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.
Assess Asthma Severity to Decide Initial Therapy
| Classification of Asthma Severity |
| Components of Severity |
Intermittent |
Persistent (Mild) |
Persistent (Moderate) |
Persistent (Severe) |
Impairment
Normal forced expiratory volume in one second (FEV1)/ forced vital capacity (FVC):
8-19 years: 85%
20-39 years: 80%
40-59 years: 75%
60-80 years: 70%
|
Symptoms |
< 2 days/week
| > 2 days/week, not daily |
Daily |
Throughout day |
| Nighttime awakenings |
< 2x/month |
3-4x/month |
> 1x/week, not nightly |
Often, 7x/week |
| Short-acting beta2-agonist use for symptoms |
< 2 days/week |
> 2 days/week, not daily and not > 1/day |
Daily |
Several times daily |
| Interference with normal activity |
None |
Minor limitation |
Some limitation |
Extremely limited |
| Lung function: |
Normal forced expiratory volume in one second (FEV1) between exacerbations |
|
|
|
| FEV1 |
> 80% |
> 80% |
60% - 80% |
< 60% |
| FEV1/FVC |
Normal |
Normal |
Reduced 5% |
Reduced > 5% |
| Risk |
Exacerbations requiring oral steroids |
0-1/year |
> 2/year |
- Consider severity & interval since last exacerbation. Frequency & severity may fluctuate over time for patient of any severity class.
- Relative annual risk of exacerbations maybe related to FEV1.
|
| Recommended step for initiating treatment |
Step 1 |
Step 2 |
Step 3 |
| Re-evaluate control in 2 to 6 weeks and adjust therapy accordingly. |
On Follow-Up, Assess Asthma Control and Step Therapy Up or Down
| Classification of Asthma Control |
| Components of Control |
Well-Controlled |
Not Well-Controlled |
Very Poorly Controlled |
| Impairment |
Symptoms |
< 2 days/week |
>2 days/week |
Throughout day |
| Nighttime awakenings |
< 2x/month |
1-3x/week |
> 4x/week |
| Short-acting beta2-agonist use for symptoms |
< 2 days/week |
>2 days/week |
Several times/day |
| Interference with normal activity |
None |
Some limitation |
Extremely limited |
| FEV1 or peak flow |
>80% |
60% - 80% |
<60% |
| Risk |
Exacerbations requiring oral steroids |
0-1x/year |
> 2x/year |
| Treatment-related adverse effects |
Intensity of medication-related side effects does not correlate to specific levels of control, but should be considered in overall assessment of risk. |
| Recommended action for treatment |
- Maintain current step
- Regular follow-up every 1-6 months
- Consider step down if well-controlled >3 months
|
- Step up 1 step
- Re-evaluate in 2-6 weeks
|
- Consider oral steroids
- Step up 1-2 steps
- Re-evaluate in 2 weeks
|
Step Approach for Asthma Management (use lowest treatment level required to maintain control)
- Quick relief medication for all patients: Inhaled short-acting beta2-agonist (SABA) as needed for symptoms [A]. Intensity of treatment depends on severity of symptoms; up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed. Use of SABA >2 days a week for symptom control (not prevention of exercise-induced bronchospasm) indicates inadequate control and the need to step up treatment.
- Patient education and environmental control at each step
- Persistent asthma: Daily long-term control therapy [A]; consult with asthma specialist if step 4 or higher [D], or progressive decreased lung function. Consider consultation at step 3 [D].
Intermittent Asthma
Step 1
Preferred: Short-acting beta2-agonist as required
Mild Persistent Asthma
Step 2
Preferred: Low-dose inhaled corticosteroid [A]
Alternative: Cromolyn or leukotriene receptor antagonist; or nedocromil; or theophylline [B]
Moderate Persistent Asthma
Step 3
Preferred: Low-dose inhaled corticosteroid + long-acting beta2-agonist [A] or medium-dose inhaled corticosteroid [A]
Alternative: Low-dose inhaled corticosteroid + either a leukotriene receptor antagonist [A] theophylline [B], or zileuton [D]
Step 4
Preferred: Medium-dose inhaled corticosteroid + long-acting beta2-agonist [B]
Alternative: Medium-dose inhaled corticosteroid + either a leukotriene receptor antagonist, theophylline [B], or zileuton [D]
Severe Persistent Asthma
Step 5
Preferred: High-dose inhaled corticosteroid + long-acting beta2-agonist [B] and consider omalizumab for patients who have immunoglobulin E (IgE)-mediated allergies [B]
Step 6
Preferred: High-dose inhaled corticosteroid + long-acting beta2-agonist + oral systemic corticosteroid [D] and consider omalizumab for patients who have IgE-mediated allergies [B]
Definitions:
Levels of Evidence for the Most Significant Recommendations
- Randomized controlled trials
- Controlled trials, no randomization
- Observational studies
- Opinion of expert panel
