CONCISE REVIEW

ATTAINING ASTHMA FOR

CONTROL CLINICIANS
IN 4 EASY STEPS

The ABCs of Asthma Control

BJORG THORSTEINSDOTTIR, MD; GERALD W. VOLCHECK, MD; BO ENEMARK MADSEN, MD;
ASHOKAKUMAR M. PATEL, MD; JAMES T. C. LI, MD, PhD; AND KAISER G. LIM, MD

On completion of this article, you should be able to: (1) properly assess impairment using the new asthma guidelines, (2)
integrate the Asthma Control Test questionnaire in routine asthma office visits, and (3) facilitate review of confounding
factors and comorbidities of uncontrolled asthma using the mnemonic AIRESMOG.

The new asthma guidelines have introduced impairment and risk
assessments into the management of asthma. Impairment
assessment is based on symptom frequency and pulmonary
function, whereas risk assessment is based on exacerbation
frequency and severity. These 2 measures determine the initial
severity of asthma in the untreated patient as well as the
degree of control in asthma once treatment has been initiated.
The focus on asthma control is important because the attain-
ment of control correlates with a better quality of life and
reduction in health care use. We describe 4 easy steps to
achieving asthma control in the ambulatory practice setting:
(1) a standardized assessment of asthma symptoms using a
5-question assessment tool called the Asthma Control Test,
(2) a simple mnemonic that provides a systematic review of the
comorbidities and clinical variables that contribute to uncon-
trolled asthma, (3) directed patient education, and (4) a sched-
ule for ongoing care. Most if not all patients can achieve good
control of their asthma with optimal care through an active
partnership with their health care professionals.
Mayo Clin Proc. 2008;83(7):814-820
ACT = Asthma Control Test; GINA = Global Initiative for Asthma;
NAEPP = National Asthma Education and Prevention Program
started, must be differentiated from asthma severity, which
is an assessment of disease intensity before the start of
therapy.3 Separating the 2 concepts dispels the common
misperception that well-controlled asthma is synonymous
with mild asthma and that poorly controlled asthma is
synonymous with severe asthma.3 More importantly, the
degree of asthma control can be used as a clinical outcome
measure for titrating anti-inflammatory medications.4
In the new NAEPP guideline, asthma severity categori-
zation is still used but has more relevance when initiating
therapy in treatment-naive patients or in those with newly
diagnosed asthma. The new stepwise treatment recom-
mends that adjustments in controller therapy now be based
on the level of asthma control and risk reduction for asthma
exacerbation.1,2 Minimizing impairment and risk is the goal
of therapy for all levels of asthma severity.1,2 The attain-
ment of asthma control correlates with improved quality of
life and reduced health care use.5,6 Asthma control has
emerged as an aggregate outcome measure of disease sever-
ity, confounding comorbidities, pharmacologic and non-
pharmacologic interventions, and adherence to therapy.1,5-7

T he concept of asthma control has assumed center stage

in both the new Global Initiative for Asthma (GINA)
and National Asthma Education and Prevention Program
This review focuses on how to assess impairment and
achieve asthma control.

(NAEPP) guidelines.1,2 The NAEPP introduced the term

impairment (Figure 1) to refer to the assessment of lung
function and of the intensity and frequency of asthma
symptoms.2 The term risk refers to exacerbation frequency
and severity. These 2 parameters determine whether a pa-
tient’s disease burden from asthma is under clinical con-
trol. Asthma control, which is an assessment of symptom
frequency and lung function once treatment has been
From the Division of Primary Care Internal Medicine (B.T.), Division of Allergic
Diseases (G.W.V., J.T.C.L., K.G.L.), Department of Emergency Medicine
(B.E.M.), and Division of Pulmonary and Critical Care Medicine (A.M.P.,
K.G.L.), Mayo Clinic, Rochester, MN. Dr Thorsteinsdottir is now with Harvard
Medical School, Boston, MA. Dr Madsen is now with Beth Israel Deaconess
Medical Center, Boston, MA.
Individual reprints of this article are not available. Address correspondence to
Kaiser G. Lim, MD, Division of Pulmonary and Critical Care Medicine, Mayo
Clinic, 200 First Street SW, Rochester, MN 55905 (lim.kaiser@mayo.edu).
© 2008 Mayo Foundation for Medical Education and Research
ATTAINING ASTHMA CONTROL
STEP 1: USE A STANDARDIZED QUESTIONNAIRE TO ASSESS
ASTHMA CONTROL
Asthma is one of the most common chronic diseases in
children and in adults in the reproductive age range. De-
spite expert guidelines and medications with demonstrated
efficacy, asthma continues to be undertreated because pa-
tients and health care professionals underestimate disease
severity.8,9 Clinicians frequently fail to ask and/or docu-
ment longitudinally the basic set of clinical information
required to assess whether asthma is under control.10,11
Their failure to do so inevitably leads to inconsistency and
variability in clinical decision making and practice. Each
clinical encounter in primary care, even those that are
unrelated to asthma, should be considered an opportunity
to assess asthma control. Assessment can be facilitated by

814 Mayo Clin Proc. • July 2008;83(7):814-820 • www.mayoclinicproceedings.com

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
 ATTAINING ASTHMA CONTROL IN 4 EASY STEPS

Classification of asthma severity

≥12 y
Components of severity
Persistent
Intermittent Mild Moderate Severe
≤2 d /wk >2 d/wk but Daily Throughout the day
Symptoms
not daily
Nighttime ≤2 times /mo 3-4 times/mo >1 time/wk but Often 7 times/wk
awakenings not nightly
Short-acting ≤2 d /wk >2 d/wk Daily Several times/d
Impairment β2-agonist use for but not daily, and
symptom control (not not more than
prevention of EIB) 1 time on any day
Normal FEV1/FVC:
Interference with None Minor limitation Some limitation Extremely limited
8-19 y 85% normal activity
20-39 y 80%
40-59 y 75% Normal FEV1
between
60-80 y 70% exacerbations
Lung function F EV1 >80% F EV1 >80% F EV1 >60% but F EV1 <60%
predicted predicted <80% predicted predicted
F EV1/FVC normal F EV1/FVC normal F EV1/FVC reduced F EV1/FVC
5% reduced >5%

0-1/y ≥2/y
Exacerbations
requiring oral Consider severity and interval since last exacerbation
Risk systemic Frequency and severity may fluctuate over time for patients in any severity category
corticosteroids
Relative annual risk of exacerbations may be related to FEV1

Step 3 Step 4 or 5
Recommended step
Step 1 Step 2 and consider short course of
for initiating t reatment
oral systemic corticosteroids
In 2-6 wk, evaluate level of asthma control that is achieved and adjust therapy
(See Figure 3 for treatment steps) accordingly

FIGURE 1. National Asthma Education and Prevention Program (NAEPP) Expert Panel 3 categorization of asthma control and stepwise approach
to adjusting asthma treatment in patients aged 12 years and older. EIB = exercise-induced bronchoconstriction; FEV1= forced expiratory volume
in the first second of expiration; FVC = forced vital capacity. Adapted from reference 2.

using the Asthma Control Test (ACT) (QualityMetric In-
corporated, Lincoln, RI), a one-page asthma control ques-
tionnaire (Figure 2) that is validated for use in the primary
care setting as well as in specialty clinics.12-17
The developers of the questionnaire started with 22
questions to catalog the frequency and intensity of asth-
ma symptoms, use of asthma medications, and the ef-
fect of asthma on daily activities. By stepwise logistic
regression, these 22 questions were trimmed to the 5
items that have the greatest agreement with a specialist’s
assessment. The ACT score was then subjected to pro-
spective validation by comparison with the specialist’s
rating of asthma control, the patient’s lung function, and
the influence on the specialist’s decision to change ther-
apy. Designed for self-administration, this simple ques-
tionnaire can be completed while patients are waiting in
the lobby for their appointment. The 5 items on the ACT
questionnaire (Figure 2) cover the 4 weeks14 before the
visit and include an assessment of the number of work
days lost or school days missed, dyspnea frequency, rescue
medication requirement, nocturnal awakenings, and self-
assessment of asthma control. These parameters are
known sources of patient dissatisfaction with asthma care.18
Each answer corresponds to a numeric score; these scores
are totaled to arrive at the ACT score. The ACT ques-
tionnaire is available in Spanish and in a version intend-
ed for children (http://www.asthmacontrol.com). By
serving as an educational tool for patients (ie, symptom
monitoring), the questionnaire can simplify the clini-
cian’s job.
The NAEPP uses the ACT score to categorize degree of
control: an ACT score of 20 or more indicates that asthma
is well controlled; 16 through 19, that it is not well con-
trolled; and 15 or lower, that it is poorly controlled.2 On the
basis of these categorizations, recommendations to step up
or step down asthma treatment can be made (Figure 3). The
ACT may help overcome some of the problems regard-
ing symptom perception in asthma, including differing

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For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
ATTAINING ASTHMA CONTROL IN 4 EASY STEPS

Asthma Control Test

This survey was designed to help you describe your asthma and how your asthma affects how you feel
and what you are able to do. To complete it, please mark an in the one box that best describes your
answer.

1. I n the past 4 w eeks, how much of the time did your asthma keep you from getting as much
done at w ork, 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

1 2 3 4 5

2. During the past 4 w eeks, how often have you had shortness of breath?
More than 3 to 6 Once or twice
once a day Once a day times a week a week Not at all

1 2 3 4 5

3. During the past 4 w eeks, how often did your asthma symptoms ( w heezing, coughing,
shortness of breath, chest tightness or pain) w ake you up at night or earlier than usual in
the morning?
4 or more 2 to 3
nights a week nights a week Once a week Once or Twice Not at all

1 2 3 4 5

4. During the past 4 w eeks, how often have you used your rescue inhaler or nebulizer
medication ( such as Albuterol, Ventolin , Proventil , Maxair or Primatene Mist ) ?
3 or more 1 or 2 2 or 3 Once a week
times per day times per day times per week or less Not at all

1 2 3 4 5

5. How w ould you rate your asthma control during the past 4 w eeks?
Not Controlled Poorly Somewhat Well Completely
at all Controlled Controlled Controlled Controlled

1 2 3 4 5

FIGURE 2. The Asthma Control Test. Copyright 2002, by QualityMetric Incorporated. Asthma Control Test is
a trademark of QualityMetric Incorporated.

sensitivity in symptom perception, discrimination between
intensity of symptoms, and reliability of clinical symp-
toms.19 The ACT has been shown to be reliable, valid, and
responsive to changes in asthma control over time.14
Review of the questionnaire also helps physicians foster a
partnership with patients and engage them in their own
asthma management.
STEP 2: TROUBLESHOOT IF ASTHMA IS NOT UNDER CONTROL
If asthma is not under control (ACT score, <20), it is
helpful to quickly run through a list of common factors
affecting control. We offer an easy mnemonic to help the
clinician quickly review potential causes of poor asthma
control and determine which aspect of asthma treatment
requires intensification or whether further diagnostic
evaluation is necessary (Table).2,20-47
STEP 3: EDUCATE THE PATIENT
Clinicians often underestimate the severity of their patients’
disease state and overestimate their patients’ knowledge of
disease management.48 They assume that their patients are
aware of the differences between reliever and maintenance
medications and overestimate the number of patients with a
current written action plan. If consistently used as a symp-
tom checklist in the physician’s office and at home, the
ACT can be a helpful tool for teaching patients about

816 Mayo Clin Proc. • July 2008;83(7):814-820 • www.mayoclinicproceedings.com

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
 ATTAINING ASTHMA CONTROL IN 4 EASY STEPS

Persistent asthma: daily medication

Intermittent
asthma Consult with asthma specialist if step 4 care or higher is required
Consider consultation at step 3

Step 6 Step up if
Step 5 Preferred:
needed
Preferred: High-dose ICS + (first, check
Step 4 LABA + oral adherence,
High-dose
ICS + LABA corticosteroid environmental
Step 3 Preferred:
Medium-dose AND control, and
Preferred: AND
comorbid
ICS + LABA
Step 2 Low-dose Consider conditions)
ICS + LABA Consider
Preferred: OR Alternative: omalizumab for omalizumab for
Low-dose ICS patients who patients who
Step 1 Medium-dose ICS Mediium-dose
have allergies have allergies Assess
Alternative: Alternative: ICS + either LTRA,
Preferred: Cromolyn, LTRA, theophylline, or control
Low-dose ICS +
nedocromil, or either LTRA, zileuton
SABA, as needed
theophylline theophylline, or
zileuton Step down if
possible
(and asthma is
Each step: Patient education, environmental control, and management of comorbidities well controlled
Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma at least
3 months)
Quick-relief medication for all patients

SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments
at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed.
Use of SABA >2 d/wk for symptom relief (not prevention of EIB) generally indicates inadequate control and
the need to step up treatment

FIGURE 3. National Asthma Education and Prevention Program Expert Panel 3 Stepwise Approach for Asthma Control. EIB = exercise-induced
bronchoconstriction; ICS = inhaled corticosteroid; LABA = long-acting β-agonist; LTRA = leukotriene receptor antagonist; SABA = short-acting β-
agonist. Adapted from reference 2.

asthma control. The patient can use a peak flow meter as an
objective measure of lung function; however, the patient
must be instructed on the proper use of the peak flow
meter because it is very effort dependent. The patient’s
personal best should be used to avoid overtreatment based
on predicted values.49 Because the other goal in the
management of asthma is to minimize the severity and
duration of asthma exacerbations, any self-management
TABLE. AIRESMOG Mnemonic for Contributors to Asthma
A Allergy2,20-22 and Adherence to therapy23-26
I Infection20 and Inflammation27,28
R Rhinitis29,30 and Rhinosinusitis31-33
E Exercise34,35 and Error in diagnosis
S Smoking36-38 and pSychogenic factors31
M Medications (β-blockers, angiotensin-converting enzyme
inhibitor, aspirin)
O Occupational exposures,39 Obesity,40-42 and Obstructive sleep
apnea31,43
G Gastroesophageal reflux disease44-47
plan must be geared toward early recognition of an asthma
attack50 and should include behavioral skills to adjust
medications primarily through the use of a written asthma
action plan. The written asthma action plan serves as a
contingency prescription to be activated when there is
worsening of asthma control.2 The ideal written asthma
action plan should be simple and readable and should in-
corporate monitoring of symptoms and lung function with
contingency instructions regarding medication changes.51-53
Patients should be instructed (1) how to monitor symptoms
with the ACT, (2) how to monitor lung function with a peak
flow meter, and (3) how to use a written asthma action plan.
The last item will put asthma triggers, medication use, and
inhaler technique in context. Patients should participate
actively in the management of their disease,2 and health care
professionals can engage patients in a dialogue regarding
the role of long-term control medications and quick-relief
medications, inhaler technique, confounding factors, and a

Mayo Clin Proc. • July 2008;83(7):814-820 • www.mayoclinicproceedings.com 817

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
ATTAINING ASTHMA CONTROL IN 4 EASY STEPS
self-management plan.3,54 A recent systematic review of
randomized controlled trials of asthma self-management
and education confirmed their efficacy in reducing
hospitalizations, emergency department visits, and noctur-
nal symptoms.55
STEP 4: BRING THE PATIENT BACK FOR MONITORING
Patients with uncontrolled asthma must have scheduled
follow-up visits to ensure adequate response to intensifi-
cation of therapy. Overtreatment and undertreatment
occur because of inadequate follow-up.56 The NAEPP
and GINA have excellent stepwise care plans to achieve
control (Figure 3).1,2 For maintenance of control, inhaled
corticosteroids are the preferred anti-inflammatory therapy
for all patients with persistent asthma and for those who
have frequent exacerbations. A stepwise intensification of
therapy is advised for any patient who has uncontrolled or
poorly controlled asthma (Figure 3). Patients should be
seen 2 to 6 weeks after treatment intensification to assess
for response. If results at baseline or at time of therapy
intensification are abnormal, lung function tests, particu-
larly spirometry, should be repeated. After confounding
AIRESMOG factors have been reviewed, asthma medi-
cation should be intensified to achieve control. Once
control has been attained, stepping down the medication
intensity should be considered. After 3 months of stabil-
ity on the current dose of controller medication,57 a step
down in medication intensity should be attempted be-
cause little incremental benefit can be expected there-
after.28 Objective measurement of pulmonary function as
well as exhaled nitric oxide can help guide clinicians in
stepping down treatment.58 After discontinuation of in-
haled corticosteroids, residual anti-inflammatory effects
can still be observed for 2 weeks58,59 and airway inflam-
mation can take a few weeks to increase, causing a sub-
stantial lag between stepping down of treatment and
worsening of asthma symptoms.60 To maintain asthma
control, the patient should be seen for a scheduled follow-
up evaluation 12 weeks (or earlier if symptoms occur)
after each decremental change in asthma medications.2,61 In
any practice, only a few patients will have frequent and
severe exacerbations. These patients may require closer
follow-up (every 3 to 6 months) to maximize opportunities
to intervene and monitor and minimize impairment and
risk.
PUTTING IT ALL TOGETHER
Patients should be taught to assess asthma control with the
ACT monthly. Clinicians can then assess the ACT score
at every clinical encounter and, if asthma is not under
control, review the clinical history with the mnemonic
AIRESMOG. On the basis of the review, they should
818 Mayo Clin Proc. • July 2008;83(7):814-820
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
consider whether referral to a specialist is appropriate or
whether further diagnostic testing is needed to confirm
diagnosis and/or rule out other diseases that confound or
mimic asthma. To reassess asthma control, clinicians
should schedule asthma follow-up within 2 to 6 weeks after
each change in medication during treatment intensification
(earlier if necessary owing to further deterioration). Patients
whose medication is being stepped down should be
followed up in 12 weeks (or earlier if symptoms recur).
Scheduled follow-up is the key to a successful step-up or
step-down approach to controlling asthma. Clinicians
should empower patients to be active participants in
managing their disease through education and a written
asthma action plan.
CONCLUSION
Through an active partnership with their health care
professionals, most patients can achieve good control of
their asthma with symptom monitoring, optimal pharmaco-
therapy, and control of confounding factors.
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• www.mayoclinicproceedings.com 819
ATTAINING ASTHMA CONTROL IN 4 EASY STEPS

CME Questions About Attaining c. Gastroesophageal reflux disease has an adjusted

Asthma Control
1. Which one of the following is not used to assess
impairment from asthma?
a. Symptoms
b. Nighttime awakenings
c. Interference with normal activity
d. Acute bronchodilator use
e. Exacerbations
2. Which one of the following statements about the
Asthma Control Test (ACT) is false?
a. Lung function testing is required to obtain a score
b. Asthma symptoms during the previous 4 weeks are
used to help determine the ACT score
c. An ACT score of less than 20 means uncontrolled
asthma
d. An ACT score of less than 16 means very poorly
controlled asthma
e. The ACT score can be used to adjust asthma
medications
3. Which one of the following statements regarding
comorbidities is false?
a. Severe chronic rhinosinusitis has an adjusted odds
ratio of 5.5 for frequent exacerbations
b. Psychological dysfunction has an adjusted odds
ratio of 11.7 for frequent exacerbations
odds ratio of 4.9 for frequent exacerbations
d. Patients with asthma who smoke have the same
response to inhaled corticosteroids as those who
do not smoke
e. Nonadherence to medication is a serious cause of
poor asthma control
4. Which one of the following is not used in the
assessment of asthma risk?
a. Progressive lung function decline
b. Frequency and severity of exacerbations
c. Adverse reaction to treatment
d. Nonadherence to therapy
e. Frequency of oral corticosteroid use
5. Which one of the following statements regarding
asthma treatment is true?
a. Lung function and symptoms continue to improve
more than 3 months after intensification of
therapy
b. Residual effects of anti-inflammatory therapy
disappear in a few days after dose reduction or
discontinuation
c. Medication should be adjusted only on the basis of
results of lung function tests (eg, spirometry)
d. Medication should be adjusted to reduce frequent
exacerbations
e. Asthma control can be attained only in mild to
moderate persistent asthma

This activity was designated for 1 AMA PRA Category 1 Credit(s).™

The Concise Review for Clinicians contributions are a CME activity, and answers to the questions
are not published in the print journal. For CME credit and the answers, see the link on our Web site
at mayoclinicproceedings.com.

820 Mayo Clin Proc. • July 2008;83(7):814-820 • www.mayoclinicproceedings.com

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