Ebook Pediatric Asthma A Clinical Support Chart A Clinical Support Chart 1St Edition American Academy of Pediatrics Online PDF All Chapter
Ebook Pediatric Asthma A Clinical Support Chart A Clinical Support Chart 1St Edition American Academy of Pediatrics Online PDF All Chapter
Ebook Pediatric Asthma A Clinical Support Chart A Clinical Support Chart 1St Edition American Academy of Pediatrics Online PDF All Chapter
https://ebookmeta.com/product/newborn-and-infant-nutrition-a-
clinical-decision-support-chart-american-academy-of-pediatrics/
https://ebookmeta.com/product/pediatric-mental-health-a-
compendium-of-aap-clinical-practice-guidelines-and-policies-1st-
edition-american-academy-of-pediatrics-aap/
https://ebookmeta.com/product/pediatric-collections-lgbtq-
support-and-care-part-3-caring-for-transgender-children-1st-
edition-american-academy-of-pediatrics-aap/
https://ebookmeta.com/product/pediatric-telehealth-best-
practices-american-academy-of-pediatrics/
Ethics Rounds a Casebook in Pediatric Bioethics 1st
Edition American Academy Of Pediatrics (Aap)
https://ebookmeta.com/product/ethics-rounds-a-casebook-in-
pediatric-bioethics-1st-edition-american-academy-of-pediatrics-
aap/
https://ebookmeta.com/product/neonatal-care-a-compendium-of-aap-
clinical-practice-guidelines-and-policies-2nd-edition-american-
academy-of-pediatrics-aap/
https://ebookmeta.com/product/pediatric-advanced-life-support-
provider-handbook-1st-edition-american-heart-association/
https://ebookmeta.com/product/coding-for-
pediatrics-2022-a-manual-for-pediatric-documentation-and-payment-
american-academy-of-pediatrics-committee-on-coding-and-
nomenclature/
https://ebookmeta.com/product/pediatric-collections-sports-
medicine-playbook-1st-edition-american-academy-of-pediatrics-aap-
editor/
Pediatric
ASTHMA A CLINICAL SUPPORT CHART
The American Academy of Pediatrics is committed to principles of equity, diversity, and inclusion in its publishing program. Editorial boards, author
selections, and author transitions (publication succession plans) are designed to include diverse voices that reflect society as a whole. Editor and author teams
are encouraged to actively seek out diverse authors and reviewers at all stages of the editorial process. Publishing staff are committed to promoting equity,
diversity, and inclusion in all aspects of publication writing, review, and production.
Thank you to the AAP Section on Pediatric Pulmonology and Sleep Medicine for their expert review.
American Academy of Pediatrics Publishing Staff
Mary Lou White, Chief Product and Services Officer/SVP, Membership, Marketing, and Publishing
Mark Grimes, Vice President, Publishing
Heather Babiar, MS, Senior Editor, Professional/Clinical Publishing
Theresa Wiener, Production Manager, Clinical and Professional Publications
Amanda Helmholz, Medical Copy Editor
Mary Louise Carr, MBA, Marketing Manager, Clinical Publications
Published by the American Academy of Pediatrics
345 Park Blvd
Itasca, IL 60143
Telephone: 630/626-6000
Facsimile: 847/434-8000
www.aap.org
The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being
of all infants, children, adolescents, and young adults.
While every effort has been made to ensure the accuracy of this publication, the American Academy of Pediatrics does not guarantee that it is accurate, complete, or without error.
Every effort has been made to ensure that the drug selection and dosages set forth in this publication are in accordance with the current recommendations and practice at the time of publication.
It is the responsibility of the health care professional to check the package insert of each drug for any change in indications or dosage and for added warnings and precautions. Every effort is made to keep
Pediatric Asthma: A Clinical Support Chart consistent with the most recent advice and information available from the American Academy of Pediatrics.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics.
Any websites, brand names, products, or manufacturers are mentioned for informational and identification purposes only and do not imply an endorsement by the American Academy of Pediatrics (AAP).
The AAP is not responsible for the content of external resources. Information was current at the time of publication.
The publishers have made every effort to trace the copyright holders for borrowed materials. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements
at the first opportunity.
This publication has been developed by the American Academy of Pediatrics. The contributors are expert authorities in the field of pediatrics. No commercial involvement of any kind has been solicited or
accepted in the development of the content of this publication.
Please visit www.aap.org/errata for an up-to-date list of any applicable errata for this publication.
Standard purchase price includes a license for one user. Licensing for additional users may be purchased.
Special discounts are available for bulk purchases of this publication. Email Special Sales at [email protected] for more information.
© 2022 American Academy of Pediatrics
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—
without prior permission from the publisher (locate title at https://publications.aap.org/aapbooks and click on © Get Permissions; you may also fax the permissions editor at 847/434-8780
or email [email protected]).
Printed in the United States of America
9-477/0422 1 2 3 4 5 6 7 8 9 10
MA1061
ISBN: 978-1-61002-614-7
eBook: 978-1-61002-615-4
Cover and publication design by LSD DESIGN LLC
Asthma affects 7.1 million children and adolescents and leads to more hospitalizations than any other medical problem.
Asthma is a chronic inflammatory condition of the airways that is characterized by 3 features: (1) airway obstruction that
is at least partially reversible by bronchodilator treatment, (2) airway hyperreactivity or hyperresponsiveness to a variety of
external stimuli, and (3) chronic inflammation of the airway. In most children with asthma, the onset begins before 5 years
of age. The following diagram depicts the general approach to the evaluation of asthma in children, according to the Global
Initiative for Asthma (GINA):
Diagnosis of Asthma: Basic GINA Approach to a Child With Respiratory Symptoms Consistent With Asthma
NO
YES
Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
Clinical urgency, and other YES Alternative diagnosis confirmed?
diagnoses unlikely
Bronchodilator reversibility may be lost during severe exacerbations or viral infections and in long-standing asthma. If bronchodilator reversibility is not found at initial presentation,
the next step depends on the availability of tests and the clinical urgency of need for treatment. Note that spirometry is of questionable validity in children under the age of 6, unless
the technician performing it is particularly skilled in working with young children. GINA indicates Global Initiative for Asthma; ICS, inhaled corticosteroid; and SABA, short-acting
β2 -adrenergic receptor agonist.
Adapted with permission from Patel SJ, Teach SJ. Asthma. Pediatr Rev. 2019;40(11):549–467.
Tab 2
Diagnosis
Diagnosing Asthma
Signs and Symptoms Triggers Additional Notes
Typical signs and symptoms Specific triggers can include Asthma is both underdiagnosed and overdiagnosed.
include Colds and viral illnesses Asthma is the most common chronic disease of children.
Polyphonic wheezes, Exercise Asthma causes more hospitalizations than any other medical problem
predominantly on expiration in children.
Exposure to cold air
Recurrent and/or chronic Intermittent asthma is most commonly a viral respiratory tract
Cough after laughing or crying
cough infection–induced phenotype in preschool-aged children but is found
Allergens, including pets, mold,
Chest tightness at all ages.
dust mites, and additional
Shortness of breath environmental exposures Persistent asthma phenotype is characterized by the absence of
Pollution (indoor or outdoor) extended symptom-free periods.
Passive exposure to smoke Seasonal allergic phenotype is characterized by allergen-specific
immunoglobulin E limited to seasonal inhalant allergens.
Strong odors
Asthma severity is indicated by
Additional Features • Interference with activity from exercise limitation
Additional allergic comorbidities (eg, allergies to dust mites, pollen, trees, • Interference with sleep from repeated nocturnal awakening
grasses, mold, cockroaches, dogs, cats) occur in most children with • Frequency of requirements for intervention measures, inhaled
asthma, including rhinitis and atopic dermatitis. bronchodilators, and oral corticosteroids
Any wheezing reported by patients and parents should be confirmed by • Urgent care visits or hospitalizations
a medical provider. Although some children will have symptoms of asthma that remit,
Additional physical examination findings include an increased chest many will have symptoms that continue well into adulthood.
anterior-posterior diameter, an expiratory abdominal push, and a Children who have symptoms of asthma that are not limited to a
prolonged expiratory phase on respiration. viral respiratory tract infection have a greater likelihood that asthma
Diagnostic Considerations symptoms will persist into adulthood.
Asthma can be difficult to diagnose in children, particularly in those Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric
<5 years of age. For children <5 years of age, a careful history of Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American
Academy of Pediatrics; 2018:201; and AAP Section on Pediatric Pulmonology.
impairment and risk is used to assess severity and control, and lung
Pediatric Pulmonology. 2nd ed. American Academy of Pediatrics; 2023.
function information is typically unavailable.
Aspiration as a cause of wheezing in children with neurological impairment
should be ruled out before a diagnosis of asthma is considered.
Many infants and toddlers wheeze during viral respiratory illnesses but
do not go on to have asthma when they are older.
Misdiagnosis of asthma as pneumonia or bronchitis can lead to
ineffective and unnecessary use of antibiotics.
Overdiagnosis of asthma can result in unnecessary use of inhaled
medications and oral steroids, as well as familial anxiety.
Differential Diagnosis
Diagnosis Age at Diagnosis Runny Nose Sputum Other Diagnostic Findings
Asthma Variable; typically >2 y Not a primary feature Rare Wheeze, chest tightness, shortness of breath
Cystic fibrosis <1 y Not a primary feature Frequent Clubbing, failure to thrive, pancreatic insufficiency
Gastroesophageal reflux disease <1 y Not a primary feature Frequent Emesis, back-arching, cough
Aspiration and/or dysphagia <2 y Not a primary feature Rare Coughing, faster breathing with eating and drinking
Primary ciliary dyskinesia <1 y Uniformly present Rare Neonatal respiratory distress common, recurrent
sinopulmonary infections
Tracheal and/or bronchial malacia <1 y Not a primary feature Absent Monophonic expiratory wheeze
Habit cough >8 y Unrelated Absent Absent when asleep
Postnasal drip <1 y Very common Rare Absence of wheezes
Foreign body >4 y Unrelated Occasional Unilateral physical examination findings
Vocal cord dysfunction >8 y Unrelated Rare Inspiratory stridor when symptomatic
Reprinted with permission from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds.
American Academy of Pediatrics; 2018:203. Adapted with permission from Rosenthal M. Differential diagnosis of asthma. Paediatr Respir Rev. 2002;3(2):148–153.
3 Tab 2. Diagnosis
Tab 3
Office Pulmonary Function Testing
Spirometry is used most commonly for the diagnosis and ongoing management of pediatric asthma, and it can typically
be performed by trained personnel in developmentally appropriate children by 5 years of age. The goal of spirometry in a
general pediatrician’s office should be to identify and manage reversible airway obstruction, which defines asthma. Spirome-
try permits an objective measurement of the degree of airway obstruction (impairment and risk), which is important because
clinically significant obstruction can be present, even when the chest appears to be clear at physical examination. In primary
care, clinical symptoms alone will lead to underestimation of asthma severity about 30% of the time. Peak flow testing alone
is highly variable, is not very sensitive as a measure of obstruction, and is no longer recommended for diagnosis. However,
it may have a role in monitoring. See Tab 23, Get Valid Spirometry Results Every Time, for the appropriate performance
of spirometry maneuvers.
Perform
maneuver
Yes Acceptability
Minimum
Age
No FET
Minimum
Discard FET? Does the FET value 2−3 s,
3−6 yrs
maneuver meet the minimum if possible
duration?
7−9 yrs ≥3 s
Yes 10+ yrs ≥6 s
maneuver
Yes FVC & FEV1
Variances
Are the variances
No Reproducible between the 2 Within 150 mL
test? best maneuvers or
Perform another
within range? Within 5%
maneuver
Yes
Save and
interpret
FET indicates forced expiratory time; FEV1, forced expiratory volume in 1 second; FV, flow volume; FVC, forced vital
capacity; and VT, volume-time.
From AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine.
Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; 2018:24. Reproduced with permission from Spirometry 360.
Spirometry test algorithm. Accessed January 7, 2022. https://www.spirometry360.org/spiro360resources.
Once a diagnosis of asthma is established, the severity of lung Indications for Spirometry
function impairment is largely based on percentage of predicted Spirometry has several indications in primary care pediatrics.
forced expiratory volume in 1 second, as follows: These include
Mild persistent (≥80%) Diagnosis and severity assessment of asthma in patients
≥5 years of age
Moderate persistent (60%–79%) Follow-up of asthma control (especially when changing
medications)
Severe persistent (<60%)
Evaluation of chronic cough
Evaluation of shortness of breath and other chronic
Spirometry and Asthma, Patients 5 Years and Older respiratory concerns
Spirometric Measurements Evaluation of baseline lung function in a patient with EIB
FEV1 FEV1: FVC (Absolute Ratios)a by Age Goal of Spirometry
(Percentage
Asthma Predicted), The goal is for the patient to have normal or near-normal lung
Severity % 5–11 y 12–19 y 20–39 y function during wellness. First and most importantly, assess
whether the predicted-FEV1 percentage and/or the FEV1:FVC
Normal ≥0.80 ≥0.85 ≥0.85 ≥0.80 ratio represents obstruction for the patient.
Mild ≥0.80 0.80–0.84 ≥0.85 ≥0.80 Additional Notes
persistent
Pulmonary function testing can be used to support a diagnosis of
Moderate 0.60–0.79 0.75 ≤0.80 0.80 ≤0.85 0.75 ≤0.80 asthma; however, most children with asthma will have normal
persistent lung function.
Severe <0.60 <0.75 <0.80 <0.75 Spirometry is used to measure how much air the patient breathes
persistent in and out and how fast the air is exhaled.
FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity. Spirometric findings of obstructive lung disease include the
a
Use actual ratios, not percentage of predicted values.
ratio of FEV1:FVC in the <5th percentile when compared to
predicted values.
Adapted from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology,
Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; More typically, an FEV1:FVC ratio of <80% is used to denote an
2018:253. obstructive process consistent with asthma in children.
A change in absolute value of predicted-FEV1 percentage of
≥12% within 15 minutes after bronchodilator administration
is considered a positive response and supports the diagnosis
of asthma; a predicted-FEV1 percentage change of <8% is
considered a negative response.
Consistent predicted-FEV1 values <60% typically warrant
subspecialty consultation.
A concomitant decrease in FEV1 and FVC is most commonly
caused by poor patient effort but may rarely reflect airflow
obstruction that can be better assessed with body
plethysmography.
A normal ratio of FEV1 to vital capacity, coupled with a
predicted–vital capacity percentage <80%, could be consistent
with a restrictive pulmonary defect; subspecialty consultation
(along with additional lung function testing, including body
plethysmography) should be sought.
Spirometric values should be assessed over time as a marker
of improvement and adherence to therapy.
EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second;
FVC, forced vital capacity.
Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine.
Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds.
American Academy of Pediatrics; 2018:202–204,253.
Tab 4
Exacerbation Assessment
Factors That Can Exacerbate Asthma Not All Wheezing Indicates Asthma Exacerbation
Factor Description
It is important to note that not all wheezing represents an asthma
Viral respiratory tract infections Viral respiratory tract infections are exacerbation. The following conditions may need to be ruled out, when
by far the most common trigger of addressing an apparent exacerbation:
asthma exacerbations.
Pneumonia
Environmental allergens in Outdoor allergens
sensitized individuals (eg, seasonal allergens such Bronchiolitis in younger children
as tree pollen, grass pollen, Bacterial tracheitis
weed pollen, and molds)
Anaphylaxis
Indoor allergens
(eg, animal dander, dust mites, Foreign-body aspiration
cockroaches, indoor molds, mice) Esophageal foreign body
Irritants Environmental tobacco smoke Bronchitis
Air pollutants Vocal cord dysfunction
(eg, ozone, sulfur dioxide)
Chest radiography is not routinely necessary at the onset of asthma
Particulate matter (eg, wood- exacerbation. However, consider obtaining a chest radiograph to rule
or coal-burning smoke) out pneumonia in the presence of focal lung examination findings,
Mycotoxins fevers, continued tachypnea, hypoxemia, or chest pain after initial
asthma therapy is administered.
Endotoxins
Dust
Strong odors or fumes
(eg, perfumes, hair sprays,
cleaning agents, incense sticks,
scented candles)
Occupational exposure Farm and barn exposure
Formaldehyde
Cedar
Paint fumes
Others
Cold, dry air
Exercise
Emotions Crying
Laughter
Emotions that can cause
hyperventilation
Comorbid conditions Rhinitis
Sinusitis
Gastroesophageal reflux
Nasal polyps
Adapted from Dinakar C. Asthma. Pediatric Care Online. Accessed January 10, 2022.
https://publications.aap.org/pediatriccare/book/348/chapter/5776728/
Asthma#aap-tpc2-2016_ch218.box1.
Tab 5
Respiratory Scoring Tools
Asthma severity scores can be used to help establish whether an asthma exacerbation is mild, moderate, or severe (see the
Table below). The scores are generally based on a variety of signs and symptoms, including respiratory rate; work of breathing;
lung examination (ie, air entry, wheezing); degree of dyspnea; oxygen saturation; inspiratory-to-expiratory time ratio; respira-
tory rate; and peak expiratory flow rate. Although several validated asthma severity scores have been developed, no single
score has been adopted universally. This tab includes some pediatric scoring systems that may be used to assess the severity
of asthma.
Respiratory Rate, Accessory Muscle Use, Decreased Breath Sounds (RAD) Score
The Respiratory rate, Accessory muscle use, Decreased breath sounds (RAD) score is an easy-to-use pediatric asthma
assessment tool for acute exacerbations, based on these 3 parameters. The RAD score may facilitate efficient treatment and
triage of pediatric patients with an acute asthma exacerbation.
RAD Score to Determine Acute Asthma Severity in Patients 5 to 17 Years of Age
Score Component Operational Definition Scoringa
Respiratory rate Respiratory rate, at rest, on room airb ≤24 = 0
>24 = 1
Accessory muscle use Any visible use of accessory muscles Present = 1
Not present = 0
Decreased breath sounds Any decreased breath sounds on auscultation Normal = 0
Any decrease = 1
RAD score Sum of 3 components 0–3
a
Summary score value range: 0–3.
b
Based on 97.5 percentiles for children ages 5–17 years of age.
Reproduced with permission from Arnold DH, Gebretsadik T, Abramo TJ, Moons KG, Sheller JR, Hartert TV. The RAD score: a simple acute asthma severity score compares favorably to
more complex scores. Ann Allergy Asthma Immunol. 2011;107(1):22–28.
Tab 6
Classifying Severity by Age
Classifying Asthma Severity and Initiating Treatment in Youths 12 Years of Age to Adults
Assessing Severity and Initiating Treatment for Patients Who Are Not Currently Taking Long-term Control Medications
Classification of Asthma Severity ≥12 Years of Age
Intermittent Persistent
Components of Severity Mild Moderate Severe
Impairment Symptoms ≤2 days/week >2 days/week but not daily Daily Throughout the day
Normal FEV1/FVC: Nighttime ≤2×/month 3–4×/month >1×/week Often 7×/week
awakenings but not nightly
8–19 yr 85%
20–39 yr 80% Short-acting β2 -agonist ≤2 days/week >2 days/week but not daily, Daily Several times
use for symptom control and not more than 1× on per day
(not prevention of EIB) any day
Interference with None Minor Some Extremely
normal activity limitation limitation limited
Lung Function Normal FEV1 between
exacerbations
FEV1 >80% FEV1 >80% FEV1 >60% but FEV1 <60%
predicted predicted <80% predicted predicted
FEV1/FVC FEV1/FVC FEV1/FVC FEV1/FVC
normal normal reduced 5% reduced 5%
Risk Exacerbations requiring oral 0–1/year ≥2/year (see note)
systemic corticosteroids (see note)
Consider severity and Interval since last exacerbation.
Frequency and severity may fluctuate over time for patients in any severity category.
Relative annual risk of exacerbations may be related to FEV1.
Recommended NIH/NHLBI step for initiating Step 1 Step 2 Step 3 Step 4 or 5
treatment (see Tab 8)
and consider short course of
oral systemic corticosteroids
In 2–6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.
EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICU, intensive care unit; NHLBI, National Heart, Lung, and Blood
Institute; NIH, National Institutes of Health. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Level of
severity is determined by assessment of both impairment and risk. Assess impairment domain by patient’s/caregiver’s recall of previous 2–4 weeks and spirometry. Assign severity
to the most severe category in which any feature occurs. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity.
In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For
treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent
asthma, even in the absence of impairment levels consistent with persistent asthma.
From Dinakar C. Asthma. Pediatric Care Online. Accessed January 10, 2022. https://publications.aap.org/pediatriccare/book/348/chapter/5776728/Asthma. Adapted from
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma.
U.S. Department of Health and Human Services; 2007.
Tab 7
Intervention Overview
Medication Dosages and Decisions for the Usual Treatment of Acute Symptoms of Asthma
Medication Dosage When to Use
Albuterol or levalbuterol MDI 2–4 inhalations, up to 6 inhalations, can be used As needed for cough, wheezing, and labored
(at a time). breathing. Scheduled use has no advantage
over as-needed use and may be deleterious
for some patients. Repeated requirements for
bronchodilator use during exacerbations generally
warrant a short course of an oral corticosteroid.
Prednisone, prednisolone, methylprednisolone, and Dosage as prednisone or prednisolone. When bronchodilator sub-responsiveness is
dexamethasone as tablets. Liquid formulations and 1–2 mg/kg/d twice daily, maximum dose identified by incomplete resolution of symptoms
oral disintegrating tablets of prednisolone for young of 40 mg twice daily. and signs from repeated use of the bronchodilator.
children. (Parenteral forms indicated only when Reevaluate if not improving within 5 days or
concerned about oral retention.) asymptomatic within 10 days. Do not taper.
Ipratropium (Atrovent HFA) MDI; ipratropium 2–4 inhalations added to albuterol when albuterol Indicated for severe acute asthma exacerbation
solution added to albuterol solution for use in does not provide sufficient bronchodilatation or in the ED when response to a β2 -adrenergic
nebulizer 0.5 mg with 2.5–5.0 mg albuterol by nebulizer receptor agonist is inadequate for relief of
respiratory distress
Tab 8
NIH/NHLBI Stepwise Approaches to Management
Updated based on the 2020 NIH/NHLBI guidelines. Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control
and may require a step up in treatment. If clear benefit is not observed within 4–6 weeks and the medication technique and adherence are satisfactory, the clinician should consider adjusting
therapy or alternative diagnoses.
Abbreviations: EIB, exercise-induced bronchoconstriction; FDA, Food and Drug Administration; ICS, inhaled corticosteroid; LABA, long-acting beta 2 -agonist; PRN, as needed;
RTI, respiratory tract infection; SABA, inhaled short-acting beta 2 -agonist.
Updated based on the 2020 guidelines.
* Cromolyn and montelukast were not considered for this update and/or have limited availability for use in the United States. The FDA issued a Boxed Warning for montelukast in March 2020.
Assess Control
First check adherence, inhaler technique, environmental factors, and comorbid conditions.
Step up if needed; reassess in 2–6 weeks.
Step down if possible (if asthma is well controlled for at least 3 consecutive months).
Consult with asthma specialist if Step 4 or higher is required. Consider consultation at Step 3.
Control assessment is a key element of asthma care. This involves both impairment and risk. Use of objective measures,
self-reported control, and health care utilization are complementary and should be employed on an ongoing basis, depending
on the individual’s clinical situation.
Updated based on the 2020 NIH/NHLBI guidelines. In Steps 3 and 4, the preferred option includes the use of ICS-formoterol 1 to 2 puffs as needed up to a maximum total daily maintenance
and rescue dose of 8 puffs (36 mcg). Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and may require
a step up in treatment. The terms ICS-LABA and ICS-formoterol indicate combination therapy with both an ICS and a LABA, usually and preferably in a single inhaler. Where formoterol is
specified in the steps, it is because the evidence is based on studies specific to formoterol. In individuals ages 5–11 years with persistent allergic asthma in which there is uncertainty in
choosing, monitoring, or adjusting anti-inflammatory therapies based on history, clinical findings, and spirometry, FeNO measurement is conditionally recommended as part of an ongoing
asthma monitoring and management strategy that includes frequent assessment.
Abbreviations: EIB, exercise-induced bronchoconstriction; FDA, Food and Drug Administration; FeNO, fractional exhaled nitric oxide; ICS, inhaled corticosteroid; LABA, long-acting
beta 2 -agonist; LTRA, leukotriene receptor antagonist; PRN, as needed; SABA, inhaled short-acting beta 2 -agonist.
Updated based on the 2020 guidelines.
* Cromolyn, Nedocromil, LTRAs including montelukast, and Theophylline were not considered for this update and/or have limited availability for use in the United States, and/or have an
increased risk of adverse consequences and need for monitoring that make their use less desirable. The FDA issued a Boxed Warning for montelukast in March 2020.
** Omalizumab is the only asthma biologic currently FDA-approved for this age range.
Tab 8
NIH/NHLBI Stepwise Approaches to Management
Updated based on the 2020 NIH/NHLBI guidelines. In Steps 3 and 4, the preferred option includes the use of ICS-formoterol 1 to 2 puffs as needed up to a maximum total daily maintenance and
rescue dose of 12 puffs (54 mcg). Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and may require a step
up in treatment. The terms ICS-LABA and ICS-formoterol indicate combination therapy with both an ICS and a LABA, usually and preferably in a single inhaler. Where formoterol is specified
in the steps, it is because the evidence is based on studies specific to formoterol. In individuals ages 12 years and older with persistent allergic asthma in which there is uncertainty in choosing,
monitoring, or adjusting anti-inflammatory therapies based on history, clinical findings, and spirometry, FeNO measurement is conditionally recommended as part of an ongoing asthma monitoring
and management strategy that includes frequent assessment. Bronchial thermoplasty was evaluated in Step 6. The outcome was a conditional recommendation against the therapy.
Abbreviations: AHRQ, Agency for Healthcare Research and Quality; EIB, exercise-induced bronchoconstriction; FDA, Food and Drug Administration; FeNO, fractional exhaled nitric oxide;
ICS, inhaled corticosteroid; LABA, long-acting beta2 -agonist; LAMA, long-acting muscarinic antagonist; LTRA, leukotriene receptor antagonist; PRN, as needed; SABA, inhaled short-acting
beta2 -agonist.
Updated based on the 2020 guidelines.
* Cromolyn and Nedocromil, LTRAs including Zileuton and montelukast, and Theophylline were not considered for this update and/or have limited availability for use in the United States and/or have
an increased risk of adverse consequences and need for more monitoring that make their use less desirable. The FDA issued a Boxed Warning for montelukast in March 2020.
** The AHRQ systematic reviews that informed this report did not include studies that examined the role of asthma biologics (e.g., anti-IgE, anti-IL5, anti-IL5R, anti-IL4/IL13). Thus, this report does
not contain specific recommendations for the use of biologics in asthma in Steps 5 and 6.
Data on the use of LAMA therapy in individuals with severe persistent asthma (Step 6) were not included in the AHRQ systematic review and thus no recommendation is made.
NIH/NHLBI stepwise approaches reproduced from U.S. Department of Health and Human Services, National Institutes of Health (NIH), and National Heart, Lung, and Blood Institute (NHLBI).
2020 Focused Updates to the Asthma Management Guidelines: A Report From the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. 2020.
Accessed February 2, 2022. https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines.
Fractional exhaled nitric oxide (FeNO) testing has a supportive role in evaluation when the diagnosis of asthma is uncertain
in patients 5 years of age and older, according to current data. The Expert Panel makes the following recommendations for
use of FeNO testing:
Recommendation 1
In individuals 5 years of age and older for whom the diagnosis of asthma is uncertain by using history, clinical findings, clinical course, and spirometry,
including bronchodilator responsiveness testing, or in whom spirometry cannot be performed, the Expert Panel conditionally recommends the addition
of FeNO measurement as an adjunct to the evaluation process. [Conditional recommendation, moderate certainty of evidence]
Clinician’s Summary: The role of an increased level of FeNO in the diagnosis of asthma is still evolving, and no definitive test exists for diagnosing
asthma. FeNO measurement may support a diagnosis of asthma in individuals for whom the diagnosis is uncertain even after a complete history, physical
examination, and spirometry testing including bronchodilator responsiveness. Recognition of allergen sensitivity is extremely important for interpreting FeNO
levels. Allergic rhinitis and atopy, which can be present in individuals with and those without asthma, are associated with increased FeNO levels, and taking
these factors into consideration is critical for accurately interpreting FeNO test results.
Recommendation 2
In individuals 5 years of age and older with persistent allergic asthma, for whom there is uncertainty in choosing, monitoring, or adjusting anti-inflammatory
therapies based on history, clinical findings, and spirometry, the Expert Panel conditionally recommends the addition of FeNO measurement as part of an
ongoing asthma monitoring and management strategy that includes frequent assessments. [Conditional recommendation, low certainty of evidence]
Clinician’s Summary: This recommendation is specific to using FeNO levels when selecting therapy for individuals with asthma and when monitoring the
response to and adjusting the dosage of anti-inflammatory therapies. This recommendation does not apply to individuals taking biologic agents, with the
exception of omalizumab, because the systematic review literature searches conducted until October 2018 did not include data on biologic agents other than
omalizumab. Clinicians must interpret FeNO levels in conjunction with other clinical data because these levels are affected by comorbid conditions, including
allergic rhinitis and atopy. The weight of the evidence suggests that when used as part of an asthma management strategy, FeNO monitoring is effective in
preventing exacerbations only when used frequently (such as every 2–3 months), but even frequent monitoring does not improve asthma control or quality
of life in individuals with asthma.
How to Use FeNO
While FeNO testing may be helpful in determining whether an individual has asthma, it cannot be used to diagnose asthma. FeNO measurements should
be performed by appropriately trained personnel who have extensive experience in interpreting the result or who consult experienced clinicians who can
interpret the findings accurately.
FeNO levels <25 ppb (or <20 ppb in children The Expert Panel offers the following suggestions Clinicians should inform individuals with
5–12 years of age) are inconsistent with T2 on how to use FeNO testing to monitor asthma: asthma who have conditions or behaviors
inflammation and suggest a diagnosis other Individuals for whom FeNO testing may be (such as smoking) that could affect the
than asthma (or that the individual has asthma useful to monitor asthma include: interpretation of the FeNO test results that
but their T2 inflammation has been managed these issues could limit the accuracy of
with corticosteroids or they have non-T2 • Individuals 5 years of age and older with diagnostic attempts.
inflammation or noneosinophilic asthma). uncontrolled persistent asthma who are
currently taking an ICS or an ICS with a FeNO test results cannot be used in isolation.
FeNO levels >50 ppb (or >35 ppb in children 5– long-acting beta2-agonist, montelukast, Their interpretation must take into account
12 years of age) are consistent with increased T2 other clinical factors and traditional measures.
or omalizumab.
inflammation and support a diagnosis of asthma. The evidence favors the use of FeNO mea-
Individuals who have T2 inflammation are more • Individuals whose symptoms indicate they
surement as an adjunct to other diagnostic
likely to respond to corticosteroid treatment. might require additional anti-inflammatory
methods (including a structured history,
therapy.
FeNO levels of 25–50 ppb (or 20–35 ppb in clinical findings, and pulmonary function
children 5–12 years of age) provide little infor- • Individuals with atopy—especially children. testing) when the results from these other
mation on the diagnosis of asthma and should • Individuals with asthma being treated by measures are not conclusive.
be interpreted with caution and attention to the providers who agree that frequent (every
clinical context. 2–3 months) assessments of asthma control
Inhaled corticosteroid treatment should not be over the course of a year are warranted.
withheld solely based on low FeNO levels.
Tab 10
GINA Stepped Approaches to Treatment
The Global Initiative for Asthma (GINA) report is an approach to the management of asthma, rather than a guideline.
The GINA strategy involves the use of control-based asthma management, which is a continual cycle of assessing,
adjusting treatment, and reviewing the response. There are 4 steps in children younger than 6 years and 5 steps in
children 6 years and older.
Tab 11
Maintenance and Control
Tab 12
SABAs
Levalbuterol
MDI 45 μg per puff, 200 puffs 2 puffs with VHC and mask every 2 puffs as needed every 4–6 h 2 puffs as needed every 4–6 h
per canister 4–6 h as needed for symptoms and for symptoms and 5 min before for symptoms and 5 min before
5 min before exercise exercise exercise
Nebulizer 0.31 mg/3 mL saline 0.31–1.25 mg in 3 mL saline every 0.31–0.63 mg every 8 h as needed 0.63–1.25 mg every 8 h as needed
0.63 mg/3 mL saline 4–8 h as needed
1.25 mg/0.5 mL saline
1.25 mg/3 mL saline
MDI, metered-dose inhaler; SABA, short-acting β2 -adrenergic receptor agonist; VHC, valved holding chamber.
From AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; 2018:261.
Tab 13
Inhaled Corticosteroids
Tab 14
LABAs and LTRAs
LABAs
Drug Available Dosages Formulation Additional Notes
Fluticasone 100/50 mcg DPI LABAs are controller medications that are used to prevent symptoms of
or salmeterol 250/50 mcg asthma from becoming severe.
500/50 mcg These agents work by stimulating β2 -adrenergic receptor agonists in the
lungs to open the airways.
Fluticasone 45/21 mcg MDI
LABAs are not a first-line medication for treatment of asthma and are not
or salmeterol 115/21 mcg used for quick relief of asthma symptoms. LABAs are ineffective for acute
230/21 mcg symptoms of asthma.
Budesonide 80/4.5 mcg MDI The use of LABAs is never indicated as monotherapy; LABAs should always
or formoterol be used in combination with ICS therapy.
160/4.5 mcg
Two agents, salmeterol and formoterol, are approved by the FDA for use in
Mometasone/ 100/5 mcg MDI children ≥12 years of age.
formoterol 200/5 mcg Children <12 years of age may be prescribed LABAs by their provider on
the basis of recommendations by the National Asthma Education and
DPI, dry-powder inhaler; LABA, long-acting β2 -adrenergic receptor agonist;
MDI, metered-dose inhaler.
Prevention Program.
From AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, LABAs should be used adjunctively for maintenance control of asthma.
Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; LABAs are indicated for persistent asthma as a step-up therapy when
2018:267. patients are unable to control symptoms with ICSs alone.
LABAs are indicated for use in combination with an ICS (ie, fluticasone,
budesonide, mometasone) for long-term control and prevention of
LABA Use symptoms in patients with moderate to severe persistent asthma.
LABAs, such as salmeterol and formoterol, are not intended as treatment LABAs are not used as monotherapy because they have been shown to
of acute exacerbations or as monotherapy for persistent asthma. These increase the risk of asthma-related deaths and they carry an FDA black
medications act by relaxing bronchial smooth muscle, improving symptoms, box warning.
and reducing the need for quick-relief medication. Formoterol has a quick onset LABAs are indicated in step 3 care and higher in children ≥5 years old
of action, like that of SABA, whereas salmeterol has a longer onset of action. with poorly controlled asthma who are already taking a low to medium
Fixed-dose combination therapy for ICS-LABA (ie, fluticasone-salmeterol, dose of ICSs.
budesonide-formoterol, mometasone-formoterol) is available and is recommended
over using separate inhalers. Their major indication is as an add-on agent when The dose should not exceed 100 mg/d for salmeterol or 24 mg/d
asthma is uncontrolled by ICS therapy alone. In those children, the ICS-LABA for formoterol.
combination therapy has been shown to be synergistic and superior to increasing LABAs can be prescribed in several preparations, including an MDI and a DPI.
ICS dose, in both effectiveness and minimization of steroid-induced adverse The most commonly used preparation for young children is an MDI. For an
effects. Notably, the FDA requires all LABA-containing medications to carry a MDI, be sure to instruct the patient and caregiver on the proper use and
black box warning regarding potential for worsening asthma while on therapy. maintenance of a holding chamber, also known as a spacer.
The FDA also specifies that LABAs should be discontinued when asthma control DPIs have the advantage of not requiring a holding chamber; however, the
is achieved, and asthma should be maintained with controllers such as ICSs. child must be able to develop sufficient inspiratory flow to activate a DPI
to deliver sufficient medication. For a DPI, be sure to instruct the patient
to rinse and spit with water each time after inhaling the dose.
Although studies have shown that young children can develop sufficient
inspiratory flow to activate DPIs to deliver sufficient medication, there is
concern whether they will consistently use proper technique daily, over time.
For this reason, many specialists limit DPIs to children at least 8–12 years of
age and only after they are able to demonstrate proper technique in the office.
Frequent asthma visits with symptom assessment are important for patients
with persistent asthma, especially when it is hard to control. If improvement
is noted with an ICS-LABA combination, steps should be taken to continue
to step down the LABA treatment, if the patient tolerates it.
DPI, dry-powder inhaler; FDA, Food and Drug Administration; ICS, inhaled corticosteroid;
LABA, long-acting β2 -adrenergic receptor agonist; MDI, metered-dose inhaler;
SABA, short-acting β2 -adrenergic receptor agonist.
Derived from AAP Section on Pediatric Pulmonology. Pediatric Pulmonology. 2nd ed.
American Academy of Pediatrics; 2023; and AAP Section on Pediatric Pulmonology
and Sleep Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC,
Dozor AJ, eds. American Academy of Pediatrics; 2018:268–269.
LTRAs
Dosing of Antileukotriene Agents
Dosage Additional Notes
1–5 Years 6–14 Years Antileukotriene agents are also referred to as leukotriene modifiers.
Drug of Age of Age Adolescents Airflow obstruction in patients with asthma results from numerous
Montelukast 4 mg at bedtime 5 mg at bedtime 10 mg at bedtime pathological processes.
(6–14 y) (≥15 y) Inflammatory infiltrates and exudates not only distinguished by eosinophils
but also including other inflammatory cell types (ie, neutrophils, monocytes,
Zafirlukast NA 10 mg twice daily 40 mg daily lymphocytes, mast cells, basophils) can fill and obstruct the airways and
(5–11 y) (≥12 y) induce epithelial damage and desquamation into the airway lumen.
Zileuton NA NA 1,200 mg twice daily Leukotrienes are potent proinflammatory mediators that can induce
(≥12 y) bronchospasm, mucus secretion, altered cellular activity, and airway edema.
FDA, Food and Drug Administration; NA, not applicable. Parents should be counseled about Two classes of leukotriene modifiers exist: inhibitors of leukotriene synthesis
the FDA warning about risk of adverse effects on sleep and behavior with montelukast. (5-LOX) and LTRAs.
From AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology, • Zileuton is the 5-LOX inhibitor used in the management of asthma.
Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; • Montelukast and zafirlukast are LTRAs used in the management of asthma.
2018:278.
LTRAs reduce the proinflammatory (increased microvascular permeability and
airway edema) and bronchoconstriction effects of leukotriene D4, especially
LTRA Use
from exercise, aspirin, and allergen-induced bronchoconstriction.
Leukotriene modifiers are popular because they can be administered in oral A stepwise approach, in addition to clinical decision-making, should be used to
form and have been shown to have bronchodilator and anti-inflammatory meet individual patient needs.
properties and to mitigate exercise-, allergen-, and aspirin-induced broncho- Antileukotriene agents are alternative medications used in the treatment of
spasm. Only montelukast (>6 months of age) and zafirlukast (>5 years of age) asthma and allergic rhinitis.
are FDA approved for children. As single agents, they are considered
alternative therapy for mild persistent asthma. They can also be used If alternative treatment is selected and well-controlled asthma is not achieved,
with ICSs. discontinue the therapy and use the preferred treatment or trial of a different
add-on therapy before stepping up the treatment. First assess adherence,
Indications, Administration, and Dosing technique, and environmental control.
LTRAs are suggested as alternative therapy for mild persistent asthma It is preferable to schedule daily, long-term medications so they are not taken
and as add-on medication with ICSs for moderate to severe persistent at school. However, prompt access to medication is essential to treat acute
asthma. symptoms or to prevent exercise-induced bronchoconstriction that may
If a child’s asthma is inadequately controlled with ICSs alone, an develop during physical education class, school recess, or organized sports.
antileukotriene agent or a LABA may be added. Most studies indicate Routine consideration for step-down to intermittent therapy should be given to
that overall, the addition of a LABA is more effective, but there are some those with well-controlled asthma, especially to children 0–4 years of age.
children for whom the addition of an antileukotriene agent may be the Adverse Effects
best choice.
LTRAs have been shown to help prevent EIB, although most specialists Dizziness, fever, headache
first try pretreatment with albuterol or another SABA. Increased levels of liver function enzymes
LTRAs are less effective than low-dose corticosteroids. Churg-Strauss syndrome
They are not used to treat acute exacerbations. Mood changes, including irritability, depression, and anxiety
Montelukast is administered orally as granules mixed with liquid or food • In 2009, the FDA issued an alert that children and adolescents may be
or as a chewable or regular tablet. at increased risk for neuropsychiatric events with antileukotriene agents,
Zafirlukast should be taken at least 1 hour before or 2 hours after meals including suicide. Because suicide and suicidal behavior are somewhat
because administration with meals decreases its bioavailability. common in the general adolescent population, the significance of this
association has not yet been definitively clarified.
When choosing an antileukotriene agent, montelukast is attractive because
it is prescribed once daily, and monitoring of liver function test results is Nightmares
not routinely needed. Abdominal pain and/or nausea
Cytochrome P450 system drug interactions
EIB, exercise-induced bronchospasm; FDA, Food and Drug Administration; 5-LOX, 5-lipoxygenase
inhibitor; ICS, inhaled corticosteroid; LABA, long-acting β2 -adrenergic receptor agonist;
LTRA, leukotriene receptor antagonist; SABA, short-acting β2 -adrenergic receptor agonist.
Derived from AAP Section on Pediatric Pulmonology. Pediatric Pulmonology. 2nd ed. American
Academy of Pediatrics; 2023; and AAP Section on Pediatric Pulmonology and Sleep Medicine.
Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American
Academy of Pediatrics; 2018:277–278.
Tab 15
Inhaled Anticholinergic Agents
Anticholinergic agents in combination with albuterol have been shown to have a positive effect on reducing the rate of
hospitalizations during acute asthma exacerbations, although, singly, they are less potent than short-acting β2-adrenergic
receptor agonists. The most common anticholinergic agent in use is ipratropium bromide because it is available in both
metered-dose inhaler and nebulized forms and has limited central nervous system adverse effects. This agent decreases
vagal tone (resulting in bronchodilation) and blocks reflex bronchoconstriction to irritants.
This tab is limited to a discussion of inhaled anticholinergic (antimuscarinic) agents and their role in respiratory disease in
children. Inhaled anticholinergic agents include
Ipratropium bromide (short acting)
Tiotropium (long acting)
Tab 16
Systemic Corticosteroids
Tab 17
Anti-immunoglobulin E Therapy
IgE plays an important role in the pathogenesis of asthma and allergic diseases.
Most patients are atopic, with positive findings from a skin test for common allergens
and with detectable allergen-specific IgE in the serum.
Exposure to allergens to which patients are sensitized can contribute to asthma
symptoms.
Anti-IgE therapy is a recombinant humanized immunoglobulin G1 monoclonal
antibody that binds to IgE with high affinity.
Omalizumab is the first FDA-approved biological therapy for asthma and the only
available anti-IgE therapy. It is FDA approved for the treatment of allergic asthma
and chronic urticaria.
• Decreases rates of asthma exacerbations, annualized rates of hospital admission,
total ED visits, unscheduled physician’s office visits, rescue therapy use, and
ICS dose
• Improves symptom scores, quality of life, and time to first asthma exacerbation
>200,000 patients with allergic asthma have been treated with omalizumab since
its approval in 2003 for people ≥12 years of age. It was approved in 2016 for people
≥6 years of age.
ED, emergency department; FDA, Food and Drug Administration; ICS, inhaled corticosteroid;
IgE, immunoglobulin E.
Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric Pulmonology,
Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American Academy of Pediatrics; 2018:289.
Tab 18
Other Biologics
Pediatricians and pediatric subspecialists should be aware of the current range of biological medications available to children
with severe asthma. In addition, general pediatricians should monitor patients for evidence of poor response to traditional
therapies and consider referring to pediatric subspecialists for evaluation of eligibility for these types of medications. Finally,
those who administer this type of care for children with asthma should be aware of the potential for anaphylaxis for many
biologics, especially omalizumab and reslizumab, and be prepared to treat and evaluate anaphylaxis and other potential
treatment-related adverse effects.
Tab 19
Trigger Management
Tab 20
Exercise-Induced Bronchoconstriction
Exercise-Induced Bronchoconstriction
Signs and Symptoms Triggers Additional Notes
Coughing, wheezing, Breathing dry and/or cold air causes Obtaining a history alone has been shown to lead to underdiagnosis
chest tightness, and airway narrowing via osmotic and thermal and overdiagnosis of EIB.
dyspnea. consequences of evaporative water loss • Rule out other origins, including vocal cord dysfunction, arrhythmias,
Mild impairment to from the airway surface. and pulmonary or cardiac shunt.
severe bronchospasm Dry or cold air in the distal airways causes • Obtain a complete family history, including asthma or relatives
and, rarely, respiratory hyperemia of bronchial vasculature and with atopy.
failure. airway edema, which further causes
airway narrowing. EIB, exercise-induced bronchoconstriction; FEV1, forced expiratory volume in 1 second;
Subtler symptoms FVC, forced vital capacity.
include fatigue, Airway narrowing causes cough. Diagnosis of Exercise-Induced Bronchoconstriction
a
Children may have EIB in addition to any of the disorders listed.
abdominal discomfort, Although the events that trigger EIB and
poor performance, and Derived from AAP Section on Pediatric Pulmonology and Sleep Medicine. Pediatric
the role of inflammatory cells are not fully Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds. American
avoidance of activities. understood, a hyperosmolar environment Academy of Pediatrics; 2018:299–301.
Exercise duration for a is thought to trigger the release of
minimum of 5–8 minutes inflammatory mediators, including Diagnosis of Exercise-Induced Bronchoconstriction
at 80% of maximum histamine, tryptase, and leukotrienes
predicted oxygen from eosinophils and mast cells.
Symptoms suggestive of EIB
consumption typically Several studies have demonstrated that
generates bronchospasm. individuals who are prone to EIB have
Symptoms peak increased levels of exhaled nitric oxide,
5–10 minutes after increased airway leukotriene levels, Perform spirometry
exercise ceases and can greater expression of mast cell genes,
last 60–90 minutes. and/or peripheral eosinophilia.
Diagnostic Considerations Spirometry results Spirometry results
EIB involves acute, transient airway narrowing that occurs during and normal abnormal
after exercise.
EIB is most often defined by ≥10% decline in FEV1 at spirometry after
exercise provocation. Elite Treat for EIB
EIB occurs in 90% of individuals with asthma. athlete? and asthma
EIB can also occur in individuals without a known diagnosis of asthma.
All patients with suspected EIB should undergo spirometry. Yes No
• Assess the patient for baseline airway obstruction (ratio of FEV1:FVC Perform bronchial
up to the lower limit of reference for age). provocation testing
Differential Diagnosisa
Unrecognized or poorly controlled asthma
Anxiety
Results normal: Results abnormal:
Deconditioning consider alternative treat EIB
Vocal cord dysfunction diagnoses
Exercise-induced laryngomalacia
Exercise-induced anaphylaxis Initiate trial of short-acting
ß2 agonist 15 to 30
Exercise-induced reflux minutes before exercise
Central airway obstruction arrhythmias
Pulmonary or cardiac shunt
Adequate response: Inadequate response:
continue treatment perform bronchial
provocation testing
Reproduced with permission from AAP Section on Pediatric Pulmonology and Sleep
Medicine. Pediatric Pulmonology, Asthma, and Sleep Medicine. Stokes DC, Dozor AJ, eds.
American Academy of Pediatrics; 2018:300; and Krafczyk MA, Asplund CA. Exercise-
induced bronchoconstriction: diagnosis and management. Am Fam Physician.
2011;84(4):427–434.
Tab 21
Asthma Control Test
Step 4 Take the test to the doctor to talk about your child’s total score. 19 may be a sign that your child’s
asthma is not controlled as well as
or less it could be. No matter what the
score, bring this test to your doctor
Have your child complete these questions. to talk about your child’s results.
1. How is your asthma today? SCORE
0 1 2 3
Very bad Bad Good Very good
2. How much of a problem is your asthma when you run, exercise or play sports?
0 1 2 3
It's a big problem, I can't do what I want to do. It's a problem and I don't like it. It's a little problem but it's okay. It's not a problem.
3. Do you cough because of your asthma?
0 1 2 3
Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time.
4. Do you wake up during the night because of your asthma?
0 1 2 3
Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time.
5 4 3 2 1 0
Not at all 1-3 days/mo 4-10 days/mo 11-18 days/mo 19-24 days/mo Everyday
6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma?
5 4 3 2 1 0
Not at all 1-3 days/mo 4-10 days/mo 11-18 days/mo 19-24 days/mo Everyday
7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma?
5 4 3 2 1 0
Not at all 1-3 days/mo 4-10 days/mo 11-18 days/mo 19-24 days/mo Everyday
TOTAL
Please turn this page over to see what your child’s total score means.
Asthma Control TestTM for teens 12 years and older. Know the score.
If your teen is 12 years or older have him take the test now and discuss the results with your doctor
Step 1 Write the number of each answer in the score box provided.
Step 2 Add up each score box for the total.
Step 3 Take the test to the doctor to talk about your child’s total score.
1. In the past 4 weeks, how much of the time did your asthma keep you
from getting as much done at work, school or at home?
All of Most of Some of A little of None of
the time 1 the time 2 the time 3 the time 4 the time 5
2. During the past 4 weeks, how often have you had shortness of breath?
More than Once 3 to 6 times Once or twice Not
once a day 1 a day 2 a week 3 a week 4 at all 5
3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness,
or pain) wake you up at night or earlier than usual in the morning?
4 or more 2 or 3 nights Once Once Not
nights a week 1 a week 2 a week 3 or twice 4 at all 5
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?
3 or more 1 or 2 times 2 or 3 times Once a week Not
times per day 1 per day 2 per week 3 or less 4 at all 5
5. How would you rate your asthma control during the past 4 weeks?
Not controlled Poorly Somewhat Well Completely
at all 1 controlled 2 controlled 3 controlled 4 controlled 5
• If your child’s score is 19 or less, it may be a sign that your child’s asthma is not under control.
• Make an appointment to discuss your child’s asthma score with their doctor. Ask if you should change your child’s asthma treatment plan.
• Ask your child’s doctor about daily long-term medications that can help control airway inflammation and constriction, the two main
causes of asthma symptoms. Many children may need to treat both of these on a daily basis for the best asthma control.
Tab 22
Tobacco Use/Vaping and Asthma
Tobacco dependence is a severe and chronic illness. It is associated with increased asthma prevalence and severity, worse
asthma control, increased bronchial hyperresponsiveness, increased risk for emergency department visits, and decreased
corticosteroid responsiveness. Tobacco smoke exposure accelerates decline in lung function in children with chronic
pulmonary problems, such as cystic fibrosis.
Children can be harmed from tobacco smoke by direct inhalation of exhaled and sidestream smoke (secondhand smoke)
and from the dermal absorption, ingestion, and inhalation of smoke that has been absorbed into surfaces (thirdhand smoke).
There is no safe level of tobacco smoke exposure, and children are harmed by tobacco and nicotine from gestation onward.
In the United States, the largest source of a child’s exposure to tobacco smoke is often the mother and other caregivers.
Maternal smoking increases a child’s risk for wheezing illnesses, including bronchiolitis and asthma. In utero exposure
affects lung development.
L ouis XV. had had enough of glory. Impatient to meet again the
new marquise, he left the army September 1, 1745, and returned
to Versailles, where his mistress awaited him in the apartment
once occupied by the Duchess de Châteauroux. This change of
reign was effected in an official manner. There was no more attempt
at mystery. The Marquise de Pompadour was presented September
15, conformably to the rules of etiquette. Every tongue at court was
wagging over this scandalous and ridiculous ceremony. Every one
wondered how the Queen would look. The King, his wife, and his
mistress thus exposed themselves to public view, and the ancient
ceremonial became merely a parody. The Princess de Conti, whose
debts and prodigalities seemed to condemn her to such complaisant
rôles, was the lady who presented her. The Marquise appeared at
first before the King, whose countenance betrayed an easily
comprehended embarrassment. Then she entered the salon of the
Queen and could not hide her confusion.
But Marie Leczinska, good and indulgent even to exaggeration,
reassured her by a gracious reception. Naming one of the few
aristocratic women with whom Madame de Pompadour was
connected, she said: “Have you any news of Madame de Saissac? I
have been much pleased to see her sometimes in Paris.” The
Marquise, touched and grateful, know not what to answer. She
reddened and stammered out: “Madame, I have the greatest passion
to please you.”
The Abbé de Bernis celebrated thus the new queen of Cythera:—
“Tout va changer: les crimes d’un volage
Ne seront plus érigés en exploits.
La Pudeur seul obtiendra notre hommage,
L’amour constant rentrera dans ses droits.
L’exemple en est donné par le plus grand des rois,
Et par la beauté la plus sage.”[29]
The choice of Louis XV. was thenceforward settled. The gallant
monarch was about to plume himself on fidelity.
What do you think of this modesty and this discretion? As Sainte-
Beuve says, these poets have a way of taking things which belongs
to them alone.
There was plenty of adulation, but there was also plenty of fault-
finding. The great ladies could not get used to seeing a bourgeoise
occupy the post of King’s mistress. They observed with malevolent
and ever alert attention this improvised marquise who tried to give
herself airs of nobility and grandeur. They recalled the fact that her
grandfather had been provision-contractor for the Hôtel des
Invalides. She is the granddaughter of a butcher, said they; they
jeered pitilessly about meat and fish; they found her awkward in her
part, like a grisette disguised as a marchioness. Exasperated at
seeing at Versailles a royal mistress not of his choosing, the Duke de
Richelieu tried, says Duclos, “to make the King consider her on the
footing of a bourgeoise out of place, a passing gallantry, a simple
amusement not adapted to remain worthily at court.” If anything in
her manners or her language was not perfectly well-bred, the favorite
became the butt of sarcasm as soon as her back was turned. Louis
XV. used to say: “It will amuse me to educate her.”
Madame de Pompadour had at all events the good sense to
maintain a humble and submissive attitude when she appeared
before the Queen. The rank and virtues of Marie Leczinska
intimidated her. Here is a curious passage which occurs in the
Memoirs of the Duke de Luynes: “Day before yesterday, as she was
returning from Mass, Madame de Pompadour said to Madame de
Luynes that she was in the keenest anxiety and most bitter sorrow;
that she knew somebody had frightfully aspersed her to the Queen;
and, without explaining to what she referred, said she hoped greatly
that the Queen would not believe it, and that she begged her to
speak about it to her. Madame de Luynes instantly gave an account
of this to the Queen.” Here is the letter written to Madame de
Pompadour by the Duchess de Luynes: “I have just been speaking
to the Queen, Madame, and I earnestly entreated her to tell me
frankly if she had anything against you; she answered in the kindliest
way that she had not, and that she was even very sensible of your
efforts to please her on all occasions; she even desired me to write
and tell you so.”
This is the reply of the Marquise: “You bring me to life again,
Madame; for three days I have been in unheard-of pain, as you will
believe without difficulty, knowing as you do my attachment to the
Queen. They have made frightful accusations against me to
Monsieur and to Madame the Dauphiness, who have been kind
enough to allow me to prove the falsity of the horrors they accuse
me of. I had been told some days ago that the Queen had been
prejudiced against me; think of my despair, who would give my life
for her, who find her goodness to me every day more precious. It is
certain that the kinder she is to me, the more will the jealousy of the
monsters of this place be employed in abusing me, unless she is so
good as to be on her guard against them and will kindly let me know
of what I am accused. It will not be difficult for me to justify myself;
the tranquillity of my soul on this subject assures me as much. I
hope, Madame, that your friendship for me, and still more your
knowledge of my character, will be the guarantees of what I am
writing you. Doubtless you must be annoyed by such a long story;
but my heart is so full that I cannot conceal it from you. You know my
sentiments toward you, Madame; they will end only with my life”
(February, 1746).
We read again in the Memoirs of the Duke de Luynes (March,
1746): “Madame de Pompadour, who knows the Queen loves
flowers, is so attentive as to send her bouquets as often as possible;
she continues to seek every occasion to please her.”
The Queen may have reflected that, after all, since a mistress was
inevitable, this one was better than another. Since he had been
directed by Madame de Pompadour, the King seemed in a less
sombre temper and looked a little less bored. But he lost in the
favorite’s society the needful energy to continue the successes of the
French arms, and sign a really glorious peace.
While Louis XV. was thus wasting away in futilities, Marshal Saxe
conquered all Belgium. Louis XV. never made his appearance at the
army from May 4 to the middle of June, 1746. After having made a
triumphal entry at Antwerp he hastened back to Versailles,
apparently to be present when the Dauphiness was delivered, in
reality to see Madame de Pompadour again. The Dauphiness died
prematurely in July. D’Argenson says she had become as good a
Frenchwoman as if she had been born at Versailles. She was
regretted, but the hurly-burly of festivities soon began again, and
Louis XV., after a very short mourning, resumed his accustomed
diversions and pretended pleasures.
The successes of his troops were as brilliant as they were rapid.
Never had France held better cards. It was a magnificent occasion to
complete national unity in the North. But though they had known how
to conquer they knew not how to profit by the victory. The King did
not comprehend his mission. He was thinking more about Madame
de Pompadour than about the war, and while his soldiers were
fighting so bravely, he, wholly given up to frivolous trifles, was
amusing himself, or, better, he was trying to do so. This nonchalance
became fatal. All the fruits of the war were lost by the treaty of Aix-la-
Chapelle (October 18, 1748).
People had believed that Louis XV., who was master of all
Belgium, of two Dutch provinces, of Savoy, and the county of Nice,
would claim to retain at least a part of his conquests. But, to the
general surprise, he declared he would not treat as a merchant, but
as a king. This more than amazing phrase signified that France
would demand nothing, nothing for so many dearly bought victories,
nothing for the five hundred thousand men she had sacrificed,
nothing for the twelve hundred millions added to the national debt.
Louis XV. restored all the conquered cities and territories. He
engaged not to rebuild the fortresses of Dunkirk; he recognized the
English succession in the Protestant line and carried complaisance
toward the vanquished of Fontenoy to the point of expelling the
Pretender, the heroic Charles Edward, from France. Add to this that
the French navy, like that of Spain, was half ruined, and that the time
was not far distant when the sailor might salute the ocean as
Britannic. It is true that the Infant Philip, married to the eldest
daughter of Louis XV., obtained the duchies of Parma and Plaisance.
But this was but a petty advantage considered as a recompense for
so many sacrifices of men and money.
As might have been expected, the peace of Aix-la-Chapelle was
profoundly unpopular. “As stupid as the peace,” people said in Paris.
The odium of it was cast upon the woman who, to play her part as
queen of the left hand, had meddled with diplomacy, finances, and
the army.
In 1746 Voltaire had written to Louis XV.:—
“Grand roi, Londres gémit, Vienne pleure et t’admire.
Ton bras va décider du destin de l’Empire.
La Sardaigne balance et Munich se répent,
Le Batave, indécis, au remords est en proie;
Et la France s’écrie au milieu de sa joie:
‘Le plus aimé des rois est aussi le plus grand!’”[30]
“I have seen all that is done under the sun, and beheld that all is
vanity and vexation of spirit. I have said within myself: Let us take
all manner of delights and let us enjoy our possessions; and I
have recognized that this too is vanity. I have condemned the
laughter of folly and I have cried unto joy: Why dost thou deceive us
vainly?”
What the Preacher thought, Louis XV. thought also. Like Solomon,
he was bored. His ennui was the terror of Madame de Pompadour.
The problem she had to solve was how to entertain a man who could
no longer be amused. The favorite trembled. Here was her favor
barely begun, and already she beheld symptoms of indifference and
lassitude in her royal lover. D’Argenson writes in 1747: “The
Pompadour is about to be dismissed. The King will live with his
family.” The Marquise was afraid lest the sovereign, who really had a
badly understood but sincere religion at bottom, might some day
conclude to be truly devout. Hence she desired at any cost to divert
him from serious ideas and plunge him, in his own despite, into the
vortex of false pleasures whose emptiness and poverty he knew so
well.
Even amid the splendors of Versailles, the new Marquise
regretted her successes as a private actress. The echo of the
applause she had become accustomed to in the parlor theatres of M.
Lenormand de Tournehem, at Étioles, and of Madame de Villemur, at
Chantemerle, still resounded in her flattered ears. Those who are
habituated to the emotions and vanities of the stage cannot easily do
without them. Madame de Pompadour was homesick for the
footlights and the boards. To play in comedy is such a fine occasion
for a pretty woman to shine! To see all eyes fixed on her; to put
beauty and her toilettes in the best lights; to be greeted when she
appears by a murmur of admiration; to receive when the play is
ended the rain of flowers and garlands that tumble at her feet; and at
last, when the actress resumes the grande dame and re-enters the
drawing-room, to glean compliments, madrigals, and enthusiastic
plaudits afresh,—what a triumph for a fashionable woman, what
exquisite joy for a coquette!
Women of the highest social rank are often jealous of actresses. It
annoys them to perceive that they have not that order of charms
which comediennes possess. They envy them the privilege of
attracting the attention of a whole theatre, of being the object of all
regards, the subject of all eulogies, and the ability to say to a lover
after a triumph: “I have played only for you, I have thought of you
alone; these flowers that have been thrown to me I give to you.”
They envy them the excitement of those noisy ovations, in
comparison with which all the flatteries of society seem tame. They
envy them above all that faculty of metamorphosis which transforms
the same woman into a shepherdess or a queen, a nymph or a
goddess, so that a man while adoring a single beauty, but a beauty
incessantly changed and transfigured, finds himself at once faithful
and inconstant.
This is why Madame de Pompadour wanted to play comedy at
Versailles. Little by little she accustomed Louis XV. to this idea. Holy
Week was always a sad time for the monarch, who was tortured by
remorse and ashamed of playing so badly his part as eldest son of
the Church. The favorite conceived the notion of enlivening this
dreaded week by interludes, half religious, half profane.
Accompanied by actors and amateurs, she sang pieces of sacred
music. This Lent à la Pompadour, this mixture of church and opera,
this exchange of religions for chamber, not to say alcove, music, was
very acceptable to such a character as Louis XV. and a devotion as
inconsistent and spurious as his. The courtiers, of course, went into
ecstasies over the charming voice of the Marquise. They reminded
the King of the triumphs of the little theatres at Étioles and
Chantemerle, and pitied him for not having seen comedy played by
so remarkable an actress. Sacred music had served its time; another
sort was now in order.
Madame de Pompadour achieved her purpose. A theatre was
constructed for her at Versailles,—a miniature theatre, an elegant
little place, a perfect gem.[31] The spot chosen was the gallery
contiguous to the former Cabinet of Medals, a dependence of the
King’s small apartments (room No. 137 of the Notice du Musée de
Versailles, by M. Eudore Soulié). Nearly one-third of the orchestra
was composed of amateurs belonging to the most illustrious families,
the other two-thirds being professional artists. The chorus singers
were selected among the King’s musicians. The dancers were boys
and girls from nine to thirteen years at most, who, on reaching the
latter age, were to enter the ballet corps of the opera, the Théâtre
Français, or the Comédie-Italienne (the little girls distinguished
themselves later on in choregraphic shows and gallantry).
Celebrated painters, Boucher at their head, supplied the decorations.
The mise en scène and the costumes were of incomparable
elegance. As to the actors and actresses, they bore such names as
the Duke de Chartres, the Duke d’Ayen, the Duke de Duras, the
Duke de Nivernais, the Duke de Coigny, the Marquis d’Entraigues,
the Count de Maillebois, the Duchess de Brancas, the Marquise
Livry, the Countess d’Estrades, Madame de Marchais, and finally,
the principal actress, the Armida of all these enchantments, the
Marquise de Pompadour. The Duke de La Vallière was chosen as
director of the troupe; as sub-director l’historiogriffe of cats, Moncrif,
academician and reader to the Queen; as secretary and prompter,
the Abbé de La Garde, librarian to the Marquise. Madame de
Pompadour drew up the regulations for the players. As approved by
the King, they contained ten articles:—
“1. In order to be admitted as an associate, it will be necessary to
prove that this is not the first time that one has acted, so as not to
make one’s novitiate in the troupe.
“2. Every one shall choose his own line of characters.
“3. No one may choose a different line from that for which he has
been accepted, without obtaining the consent of all the associates.
“4. One cannot, in case of absence, appoint his substitute (a right
expressly reserved to the Society which will appoint by an absolute
majority).
“5. On his return, the person replaced will resume his own line.
“6. No associate can refuse a part appropriate to his line under
pretext that such a part is unsuitable to his manner of acting or too
fatiguing.
“7. The actresses alone have the right to select the pieces to be
represented by the troupe.
“8. They shall also have the right to fix the day of representation,
the number of rehearsals, and the days and hours when they shall
occur.
“9. Each actor is bound to be present at the precise hour
appointed for the rehearsal under penalty of a fine which the
actresses alone shall determine among themselves.
“10. To the actresses alone a half-hour’s grace is accorded, after
which the fine they will have incurred shall be decided by themselves
only.
“A copy of these statutes will be given to each secretary, who shall
be bound to fetch it to each rehearsal.”
Madame de Pompadour was quite right in drawing up a severe
code of regulations, for it is not an easy thing to establish discipline
in a troupe composed of society people, where the intrigues of the
courtier are added to the vanity of the actor. What petty jealousies,
what mean vanities! What manœuvres to obtain this or that part,
what solicitations and cabals to ensure merely a spectator’s place in
the cœnaculum!
Louis XV. occupied himself seriously with such trifles. The
direction of this miniature theatre gave him no fewer cares than the
government of France. He reserved to himself the right of selecting
the spectators, and it was a signal favor to have been thus chosen.
Notwithstanding their ardent desire to be among the privileged
persons, neither Marshal de Noailles, the Duke de Gesores, nor the
Prince de Conti were admitted to the opening of the theatre. It took
place January 17, 1747. Tartuffe was given. Madame de Pompadour
played Dorine. The first theatrical season of the little cabinets lasted
until March 17.
After having secured applause as an actress in Tartuffe, Les Trois
Cousines, and Le Préjugé à la Mode, the Marquise triumphed as a
cantatrice in Erigone: “Madame de Pompadour sang very well,” says
the Duke de Luynes; “her voice has not much volume, but a very
agreeable sound; she knows music well and sings with much taste.”
The second theatrical season lasted from December 20, 1747, to
March 30, 1748. The first representation comprised a comedy, Le
Mariage fait et rompu, and a pastoral, Ismène, the words by Moncrif.
Voltaire’s Enfant prodigue was given December 20, to the author’s
great joy. Madame de Pompadour had promised Gresset to produce
Le Merchant. She kept her word. The play required two months of
study. It was given February 6, 1748, Madame de Pompadour
playing Lisette. The Duke de Nivernais was excellent as Valère, and
the Duke de Chartres took the part of Géronte. The grateful Gresset
thanked the Marquise thus:—
“On ne trace que sur le sable
La parole vague et peu stable
De tous les seigneurs de la cour;
Mais sur le bronze inaltérable
Les Muses ont tracé le nom de Pompadour
Et sa parole invariable.”[32]
L ouis XV. had made his mistress what one might call a vice-queen.
She had the power, luxury, riches, and adulations of royalty;
everything, in fact, except its moral prestige. Surrounded by a
court of ministers, prelates, and nobles, she throned it in the midst of
pomp and opulence. She was the type of the woman à la mode,
elegant, coquettish, absolute, always on show, insatiable for praise
and success, thirsting for dignities, pleasures, and money; playing
not merely the great lady, but the sovereign, having her courtiers, her
creatures, her poets, reigning alike over the King and the kingdom.
M. Arsène Houssaye has said with justice: “Louis XV. had three
prime ministers: Cardinal Fleury, the Duke de Choiseul, the Marquise
de Pompadour.” But the Marquise was not an ordinary prime
minister; she was a prime minister doubled with a mistress. To a
woman invested with this exaggerated rôle, a display of power was
necessary. The favorite set herself to create around her a sort of
decorum, etiquette, and factitious grandeur. Like little women who
wear enormously high heels, she made herself a pedestal. Madame
d’Étioles had disappeared; nothing remained but the Marquise de
Pompadour. To be a marchioness did not satisfy her, and she
demanded and obtained the tabouret and the honors of a duchess.
She had a box at the court theatre with a grating behind which she
shut herself up tête-à-tête with the King. In the chapel a gallery in the
grand tribune was reserved for her and her suite. People waited on
her stairway at the hour of her toilette just as they await a ministerial
audience in an ante-chamber. She used to say to the ministers:
“Continue; I am satisfied with you,” and to the foreign ambassadors:
“Observe that on Tuesdays the King cannot see you, gentlemen, for
I think you will hardly follow us to Compiègne.”
One of the cabinets in her apartment was full of petitions.
Solicitors approached her with respectful fear. The ducal mantle and
velvet cap figured on the panels of her carriages. A nobleman
carried her mantle and awaited her coming in the ante-chamber. A
man of illustrious birth, a Chevalier d’Hénen, of the family of the
Princes de Chimay, rode at her carriage door as equerry. She was
served at table by a Chevalier of Saint Louis, her steward Colin, a
napkin under his arm. Her chambermaid was a woman of quality,
Madame du Hausset, who has left such curious Memoirs. The all-
powerful favorite had not forgotten her family. Her father was
ennobled in 1747. Her brother, Abel Poisson, became successively
Marquis de Vandières, Marquis de Marigny, Marquis de Ménars. The
marquisate not contenting him, he obtained a place created for
Colbert, that of superintendent of crown buildings. He was as a
patron of artists a Mecænas, an arbiter elegantiarum. The King, who
treated him as his brother-in-law, gave him the blue ribbon and put
him on an equality with the greatest nobles of the realm. Young
Alexandrine, the daughter of Madame de Pompadour and M. de
Étioles, was brought up at Paris in the convent of the Assumption.
The nuns showed her the greatest attention. She was addressed
by her baptismal name, as was then the custom for princesses of the
blood, and she was expected to make one of the most brilliant
marriages in France. Madame de Pompadour desired pomp even in
death. She bought a splendid sepulchre in the Capuchin convent in
the Place Vendôme, Paris, from the Trémoille family. There she built
a magnificent mausoleum, where her mother was interred and where
she reserved a place for herself.[35]
The favorite had not simply power, but beauty; beauty, that
supreme weapon. A veritable magician, she transformed herself at
will. As mobile as the clouds, as changeful as the wave, she
renewed and metamorphosed herself incessantly. No actress knew
better than she how to compose an attitude or a countenance. In her
whole person there was an exquisite grace, an exceptional charm, a
taste, an elegance which amounted to subtlety. La Tour, the pastel
painter, is he who has best reproduced her animated, spirituelle,
triumphant physiognomy, the eyes full of intelligence and audacity,
the satin skin, the supple figure, the general harmony, the charming
and coquettish whole.
All the splendors of luxury were like a frame to the picture. A new
Danaë, the Marquise disappeared under a shower of gold. It is
known exactly what she cost France from September 9, 1745, the
time when her favor began, until April 15, 1764, the day of her death.
M. Le Roy has discovered an authentic document,[36] containing an
account of the favorite’s expenses during this period of nearly twenty
years. The total is 35,924,140 livres. In this list of expenses is found
the pension granted to Madame Lebon for having predicted to the
Marquise, then only nine years old, that she would one day be the
mistress of Louis XV.
Nothing seemed fine enough for Madame de Pompadour, either in
dress, lodgings, or furniture. At Versailles she secured for herself on
the ground floor, on the terrace looking toward the parterre on the
north, the magnificent apartments occupied by the Duke and
Duchess de Penthièvre.[37] (Part of the ministry of foreign affairs is
established there at present. The minister’s study is the same as that
of Madame de Pompadour. Her bedchamber is now the thirteenth
hall of the marshals, her ante-chamber the hall of famous warriors.)
The favorite bought a superb house in the city communicating by
a passage with the apartments of the palace (it is now the hôtel des
Réservoirs). In 1748 she acquired the château of Ciécy and the
estate of Aunay, and in 1749 the château of La Celle, near
Versailles. In 1750 she inaugurated, on the hill commanding the
Seine, between Sèvres and Meudon, that enchanting abode of
Bellevue, where all the arts rivalled each other to create a magic
entity. The ante-chamber with statues by Adam and Falconnet; the
dining-room with paintings of game and fish by Oudry; the salon
decorated by Vanloo; the apartment of the Marquise, hung with
Boucher’s glowing pictures; the park with its parterres of rare
flowers, its fine trees, grottos, and fountains, its statues by Pigalle
and Coustou, its varied perspectives, its immense horizons,—all
made of Bellevue a real palace of Armida. At Versailles, the
Marquise obtained from the King a portion of the little park wherein
to construct a gem of architecture, which she called the Hermitage; it
cloaked extreme elegance under an appearance of simplicity. It had
fine Persian hangings, panelled wainscotings decorated by the most
skilful painters, thickets of myrtles, lilacs, and roses. This habitation
is no longer in existence; a part of its site is occupied by the rue de
l’Ermitage at Versailles. The Marquise had a house at Compiègne
and a lodge at Fontainebleau. At Paris she bought, for seven
hundred and thirty thousand livres, the hôtel d’Evreux, which is now
the Élysée.
At the Trianon her apartment was on the same floor with that of
Louis XV. At Clécy she received as if in a royal château. The King’s
visits to this splendid residence used to last three or four days, and
cost about one hundred thousand livres.
A woman so influential could not fail to have a swarm of flatterers.
The resources of fawning and hyperbole were exhausted in her
favor. The most exaggerated of her sycophants was Voltaire—
Voltaire to whom the republicans are nowadays raising statues. He
treated the Marquise as a superior being, a goddess, and pushed his
flattery to absurdity, to platitude. In 1745, the moment when the reign
of the favorite began, he sent her this compliment:—
“Sincère et tendre Pompadour
(Car je peux vous donner d’avance
Ce nom qui rime avec l’amour
Et qui sera bientôt le plus beau nom de France),
Ce tokai dont Votre Excellence
Dans Étioles me régala,
N’a-t-il pas quelque ressemblance
Avec le roi qui le donna?
Il est, comme lui, sans mélange;
Il unit, comme lui, la force à la douceur,
Plaît aux yeux, enchante le cœur,
Fait du bien et jamais ne change.”[38]