Managing Asthma in Children 12 years of Age and Adults

Once a patient has been classified for the level of severity of their asthma, the health care provider can use the stepwise approach to gain or maintain control the patient's asthma.

Stepwise Treatment Approach

Quick-Relief for All Patients

Short-acting bronchodilator: inhaled b₂-agonist (2-4 puffs) as needed for symptoms. Intensity of treatment will depend on severity of exacerbation. Click here to learn more about quick-relief medications.

Notes

The stepwise approach presents general guidelines to assist clinical decision making. Asthma is highly variable; clinicians should tailor medication plans to the needs of individual patients. 

• A course of oral steroids may be needed at any time and step.  

• Patients with exercise-induced bronchospasm should take 2 to 4 puffs of an inhaled b₂-agonist 5-60 minutes before exercise.  

• Referral to an asthma specialist for consultation or co-management is recommended for patients requiring step 3 or 4 care. Referral may be considered for step 2 care.

• There are certain known risk factors for death from asthma, click here for more information.

Gaining Control

The physician’s judgment of an individual patient’s needs and circumstances will determine at what step to initiate therapy. The recommended approach to gaining control of asthma:

• At the onset, give therapy at a higher level to achieve rapid control and then step down to the minimum therapy needed to maintain control. A higher level of therapy can be accomplished by either adding a course of oral steroids to inhaled steroids, cromolyn, or nedocromil or using a higher dose of inhaled steroids.

•  If control is not achieved with initial therapy (e.g. within 1 month), the step selected, the therapy in the step, and possibly the diagnosis should be reevaluated.

Maintaining Control

Increases or decreases in medications may be needed as asthma severity and control vary over time. The NHLBI guidelines recommend follow-up visits every 1-6 months to monitor the patient’s asthma. In addition, patients should be instructed to monitor their symptoms (and peak flow if used) and adjust therapy as described in their Asthma Action Plan.

Step Down Therapy

Gradually reduce or “step down” long-term-control medications after several weeks or months of controlling persistent asthma (i.e., the goals of asthma therapy are achieved). In general, the last medication added to the medical regimen should be the first medication reduced.

Inhaled steroids may be reduced about 25 percent every 2 to 3 months until the lowest dose required to maintain control is reached. For patients with persistent asthma, anti-inflammatory medications should be continued. Click here to learn more about long-term controller medications.

For patients who are taking oral steroids daily on a long-term basis, referral for consultation or care by an asthma specialist is recommended. Patients should be closely monitored for adverse side effects . Continuous attempts should be made to reduce daily use of oral steroids when asthma is controlled:

• Maintain patients on the lowest possible dose of oral steroids (single dose daily or on alternate days).

• Use high doses of inhaled steroids to eliminate or reduce the need for oral steroids.

Step Up Therapy

The presence of one or more indicators of poor asthma control, may suggest a need to increase or “step up” therapy. Before increasing therapy, alternative reasons for poorly controlled asthma should be considered. Referral to a specialist for co-management or consultation may be appropriate, click here to learn when to refer patients to an asthma specialist.   

Indicators of poor asthma control:

• They are awakened at night with symptoms

• They have an urgent care visit

• Patient has increased need for short-acting inhaled b₂-agonists (excludes use for upper respiratory viral infections and exercise-induced bronchospasm) OR

— At step 1: Used short-acting inhaled b₂–agonists more than two times in a week

— At steps 2-3: Used short-acting inhaled b₂-agonists more than three to four times a day OR used this medication on a daily basis for a week or less

— Patient used more than one canister of short-acting inhaled b₂-agonist in one month

Before increasing Medications – Assess Reasons for Poor Asthma Control – ICE

• Inhaler technique – Check patient’s technique.

• Compliance – Ask when and how much medication the patient is taking.

• Environment - Ask patient if something in his or her environment has changed.

Is there environmental tobacco smoke in the home? Find out about cotinine levels, which can help track exposure to tobacco smoke and its toxic constituents using a saliva, blood or urine test.

You may also want to consider an alternative diagnosis. Assess patient for presence of other upper respiratory disease.

The addition of a 3- to 10-day course of oral steroids may be needed to reestablish control during a period of gradual deterioration or a moderate-to-severe exacerbation.  If symptoms do not recur after the course of steroids (and peak flow remains normal) the patient should continue in the same step. However, if the steroid course controls symptoms for less than 1 to 2 weeks, or if courses of steroids are repeated frequently, the patient should move to the next higher step in therapy.

Adapted from the Practical Guide for the Diagnosis and Management of Asthma, NIH Publication No. 97-4053, October 1997, National Institutes of Health, National Heart, Lung and Blood Institute