]}.
• CTS 2017 (older statement, ^{[S3 abstract]}): blood or sputum eosinophils, total IgE and FeNO can help find who will respond; tiotropium can be added in people 12 and over who are uncontrolled on ICS/LABA; chronic macrolide may reduce exacerbations in people 18 and over with severe asthma; anti-IgE for age 6 and over with allergy to a perennial allergen and poor control despite high-dose ICS plus a second controller; anti-IL5 for adults 18 and over with severe eosinophilic asthma and repeated exacerbations; bronchial thermoplasty has an uncertain role.
• Current Health Canada labels (add-on maintenance, never for acute relief):

• None of these relieves an acute attack or status asthmaticus ^{[S10 to S14]}. A biologic is added to, not a replacement for, the ICS/LABA.
• Daily-life example: a 14-year-old with severe allergic asthma keeps the daily controller and gets an injection every few weeks at a clinic; it lowers the number of attacks but does not stop one that has already started.

Must remember for the exam: biologics are add-on maintenance injections for severe asthma, started by specialists, never for acute relief; omalizumab = allergic (anti-IgE), mepolizumab/benralizumab = eosinophilic (anti-IL-5 pathway), tezepelumab = severe asthma 12+, dupilumab = type 2 or oral-steroid-dependent. Omalizumab carries an anaphylaxis warning.

Blueprint area: 1A Clinical Care.

11. Counselling and adherence (what to tell the patient)

1. Asthma is a long-term condition; the controller is taken every day, even when well (it prevents attacks). The reliever is only for symptoms ^{[S1 p352-353; S6 p7]}.
2. Show the inhaler technique at every visit and ask the patient to demonstrate it. Make sure a spacer is used with any pMDI (valved holding chamber) ^{[S1 p353-354]}.
3. Rinse the mouth and gargle with water after ICS (and spit); clean dentures. Report white patches or a sore mouth ^{[S6 p12; S4 Warnings and Precautions]}.
4. Know when the inhaler is empty (dose counter or count the doses). Do not use an empty inhaler ^{[S1 p352-353]}.
5. Keep the reliever with you. If you need it more than 2 times a week, or relief wears off within 3 hours, call the clinic ^{[S1 p354; S5 4.1]}.
6. Do not use the SABA before every controller dose "to open the airways" ^{[S1 p354]}.
7. Avoid smoke and vaping. Ask about work exposures ^{[S1 p352]}.
8. Montelukast: watch for mood or sleep change ^[S8].
9. Ask about adherence without blame: cost, side effects, forgetting, fear of steroids. Offer simple fixes (once-daily forms, a daily habit, PRN bud/form for age 12+ with poor adherence) ^{[S1 p355; S2]}.
10. Get a flu shot every year; ask about other vaccines (section 9.4).
11. Keep the written action plan where it can be seen; review it with the doctor once or twice a year (frequency not set in the files read).
12. Pharmacist checks: refill pattern (many reliever refills and few controller refills means poor control), duplicate ICS, drug interactions (beta-blockers), growth in children, and when to refer.

12. When to refer to an asthma specialist (CTS 2021 [S1 p357-358])

• Diagnostic uncertainty.
• Children not controlled on a moderate dose of ICS with correct technique and adherence.
• Suspected or confirmed severe asthma.
• A life-threatening event such as an ICU admission.
• Need for allergy testing to look for environmental allergens.
• Confirmed or suspected work-related asthma.
• Any asthma hospitalization (all ages), 2 or more ED visits (all ages), or 2 or more courses of systemic steroids (children).
• Frequent courses of oral corticosteroid (adults and children).
• An asthma specialist = a specialist in asthma, respirology, paediatrics or allergy/immunology with access to lung function testing and certified asthma/respiratory educators ^{[S1 p358]}.
• Pharmacist reminder: call the clinician the same day for urgent worsening, or direct to emergency care when the action plan red zone applies.

13. Quick quiz (study yourself)

1. How is asthma confirmed in a 10-year-old?
2. What reliever use per week means NOT well controlled?
3. Which four risk factors put a well-controlled patient at higher risk?
4. A 25-year-old on PRN salbutamol uses 3 canisters a year. What is the next step?
5. What is the first add-on for a 30-year-old not controlled on low-dose ICS?
6. Why must LABA not be used alone?
7. What should the patient do after using an ICS inhaler?
8. What boxed warning applies to montelukast?
9. Which flu vaccine type is not for severe asthma on high-dose inhaled steroids?
10. Which biologic is for allergic asthma with a positive skin test to a perennial allergen?

Answers: 1. Spirometry showing reversible obstruction (FEV1/FVC below lower limit of normal and FEV1 rise of 12% or more). 2. More than 2 doses a week (also daytime symptoms more than 2 days a week). 3. Past severe exacerbation, poor control, more than 2 SABA inhalers a year, current smoking. 4. Overuse of SABA = higher risk: start daily ICS + PRN SABA, or PRN bud/form (age 12+). 5. Daily ICS/LABA in the same inhaler (alternatives: LTRA or medium-dose ICS). 6. LABA alone raises the risk of asthma-related death and hospitalization. 7. Rinse the mouth and gargle with water (and spit). 8. Serious neuropsychiatric events (agitation, aggression, depression, sleep disturbance, suicidal thoughts). 9. The nasal live attenuated vaccine (LAIV). 10. Omalizumab (Xolair).

14. Label vs guideline, and Canada vs international (none of these points is tested in the MCQs)

Unconfirmed items

• No Canadian pregnancy recommendation for asthma could be confirmed (CTS 2021 has no pregnancy section; the CTS 2012 guideline was not in the library). The pregnancy points come from GINA 2026 and the labels.
• The Health Canada labels for Pulmicort, Qvar, Advair/Zenhale (ICS/LABA other than Symbicort), terbutaline (Bricanyl), Arnuity and Asmanex were not found or not opened. Their doses come only from the CTS dose table. Do not use them for label facts.
• The Symbicort, Flovent, Spiriva, Singulair, Alvesco and Tezspire labels in the library are older than 2023; newer versions may change ages, doses or warnings.
• Figure 3 (the treatment approach picture) and Figure 1 (the preschool diagnosis flowchart) were pictures and could not be read as text; their content was taken from the text, tables and the focused update.
• Exact red-zone wording of the action plan, asthma review frequency, and emergency (ED) treatment doses were not in the files read and are not given.
• The CTS dose table cell layout for preschool and 6 to 11 years was read from extracted text; the age groups for ciclesonide and budesonide in preschoolers are marked "n/a" in the table.
• The vaccine facts for pneumococcal and RSV are only the risk-list statements; the number of doses and the product choice were not reviewed.
• Doses are for exam study only, not for real patients. Not affiliated with or endorsed by PEBC.

Study aid, not medical advice. Check official sources before any patient decision.

MapleRxPrep

Found an error? Email maplerxprep@proton.me with the file name, version and page.