Table 3. Stepwise Approach for Managing Asthma in Adults and Children Older than 5 Years of Age

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Table 3. Stepwise Approach For Managing Asthma In Adults And Children Older Than 5 Years Of Age
Treatment (Preferred treatments are in bold print)
	Long-term Control	Quick Relief	Education
STEP 4 Severe Persistent	Daily medications: Anti-inflammatory: inhaled corticosteroid (high dose) AND Long-acting bronchodilator: either Long-acting inhaled beta₂-agonist, sustained-release theophylline, or long-acting beta₂-agonist tablets AND Corticosteroid tablets or syrup long term (2 mg/kg/day, generally do not exceed 60 mg per day).	Short-acting bronchodilator: inhaled beta₂-agonists as needed for symptoms. Intensity of treatment will depend on severity of exacerbation. Use of short-acting inhaled beta₂-agonists on a daily basis, or increasing use, indicates the need for additional long-term-control therapy.	Steps 2 and 3 actions plus: Refer to individual education/counseling
STEP 3 Moderate Persistent	Daily medication: Either Anti-inflammatory: inhaled corticosteroid (medium dose) OR Inhaled corticosteroid (low-medium dose) and add a long-acting bronchodilator, especially for nighttime symptoms: either long-acting inhaled beta₂-agonist, sustained-release theophylline, or long-acting beta₂-agonist tablets. If needed Anti-inflammatory: inhaled corticosteroids (medium-high dose) AND Long-acting bronchodilator, especially for nighttime symptoms, either long-acting inhaled beta₂-agonist, sustained-release theophylline, or long-acting beta₂-agonist tablets.	Short-acting bronchodilator: inhaled beta₂-agonists as needed for symptoms. Intensity of treatment will depend on severity of exacerbation. Use of short-acting inhaled beta₂-agonists on a daily basis, or increasing use, indicates the need for additional long-term-control therapy.	Step 1 actions plus: Teach self-monitoring Refer to group education if available Review and update self-management plan
STEP 2 Mild Persistent	One daily medication: Anti-inflammatory: either inhaled corticosteroid (low doses) or cromolyn or nedocromil (children usually begin with a trial of cromolyn or nedocromil). Sustained-release theophylline to serum concentration of 5-15 mcg/mL is an alternative, but not preferred, therapy. Zafirlukast or zileuton may also be considered for patients ³ 12 years of age, although their position in therapy is not fully established.	Short-acting bronchodilator: inhaled beta₂-agonists as needed for symptoms. Intensity of treatment will depend on severity of exacerbation. Use of short-acting inhaled beta₂-agonists on a daily basis, or increasing use, indicates the need for additional long-term-control therapy.
STEP 1 Mild Intermittent	No daily medication needed.	Short-acting bronchodilator: inhaled beta₂-agonists as needed for symptoms. Intensity of treatment will depend on severity of exacerbation. Use of short-acting inhaled beta₂-agonists more than 2 times a week may indicate the need to initiate long-term-control therapy.	Teach basic facts about asthma Teach inhaler/spacer/holding chamber technique Discuss roles of medications Develop self-management plan Develop action plan for when and how to take rescue actions, especially for patients with a history of severe exacerbations Discuss appropriate environmental control measures to avoid exposure to known allergens and irritants
Step down -- 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 technique, adherence, and environmental control (avoidance of allergens or other factors that contribute to asthma severity).
NOTE: The stepwise approach presents general guidelines to assist clinical decision making; it is not intended to be a specific prescription. Asthma is highly variable; clinicians should tailor specific medication plans to the needs and circumstances of individual patients. Gain control as quickly as possible; then decrease treatment to the least medication necessary to maintain control. Gaining control may be accomplished by either starting treatment at the step most appropriate to the initial severity of the condition or starting at a higher level of therapy (e.g., a course of systemic corticosteroids or higher dose of inhaled corticosteroids). A rescue course of systemic corticosteroids may be needed at any time and at any step. Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. This may be especially common with exacerbations provided by respiratory infections. A short course of systemic corticosteroids is recommended. At each step, patients should control their environment to avoid or control factors that make their asthma worse (e.g., allergens, irritants); this requires specific diagnosis and education. Referral to an asthma specialist for consultation or comanagement is recommended if there are difficulties achieving or maintaining control of asthma or if the patient requires step 4 care. Referral may be considered if the patient requires step 3 care.

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