The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.
Regular Use of Controller Medications
- Prescribe daily use of inhaled corticosteroids [A] (with nebulizer or metered-dose inhaler with holding chamber with or without face mask or dry powder inhaler).
- Add intermediate or long acting inhaled beta2 agonist (LABA)1,2 if symptoms persist despite maximum inhaled steroid dose [A]. LABA should not be used as the first medication to treat asthma or as mono-therapy [D]. (LABA therapy has been associated with increased risk of severe asthma exacerbations and asthma-related deaths.)
- Avoid the regular scheduled use of short-acting beta2 agonists for long-term control of asthma.
- Prescribe spacer for all metered-dose inhalers [A].
Frequency
Reassess at least every 6 months, or at each periodic visit.
1Inhaled corticosteroids with long-acting beta2 agonists are preferred therapy for moderate persistent asthma. Alternative treatments include inhaled corticosteroids with either leukotriene receptor antagonist or theophylline.
2Alternative therapies for mild persistent asthma include cromolyn (nebulizer is preferred or metered-dose inhaler with holding chamber) or leukotriene receptor antagonist.
Management of Acute Exacerbations
- Prescribe short-acting, inhaled beta2 agonist3, 4 [A] by nebulizer or face mask and space or holding chamber.
- Prescribe oral steroids for acute exacerbations that fail to respond adequately4 [A].
- Routine use of antibiotics for exacerbations is not recommended.
Frequency
During acute episode
3Prescribe these medications for the patient to have at home to use in the event of an acute exacerbation.
4Alternative treatment: Oral beta2 agonist
Medical Follow-Up after Discharge
- Recommend and schedule, if possible, follow-up outpatient visit at discharge from hospital or emergency department [D].
Frequency
Visit within 3 to 5 days of discharge
Periodic Assessment – Monitoring, Management, and Education
- Patients receiving LABA should have close surveillance to assess benefit and safety of medication.
- Provide and review written action plan for self-management (e.g., http://www.getasthmahelp.org/simple%20child%20control%20plan.pdf).
- Assess adherence to written action plan, family psychosocial status, asthma control, triggers, medication use and side effects.
- Recommend influenza immunization and ensure age appropriate immunization status (e.g., pneumococcal vaccine).
- Educate family and patient regarding:
- Use of asthma action plan, inhaler, spacer, nebulizer and medications.
- Importance of using long-term control medication (i.e., inhaled corticosteroids) [D].
- Recognition and treatment of symptoms and when to seek medical attention.
- Identification and avoidance of specific triggers.
- Smoking cessation and secondhand smoke avoidance [C].
Frequency
At each periodic visit
Referral
- Consultation with an asthma specialist is recommended when patient is not responding optimally to asthma therapy; has signs, symptoms or conditions that make it difficult to obtain asthma control; or following a life-threatening asthma exacerbation.
Definitions:
Levels of Evidence for the Most Significant Recommendations
- Randomized controlled trials
- Controlled trials, no randomization
- Observational studies
- Opinion of expert panel
