Guidelines for the Diagnosis and Management of Asthma in Adult and Pediatric Patients

Table of Contents
Introduction
Diagnosis and Management Flowchart
Diagnosis and Management Summary
Stepwise Management Summary
Practice Recommendations
1. Diagnosis/ Assessment of Severity
2. Medications
3. Patient Education
4. Exacerbations
5. Special Situations (Exercise-Induced Bronchospasm & Pregnancy)
6. Asthma Specialist Consultation
Additional Provider References or Appendix
Evidence/References
Acknowledgements

INTRODUCTION
Guidelines are designed to assist clinicians by providing a framework for the evaluation and treatment of patients.
These guidelines outline the preferred approach for most patients. They are not intended to replace a clinician's
judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a
problem. The guidelines below are adapted from the National Asthma Education and Prevention Program.
(2007). Guidelines for the Diagnosis and Management of Asthma (Summary Report). U.S. Department of Health
and Human Services, Expert Panel 3, 1-60.

What is Asthma:
Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play
a role: in particular, mast cells, eosinophils, neutrophils (especially in sudden onset, fatal exacerbations,
occupational asthma, and patients who smoke), Tlymphocytes, macrophages, and epithelial cells. In
susceptible individuals, this inflammation causes recurrent episodes of coughing (particularly at night or
early in the morning), wheezing, breathlessness, and chest tightness. These episodes are usually
associated with widespread but variable airflow obstruction that is often reversible either spontaneously
or with treatment.

The goals of asthma therapy are to prevent chronic asthma symptoms and asthma exacerbations,
maintain normal activity levels, have normal or near normal lung function, experience no or minimal side
effects and have patient satisfaction with asthma care.

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 Diagnosis and Management of Asthma

Patient presents with

symptoms of asthma

Establish
diagnosis of Previous
asthma and no diagnosis of
determine level of asthma?
severity

yes

Assess severity of
Acute asthma Does patient need ED
yes asthma yes Send to ED
exacerbation? or inpatient
exacerbation
management?

no
no

Evaluation: Management of asthma

• Medical history exacerbation
• Use of validated questionnaire • Beta2-agonists
• Assess asthma triggers • Corticosteroids
• Physical examination
• Measure lung function
• Consider consultation and/or
allergy testing
Assess response
to treatment
yes

Determine level of
asthma control

Step care of
Does patient need ED or
pharmacologic
inpatient asthma
treatment
management?

Asthma Education
• Basic facts about asthma
• How medications work
• Inhaler technique
• Written action plan based on no
home peak flow rate
• Environmental control measures
• Emphasize need for regular
follow-up visits

Schedule regular follow-up visits

to assess control and potentially
step-up or step-down care.

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PRACTICE RECOMMENDATIONS

3
4
PRACTICE RECOMMENDATIONS

1. Diagnosis/Assessment of Asthma
The presence of multiple key indicators increase the probability of asthma.
• Wheezing
o High-pitched whistling sounds when breathing out—especially in children.
o A lack of wheezing and a normal chest examination do not exclude asthma.
• History of any of the following:
o Cough (worse particularly at night)
o Recurrent wheeze
o Recurrent difficulty in breathing
o Recurrent chest tightness
• Symptoms occur or worsen in the presence of:
o Exercise
o Respiratory infection
o Allergens (e.g., animals with fur or hair, house-dust mites, mold, pollen, foods)
o Irritants (e.g. tobacco or wood smoke, airborne chemicals, perfumes, scents)
o Changes in weather
o Emotions (e.g. laughing, crying, stress)
o Hormonal changes
o Co-morbidities such as gastroesophogeal reflux disease (GERD)
• Symptoms occur or worsen at night, awakening the patient.

Recommended Methods to Establish the Diagnosis

• Detailed medical history. “Suggested Items for Medical History”
For questions to include See figure 1in Additional Provider Resources
• Physical examination may reveal findings that increase the probability of asthma, but the
absence of these findings does not rule out asthma because the disease is variable and signs
may be absent between episodes. The examination focuses on:
o Upper respiratory tract (increased nasal secretion, mucosal swelling and or/nasal
polyp)
o 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)
o Skin (atopic dermatitis, eczema)
• Spirometry may demonstrate obstruction and assesses reversibility in patients ≥ 5 years of
age. Patients’ perceptions of their airflow obstruction are highly variable.
o Spirometry may be ordered in clinic or hospital-based pulmonary function lab.
• Consider referral to an asthma specialist if patient is on a moderate to high dose of Inhaled
Corticosteroids (ICS), has uncontrolled asthma, or has co-morbid conditions.

Assessing Severity for Treatment Initiation/Assessing Control for Treatment Monitoring and
Modification
• Severity: Intensity of the disease; combination of impairment and risk to establish level of
severity. (would includes table from the national guidelines here) (To assess severity refer
to figures 3 and 6)
• Impairment: Frequency and intensity of symptoms and functional limitations the patient is
currently experiencing or has recently experienced.
• Risk: The likelihood of either asthma exacerbations (acute or subacute episodes of
progressively worsening shortness of breath, cough, wheezing, and chest tightness, or some
combinations of these symptoms), progressive decline in lung function (or for children,
reduced lung growth), or risk of adverse effects from medication.

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 • Control: The degree to which the manifestations of asthma are minimized by therapeutic
intervention and the goals of therapy are met; similar to severity, combination of impairment
and risk guide level of asthma control. (To assess control refer to figures 4 and7; for
stepwise approach to therapy modification refer to figures 5 and 8)
o Validated control questionnaires are available. For examples visit:
• Asthma Control Test (ACT): A questionnaire that will help determine if asthma is under
control and that the treatment plan is effective or alterations in medication should be
considered.
• A patient diagnosed with asthma should take the ACT with their primary care
physician clinic once a year.
• To take an ACT test:
• http://www.asthmacontrol.com/index.html (adult ages >12)
• http://www.asthma.com/resources/child-asthma-control-test.html (pediatric
ages 4-11)
• http://asthmatracktest.com/ (for children <5 years)
• Responsiveness: The ease with which asthma control is achieved by therapy.
• Follow-up Visits: The frequency of monitoring is a matter of clinical judgment. In general,
visits should be scheduled:
o 2- to 6- week intervals for patients who are just starting therapy or who require a step
up in therapy to achieve or regain asthma control.
o 1- to 6- month intervals after asthma control is achieved to monitor whether asthma
control is maintained. The interval will depend on factors such as the duration of
asthma control or the level of treatment required.
o Consider scheduling visits at 3-month intervals if a step down in therapy is
anticipated.

2. Medications (Ask patients about all medications and interventions they are using.)

Medications for Asthma Management

Common Quick-Relief
Medication Prescriptions or Long-Term Purpose Considerations
Inhaled Long-term Reduce airway They are the
Corticosteroids (ICS) hyperresponsiveness, preferred controller
inhibit inflammatory cell medication for all
migration and activation age groups.
and block late phase
reaction to allergen. Metered dose
inhalers (MDIs) may
be used with a
spacer.
Leukotriene Modifiers Long-term Interfere with the pathway
of leukotriene mediators,
which are released from
mast cells, eosinophils, and
basophils.
Long Acting Beta Salmeterol, Long-term Bronchodilation of at least They must be used
Agonists (LABAs) formoterol 12 hours after a single in combination with
dose. an ICS.
Combination products Long-term LABA & ICS for moderate Step 3 care or
persistent asthma. above.
Immunomodulators Omalizumab Long-term Prevents binding of IgE to
(anti-IgE) the high-affinity receptors
on basophils and mast
cells.

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Methylxanthines
Mast Cell Stabilizers
Short Acting Beta
Agonists (SABAs)
Anticholinergics
Systemic
Corticosteriods
Complementary and
Alternative
Medications (CAMS)
Long-term Mild to moderate
bronchodilator used as
alternative therapy for mild
persistent asthma or as
adjunctive therapy with ICS
in patients ≥5 years of age.
Stabilize mast cells and
interfere with chloride
channel function.
Albuterol, Quick-relief Bronchodilators that relax
levalbuterol, smooth muscle.
and pirbuterol
Quick-relief Inhibit muscarinic
cholinergic receptors and
reduce intrinsic vagal tone
of the airway.
Quick-relief Used for severe
exacerbations in addition to
SABAs to speed recovery
and to prevent recurrence
of exacerbations.
Complementary Evidence is insufficient to
and Alternative recommend or not
Medications recommend most CAMS or
(CAMS) treatments for asthma.
Not preferred
therapy.
Cromolyn Sodium
available only in
nebulized form. Not
preferred therapy
May be used as an
alternative to
SABAs in patients
who cannot tolerate
SABAs.
Patients who use
herbal treatments
for asthma should
be cautioned about
potential drug
interactions and
harmful ingredients

Asthma Medications by Category

Drug (Brand name) Drug (Generic name) Number of puffs/doses
Bronchodilators
Proair HFA Albuterol 200
Proventil HFA Albuterol 200
Ventolin HFA Albuterol 200
Ventolin HFA Albuterol 60
Albuterol Nebs (0.083%, 25) Albuterol 25
Albuterol Syrup 2mg/5ml Albuterol 480ml
Maxair* Pirbuterol 400
Xopenex MDI Levalbuterol 200
Xopenex nebules 0.31mg/3ml;
0.63mg/3mls; 1.25mg/3ml Levalbuterol 24
Combivent MDI* Albuterol/ipratropium 200
Duoneb Albuterol/ipratropium 60
albuterol/ipratropium Nebs 60
ipratropium nebs 25
Foradil Formoterol 12mcg/cap 60 caps
Perforomist Formoterol nebs 20mcg/2ml 60 vials
Serevent Salmeterol 60

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 Spiriva Tiotropium 30
ICS
Qvar 40mcg Beclomethasone 100
Qvar 80mcg Beclomethasone 100
Pulmicort Flexhaler 90mcg Budesonide 60
Pulmicort Flexhaler 180mcg Budesonide 120
Pulmicort Respule 250mcg Budesonide 30
budesonide nebs 250mcg Budesonide 15
Pulmicort Respule 500mcg Budesonide 30
Budesonide nebs 500mcg Budesonide 15
Pulimicort Respules 1mg Budesonide 30
Alvesco HFA 80mcg Ciclesonide 60
Alvesco HFA 160mcg Ciclesonide 60
Flovent HFA 44mcg Fluticasone 120
Flovent HFA 110mcg Fluticasone 120
Flovent HFA 220mcg Fluticasone 120
Flovent Diskus 50mcg Fluticasone 60
Flovent Diskus 100mcg Fluticasone 60
Flovent Diskus 250mcg Fluticasone 60
Asmanex 110mcg Mometasone 30
Asmanex 220mcg Mometasone 30
Asmanex 220mcg Mometasone 60
Asmanex 220mcg Mometasone 120
ICS/LABA
Symbicort HFA 80/4.5 Budesonide/formoterol 120
Symbicort HFA 160/4.5 Budesonide/formoterol 120
Advair HFA 45/21 Fluticasone/salmeterol 120
Advair HFA 115/21 Fluticasone/salmeterol 120
Advair HFA 230/21 Fluticasone/salmeterol 120
Advair Diskus 100/50 Fluticasone/salmeterol 60
Advair Diskus 250/50 Fluticasone/salmeterol 60
Advair Diskus 500/50 Fluticasone/salmeterol 60
Dulera 100/5 Mometasone/formoterol 120
Dulera 200/5 Mometasone/formoterol 120
LTRA's
Singulair 4mg Montelukast 30
Singulair 5mg Montelukast 30
Singulair 10mg Montelukast 30
Accolate 10mg Zafirlukast 60
Zyflo CR 600mg Zileuton 120
Oral CS
Prednisone
0.5mg, 1mg, 2.5mg, 5mg, 10mg, 20mg,
Tablets 50mg
Solution 5mg/5ml
Prednisolone
Oral disintegrating tablets 10mg, 15mg, 30mg
Solution 5mg/5ml, 15mg/5ml
Methylprednisonlone
Dose-pak 21 x 4mg tablets

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 Tablets 2mg, 4mg, 8mg, 16mg
Dexamethasone
0.5mg, 0.75mg, 1.5mg., 2mg, 4mg, 6mg,
Tablets 8mg
Solution 0.5mg/5ml

3. Patient Education for a Partnership in Care

• Role of Medications: Understanding the Difference
o Long-term control medications: prevent symptoms by reducing inflammation. Must be
taken daily. Do not give quick relief.
o Quick-relief medications: short acting beta agonists (SABA) relax airway muscles to
provide prompt relief of symptoms. Do not expect them to provide long-term asthma
control. Using SABA >2 days a week indicates the need for starting or stepping up long-
term control medications.
• Patient Skills
o Taking medications correctly and consistently
 Inhaler technique (demonstrate to the patient and have the patient return the
demonstration)
 Use of devices as prescribed (e.g. valved holding chamber (VHC) or spacer,
nebulizer)
o Identifying and avoiding environmental exposures that worsen the patient’s asthma; e.g.,
allergens, irritants, tobacco smoke.
o Self-monitoring
 Assess level of asthma control.
 Monitor symptoms and, if prescribed, peak expiratory flow (PEF) measures.
 Recognize early signs and symptoms of worsening asthma.
o Using a written asthma action plan (refer to figure 2) to know when and how to:
 Take daily actions to control asthma.
 Adjust medication in response to signs of worsening asthma.
 Electronic asthma action plans are located on Health Link.
o Seeking medical care when appropriate.
• Additional education materials are available at the following website:
o http://www.uwhealth.org/healthfacts/B_EXTRANET_HEALTH_INFORMATION-
FlexGroup-Show_Public_HFFY_Category_1103038147775.html
• Patient education (verbal & written) should occur at all patient points of care (clinic &
hospital visits, pharmacy pick-up, etc).
• Control of Environment Factors and Comorbid Conditions That Affect Asthma
• Environmental Allergens and Irritants--Identify allergens and pollutants or other irritant
exposures. The most troublesome allergen for both children and adults are those that are
inhaled.
o Advise patients to reduce exposure to allergens and pollutants or irritants which are
triggers for their asthma.
o Consider subcutaneous allergen immunotherapy for patients who have persistent asthma
when there is clear evidence of a relationship between symptoms and exposure to an
allergen to which the patient is sensitive.
o Administer inactivated influenza vaccination for patients ages 6 months and older who
have asthma.
• Comorbid—Identify and treat comorbid conditions that may impede asthma management.
o Allergic Bronchopulmonary Aspergillosis (ABPA)
o Gastroesophageal Reflux (GERD)
o Obese or overweight patients may be advised that weight loss may help control asthma.
o Obstructive Sleep Apnea (OSA) may be considered in patients who don’t have well
controlled asthma, particularly ones who are overweight.

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 o Rhinitis or sinusitis should be evaluated in patients who have asthma, because the
interrelationship of the upper and lower airway suggests that therapy for the upper airway
will improve asthma control.
o Stress and depression should be considered in patients who have asthma that is not well
controlled. Additional education to improve self-management and coping skills may be
helpful.
4. Managing Asthma Exacerbations: Asthma exacerbations are acute or subacute episodes of
progressively worsening shortness of breath, cough, wheezing, and chest tightness, or some
combinations of these symptoms.
• Classifying Severity
o Severe exacerbation can be life threatening and can occur in patients at any level of
asthma severity.
o Patients at high risk of asthma-related death require special attention—particularly
intensive education, monitoring, and care. Such patients should be advised to seek
medical care early during an exacerbation. Risk factors for asthma –related death
include:
 Previous severe exacerbations
 Two or more hospitalizations or ›3 visits in past year
 Use of ›2 canisters of SABA per month
 Difficulty perceiving airway obstruction or the severity of worsening asthma
 Illicit drug use
 Major psychosocial problems or psychiatric disease
 Co morbidities, such as cardiovascular disease or other chronic lung
disease
• Home Management
o Early treatment by the patient at home is the preferred strategy for managing asthma
exacerbations.
o Patients should be instructed how to:
 Use a written asthma action plan that notes when and how to treat signs of
an exacerbation.
 Recognize early indicators of an exacerbation.
 Adjust their medications.
 Remove or withdraw allergens or irritants.
 Monitor response to treatment and promptly communicate with the clinician
about any serious deterioration in symptoms or PEF or about decreased
responsiveness to SABA treatment, including decreased duration of effect.
o Severe exacerbations should be treated with oral corticosteroids.
• Management in the Urgent or Emergency Care and Hospital Setting
o Administer supplemental oxygen to correct significant hypoxemia in moderate or severe
exacerbations.
o Administer repetitive or continuous administration of SABA to reverse airflow obstruction
rapidly.
o Administer systemic corticosteroids to decrease airway inflammation in moderate or
severe exacerbations or for patients who fail to respond promptly and completely to
SABA treatment.
o Monitor response to therapy with serial assessments.

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 Management of Asthma Exacerbations: Emergency Department and Hospital-Based Care

Initial assessment: Brief history, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate). PEF or
FEV1, oxygen saturation, and other tests as indicated.

FEV1 or PEF 40-69% (Mild-to-Moderate) FEV1 or PEF <40% (Severe)

· Oxygen to achieve SaO2 ≥90%
· Inhaled SABA by nebulizer or MDI with valved
holding chamber, up to 3 doses in first hour
· Oral systematic corticosteroids if no immediate
response or if patient recently took oral systemic
corticosteroids
Impending or Actual Respiratory Arrest
· Oxygen to achieve SaO2 ≥90%
· Intubation and mechanical
· High-dose inhaled SABA plus ipratropium by
ventilation with 100% oxygen
nebulizer or MDI plus valved holding
· Nebulized SABA and ipratropium
chamber, every 20 minutes or continuously
· Intravenous corticosteroids
for 1 hour
· Consider adjunct therapies
· Oral systemic corticosteroids

Repeat Assessment Admit to Hospital Intensive Care

Symptoms, physical examination, PEF, O2 Saturation, other tests as needed (See box below)

Severe Exacerbation
Moderate Exacerbation FEV1 or PEF <40% predicted/personal best
FEV1 or PEF 40-69% predicted/personal best Physical exam: severe symptoms at rest, accessory muscle use, chest
Physical exam: moderate symptoms retraction
· Inhaled SABA every 60 minutes History: high-risk patient
· Oral systemic corticosteroid No improvement after initial treatment
· Continue treatment 1-3 hours, provided there is · Oxygen
improvement: make admit decision in <4 hours · Nebulized SABA plus ipratropium, hourly or continuous
· Oral systemic corticosteroids
· Consider adjunct therapies

Good Response Incomplete Response

· FEV1 or PEF 40-69% Poor Response
· FEV1 or PEF≥70%
· Mid-to moderate symptoms FEV1 or PEF <40%
· Response sustained 60 minutes
PCO2 ≥42mmHg
after last treatment
Physical exam: symptoms severe,
· No distress Individualized decision regarding drowsiness, confusion
· Physical exam: normal hospitalization

Discharge Home Admit to Hospital Ward Admit to Hospital Intensive Care

· Continue treatment with inhaled SABA · Oxygen · Oxygen
· Continue course of oral systemic corticosteroid · Inhaled SABA · Inhaled SABA hourly or
· Consider initiation of an ICS · Systemic (oral or intravenous) continuously
· Patient education corticosteroid · Intravenous corticosteroid
-Review medication, including inhaler technique · Consider adjunct therapies · Consider adjunct therapies
-Review/initiate action plan · Monitor vital signs, FEV1, or PEF, · Possible intubation and
-Recommend close medical follow-up SaO2 mechanical ventilation

Improve Improve

Discharge Home
· Continue treatment with inhaled SABA
· Continue course of oral systemic corticosteroid
· Continue on ICS. For those not on long-term control therapy, consider initiation of an ICS
· Patient education (e.g., review medications, including inhaler technique, review/initiate
action plan and, whenever possible, environmental control measures, and recommend
close medical follow-up)
· Before discharge, schedule follow-up appointment with primary care provider and/or
asthma specialist in 1-4 weeks

Key
FEV1, forced expiratory volume in 1 second; ICS, inhaled corticosteroid; MDI, metered-dose inhaler; PCO2, partial pressure carbon dioxide; PEF, peak
expiratory flow; SABA, short-acting beta2-agonist; SaO2, oxygen saturation

5. Special Situations
Exercise-Induced Bronchospasm (EIB)
EIB should be anticipated in all asthma patients. A history of cough, shortness of breath, chest pain or
tightness, wheezing, or endurance problems during exercise suggests EIB.
• Long-term control therapy
o Initiate or step up long-term control medications
• Pretreatment before exercise

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 o Inhaled beta2-agonists will prevent EIB for more than 80 % of patients. SABA used
approximately 5-15 minutes prior to exercise may be helpful for 2-3 hours. LABA can
be protective up to 12 hours, but should not be used without an ICS.
o Leukotriene receptor antagonists (LTRAs), with an onset of action generally hours
after administration, can attenuate EIB in up to 50% of patients.
o A warm-up period before exercise may reduce the degree of EIB.
o A mask or scarf over the mouth may attenuate cold-induced EIB.

Managing Asthma During Pregnancy

• General Principles:
o It is safer for pregnant women with asthma to be treated with asthma medications
than for them to have asthma symptoms and exacerbations and risk of fetal hypoxia.
o Proper control of asthma should enable a woman with asthma to maintain a normal
pregnancy with little or no risk to her or her fetus.
o The greatest amount of safety data to supports budesonide. However, one can stay
on their current ICS.
• Step 1: Intermittent Asthma
o Albuterol is the preferred SABA because it has an excellent proven safety profile
during pregnancy.
• Step 2: Mild Persistent Asthma
o Budesonide is the preferred ICS because more supportive data are available on
using budesonide in pregnant women than are available on other ICS.
o Leukotriene modifiers are an alternative but not preferred treatment for pregnant
women whose asthma was successfully controlled with this medication prior to their
pregnancy.
• Step 3: Moderate Persistent Asthma (two preferred treatment options)
o Combination of low-dose ICS and a LABA.
o Increasing the dose of ICS to the medium dose range.
• Step 4: Severe Persistent Asthma
o Refer to an asthma specialist.
o If additional medication is required after adherence with step 3 was assessed, then
the corticosteroid dose should be increased within the high-dose range, and use of
budesonide is preferred.
o If this is insufficient, then the addition of systemic corticosteroids is warranted;
although data are uncertain about some risks of oral corticosteroids during
pregnancy, severe uncontrolled asthma poses a definite risk to the mother and fetus.

6. Asthma Specialist Consultation

Indications for asthma specialist consultation include:
• Asthma is unresponsive to therapy.
• Asthma is not well controlled within 3-6 months of treatment.
• Life-threatening asthma exacerbation.
• Hospitalization for asthma.
• Required >2 bursts of oral corticosteroids in 1 year.
• Requires higher level step care.
• Immunotherapy is being considered.

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 Stepwise Approach for Managing Asthma During Pregnancy and Lactation: Treatment

Classify Severity: Clinical Features

Before Treatment or Adequate Control · Medications required to maintain long-term control.

Symptoms/Day PEF or FEV1 · Daily medications.

Symptoms/Night PEF Variability

· Preferred treatment: high-dose inhaled corticosteroid AND long-acting inhaled beta2-agonist

AND, if needed, corticosteroids tablets or syrup long-term (2 mg/kg per day, generally not to
Step 4—Severe Persistent
exceed 60 mg per day). (Make repeat attempts to reduce systemic corticosteroid and maintain
control with high-dose inhaled corticosteroid.*)
Continual ≤60%
Frequent >30%
· Alternative treatment: high-dose inhaled corticosteroid* AND sustained release theophylline to
serum concentration of 5-12 mcg/mL.

Step 3—Moderate Persistent · Preferred treatment: Either low-dose inhaled corticosteroids* and long-acting inhaled beta2-
agonist OR Medium-dose inhaled corticosteroids.
Daily >60%-<80%
>1 night/week >30% · If needed (particularly in patients with recurring severe exacerbations), medium-dose inhaled
corticosteroid* and long-acting inhaled beta2-agonist.

Step 2—Mild Persistent

· Preferred treatment: Low-dose inhaled corticosteroid.*
>2days/week, but <daily ≥80%
· Alternative treatment (listed alphabetically): cromolyn, leukotriene receptor antagonist+ OR
>2 nights/month 20%- Sustained-release theophylline to serum concentration of 5-12 mcg/mL.
30%

Step 1—Intermittent · No daily medication needed

≤2 days/weeks ≥80% · Severe exacerbations may occur, separated by long periods of normal lung function and no
≤2 nights/month <20% symptoms. A course of systemic corticosteroid is recommended.

Quick Relief—All Patients

· Short-acting bronchodilator: 2-4 puffs short-acting inhaled beta2- agonist.± as needed for symptoms.
· Intensity of treatment will depend on severity of exacerbation; up to 3 treatments at 20-minute intervals or a single nebulizer treatment as
needed. Course of systemic corticosteroid may be needed.
· Use of short-acting inhaled beta2- agonist± >2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate
the need to initiate (increase) long-term control therapy.

Step Down Notes:

Review treatment every 1-6 months; a gradual stepwise
reduction in treatment may be possible.
Step Up
If control is not maintained, consider step up. First, review patient
medication administration technique, adherence, and
environmental control.
Goals of Therapy: Asthma Control
· Minimal or no chronic symptoms day or night.
· Minimal or no exacerbations.
· No limitations on activities; no school/work missed.
· Maintain (near) normal pulmonary function.
· Minimal use of short-acting inhaled beta2- agonist.±
· Minimal or no adverse effects from medications.
· Classify severity: assign patient to most severe step in
which any feature occurs (PEF is percent of personal best;
FEV 1 is percent predicted).
· Gain control as quickly as possible (consider a short course
of systematic corticosteroid), then step down to the least
medication necessary to maintain control.
· Minimize use of short-acting inhaled beta2-agonist ± (e.g.,
use of approximately one canister a month even if not using
it every day indicates inadequate control of asthma and the
need to initiate or intensify long-term control therapy).
· Provide education on self-management and controlling
environmental factors that make asthma worse (e.g.,
allergens, irritants).
· Refer to an asthma specialist if there are difficulties
controlling asthma or if step 4 care is required. Referral may
be considered if step 3 care is required.

* There are more data on using budesonide during pregnancy than on using other inhaled corticosteroids.
+ There are minimal data on using leukotriene receptor antagonists in humans during pregnancy, although there are reassuring animal data
submitted to FDA.
± There are more data on using albuterol during pregnancy than on using other short-acting inhaled beta2-agonists.

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 Management of Asthma Exacerbation During Pregnancy and Lactation

Assess Severity

Measure PEF: Value <50% personal best of predicted suggests severe

exacerbation

Note signs and symptoms: Degrees of cough, breathlessness, wheeze,

and chest tightness correlate imperfectly with severity of exacerbation

Accessory muscle use and suprasternal retractions suggest severe

exacerbation

Note presence of fetal activity*

Initial Treatment

Short-acting inhaled beta2-agonist: up to 3 treatments of 2-4

puffs by MDI at 20-minute intervals or single nebulizer
treatment

Poor Response
Good Response
Severe Exacerbation:
Mild Exacerbation: Incomplete Response
PEF <50% predicted or personal
PEF >80% predicted or personal
best
best Moderate exacerbation:
PEF50%-80% predicted to
Marked wheezing and shortness
No wheezing or shortness of breath personal best
of breath
Response to short-acting inhaled Persistent wheezing and
Decreased fetal activity*
beta2-agonist sustained for 4 hours shortness of breath
___________________________
Treatment:
Appropriate fetal activity* Decreased fetal activity*
Add oral corticosteroids
_____________________________ ___________________________
Repeat short-acting inhaled beta2-
Treatment: Treatment:
agonist immediately
May continue short-acting inhaled Add oral corticosteroid
beta2-agonist every 3-4 hours for
If distress is severe and
24-48 hours. Continue short-acting inhaled
nonresponsive, patient should call
beta2-agonist
clinician immediately and proceed
For patients on inhaled
to emergency department:
corticosteroid, consider 3-4 times
consider calling ambulance or 911
their usual dose for 7-10 days

Patient should contact clinician Patient should contact Patient should proceed to
for follow-up instructions clinician urgently emergency department

MDI=Metered-dose inhaler
PEF=Peak expiratory flow
*Fetal activity is monitored by observing whether fetal kick counts decreased over time

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 ADDITIONAL PROVIDER RESOURCES
Figure 1: Suggested Items for Medical History
Suggested Items for Medical History*

A detailed medical history of the new patient who is known or thought to have asthma should address the following items

1. Symptoms 5. Family history

· Cough · History of asthma, allergy, sinusitis, rhinitis, eczema, or nasal
· Wheezing polyps in close relatives
· Shortness of breath
· Chest tightness 6. Social history
· Sputum production · Daycare, workplace, and school characteristics that may interfere
with adherence
2. Pattern of symptoms · Social factors that interfere adherence, such as substance abuse
· Perennial, seasonal, or both · Social support/social networks
· Continual, episodic, or both · Level of education completed
· Onset, duration, frequency (number of days or nights, per week · Employment
or month)
· Diurnal variations, especially nocturnal and on awakening in 7. History of exacerbations
early morning · Usual prodromal signs and symptoms
· Rapid onset
3. Precipitating and/or aggravating factors · Duration
· Viral respiratory infections · Frequency
· Environmental allergens, indoor (e.g., mold, house-dust mite, · Severity (need for urgent care, hospitalization, intensive care unit
cockroach, animal dander or secretory products) and outdoor (ICU) admission)
(e.g., pollen) · Life-threatening exacerbations in the past year
· Characteristics of home including age, location, cooling and · Usual patterns and management (what works?)
heating system, wood burning stove, humidifier, carpeting over
concrete, presence of molds or mildew, presence of pets with fur 8. Impact of asthma on patient and family
or hair, characteristics of rooms where patient spends time (e.g., · Episodes of unscheduled care (emergency department (ED),
bedroom and living room with attention to bedding, floor urgent care, hospitalization)
covering, stuffed furniture) · Number of days missed from work/school
· Smoking (patient and others in home or daycare) · Limitation of activity, especially sports and strenuous work
· Exercise · History of nocturnal awakening
· Occupational chemicals or allergens · Effect of growth, development, behavior, school or work
· Environmental change (e.g., moving to new home, going on performance and lifestyle
vacation, and/or alterations in workplace, work processes or · Impact on family routines, activities, or dynamics
materials used) · Economic impact
· Irritants (e.g., tobacco smoke, strong odors, air pollutants,
occupational chemicals, dusts and particulates, vapors, gases 9. Assessment of patient’s and family’s perceptions of disease
and aerosols) · Patient’s parent’s and spouse's/ partner’s knowledge of asthma
· Emotions (e.g., fear, anger, frustration, hard crying or laughing) and belief in the chronicity of asthma and in the efficacy of
· Stress (e.g., fear, anger, frustration) treatment
· Drugs (e.g., aspirin and other nonsteroidal anti-inflammatory · Patient’s perception and beliefs regarding use and long-term
drugs, beta-blockers, including eye drops, others) effects of medications
· Food, food additives, and preservatives (e.g., sulfites) · Ability of patient and parents, spouse or partner to cope with
· Changes in weather, exposure to cold air disease
· Endocrine factors (e.g., menses, pregnancy, thyroid disease) · Level of family support and patient’s and parent’s, spouse’s or
partner’s capacity to recognize severity
· Comorbid conditions (e.g. sinusitis, rhinitis, gastroesphogeal
· Economic resources
reflux disease (GERD)) · Sociocultural beliefs
4. Development of disease and treatment
· Age of onset and diagnosis
· History of early-life injury to airways (e.g., bronchopulmonary
dysplasia, pneumonia, parental smoking)
· Progression of disease (better or worse)
· Present management and response, including plans for
managing exacerbations
· Frequency of using short-acting beta2-agonist (SABA)
· Need for oral corticosteroids and frequency of use

* This list does not represent a standardized assessment or diagnostic instrument. The validity and reliability of this list have
not been assessed.

15
Figure 2: Asthma Action Plan

16
Figure 3: Classifying Asthma Severity and Initiating Therapy in Children
Classifying Asthma Severity and
Initiating Therapy in Children

Components of Persistent
Severity Intermittent
Mild Moderate Severe

Ages Ages Ages Ages Ages Ages Ages Ages

0-4 5-11 0-4 5-11 0-4 5-11 0-4 5-11

>2 days/week
Symptoms ≤2 days/week Daily Throughout the day
but not daily

>1x/week but not Often

Nighttime Awakenings 0 ≤2x/month 1-2x/month 3-4x/month 3-4x/month >1x/week
nightly 7x/week

Short-acting beta2-agonist use for >2 days/week

Impairment ≤2 days/week Daily Several times per day
symptom control but not daily

Interference with normal activity None Minor limitation Some limitation Extremely limited

Normal FEV1 between

Lung function exacerbations >80 %
60%-80% <60%
o FEV1 (predicted) or peak flow N/A >80 % N/A N/A N/A
(personal best FEV1/FVC) >80 %
75%-80% <75%
>85%

≥2 exacerbations in
≥2x/year (see
6 months requiring
notes)
oral systemic
Exacerbations requiring oral
corticosteroids, or
systemic corticosteroids (consider Relative
Risk 0-1/year (see notes) ≥4 wheezing
severity and interval since last annual risk
episodes/1 year
exacerbation) may be
lasting >1 day AND
related to
risk factors for
FEV1
persistent asthma

Step 3
Step 3
and
and
consider
consider Step 3: medium-dose Step 3: medium-dose
short
short ICS option and ICS option OR step 4
Step 1 Step 2 course of
Recommended step for initiation therapy course of consider short course and consider short
(for both age groups) (for both age groups) oral
oral of oral systemic course of oral systemic
systemic
(See “Stepwise Approach for Managing Asthma” for systemic corticosteroids corticosteroids
corticost
treatment steps) corticoste
eroids
roids

In 2-6 weeks, depending on severity, evaluate level of asthma control that is achieved.
o Children 0-4 years old: if no clear benefit is observed in 4-6 weeks, stop treatment and consider alternative diagnosis or adjusting therapy.
o Children 5-11 years old: adjust therapy accordingly.

Key: FEV1, forced expiratory volume

in 1 second; FVC, forced vital capacity;
ICS, inhaled corticosteroids; ICU,
intensive care unit; N/A, not applicable

Notes:
-- Level of severity is determined by both impairment and risk. Assess impairment domain by caregiver’s recall of previous 2–4 weeks.
Assign severity to the most severe category in which any feature occurs.

--Frequency and severity of exacerbations

may fluctuate over time for patients in any severity category.
At present, there are inadequate data to correspond frequencies
of exacerbations with different levels of asthma severity. In general, more frequent and severe exacerbations
(e.g., requiring urgent, unscheduled care, hospitalization,
or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients with ≥2 exacerbations described
above may be considered the same as patients
who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.

17
Figure 4: Assessing Asthma Control and Adjusting Therapy in Children
Assessing Asthma Control and Adjusting Therapy in Children

Components of
Control Well Controlled Not Well Controlled Very Poorly Controlled

Ages Ages Ages Ages Ages Ages

0-4 5-11 0-4 5-11 0-4 5-11

≤2 days/week, but not more than once on ≥2 days/week or multiple times

Symptoms Throughout the day
each day on ≤2 days/week

>1x/week ≥2x/week
Nighttime Awakenings ≤1x/month >1x/month ≥2x/month

Short-acting beta2-agonist use for

symptom control (not prevention of ≤2 days/week >2 days/week Several times per day
Impairment
EIB)

Interference with normal activity None Some limitation Extremely limited

Lung function
o FEV1 (predicted) or peak flow <60%
N/A >80 % N/A 60-80% N/A
(personal best)
o FEV1/FVC <75%
>80% 75-80%

Exacerbations requiring oral

0-1x/year 2-3x/year ≥2x/year >3x/year ≥2x/year
systemic corticosteroids

Requires long-term
Risk Reduction in lung growth N/A
follow-up N/A N/A

Medication side effects can vary in intensity from none to very troublesome and worrisome. The
Treatment-related adverse effects level of intensity does not correlate to specific levels of control, but should be considered in the
overall assessment of risk.

o Maintain current step

o Regular follow-up every 1-6
months
o Consider step down if well
controlled for at least 3 months.
Recommended action for treatment
(See “Stepwise Approach for Managing Asthma” for
treatment steps)
o Consider short course of oral
Step up at
Step up 1 step systemic corticosteroids
least 1 step
o Step up 1-2 steps
Before step up:
o Review adherence to medication, inhaler technique, and
environmental control.
o If alternative treatment was used, discontinue it and use preferred
treatment for that step.

Reevaluate the level of asthma control in 2-6 weeks to achieve control;

every 1-6 months to maintain control.
Children 0-4 years old: if no clear benefit is observed in 4-6 weeks,
consider alternative diagnoses or adjusting therapy.
Children 5-11 years old: adjust therapy accordingly

For side effects, consider alternative treatment options.

Key: EIB, exercise-induced bronchospasm, FEV1, forced expiratory volume in 1 second; FVC, forced vital
capacity; ICU, intensive care unit; N/A, not applicable

Notes:
--The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient’s or caregiver’s
recall of previous 2–4 weeks. Symptom assessment for longer periods should reflect a global
assessment, such as whether the patient’s asthma is better or worse since the last visit. At present, there are inadequate data to
correspond frequencies of exacerbations with different levels of asthma control. In general, more
frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer
disease control.

18
Figure 5: Stepwise Approach for Managing Asthma Long Term in Children
Stepwise Approach for Managing Asthma Long Term in Children, 0-4 Years of Age and 5-11 Years of Age

Step up if needed (first check inhaler technique, adherence, environmental control, and comorbid conditions)

Assess control

Step down if possible (and asthma is well controlled at least 3 months)

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6

Persistent Asthma: Daily Medication
Intermittent Asthma
Consult with asthma specialist if step 3 care of higher is required. Consider consultation at step 2.
Children 0-4 Years of Age

High-dose ICS
Medium-dose ICS High-dose ICS +
Medium-dose ICS + + LABA or Montelukast
Preferred SABA PRN Low-dose ICS
LABA or Montelukast LABA or Montelukast +
Oral corticosteroids ICS

Alternative Cromolyn or Montelukast

Each step: Patient Education and Environmental Control

o SABA as needed for symptoms; intensity of treatment depends on severity of symptoms.

Quick-Relief o With viral respiratory symptoms SABA 4-6 hours up to 24 hours (longer with physician consult). Consider short course of oral systemic corticosteroids if
Medications exacerbation is severe or patient has history of previous severe exacerbations.
Caution: frequent use of SABA may indicate the need to step up treatment. See recommendations on initiating daily long-term control therapy.

Persistent Asthma: Daily Medication

Intermittent Asthma
Consult with asthma specialist if step 3 care of higher is required. Consider consultation at step 2.
High-dose ICS
Medium-dose ICS High-dose ICS +
Children 5-11 Years of Age

Low-dose ICS + + LABA

Preferred SABA PRN Low-dose ICS + LABA LABA +
LABA, LTRA, or Oral corticosteroids
Theophylline
High-dose ICS
OR Medium-dose ICS High-dose ICS +
Medium-dose ICS + + LTRA or Theophylline
Alternative LTRA or Theophylline LTRA or Theophylline +
Oral corticosteroids

Each Step: Patient Education, Environmental Control and Management of Comorbidities

Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have persistent, allergic asthma.

o 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.
Quick-Relief
Medications
Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up
treatment.

Notes: Children 0-4 Years of Age Notes: Children of 5-11 Years of Age
Key: ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting
beta2-agonist.

• If an alternative treatment is used and
response is inadequate, discontinue it and
use the preferred treatment before stepping
up.
• If clear benefit is not observed within 4-6
weeks, and patients/family’s medication
technique and adherence are satisfactory,
consider adjusting therapy or an alternative
diagnosis.
• Studies on children 0-4 years of age are
limited. Step 2 preferred therapy is based on
Evidence A. All other recommendations are
based on expert opinion and extrapolation
from studies in older children.
• Clinicians who administer immunotherapy
should be prepared and equipped to identify
and treat anaphylaxis that may occur.
• If an alternative treatment is used and response is inadequate,
discontinue it and use the preferred treatment before stepping up.
• Theophylline is a less desirable alternative due to the need to
monitor serum concentration levels.
• Steps 1 and 2 medications are based on Evidence A. Step 3 ICS
and ICS plus adjunctive therapy are based on Evidence B for
efficacy of each treatment and extrapolation from comparator
trials in older children and adults—comparator trials are not
available for this age group; steps 4-6 are based on expert
opinion and extrapolation from studies in other children and
adults.
• Immunotherapy for steps 2-4 is based on Evidence B for house
dust mites, animal danders, and pollens; evidence is weak or
lacking for molds and cockroaches. Evidence is strongest for
immunotherapy with single allergens. The role of allergy in
asthma is greater in children than adults.
• Clinicians who administer immunotherapy should be prepared
and equipped to identify and treat anaphylaxis that may occur.

19
Figure 6: Classification of Asthma Severity ≥12 years
Classification of Asthma Severity
≥12 years

Components of
Persistent
Severity
Intermittent
Mild Moderate Severe

>2 days/week
Symptoms ≤2 days/week Daily Throughout the day
but not daily

Often
Nighttime Awakenings ≤2x/month 3-4x/month >1x/week but not nightly
7x/week
Impairment
Short-acting beta2-agonist use for >2 days/week
Normal FEV1/FVC
symptom control (not prevention of ≤2 days/week but not daily, and not more than 1x Daily Several times per day
8-19 yr 85%
EIB) on any day
20-39 yr 80%
40-59 yr 75%
60-80 yr 70%
Interference with normal activity None Minor limitation Some limitation Extremely limited

o Normal FEV1 between o FEV1 >60% but <80%

o FEV1 >80% predicted o FEV1 <60% predicted
Lung function exacerbations predicted
o FEV1 >80% predicted
o FEV1 /FVC normal o FEV1 /FVC reduced >5%
o FEV1 /FVC normal o FEV1 /FVC reduced 5%

0-1/year (see notes) ≥2 year (see note)

Exacerbations requiring oral

Risk Consider severity and interval since last exacerbation.
systemic corticosteroids
Frequency and severity may fluctuate over time for patients in any severity category.

Relative annual risk of exacerbations may be related for FEV1.

Step 3 Step 4
Recommended step for initiation therapy Step 1 Step 2

(See “Stepwise Approach for Managing Asthma” for

treatment steps)
And consider short course of oral systemic corticosteroids

In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.

Key: EIB, exercise-induced bronchospasm, FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICU,
intensive care unit
Notes:
• 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 (e.g., 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.

20
Figure 7: Assessing Asthma Control and Adjusting Therapy in Youths ≥12 Years of Age and Adults

Assessing Asthma Control and Adjusting Therapy in Youths ≥12 Years of Age and Adults
Components of
Control
Well Controlled Not Well Controlled Very Poorly Controlled

Symptoms ≤2 days/week >2 days/week Throughout the day

Nighttime Awakenings ≤2x/month 1-3x/week ≥4x/week

Interference with normal activity None Some limitation Extremely limited

Short-acting beta2-agonist use for

Impairment symptom control (not prevention of ≤2 days/week >2 days/week Several times per day
EIB)

FEV1 or peak flow >80 % predicted/personal best 60-80% predicted/personal best <60% predicted/personal best

Validated questionnaires
ATAQ 0 1-2 3-4
ACQ ≤0.75* ≥1.5 N/A
ACT ≥20 16-19 ≤15

0-1/year ≥2/year (see note)

Exacerbations requiring oral
systemic corticosteroids
Consider severity and interval since last exacerbation.

Risk Progressive loss of lung function Evaluation requires long-term follow-up care.

Medication side effects can vary in intensity from none to very troublesome and worrisome. The
Treatment-related adverse effects level of intensity does not correlate to specific levels of control, but should be considered in the
overall assessment of risk.

Recommended action for treatment o Consider short course of oral

o Maintain current step
o Step up 1 step systemic corticosteroids
o Regular follow-up every 1-6
(See “Stepwise Approach for Managing Asthma” for o Reevaluate in 2-6 weeks o Step up 1-2 steps
months to maintain control
treatment steps) o For side effects, consider o Reevaluate in 2 weeks
o Consider step down if well
alternative treatment options o For side effects, consider
controlled for at least 3 months.
alternative treatment options

*ACQ values of 0.76–1.4 are indeterminate regarding well-controlled asthma.

Key: EIB, exercise-induced bronchospasm; ICU, intensive care unit
Notes:
• The level of control is based on the most severe impairment or risk category. Assess impairment domain by
patient’s recall of previous 2–4 weeks and by spirometry/or peak flow measures. Symptom assessment for longer periods should reflect a
global assessment, such as inquiring whether the patient’s asthma is better or
worse since the last visit.
• At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma
control. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission)
indicate poorer disease control. 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 not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma.
ATAQ = Asthma Therapy Assessment Questionnaire©
ACQ = Asthma Control Questionnaire©
ACT = Asthma Control Test™
Minimal Important Difference: 1.0 for the ATAQ; 0.5 for the ACQ; not determined for the ACT.
Before step up in therapy:
— Review adherence to medication, inhaler technique,
environmental control, and comorbid conditions.
— If an alternative treatment option was used in a step,
discontinue and use the preferred treatment for that step.

21
Figure 8: Stepwise Approach for Managing Asthma in Youths ≥12 Years of Age and Adults
Persistent Asthma: Daily Medication
Intermittent
Consult with asthma specialist if step 4 care or higher is required.
Asthma
Consider consultation at step 3.

Step up if needed
Step 6
(First, check
Preferred: adherence,
Step 5 environmental
High-dose ICS + control, and
Step 4 Preferred: LABA + oral comorbid
Step 3 High-dose ICS + corticosteroid conditions)
Preferred: LABA
Preferred: Medium-dose ICS AND Assess Control
Low-dose ICS + + LABA AND
Step 2 LABA Consider Step down if
OR Medium-dose Alternative: Consider Omalizumab for possible
Preferred: ICS Medium-dose Omalizumab for patients who have
Low-dose ICS ICS+ either LTRA, patients who have allergies (And asthma is
Alternative: Theophylline, or allergies well controlled at
Step 1 Alternative: Low-dose ICS + Zileuton least 3 months)
Cromolyn, LTRA, either LTRA,
Preferred: Nedocromil, or Theophylline, or
SABA PRN Theophylline Zileuton

Each step: Patient education, environmental control, and management of comorbidities.

Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).

Quick -relief medication for all patients:

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

Note: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy.
Key: ICS, inhaled corticosteroid; LABA, long acting inhaled beta2-agonist; LTRA, leukotriene receptor
antagonist; SABA, inhaled short-acting beta2-agonist
Notes:
• If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before
stepping up.
• Zileuton is a less desirable alternative due to limited studies as adjunctive therapy and the need to monitor liver function. Theophylline requires
monitoring of serum concentration levels.
• In step 6, before oral corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or
zileuton may be considered, although this approach has not been studied in clinical trials.
• Step 1, 2, and 3 preferred therapies are based on Evidence A; step 3 alternative therapy is based on Evidence A for
LTRA, Evidence B for theophylline, and Evidence D for zileuton. Step 4 preferred therapy is based on Evidence B,
Disclaimer:
and alternative Guidelines
therapy is based areondesigned
Evidence B to assistandclinicians
for LTRA theophyllinebyand
providing a zileuton.
Evidence D framework Step 5for the evaluation and
treatment of patients.
preferred therapy is based This guideline
on Evidence outlines
B. Step thetherapy
6 preferred preferred approach
is based on (EPR—2for most
1997) andpatients.
Evidence B It
foris not intended to
omalizumab.
replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will
• Immunotherapy for steps 2–4 is based on Evidence B for house-dust mites, animal danders, and pollens; evidence is
notweak
fit the clinical
or lacking condition
for molds contemplated
and cockroaches. Evidencebyisastrongest
guideline and that a guideline
for immunotherapy will rarely
with single allergens. Theestablish
role the only
appropriate approach
of allergy in asthma to ain problem.
is greater children than in adults.
• Clinicians who administer immunotherapy or omalizumab should be prepared and equipped to identify and treat
anaphylaxis that may occur.

22
 1. Guidelines for the Diagnosis and Management of Asthma (Summary Report).
http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf. Updated 2007. Accessed September 23,
2011.
2. Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment (Quick
Reference). http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg/astpreg_qr.pdf. Updated 2004.
Accessed September 23, 2011.

ACKNOWLEDGEMENTS

Disclaimer: Guidelines are designed to assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not intended to
replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will
not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.

23