asthma

Stepwise Approach for Managing Asthma in Adults and Children Older Than 5 Years of Age: Treatment

Is your child meeting the goals of the updated asthma guidelines?

• Minimal or no chronic symptoms day or night
• Minimal or no exacerbations
• No limitations on activities; no school/work/parent's work missed
• Peak Flows greater than 80% of personal best
• Minimal use of short-acting inhaled beta 2 -agonist (< 1x per day, < 1 canister/month)
• Minimal or no adverse effects from medications
  
  

If not, he may need a step up in his treatment regimen. For help, first classify your child's asthma severity based on the symptoms he is having, either during the day or at night. Next, review the preferred daily medications. If your child isn't on a preferred treatment and he is not doing well, you may want to see your Pediatrician to talk about changing his treatment plan.

Step 4 - Severe Persistent

• Continual daytime symptoms or frequent nighttime symptoms
• Peak flows less than or equal to 60% of his personal best or more than 30% variability in daily peak flow measurements.
• Preferred daily medications:
  • – High-dose inhaled corticosteroids AND Long-acting inhaled beta 2 -agonists AND, if needed, Corticosteroid tablets or syrup long term (2 mg/kg/day, generally do not exceed 60 mg per day). (Make repeat attempts to reduce systemic corticosteroids and maintain control with high-dose inhaled corticosteroids.)

Step 3 - Moderate Persistent

• Daily daytime symptoms or symptoms more than 1 night a week
• Peak flows 60% to 80% of his personal best or more than 30% variability in daily peak flow measurements.
• Preferred daily medications:
  • Low-to-medium dose inhaled corticosteroids and long-acting inhaled beta 2 -agonists.
• Alternative treatment:
  • Increase inhaled corticosteroids within medium-dose range OR Low-to-medium dose inhaled corticosteroids and either leukotriene modifier or theophylline.
• If needed (particularly in patients with recurring severe exacerbations):
  • Preferred treatment: Increase inhaled corticosteroids within medium-dose range and add long-acting inhaled beta 2 -agonists.
  • Alternative treatment: Increase inhaled corticosteroids within medium-dose range and add either leukotriene modifier or theophylline.

Step 2 - Mild Persistent

• Daytime symptoms more than twice a week but less than once a day or symptoms more than 2 nights a month
• Peak flows more than or equal to 80% of his personal best or 20% to 30% variability in daily peak flow measurements.
• Preferred daily medications:
  • Low-dose inhaled corticosteroids.
• Alternative treatment:
  • Cromolyn, leukotriene modifier, nedocromil, OR sustained release theophylline to serum concentration of 5–15 mcg/mL.

Step 1 - Mild Intermittent

• Daytime symptoms less than or equal to 2 days a week and less than or equal to 2 nights a month
• Peak flows more than or equal to 80% of his personal best and less than 20% variability in daily peak flow measurements.
• No daily medications needed
• Severe exacerbations may occur, separated by long periods of normal lung function and no symptoms. A course of systemic corticosteroids is recommended.
  
  

Quick Relief (All Patients)

• Short-acting bronchodilator: 2–4 puffs short-acting inhaled beta 2 -agonists 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 corticosteroids may be needed.
• Use of short-acting beta 2 -agonists >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

• Review treatment every 1 to 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 technique, adherence, and environmental control.

Notes

• The stepwise approach is meant to assist, not replace, the clinical decisionmaking required to meet individual patient needs.
• Classify severity: assign patient to most severe step in which any feature occurs (PEF is % of personal best; FEV 1 is % predicted).
• Gain control as quickly as possible (consider a short course of systemic corticosteroids); then step down to the least medication necessary to maintain control.
• Provide education on self-management and controlling environmental factors that make asthma worse (e.g., allergens and 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
  
  

Next page > Asthma Control Medications

NIH Publication No. 02-5075 July 2002

*Updates the NAEPP Expert Panel Report 2 (NIH Publication No. 97-4051).

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