Asthma: Diagnosis and Treatment Guideline

Asthma
Diagnosis and Treatment Guideline

Diagnosis
Establish a Diagnosis
Identify Precipitating Factors and Aggravating Comorbidities
Classify Severity or Assess Control
Patients aged 04 years
Patients aged 12 years and older
2
3
3
4
6
8
Treatment
Goals
Lifestyle/Non-Pharmacologic Options
Pharmacologic Options: Stepwise Charts
13
15
17
Follow-up/Monitoring
Condition/Complication Monitoring
Comorbidity Screening
Comorbidity Prevention
19
19
19
Evidence Summary
References
Clinician Lead and Guideline Development
20
22
23
Appendices
1. Asthma Action Plan
2. Asthma Control Test For children aged 411 years
3. Asthma Control Test For people aged 12 years and older
24
26
27
10
11
Most recent comprehensive literature review: September 2011
Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health
care for specific clinical conditions. While guidelines are useful aids to assist providers in determining appropriate
practices for many patients with specific clinical problems or prevention issues, guidelines are not meant to replace
the clinical judgment of the individual provider or establish a standard of care. The recommendations contained in the
guidelines may not be appropriate for use in all circumstances. The inclusion of a recommendation in a guideline
does not imply coverage. A decision to adopt any particular recommendation must be made by the provider in light of
the circumstances presented by the individual patient.
Asthma Diagnosis and Treatment Guideline

Copyright 19992012 Group Health Cooperative. All rights reserved.
Diagnosis
Establish a diagnosis
To establish a diagnosis of asthma:
Use history and physical to determine whether symptoms of recurrent episodes of airflow
obstruction or airway hyperresponsiveness are present. (Table 1)
Use spirometry in patients 5 years and older to determine whether airflow obstruction is at least
partially reversible. (Table 2)
Consider alternative diagnoses or comorbid conditions:
- Pulmonary diseases (e.g., COPD, pulmonary fibrosis, bronchiectasis, tracheobronchial stenosis
or malacia)
- Upper airway conditions (e.g., chronic rhinosinusitis, vocal cord dysfunction, obstructive sleep
apnea)
- Foreign body
- Obesity
- GERD
- Hyperventilation syndrome
Table 1. History and physical examination
Pertinent positives
History
Physical
examination
Recurrent episodes of wheezing, coughing, chest tightness.

Symptoms occur or worsen in the presence of any of the following: exercise, viral
infection, inhaled allergens, irritants (e.g., wood smoke, airborne chemicals),
changes in weather, strong emotional expression, stress, menstrual cycles.
Symptoms occur or worsen at night.
Upper respiratory tract: increased nasal secretion, mucosal swelling, and/or nasal
polyp.
Chest: sounds of wheezing during normal breathing or prolonged phase of forced
exhalation, hyperexpansion of the thorax, use of accessory muscles, appearance
of hunched shoulders, chest deformity.
Skin: atopic dermatitis, eczema.
Table 2. Recommendations for diagnosing asthma

Spirometry is strongly encouraged for patients aged 5 years or older to demonstrate whether airflow
obstruction is at least partially reversible. 1
Test
Results diagnostic of asthma
Spirometry: FEV1 /FVC Ages

819
2039
4059
6080
Spirometry: FEV1
1
FEV1 /FVC
Less than 0.85
Less than 0.80
Less than 0.75
Less than 0.70
FEV1 less than 80% of predicted.

1
Impairment is reversible.
To determine reversibility, FEV1 is measured before and after the patient inhales a short-acting beta2
agonist (SABA). In patients of all ages, reversibility is indicated by an increase of at least 12% in FEV1 from
baseline; in adults, an increase in FEV1 of greater than 200 mL from baseline also constitutes reversibility.
Some patients who have signs and symptoms of asthma may not demonstrate reversibility until after a 2- to
3-week trial of oral corticosteroid therapy is administered to help improve their asthma control.
Note: Having normal lung function does not exclude the diagnosis of asthma, especially in children.
Identify precipitating factors and aggravating comorbidities

Precipitating factors of episodic symptoms include exposure to inhaled allergens or irritants at
home, school, work, daycare, or other locations.
Comorbidities that may aggravate asthma include allergic bronchopulmonary aspergillosis, GERD,
obesity, obstructive sleep apnea, rhinitis/sinusitis, stress, and depression.
Classify severity or assess control

Asthma severity is the intrinsic intensity of the disease process. It is assessed at the initial
presentation of symptomatic patients who are not currently taking long-term control medications.
Severity classification is used to guide decisions about initial therapy.
Asthma control is the degree to which asthma symptoms are minimized in patients who are
currently taking medications. The degree of control is used to determine whether the medications
should be adjusted.
Severity and control are determined by examining levels of impairment (the frequency and intensity
of symptoms) and the risk of asthma exacerbation or progressive decline in lung function.
The following recommendations for classifying asthma severity and assessing asthma control are divided
into three age groups: 04 years, 511 years, and 12 years and older.

To classify asthma severity in patients not on medications, see Table 3a.
To assess asthma control in patients already on medications, see Table 3b.
Table 3a. Patients aged 04 years not on medications: classifying asthma severity
Assess each component over the last 24 weeks. The result is based on the score of the most severe
component.
Impairment
Intermittent
asthma
Moderate
Severe
Up to
2 days/week
More than
2 days/week
Daily
Throughout the day
Nighttime
awakenings
12x/month
34x/month
More than 1x/week
Up to
Short-acting
beta2 agonist use 2 days/week
(for rescue, not
exercise
prophylaxis)
More than
2 days/week
Daily
Several times a day
Interference with None

normal activity
Minor limitation
Some limitation
Extreme limitation
N/A
N/A
N/A
N/A
N/A
N/A
FEV1 /FVC
N/A
Risk
Exacerbations
Up to 1x/year
requiring systemic
corticosteroids
Therapy
recommendation
See 04 Year
Stepwise Chart,
pp. 1213.
Mild
Symptoms
Lung function:
FEV1 predicted N/A
Persistent asthma
Initiate therapy
at Step 1.
2 or more exacerbations in 6 months 1 or

4 or more wheezing episodes in the year lasting longer than a
day and having risk factors for persistent asthma 2
Initiate therapy
at Step 2.
Initiate therapy
at Step 3.
Initiate therapy
at Step 3.
Consider short
Consider short
course of systemic course of systemic
corticosteroids.
corticosteroids.
Patients with 2 or more exacerbations may be considered the same as patients who have persistent asthma,
even in the absence of impairment consistent with persistent asthma.
Initiate daily long-term control therapy for children who had 4 or more episodes of wheezing in the past year
that lasted longer than 1 day and affected sleep and who have either:
One of the following: parental history of asthma, physician diagnosis of atopic dermatitis, or evidence of
sensitizations to inhaled allergens, or
Two of the following: sensitization to foods, blood eosinophilia of 4% or higher, or wheezing apart from
colds.
Table 3b. Patients aged 04 years currently taking medications: assessing asthma control
Assess each component over the last 24 weeks. The result is based on the score of the most
severe component.
Asthma is:
Impairment
Well controlled
Not well controlled
Very poorly controlled
Symptoms
Up to 2 days/week but More than 2 days/week

not more than once a or multiple times up to
day
2 days/week
Throughout the day
Nighttime
awakenings
Up to 1x/month
More than 1x/month
More than 1x/week
Short-acting beta2
Up to 2 days/week
agonist use (for
rescue, not exercise
prophylaxis)
More than 2 days/week
Several times a day
Interference with
normal activity
None
Some limitation
Extreme limitation
N/A
N/A
N/A
N/A
N/A
N/A
Questionnaire
N/A
N/A
N/A
Risk
Exacerbations
requiring systemic
corticosteroids
01x/year
23x/year
More than 3x/year
Therapy
recommendation
See 04 Year
Stepwise Chart,
pp. 1213.
Maintain therapy at
current step.
Step up 1 step. 1
Step up 12 steps. 1
Follow-up
Every 16 months
Lung function:
FEV1 predicted
FEV1 /FVC
Consider short course

of systemic
corticosteroids.
If well controlled for

3 months or longer,
consider step down.
26 weeks
2 weeks
Before stepping up therapy, review adherence to medication, inhaler technique, and environmental control.

Table 4a. Patients aged 511 years not on medications: classifying asthma severity
component.
Impairment
Intermittent
asthma
Persistent asthma
Mild
Moderate
Severe
Symptoms
Up to
2 days/week
More than
2 days/week
Daily
Throughout the day
Nighttime
awakenings
Up to 2x/month
34x/month
More than 1x/week

but not nightly
Often 7x/week
Short-acting beta2
Up to
agonist use (for
2 days/week
prophylaxis)
More than
2 days/week
Daily
Several times a day
Interference with
normal activity
Minor limitation
Some limitation
Extreme limitation
Normal between Greater than 80%

exacerbations;
greater than
80%
6080%
Less than 60%
Greater than
0.85
Greater than 0.80
0.750.80
Less than 0.75
Up to 1x/year
At least 2x/year 2
At least 2x/year 2
At least 2x/year 2
Initiate therapy
at Step 1.
Initiate therapy
at Step 2.
Initiate therapy
at Step 3, mediumdose inhaled
corticosteroid
option.
Initiate therapy
at either Step 3,
medium-dose
inhaled
corticosteroid
option, or at Step 4.
Lung function:
FEV1 predicted
FEV1 /FVC 1
Risk
Exacerbations
requiring systemic
corticosteroids
Therapy
recommendation
See 511 Year
Stepwise Chart, pp.
1415.
None
Consider short
course of systemic Consider short
course of systemic
corticosteroids.
corticosteroids.
1
2
Relevant annual risk may be related to FEV1.

Patients with 2 or more exacerbations may be considered the same as patients who have persistent asthma,
even in the absence of impairment consistent with persistent asthma.
Table 4b. Patients aged 511 years currently taking medications: assessing asthma control
component.
Asthma is:
Impairment
Well controlled
Not well controlled
Symptoms
Up to 2 days/week

or multiple times on up
to 2 days/week
Throughout the day
Nighttime awakenings
Up to 1x/month
At least 2x/month
At least 2x/week
Short-acting beta2 agonist

use (for rescue, not
exercise prophylaxis)
Up to 2 days/week
Several times a day
Interference with normal

activity
None
Some limitation
Extreme limitation
Greater than 80%
6080%
Less than 60%
Greater than 0.80
0.750.80
Less than 0.75
Questionnaire Childhood
ACT score
20 or higher
1319
12 or lower
Risk
Exacerbations requiring
systemic corticosteroids
01x/year
23x/year
More than 3x/year
Therapy recommendation
See 511 Year Stepwise
Chart, pp. 1415.
Maintain therapy at
current step.
Step up at least 1
step. 1
Step up 12 steps. 1
Lung function:
FEV1 predicted
FEV1 /FVC
Consider short course

of systemic
corticosteroids.
If well controlled for

at least 3 months,
consider step
down.
Follow-up
1
Every 16 months
26 weeks
2 weeks

Table 5a. Patients aged 12 years and older not on medications: classifying asthma severity
component.
Impairment
Intermittent
asthma
Persistent asthma
Mild
Moderate
Severe
Symptoms
Up to
2 days/week
More than
2 days/week
Daily
Throughout the day
Nighttime
awakenings
Up to 2x/month
34x/month
More than 1x/week

but not nightly
Often 7x/week
Short-acting beta2
Up to
agonist use (for
2 days/week
prophylaxis)
More than
2 days/week but
not more than
1x/day
Daily
Several times a day
Interference with
normal activity
Minor limitation
Some limitation
Extreme limitation
6080%
Less than 60%
None
Lung function:
Normal between Greater than 80%
FEV1 predicted or exacerbations;
personal best
greater than
80%
FEV1 /FVC 1
Risk
Exacerbations
requiring systemic
corticosteroids
Normal
Normal
Reduced 0.05
Reduced more than

0.05
Up to 1x/year
At least 2x/year 2
At least 2x/year 2
At least 2x/year 2
Initiate therapy
at Step 2.
Initiate therapy
at Step 3.
Initiate therapy
at Step 4 or 5.
Initiate therapy
Therapy
at Step 1.
recommendation
See 12+ Year Stepwise
Chart, pp. 1617.
Consider short
Consider short
course of systemic course of systemic
corticosteroids.
corticosteroids.
Normal FEV1 /FVC by age group:

819 years = 0.85
2039 years = 0.80
4059 years = 0.75
6080 years = 0.70
Patients with 2 or more exacerbations may be considered the same as patients who have persistent
asthma, even in the absence of impairment consistent with persistent asthma.
Table 5b. Patients aged 12 years and older currently taking medications: assessing asthma
control
component.
Asthma is:
Impairment
Well controlled
Not well controlled
Symptoms
Up to 2 days/week
Throughout the day
Nighttime awakenings
Up to 2x/month
13x/week
At least 4x/week
Short-acting beta2 agonist

use (for rescue, not
exercise prophylaxis)
Up to 2 days/week
Several times a day
Interference with normal

activity
None
Some limitation
Extreme limitation
Lung function (FEV1

predicted or personal best)
Greater than 80%
6080%
Less than 60%
Questionnaire ACT score
20 or higher
1619
15 or lower
Risk
Exacerbations requiring
systemic corticosteroids
Up to 1x/year
At least 2x/year
At least 2x/year 2
Step up at least 1
step. 1
Step up 12 steps. 1
Consider short
course of systemic
corticosteroids.
26 weeks
2 weeks
Maintain current
Therapy recommendation
See 12+ Year Stepwise Chart, step.
pp. 1617.
If well controlled
for at least
3 months,
consider step
down.
Follow-up
1
Every 16 months
Treatment
Goals
Table 6. Goals of asthma treatment
Reduce
impairment.
Reduce risk.
Prevent chronic and troublesome symptoms.

Require infrequent use (up to 2 days a week) of short-acting beta2 agonists
(SABA) for quick relief of symptoms (not including their use to prevent exerciseinduce bronchospasm).
Maintain near-normal lung function.
Maintain normal activity levels (including exercise and other physical activity).
Prevent exacerbations and minimize the need for emergency care or
hospitalization.
Have minimal or no adverse effects of pharmacotherapy
Prevent loss of lung function; for children, prevent reduced lung growth.
10
Lifestyle Modifications/Non-Pharmacologic Options

For patient self-management strategies, see Table 7a.
For additional asthma management strategies, see Table 7b.
Table 7a. Patient self-management strategies for asthma
Self-monitor
symptoms.
Patient monitors symptoms and/or uses a peak flow meter to assess control and signs
of worsening.
Consider use of a peak flow meter for patients who have moderate or severe
persistent asthma or a history of severe exacerbations, or who poorly perceive airflow
obstruction and worsening asthma. Patient instructions for using peak flow meters are
available on ghc.org, at
https://provider.ghc.org/open/caringForOurMembers/patientHealthEducation/conditionsDiseases
/peakFlowMeter.pdf
Follow an
Asthma Action
Plan.
With provider, patient develops and follows a written Asthma Action Plan that includes
instructions for:
Daily management
Environmental control measures
Self-monitoring to assess control and signs of worsening either through
symptoms or peak flow
Managing worsening asthma
Take medication Patient instructions for using the following inhalers and devices are available on
correctly.
ghc.org, at
https://provider.ghc.org/open/caringForOurMembers/patientHealthEducation/index.jhtml
Select Conditions, Diseases, & Symptoms > Asthma.

Metered-Dose Inhaler
Inhaler by Chamber
Valved Holding Chamber
Diskus Inhaler
Flonase Nasal Spray
Nasarel Nasal Spray
Spiriva HandiHaler
Twisthaler
Nebulizer with Air Compressor
Limit/control
environmental
factors that
trigger or worsen
symptoms.
Tobacco smoke
Strong odors or sprays
Dust mites
Cockroaches
Animal dander
Pollen and outdoor mold
Indoor mold
11
Table 7b. Additional strategies for asthma management

Treat comorbid
conditions that
worsen asthma.
Allergic bronchopulmonary aspergillosis

GERD
Obesity
Obstructive sleep apnea
Rhinitis
Sinusitis
Stress or depression
Consider
immunotherapy.
Consider a referral to an allergy specialist for immunotherapy for patients who

have allergies, mild or moderate persistent asthma, and a clear relationship
between asthma symptoms and exposure to an allergen.
Encourage
physical activity.
Encourage patient to engage in physical activity. Exercise has significant health

benefits; exercise-induced asthma symptoms can be controlled, and
engagement in regular exercise is encouraged.
Encourage
tobacco
cessation.
Advise patient to quit smoking.

See the Tobacco Use Guideline for recommendations.
Encourage
weight
management.
The risk of serious health conditions increases with body mass index (BMI) of 25
or higher. While most overweight or obese adults can lose weight by eating a
healthy diet or increasing physical activity, doing both is most effective.
See the Weight Management Guideline for recommendations and further
information.
Pharmacologic Options
Stepwise charts for long-term management of asthma begin on the following page.
12
Pharmacologic Options: Stepwise Approach to Long-term Asthma Management in Patients Aged 04 Years
For notes to this chart, including abbreviations used, see following page.
INTERMITTENT
Symptoms
Step 1
PERSISTENT
Symptoms
Step 2
Step 3
Step 4
Step 5
Refer to asthma specialist
Step 6
Refer to asthma specialist
Quick-relief medication (as needed)

SABA
Albuterol HFA
w/spacer
90 mcg/puff
2 puffs every
46 hours prn
SABA
Albuterol HFA w/spacer
90 mcg/puff
2 puffs every 46 hours prn
SABA
90 mcg/puff
Long-term control medicationPREFERRED
SABA
90 mcg/puff
SABA
90 mcg/puff
SABA
90 mcg/puff
High-dose ICS
1st line
Fluticasone (Flovent)
HFA/MDI
Greater than 176 mcg twice
daily, delivered with face
mask and spacer
High-dose ICS
1st line
HFA/MDI
Greater than 176 mcg twice
mask and spacer
2nd line (age over 12 months)

Budesonide (Pulmicort
Respules) nebulization
suspension
Greater than 1 mg, divided
13x daily

suspension
Greater than 1 mg, divided 1
3x daily
and
either LTRA
(Age 24 years)
Montelukast (Singulair) tablet
(PA)
4 mg daily at bedtime
or LABA
(Age 4 years)
Salmeterol (Serevent) DPI
(PA)
50 mcg every 12 hours
and
either LTRA
(Age 24 years)
(PA)
or LABA
(Age 4 years)
(PA)
1,2
Low-dose ICS
1st line
HFA/MDI 88 mcg twice
mask and spacer
Medium-dose ICS
1st line
HFA/MDI 88176 mcg twice
mask and spacer
Medium-dose ICS
1st line
Fluticasone (Flovent) HFA/MDI
88176 mcg twice daily,
delivered with face mask and
spacer
2nd line (age over 12

months)
suspension
0.250.5 mg, divided
13x daily

suspension
0.51 mg, divided
13x daily

suspension
0.51 mg, divided 13x daily
Long-term control
medication
2,3
ALTERNATIVE
LTRA
Age 1223 months:
Montelukast (Singulair) oral
granules (NF)
Age 24 years:
Montelukast (Singulair)
tablet (PA)
and
either LTRA
(Age 24 years)
(PA)
or LABA
(Age 4 years)
(PA)
and
Oral systemic
corticosteroid
Prednisone burst:
12 mg/kg/day.
Maximum 60 mg/day for
310 days
13
NOTES to Stepwise Approach, Patients Aged 04 Years

Abbreviations
SABA
short-acting beta2 agonist
ICS
inhaled corticosteroid
LABA
long-acting beta2 agonist
LTRA
leukotriene receptor antagonist
PA
prior authorization required
DPI
dry powder inhaler
MDI
metered-dose inhaler
HFA
hydrofluoroalkane
Notes
1
Inhaled corticosteroids
The safety and efficacy of inhaled corticosteroids aged under 12 months has not been established. Children aged under 4 years generally require delivery of ICS through
a face mask that fits snugly over the nose and mouth, avoiding nebulization into the eyes. The childs face should be washed after each treatment to prevent local
corticosteroid side effects.
Fluticasone HFA: The low dose for children up to 4 years of age is higher than that for children 511 years of age due to lower dose delivered with face mask and data
on efficacy in young children.
Budesonide: Use only jet nebulizers (Pari), as ultrasonic nebulizers are ineffective for suspension, and use only with a Pari mask (which has no holes that can allow
medicine to reach the eyes). Budesonide suspension is compatible with albuterol, ipratropium, and levalbuterol nebulizer solutions in the same nebulizer.
2
Leukotriene receptor antagonist (montelukast):

Not covered for allergic rhinitis, sinusitis or atopic dermatitis
Prior Authorization criteria:
1. Patients aged 12 months or over who have asthma and are unable to use inhaled corticosteroids because of medical contraindications or inability to manipulate
the inhaler. In these patients, a clinical response to montelukast must be documented for continued coverage. Rationale: montelukast is less effective than
inhaled corticosteroids.
2. For children under 12 years of age with asthma who are able to use inhaled corticosteroids, but not controlled on medium-dose inhaled corticosteroid
monotherapy, montelukast can be added to inhaled corticosteroid treatment.
3. For treatment of exercise-induced bronchospasm for athletes and children who do not have indications for inhaled corticosteroids and fail albuterol because
they are active for a substantial part of the day or because the time of their activity is not predictable.
4. For individuals who have history of systemic (anaphylactic) reaction to allergy immunotherapy, and poor response to at least one antihistamine pre-treatment
(i.e., diphenhydramine, loratadine, fexofenadine, cetirizine), montelukast can be added to antihistamine pre-treatment.
Other alternatives
Theophylline:
- Starting dose: 10 mg/kg/day
- Usual maximum for age under 12 months: [0.2 (age in weeks) + 5] = mg/kg/day
- Usual maximum for age 12 months or over: 16 mg/kg/day
14
Pharmacologic Options: Stepwise Approach to Long-term Asthma Management in Patients Aged 511 Years
For notes to this chart, including abbreviations used, see following page.
INTERMITTENT
Symptoms
Step 1
PERSISTENT
Symptoms
Step 2
Step 3
Step 4
Step 5
Refer to asthma
specialist
Step 6
Refer to asthma
specialist

SABA
Albuterol HFA
w/spacer
90 mcg/puff
2 puffs every 4
6 hours prn
SABA
90 mcg/puff
2 puffs every 46 hours
prn
SABA
90 mcg/puff
SABA
90 mcg/puff
SABA
90 mcg/puff
prn
SABA
90 mcg/puff
prn
Medium-dose ICS/LABA:
Fluticasone/salmeterol (Advair
Diskus) DPI 100 mcg/50 mcg
twice daily, 12 hours apart
(PA: criteria include not well
controlled on medium-dose ICS)
High-dose ICS/LABA:
Fluticasone/salmeterol
(Advair Diskus) DPI
250 mcg/50 mcg
500 mcg/50 mcg twice
daily, 12 hours apart
(PA: criteria include not
well controlled on
medium-dose ICS)
High-dose ICS/LABA:
Fluticasone/salmeterol
(Advair Diskus) DPI
250 mcg/50 mcg
500 mcg/50 mcg twice
daily, 12 hours apart
(PA: criteria include not
well controlled on
medium-dose ICS)

Low-dose ICS
1st line
HFA/MDI w/spacer
4488 mcg twice daily
Medium-dose ICS
1st line
w/spacer
2nd line
Beclomethasone (QVAR)
HFA/MDI w/spacer
2nd line
Beclomethasone (QVAR) HFA/MDI
w/spacer
Long-term control medicationALTERNATIVE

LTRA
tablet (PA)
Age 5 years: 4 mg daily
at bedtime
Age 611 years: 5 mg
daily at bedtime
1, 2
Low-dose ICS
1st line
w/spacer
Medium-dose ICS
1st line
w/spacer
2nd line
w/spacer
2nd line
w/spacer
and
either LABA
Salmeterol (Serevent) DPI (PA)
or LTRA
Montelukast (Singulair) tablet (PA)
and LTRA
(PA)
Age 5 years: 4 mg daily at bedtime

Age 611 years: 5 mg daily at
bedtime

bedtime
bedtime
15
and Oral systemic

corticosteroid
Prednisone burst:
12 mg/kg/day.
Maximum 60 mg/day for
310 days
NOTES to Stepwise Approach, Patients Aged 511 Years

Abbreviations
SABA
ICS
LABA
LTRA
PA
DPI
dry powder inhaler
MDI
HFA
hydrofluoroalkane
Notes
1
3. For treatment of exercise-induced bronchospasm for athletes and children who do not have indications for inhaled corticosteroids and fail albuterol because they
are active for a substantial part of the day or because the time of their activity is not predictable.
2
Other alternatives
Theophylline:
- Starting dose: 10 mg/kg/day up to 300 mg/day
- Usual maximum dose: 16 mg/kg/day up to 600 mg/day
16
Pharmacologic Options: Stepwise Approach to Long-term Asthma Management in Patients Aged 12 Years and Older
For notes to this chart, including note about pregnancy and abbreviations used, see following page.
INTERMITTENT
Symptoms
Step 1
PERSISTENT
Symptoms
Step 2
Step 3
Step 4
Step 5
Refer to asthma
specialist
Step 6
Refer to asthma
specialist

SABA
Albuterol HFA
w/spacer
90 mcg/puff
2 puffs every 4
6 hours prn
SABA
90 mcg/puff
prn
SABA
90 mcg/puff

Low-dose ICS
1st line Beclomethasone
(QVAR) HFA/MDI w/spacer
2nd line
Mometasone (Asmanex)
Twisthaler (PA)
220 mcg once daily
Medium-dose ICS
1st line
Beclomethasone
2nd line
Mometasone (Asmanex) Twisthaler (PA)
440 mcg once daily
SABA
90 mcg/puff
prn
Medium-dose
ICS/LABA:
Mometasone/formoterol
(Dulera) 100 mcg/5 mcg
per inhalation, 2 puffs
twice daily (PA: criteria
include not well
controlled on mediumdose ICS)
High-dose ICS/LABA:
(Dulera) 200 mcg/5 mcg
per inhalation, 2 puffs
twice daily (PA: criteria
include not well controlled
on medium-dose ICS)
High-dose ICS/LABA:
(Dulera)
200 mcg/5 mcg per
inhalation, 2 puffs twice
daily (PA: criteria
include not well
controlled on mediumdose ICS)
2,3
Low-dose ICS/LABA
Fluticasone/salmeterol (Advair Diskus)
100 mcg/50 mcg twice daily, 12 hours
apart (PA)
or
Low-dose ICS
1st line
Beclomethasone
2nd line
Mometasone (Asmanex) Twisthaler (PA)
220 mcg once daily
and LTRA
Montelukast (Singulair) tablet (PA)
Age 1214 years: 5 mg daily at bedtime
Age 15 years and older: 10 mg daily at
bedtime
SABA
90 mcg/puff
prn
Long-term control medicationALTERNATIVE

LTRA
tablet (PA)
Age 1214 years:
Age 15 years and older:
SABA
90 mcg/puff
prn
Medium-dose ICS
1st line
Beclomethasone (QVAR)
HFA/MDI w/spacer
2nd line
Mometasone (Asmanex)
Twisthaler (PA)
440 mcg once daily
and LTRA
tablet (PA)
Age 1214 years:
Age 15 years and older:
17
and Oral systemic

corticosteroid
Prednisone burst:
4060 mg/day as single
or 2 divided doses for
310 days
NOTES to Stepwise Approach, Patients Aged 12 Years and Older

Abbreviations
SABA
ICS
LABA
LTRA
PA
DPI
dry powder inhaler
MDI
HFA
hydrofluoroalkane
Notes
1
Pregnancy
Inhaled corticosteroids (ICS) are the preferred medication for long-term asthma control in pregnancy. Budesonide (class B) is the preferred ICS because more data are
available on using budesonide in pregnant women than are available on other ICS, and the data are reassuring.

3. For treatment of exercise-induced bronchospasm for athletes and children who do not have indications for inhaled corticosteroids and fail albuterol because they
are active for a substantial part of the day or because the time of their activity is not predictable.
Other alternatives
Theophylline:
- Starting dose: 10 mg/kg/day up to 300 mg/day
- Usual maximum dose: 800 mg/day
Tiotropium: While effective for patients with COPD, is not recommended for the management of asthma
Omalizumab (Xolair): Patients on this medication, if they meet the pre-service approval criteria for office-administered injectables, are managed by Allergy and
Pulmonary.
18
Follow-up/Monitoring
To optimize treatment and prevent complications, the following periodic monitoring is advised:
Table 8. Frequency of follow-up in patients with asthma
Patients level of asthma control
Frequency
Well controlled
16 months
Gaining control/stepping up therapy
26 weeks
Stepping down therapy
3 months
Table 9. Recommended periodic monitoring of conditions and complications

Assessment
1
2
Frequency
For patients aged 5 years or older, ask patient to complete and

then review the Childhood Asthma Control Test (ages 511) or the
Asthma Control Test 1 (ACT) (ages 12 and up).
Assess level of impairment.
Assess level of risk.
Review written Asthma Action Plan.
Ascertain patient adherence.
Determine if therapy should be maintained, stepped down, or
stepped up. Consider stepping down therapy is patient has been
stable at least 3 months.
Spirometry 2
Every visit
12 years, more frequently if

patient is not well controlled
See Appendix 2 for Asthma Control Tests (ACTs).

Appropriate for patients aged 5 years and up.
Comorbidity Screening
Table 10. Recommended comorbidity screening for patients with asthma
Comorbid condition
Test(s)
Depression
Consider screening with the Patient Health Questionnaire (PHQ-9). 1, 2
See the Adult Depression and Adolescent Depression guidelines for additional guidance. Patients with major
depression can be treated in primary care or offered a referral to Behavioral Health Services for counseling and/or
drug therapy.
Evidence suggests that patients with depression are less likely to be adherent to recommended management plans
and less likely to be effective at self-management.
Comorbidity Prevention
Recommend an annual flu vaccine to help patients prevent influenza.
The pneumococcal polysaccharide vaccine (PPV23) is now recommended for asthmatic patients aged
1964 (PPV23 is already recommended for all patients aged 65); see the CDC guideline at
http://www.cdc.gov/vaccines/vpd-vac/pneumo/
Copyright 19992012 Group Health Cooperative. All rights reserved.
19
Evidence Summary
Accuracy and reliability of screening and diagnostic tests
Use of spirometry in the diagnosis and initial assessment of asthma
There is fair evidence that objective assessment of pulmonary function using spirometry, in addition to the
medical history and physical examination, could improve the diagnosis of asthma and the determination
of severity in adults and children 418 years of age.
Researchers found that clinical symptoms alone underestimated spirometry-determined severity in 31%
of the children, and spirometry alone underestimated clinician-determined severity by 40% (Cowen et al
2007). An earlier study showed that 49% of the patients predicted to be abnormal with clinical evaluation
had normal spirometry, and 10% predicted to be normal clinically had abnormal spirometry (Nair et al
2005). In another study (Stout et al 2006), one-third of the children with moderate to severe asthma were
reclassified to a more severe category when pulmonary function tests were considered in addition to the
symptoms.
Impact of spirometry on management decisions
There is fair evidence that the use of spirometry has an impact on management decisions. There is,
however, insufficient evidence to determine that treatment decisions based on spirometry results reduce
morbidity and mortality due to asthma.
In Nair and colleagues 2005 study, providers made the initial treatment decisions before receiving the
pulmonary function test results. The treatment decisions were then revised, if needed, after reviewing the
results. Based on spirometry results, changes were made in the management decisions for 15% of the
patients. In these cases the provider was more likely to increase (75%) than to maintain (20%) or
decrease (5%) therapy.
Assessment of asthma control
Measures for assessing asthma control
There are multiple questionnaires for the assessment of asthma control. These include: the Asthma
Control Test (ACT), Asthma Therapy Assessment Questionnaire (ATAQ), Asthma Control Questionnaire
(ACQ), Mini Asthma Quality of Life Questionnaire, and others.
There is insufficient evidence to determine the effect of monitoring asthma patients with any of these
questionnaires on health outcomes.
There is no established gold standard for assessing asthma control, and there is insufficient evidence to
determine that one test is superior to the other in monitoring control. The majority of the questionnaires
were validated for assessing asthma control in patients with persistent asthma. However, no published
randomized controlled trials (RCTs) compared one questionnaire with the other, nor studied the effect of
monitoring asthma patients with any of these questionnaires on health outcomes.
Frequency of periodic monitoring of control
There is insufficient evidence to determine the most appropriate frequency of monitoring for asthma.
There were no published trials that compared the effect of different frequencies of visits to the clinician on
asthma control and outcomes.
Pharmacologic therapy
Comparative effectiveness and safety of montelukast (Singulair) versus inhaled corticosteroids
(ICS) in patients with mild to moderate asthma
There is evidence form a valid meta-analysis (Castro-Rodriguez 2010) of 18 RCTs (N=3,757) that
compared to montelukast, ICS leads to better asthma control and lung function, and fewer asthma
exacerbations requiring systemic steroids among school-age children and adolescents with mild to
moderate persistent asthma
20
The meta-analysis does not provide sufficient evidence to determine whether the addition of montelukast
to ICS would improve outcomes.
Step-up therapy for children with uncontrolled asthma while receiving ICS
The Best Add-on Therapy Giving Effective Responses (BADGER) trial (Lemanske 2010) evaluated the
differential response to 3 step-up therapies for children 6-17 years of age with uncontrolled mild to
moderate asthma while on low-dose inhaled corticosteroids. The study also aimed at identifying patient
characteristics that could be used to predict the response to step-up treatment.
The primary outcomes of the trial were differential response to the step-up therapies based on need for
oral prednisone for acute exacerbations, number of asthma control days, and FEV1.
The results of the study show that higher proportion had a better response to LABA than to LTRA (52%
vs. 34%, p=0.02) and a better response to LABA than to high-dose ICS (54% vs. 32%, p=0.004), without
significant differences between LTRA and high-dose ICS.
There is insufficient published evidence to determine the relative long-term safety of the three regimens.
Omalizumab
The published studies on omalizumab show that its use as an add-on therapy to steroids may have a
statistically significant but minimal and clinically irrelevant benefit over placebo in reducing asthma
exacerbations among patients with moderate to severe allergic asthma.
There is some evidence that omalizumab does not improve pulmonary function and has more treatmentrelated adverse events than placebo.
There is insufficient evidence to determine the long-term safety and efficacy of omalizumab in patients
with moderate to severe allergic asthma.
There is no evidence to determine how long treatment with omalizumab should last, and what happens if
it is discontinued.
Tiotropium bromide (Spiriva)

The results of the published trials on the use of tiotropium for asthma patients do not provide sufficient
evidence to determine the long-term safety and clinical efficacy of tiotropium as an add-on therapy for
patients with mild to moderate asthma inadequately controlled with low-dose ICS, or with severe asthma
inadequately controlled with high-dose ICS plus LABA.
Long-acting beta2 agonists (LABA)

There is evidence that LABA used alone may increase the risk of asthma-related fatal and nonfatal
adverse events.
There is conflicting evidence on the effect of concomitant use of ICS on reducing the harms associated
with LABA. Findings from the Ducharme meta-analysis (2011) support the use of a single inhaler for the
delivery of LABA and ICS.
21
References
Busse WW, Morgan WJ, Gergen PJ, et al. Randomized trial of omalizumab (anti-IgE) for asthma in innercity children. N Engl J Med. 2011 Mar 17;364(11):10051015.
Castro-Rodriguez JA, Rodrigo GJ. The role of inhaled corticosteroids and montelukast in children with
mild-moderate asthma: results of a systematic review with meta-analysis. Arch Dis Child. 2010
May;95(5):365370.
Cates CJ, Cates MJ. Regular treatment with salmeterol for chronic asthma: serious adverse events.
Cochrane Database Syst Rev. 2008;3:CD006363.
Cates CJ, Cates MJ, Lasserson TJ. Regular treatment with formoterol for chronic asthma: serious
adverse events. Cochrane Database Syst Rev. 2008;4:CD006923.
Cates CJ, Lasserson TJ, Jaeschke R. Regular treatment with salmeterol and inhaled steroids for chronic
asthma: serious adverse events. Cochrane Database Syst Rev. 2009;3:CD006922.
Cates CJ, Lasserson TJ, Jaeschke R Regular treatment with formoterol and inhaled steroids for chronic
asthma: serious adverse events. Cochrane Database Syst Rev. 2009;2:CD006924.
Cowen MK, Wakefield DB, Cloutier MM. Classifying asthma severity: objective versus subjective
measures. J Asthma. 2007 Nov;44(9):711715.
Ducharme FM, Lasserson TJ, Cates CJ. Addition to inhaled corticosteroids of long-acting beta2-agonists
versus anti-leukotrienes for chronic asthma. Cochrane Database Syst Rev. 2011;5:CD003137.
DOI:10.1002/14651858.CD003137.pub4.
Hanania NA, Alpan O, Hamilos DL, et al. Omalizumab in severe allergic asthma inadequately controlled
with standard therapy: a randomized trial. Ann Intern Med. 2011 May 3;154(9):573-582.
Kerstjens HA, Disse B, Schrder-Babo W, et al. Tiotropium improves lung function in patients with severe
uncontrolled asthma: a randomized controlled trial. J Allergy Clin Immunol. 2011 Aug;128(2):308314.
Epub 2011 Jun 2.
Lanier B, Bridges T, Kulus M, Taylor AF, Berhane I, Vidaurre CF. Omalizumab for the treatment of
exacerbations in children with inadequately controlled allergic (IgE-mediated) asthma. J Allergy Clin
Immunol. 2009 Dec;124(6):12101216.
Lemanske RF Jr, Mauger DT, Sorkness CA, et al for the Childhood Asthma Research and Education
(CARE) Network of the National Heart, Lung, and Blood Institute. Step-up therapy for children with
uncontrolled asthma receiving inhaled corticosteroids. N Engl J Med. 2010 Mar 18;362(11):975985.
Lui AH, Zeiger RS, Sorkness CA, et al The Childhood Asthma Control Test*: Retrospective determination
and clinical validation of a cut point to identify children with very poorly controlled asthma J Allergy Clin
Immunol. 2010;126:267273.
Nair SJ, Daigle KL, DeCuir P, Lapin CD, Schramm CM. The influence of pulmonary function testing on
the management of asthma in children. J Pediatr. 2005 Dec;147(6):797801.
Peters SP, Kunselman SJ, Icitovic N, et al for the National Heart, Lung, and Blood Institute Asthma
Clinical Research Network. Tiotropium bromide step-up therapy for adults with uncontrolled asthma.
N Engl J Med. 2010 Oct 28;363(18):1715-1726.
Rodrigo GJ, Neffen H, Castro-Rodriguez JA. Efficacy and safety of subcutaneous omalizumab vs placebo
as add-on therapy to corticosteroids for children and adults with asthma: a systematic review. Chest.
2011 Jan;139(1):28-35.
Salpeter SR, Wall AJ, Buckley NS. Long-acting beta-agonists with and without inhaled corticosteroids and
catastrophic asthma events. Am J Med. 2010 Apr;123(4):322-8.e2.
Stout JW, Visness CM, Enright P, et al. Classification of asthma severity in children: the contribution of
pulmonary function testing. Arch Pediatr Adolesc Med. 2006 Aug;160(8):844850.
22
Clinician Lead and Guideline Development

Clinician Lead
David K. McCulloch, MD
Medical Director, Clinical Improvement
Phone: 206-326-3938
Clinician Lead
Paula Lozano, MD, MPH
Associate Medical Director of Preventive Care
Phone: 206-326-3938
Most recent comprehensive literature review: September 2011
Process of Development
This evidence-based guideline was developed using an explicit evidence-based process, including
systematic literature search, critical appraisal with evidence grading, and evidence synthesis. The
following specialties were represented on the development and/or update teams: allergy, pulmonary,
epidemiology, respiratory therapy, family medicine, nursing, pharmacy.
These guidelines are adapted from the 2007 national guidelines published by the National Asthma
Education and Prevention Program, an NIH agency. The Group Health recommendations further refine
the preferred range of medications listed for each step on the formulary.
23
Asthma action plan for adults

Your self-care plan to prevent and treat acute episodes
Keeping your asthma in good control can make it easier to do normal daily activities. Good
control can also help you avoid trips to the emergency room or hospital to treat a flare up or
episode of asthma.
Many people cant tell when their asthma is starting to flare up until after they are well into an
episode. Developing an asthma action plan can help you keep your asthma under control and
avoid episodes.
Putting your asthma action plan together

Your asthma action plan is based on your symptoms and best possible peak flow number. Take
your personal best peak flow recorded on your chart. Your personal best is ________.
The Peak Flow Zone System

Peak flow numbers are often put into zones set up like a traffic light. This helps you know what
to do when your peak flow number changes. Your asthma medicines depend on if youre in the
green, yellow, or red zone. See the back of this page to set up your asthma action plan.
Medicines for asthma

Controller medicines are used everyday to help keep your airways open. Examples include
inhaled corticosteroids such as QVAR, Flovent, Advair, and oral medicine such as Singulair.
Rescue medicines are used to relax the airways in your lungs to help stop an episode. Albuterol
is one example of a rescue medicine.
Oral corticosteroids (called oral steroids) are medicines that treat the swelling and extra mucus
produced by inflamed airways. Examples include prednisone and Medrol. These are similar to
the steroids our bodies make every day (they are not the muscle-building type of steroids.)
Youll use an oral steroid if your rescue medicine doesnt work to control a flare of asthma.
Side effects of oral steroids
Taking oral steroids for a short time rarely causes side effects. When side effects do happen, they
can usually be reversed once you stop taking the medicine.
Side effects include the following: mood changes, acne, problems sleeping, full or red cheeks,
feeling hungrier, and gaining weight. Steroids can also make some health problems worse.
These include peptic ulcer disease, tuberculosis, glaucoma, depression, aseptic necrosis, high
blood pressure or diabetes. If you have, or have had, any of these health conditions, talk to your
doctor before taking oral steroids.
page 1 of 2
Continued on next page
Green Zone: I feel well

You want to be here every day. If
youre in this zone it means you
have no signs of an asthma episode.
You can do your usual activities and
sleep without having symptoms.
Peak flow above: __________
(over 80% of personal best)
Yellow Zone: I do not feel well

You might have mild or moderate
signs of an asthma episode. These
could include coughing, wheezing,
being short of breath or feeling
tightness in the chest. Symptoms
might keep you from your usual
activities or sleeping.
High Yellow Zone:
Peak flow: _______ to _______
(65-80% of personal best)
Low Yellow Zone:
Peak flow: _______ to _______
(50%-65% of personal best)
Take your inhaled corticosteroid as usual.

You may sometimes need a rescue medicine: Use
albuterol MDI (Ventolin, Proventil) inhaler, 1-2 puffs

every 4-6 hours as needed and before exercise.
If you need your rescue medicine more than 2 times a
week, talk to your doctor about increasing your controller
medicines.
High Yellow Zone
Use albuterol inhaler: 2-4 puffs every 20 minutes for
up to 1 hour or until you return to the green zone.
Check peak flow 10 minutes after each treatment.
If you stay in this zone for more than 12 hours, take
twice as much of your inhaled corticosteroid, unless
your doctor has given you other instructions. Do this
until your peak flow stays in the green zone for the
same amount of time that it was in the yellow zone.
If youre in the high yellow zone for more than 5 days, call
your doctor.
Low Yellow Zone
Use albuterol inhaler and check peak flow following
instructions above.
If your peak flow doesnt reach the high yellow zone with
3 albuterol treatments or it drops back into the low yellow
zone within 4 hours:
If you have prednisone, take it by following the
directions listed below in the red zone. Call your
doctor whenever you start taking prednisone.
If you dont have prednisone, call your doctor. After
hours, call the Consulting Nurse Service:
1-800-297-6877.
Let your doctor know if you keep going into the yellow zone. We might need to change your
controller medicines to keep your asthma under better control and avoid episodes.
Red Zone: I feel awful
This is an emergency. Your
asthma is seriously out of control.
Signs include coughing, having
trouble breathing, wheezing
loudly, or having trouble walking
or talking. If you arent wheezing,
it could be because air cant easily
move out of your airways.
Peak flow below: __________
(below 50% of personal best)
Use albuterol inhaler: 4-6 puffs every 10 minutes for up
to 30 minutes or until you return to the yellow zone.
Check peak flow 10 minutes after each treatment.
If you have prednisone, take 60 mg right away. Then

take 20 mg twice a day for at least 3 days, even if your
symptoms go away or your peak flow stays in the green
zone for 24 hours. Do not take prednisone for more
than 10 days. Call your doctor whenever you start
taking prednisone.
If you dont have prednisone, call your doctor. After
hours, call the Consulting Nurse Service:
1-800-297-6877,
Call your doctor. Follow-up is critical.
If you dont return to the yellow zone within 30
minutes or your asthma gets worse, get medical care
right away.
If your lips or fingernails become blue or if youre struggling to breathe, call 911 right away.
PHER
DA-3241
page 2 of 2
Rev. date 2010230
2010 Group Health Cooperative
Enter Name
Todays Date:
Enter Address
Patients Name:
Enter City/State/Zip
Childhood Asthma Control Test for children 4 to 11 years.

This test will provide a score that may help the doctor determine if your childs asthma treatment plan is working or if it might be time for a change.
How to take the Childhood Asthma Control Test
Step 1 Let your child respond to the first four questions (1 to 4). If your child needs help reading or understanding the question, you may
help, but let your child select the response. Complete the remaining three questions (5 to 7) on your own and without letting your
childs response influence your answers. There are no right or wrong answers.
If your childs score is 19 or less, it

may be a sign that your childs
or less asthma is not controlled as well
as it could be. Bring this test to
the doctor to talk about the results.
Step 2 Write the number of each answer in the score box provided.
19
Step 3 Add up each score box for the total.

Step 4 Take the test to the doctor to talk about your childs total score.
Have your child complete these questions.

1. How is your asthma today?
SCORE
Very bad
Bad
Good
Very good
2. How much of a problem is your asthma when you run, exercise or play sports?
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
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?
Yes, all of the time.
Yes, most of the time.
2
Yes, some of the time.
No, none of the time.
Please complete the following questions on your own.

5. During the last 4 weeks, how many days did your child have any daytime asthma symptoms?
5
Not at all
1-3 days
4-10 days
11-18 days
19-24 days
Everyday
11-18 days
19-24 days
Everyday
6. During the last 4 weeks, how many days did your child wheeze during the day because of asthma?
5
Not at all
1-3 days
3
4-10 days
7. During the last 4 weeks, how many days did your child wake up during the night because of asthma?
5
Not at all
1-3 days
4-10 days
11-18 days
19-24 days
Everyday
Asthma Control Test. AsthmaControl.com. GlaxoSmithKline, 2002. Web. 9 Apr 2010.

<http://www.asthmacontrol.com/hcp.html>.
DA-3320
Rev. Date 2010105
TOTAL
Enter Address
Enter Name
Enter Address
Patients Name:
Todays Date:
Patients Name:
FOR
PATIENTS:
Take the Asthma Control TestTM (ACT) for people 12 yrs and older.
FOR PATIENTS:
Know your score. Share your results

with your doctor.
TM
Take the Asthma Control Test
(ACT) for people 12 yrs and older.
Step 1 Write the number of each answer in the score box provided.
Know your score.
Share your results with your doctor.
Step 2 Add the score boxes for your total.

Step 3
1 Take
Writethe
thetest
number
each to
answer
in theyour
score
box provided.
Step
to theofdoctor
talk about
score.
Step 2 Add the score boxes for your total.
Step 3 Take the test to the doctor to talk about your 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
the time
Most of
the time
Some of
the time
A little of
the time
None of
the time
A little of
the time
None of
the time
Not at all
1
2
3
4
5
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
3
2. During
shortness
of breath?
the time the past 14 weeks,thehow
timeoften have2you hadthe
time
More than
once a day
3 to 6 times
Once or twice
a week
More than
3 to 6 times
Once or twice
Once a day
1
2
3
a week
2. During the past 4 weeks, how often have you had shortness of breath?
SCORE
SCORE
day did your

Not atchest
all tightness
2 asthma
3
4 of breath,
5
3. During
the past 41 weeks,Once
howaoften
symptoms (wheezing,
coughing,
shortness
a week
a week
once a day
or pain) wake you up at night or earlier than usual in the morning?
2 or 3 nights
4 or more
Once
Once
a week (wheezing,
Not at chest
all
2 asthma
3
4 of breath,
5
3. nights
Duringa week
the past 14 weeks,a how
symptoms
coughing,
tightness
weekoften did your
or twice shortness
or pain) wake you up at night or earlier than usual in the morning?
3 nights
Once
or more
Once
a week
4. 4nights
During
the past 14 weeks,2a or
how
often have2 you used
your
rescue inhaler
or nebulizer
medication
albuterol)?
Notas
at all
3
4 (such
5
week
or twice
a week
1 or 2 times
3 or more
times per day
Once a week
2 or 3 times
Not at all
1
2
3
4
5
per day
or less
per week
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?
1 or 2 times
2 or 3 times
or more
5. 3times
How
would
you rate
asthma
control 2during the
past 4 weeks?3
1 yourper
day
per week
per day
Poorly
controlled
Not controlled
at all
Somewhat
controlled
1
2
3
5. How would you rate your asthma control during the past 4 weeks?
Not controlled
at all
Poorly
controlled
Somewhat
controlled
Once a week
or less
Well
controlled
Not at all
Completely
controlled
Well
controlled
Completely
controlled
Copyright 2002, by QualityMetric Incorporated.

Asthma Control Test is a trademark of QualityMetric Incorporated.
TOTAL
TOTAL
Copyright 2002, by QualityMetric Incorporated.

Asthma Control Test is a trademark of QualityMetric Incorporated.
If your score is 19 or less, your asthma may not be controlled as well as it could be.
Talk to your doctor.
If your score is 19 or less, your asthma may not be controlled as well as it could be.
FOR PHYSICIANS:
Talk to your doctor.
The ACT is:
Recognized by the National Institutes of Health
FOR
PHYSICIANS:
A simple,
5-question tool that is self-administered by the patient
Clinically
validated by specialist assessment and spirometry1
The
ACT is:
A simple, 5-question tool that is self-administered by the patient
Clinically validated by specialist assessment and spirometry1
Reference: 1. Nathan RA et al. J Allergy Clin Immunol. 2004;113:59-65.
Asthma Control Test. AsthmaControl.com. GlaxoSmithKline, 2002. Web. 9 Apr 2010.
<http://www.asthmacontrol.com/hcp.html>.
Reference: 1. Nathan RA et al. J Allergy Clin Immunol. 2004;113:59-65.
DA-3320 -1 Rev. Date 2010105
Recognized by the National Institutes of Health

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Asthma

Diagnosis and Treatment Guideline

Most recent comprehensive literature review: September 2011

Asthma Diagnosis and Treatment Guideline

Recurrent episodes of wheezing, coughing, chest tightness.

Table 2. Recommendations for diagnosing asthma

Results diagnostic of asthma

Spirometry: FEV1 /FVC Ages

FEV1 less than 80% of predicted.

Asthma Diagnosis and Treatment Guideline

Identify precipitating factors and aggravating comorbidities

Classify severity or assess control

Asthma Diagnosis and Treatment Guideline

Patients aged 04 years

Throughout the day

More than 1x/week

Several times a day

Interference with None

2 or more exacerbations in 6 months 1 or

Asthma Diagnosis and Treatment Guideline

Not well controlled

Very poorly controlled

Up to 2 days/week but More than 2 days/week

Throughout the day

More than 1x/month

More than 1x/week

More than 2 days/week

Several times a day

More than 3x/year

Consider short course

If well controlled for

Asthma Diagnosis and Treatment Guideline

Patients aged 511 years

Throughout the day

More than 1x/week

Several times a day

Normal between Greater than 80%

Less than 60%

Greater than 0.80

Less than 0.75

Relevant annual risk may be related to FEV1.

Asthma Diagnosis and Treatment Guideline

Not well controlled

Very poorly controlled

More than 2 days/week

Throughout the day

Short-acting beta2 agonist

More than 2 days/week

Several times a day

Interference with normal

Greater than 80%

Less than 60%

Greater than 0.80

Less than 0.75

More than 3x/year

Consider short course

If well controlled for

Asthma Diagnosis and Treatment Guideline

Patients aged 12 years and older

Throughout the day

More than 1x/week

Several times a day

Less than 60%