Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

When to Use a Controller
  • Inhaled corticosteroids are the main treatment for control of asthma.
  • Other medications are used as adjuncts when control is not achieved with an adequate dose of inhaled corticosteroids.
  • Controllers must be taken regularly long-term to prevent or decrease inflammation and edema of the airways.
  • Slow onset of action.
  • The management goal for children should always be the lowest dose of inhaled corticosteroids necessary to control symptoms, therefore medication dose needs to be assessed regularly and reduced or discontinued when appropriate.


First Line Controllers Corticosteroids (Inhaled)

  • Inhaled route is the preferred method of delivery.
  • Inhaled steroids are recommended as the mainstay of treatment for persistent asthma in children, except for those whose disease is so mild that they only require infrequent, as-needed ß2-agonist treatment (Boulet et al., 2001).

Corticosteroids (Systemic)

  • Used in short bursts for asthma exacerbations.
  • Used longer term for severe persistent asthma not responding to usual first line therapy.
  • Less side effects with low dose alternate day dosing (Murray & Nadel, 2000)

Second Line Controllers Leukiotriene Antagonists

  • Are used in conjunction with inhaled corticosteroids and are not to be used as first line medication for asthma in children (Ducharme & Hicks, 2000).

Long-Acting ß2-agonists (LABA)

  • When additional therapy is required, long-acting ß2-agonists (salmeterol and formoterol) are the primary choice, versus theophylline or ipratropium bromide (Boulet et al., 1999).
  • LABA’s assist corticosteroids in achieving and maintaining asthma control and are not recommended for use in the absence of inhaled anti-inflammatory therapy.

Third Line Controllers Theophylline

  • No evidence that aminophylline is of benefit for mild to moderate asthma and side effects are common (Boulet et al., 1999).
  • May have steroid sparing effects.
  • Therapy should only be attempted in children with severe or steroid dependent asthma.
  • Serum levels need to be monitored regularly.

Sodium Cromoglycate/Nedocromil

  • Non-steroidal anti-inflammatory controller medications that have an inconvenient dosing frequency.
  • Sodium cromoglycate is ineffective in children (Tasche, Uijen, Bernsen, de Jongste & van Der Wouden, 2000).
  • Nedocromil is of benefit in 5-12 year olds (Spooner, Saunders & Rowe, 2000).

Teaching Tips for Nurses:

  • Emphasize to parents that inhaled corticosteroids need to be taken on a regular/daily basis long-term to be effective, even when the child seems well.
  • Advise children/parents that controller medication should not be decreased or stopped unless advised by a physician.