Adults and Children over 12 Asthma Adults and Children over 12

Epidemiology 15 million adults in the US Children 3-7% of children in the US Asthma prevalence increased by 160% in children in past 20 years 80% of people with asthma had onset before age 5

Pathophysiology Airway obstruction (reversible) Airway hyper-reactivity or hyper-responsiveness to stimuli (or triggers) Airway inflammation

Common Triggers Viral respiratory infections Exercise Irritants such as tobacco smoke, fumes, perfumes Allergens Animal dander, dust mites, cockroaches, food, mold, grass, pollen, trees Change in weather Emotional expressions such as laughter or anger GERD

Risk Factors Fetal exposure to tobacco smoke Prematurity RSV less than 4 mo FH of atopy or asthma Obesity (correlation)—tends to be more severe Less responsive to inhaled corticosteroids Same response to leukotriene inhibitors

Differential Diagnosis--children Viral respiratory infection, bronchiolitis, bronchitis Allergic rhinitis and sinusitis—Upper Airway Cough Syndrome (UACS)--drainage Foreign body, vocal cord dysfunction, vascular ring (aortic anomaly), tracheal stenosis, tumor, laryngomalacia Obstruction of small airways Cystic fibrosis, bronchopulmonary dysplasia (CLD) congenital heart disease GERD

Differential Diagnosis—Adults COPD—NOT reversible CHF PE Mechanical Obstruction (tumor) Laryngeal dysfunction Cough secondary to ACEI GERD Upper Airway Cough Syndrome (UACS)—PND

Plan Asthma Diagnosis and Treatment Establish Diagnosis Establish Asthma Severity—based on: Functional impairment Risk Level Goal in Treatment Reduce impairment Reduce risk (exacerbations, ER, hospitalization, oral steroid use) Monitor with follow-up visits

Presentation—Recurrent Symptoms Children and teens Cough with exercise—EIB Cough at HS and am, or with laughter Fatigue with running Adults—cough, fatigue with exercise Chest tightness, difficulty breathing

Presentation—Recurrent Symptoms Worse at night or early am Worse with exercise Worse with viral infections Worse with exposure to allergens (seasonality) Worse with irritants—fumes, smoke Worse with change in weather Worse with laughing hard or crying Worse with stress, emotional factors

Classification Assess severity before making treatment plan 4 levels Intermittent Mild persistent Moderate persistent Severe persistent Includes assessment of impairment and risk Impairment—patient symptoms and spirometry Risk—categorized by the frequency of exacerbations requiring oral steroid use

Intermittent Asthma—≥ 12 yo Symptoms— ≤ 2 days a week Night time awakenings— ≤ 2 times a month Short acting β-agonist for sx— ≤ 2 days a week Interference with normal activity—None Lung function— Normal FEV1 between exacerbations; FEV1 > 80 percent of predicted; FEV1/FVC normal FEV1 < 12% change after bronchodilator use Risk—0-1 oral steroids/year

Mild Persistent Asthma--≥ 12 yo Symptoms— >2 but < 7 days a week Night time awakenings— 3-4 times a month Short acting β-agonist for sx— > 2 days a week but not more than once a day Interference with normal activity—Minor Lung function FEV1 ≥ 80 percent of predicted; FEV1/FVC normal or > 80% FEV1 > 12% change after bronchodilator use Risk ≥ 2 per year

Moderate Persistent Asthma-- ≥ 12 Symptoms— daily Night time awakenings— > once/wk but < 7 Short acting β-agonist for sx— daily Interference with normal activity—Some limitation Lung function— FEV1 > 60 percent but < 80 percent of predicted FEV1/FVC reduced 5 percent Risk ≥ 2 per year

Severe Persistent Asthma-- ≥ 12 yo Symptoms— throughout the day Night time awakenings— often 7 times/week Short acting β-agonist for sx— several times/day Interference with normal activity—Extreme limitation Lung function— FEV1 < 60 percent of predicted FEV1/FVC reduced > 5 percent Risk ≥ 2 per year

FEV1/FVC Normals by Age FEV1 = forced expiratory volume in one second FVC = forced vital capacity FEV1/FVC 8 to 19 years— 85 percent 20 to 39 years—80 percent 40 to 59 years—75 percent 60 to 80 years—70 percent

So how to determine severity? Look at the guidelines for assessment Symptoms Night time awakenings Short acting β-agonist for sx Interference with normal activity All Subjective data—these are things your patient has to tell you. Not all wheezes or cough are asthma Remember your differentials, (CHF, PE, GERD, meds etc) Look at seasonality of symptoms, triggers

Objective Remember your differentials Cardiac, GI, Atopic, Respiratory, Mass, PND (UACS) General—any distress, sitting holding torso up, pallor, minimal talking Eyes—signs of viral or allergic externally, cardiac on fundal exam Ears—OME Nose—Boggy, Mucus Mouth—Hydrated, Posterior pharynx—drainage, cobblestoning? Neck—JVD, nodes, trachea, thyroid Upper Airway Cough Syndrome--Drainage

Objective Lungs—all lobes, anterior and posterior Have patient cough while auscultating Cardiac—Murmur, Gallop. Upright and supine Abdomen—AAA, mid-epigastric pain Skin—back, abdomen, legs, antecubital areas—Eczema, Dermatographism

Assessment Diagnostic Tests Age > 5 years—Spirometry (PFT)—Pre and Post Bronchodilator Age < 5 years—response to short-acting β-agonist (SABA)

Plan—Goals of Therapy Maintain asthma control Reduce impairment, maintain activity levels Maintain normal or near-normal pulmonary function Reduce risk—prevent exacerbations Provide appropriate medication with minimal or no adverse effects Address environmental factors Help patients learn self-management skills Reassess Control—Well controlled to poorly controlled.

Overall Treatment—Step Approach ALL patients get a short-acting β-agonist (SABA) Step UP if needed (first, check adherence, environmental control, and comorbid conditions) Step DOWN if asthma is well controlled for at least 3 months If patient uses inhaled SABA ≥ 2 days a week for symptom relief (not for prevention of EIB) Consider inadequate control or adherence Need to step up treatment

Oral Steroid Use For treatment purposes, patients who had two or more exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma. So ≥ 2 oral steroids/year = Persistent asthma Adapted from National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 3: guidelines for the diagnosis and management of asthma. Summary report 2007:344. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed January 8, 2009.

Treatment—Step Approach ≥ 12 yo Step 1—Intermittent—short acting β-agonist (SABA) Step 2—Preferred: Low-dose inhaled corticosteroid Alternative: Cromolyn (Intal), leukotriene antagonist Step 3—Preferred: Low or medium-dose inhaled corticosteroid plus long-acting inhaled β-agonist Alternative: low-dose inhaled corticosteroid, plus leukotriene antagonist, theophylline, or zileuton (Zyflo) Step 4—Preferred: Medium-dose inhaled corticosteroid plus long-acting inhaled β-agonist Alternative: medium-dose inhaled corticosteroid, plus leukotriene antagonist, theophylline, or zileuton

Treatment—Step Approach ≥ 12 yo Step 5—Preferred: High-dose inhaled corticosteroid, plus long-acting inhaled β-agonist Consider omalizumab (Xolair) for patients who have allergies Step 5—Preferred: High-dose inhaled corticosteroid, plus long-acting inhaled β-agonist plus oral corticosteroid

CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS ≥ 12 YEARS OF AGE AND ADULTS Components of Severity Classification of Asthma Severity (≥12 years of age) Intermittent Persistent Mild Moderate Severe Impairment Normal FEV1/FVC: 8-19 yr 85% 20-39 yr 80% 40-59 yr 75% 60-80 yr 70% Symptoms ≤ 2 days/week >2 days/week but not daily Daily Throughout the day Nighttime awakenings ≤ 2x/month 3-4x/month >1x/week but not nightly Often 7x/week Short-acting beta2-agonist use for symptom control (not prevention of EIB) >2 days/week but not daily, and not more than 1x on any day Several times per day Interference with normal activity None Minor limitation Some limitation Extremely limited Lung function Normal FEV1 between exacerbations FEV1 > 80% predicted FEV1/FVC normal FEV1 >80% predicted FEV1 >60% but <80% predicted FEV1/FVC reduced 5% FEV1< 60% predicted FEV1/FVC reduced >5% Risk Exacerbations requiring oral systemic corticosteroids 0-1/year ≥ 2/year Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category Relative annual risk of exacerbations may be related to FEV1 Recommended Step for Initiating Treatment Step 1 Step 2 Step 3 Step 4 or 5 and consider short course of oral systemic corticosteroids In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly The stepwise approach is meant to assist, not replace the clinical decision making required to meet individual patient needs. Level of severity is determined by assessment of both impairment and risk. Assess impairment domain by patient’s /caregiver’s recall of previous 2-4 weeks and spirometry. Assign severity to the most severe category in which any feature occurs. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma. The text below is a narration of the table for the visually impaired using an electronic reading device: Title of table is classifying Asthma severity and initiating treatment in youths greater than or equal to 12 years of age and adults: Assessing severity and initiating treatment for patients who are not currently taking long term control medication. The Key for this table is: FEV! Is forced expiratory volume in 1 second; FVC is forced vital capacity; ICU is intensive care unit. The components of severity are impairment and risk. Impairment is subdivided into symptoms, nighttime awakenings, short-acting beta two agonist use for symptom control not including the prevention of exercise induced bronchospasm, interference with normal activity and lung function. Risk involves the number of exacerbations requiring oral systemic corticosteroids. For a severity classification of "Intermittent," asthma symptoms are less than or equal to 2 days per week. Nighttime awakenings are less than or equal to 2 times per month. Use of short-acting beta 2 agonist use for symptom control (not prevention of exercise induced bronchospasm) is less than or equal to 2 days per week. No interference with normal activity. Lung function is normal FEV1 between exacerbations, FEV1 is greater than 80% predicted and FEV1 / FVC is normal. Risk is classified as intermittent if exacerbations requiring oral systemic corticosteroids occur 0 to 1 time per year. Recommended step for initiating treatment is Step 1. For a severity classification of "Persistent mild," asthma symptoms are greater than 2 days per week, but not daily. Nighttime awakenings are 3 to 4 times per month. Use of short-acting beta 2 agonist use for symptom control (not prevention of exercise induced bronchospasm) is greater than 2 days per week, but not daily, and not more than 1 time on any day. Minor limitation with normal activity. Lung function is FEV1 is greater than 80% predicted and FEV1/FVC is normal. Risk is classified as persistent mild if exacerbations requiring oral systemic corticosteroids occur greater than or equal to 2 times per year. Recommended step for initiating treatment is Step 2. For a severity classification of "Persistent Moderate," asthma symptoms are daily. Nighttime awakenings are more than 1 time per week, but not nightly. Use of short-acting beta 2 agonist use for symptom control (not prevention of exercise induced bronchospasm) is daily. Some limitation with normal activity. Lung function is FEV1 is greater than 60%, but less than 80% predicted, and FEV1/FEV reduced 5%. Risk is classified as persistent moderate if exacerbations requiring oral systemic corticosteroids occur greater than or equal to 2 times per year. Recommended step for initiating treatment is step3, and consider short course of oral systemic corticosteroids. For a severity classification of "persistent severe," asthma symptoms are throughout the day. Nighttime awakenings are often 7 times per week. Use of short-acting beta 2 agonist use for symptom control (not prevention of exercise induced bronchospasm) is several times per day. Extreme limits with normal activity. Lung function is FEV1 is less than 60% predicted, and FEV1/FVC is reduced greater than 5%. Risk is classified as persistent severe if exacerbations requiring oral systemic corticosteroids occur greater than or equal to 2 times per year. Recommended step for initiating treatment is step 4 or 5, and consider short course of oral systemic corticosteroids. For all classifications: in determining risk, consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time or patients in any severity category. Relative annual risk of exacerbations may be related to FEV1. For all classifications of severity, in 2-6 weeks, evaluate level of asthma control that is achieved And adjust therapy accordingly. Note: At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (for example, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had greater than or equal to 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.

Stepwise Approach for Managing Asthma in Youths ≥ 12 Years of Age and Adults Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3. Step 6 Preferred: High-dose ICS + LABA + oral corticosteroid AND Consider Omalizumab for patients who have allergies Step 5 Preferred: High-dose ICS + LABA AND Consider Omalizumab for patients who have allergies Step up if needed (first, check adherence, environmental control, and comorbid conditions) Step down if possible (and asthma is well controlled at least 3 months) Step 4 Preferred: Medium-dose ICS + LABA Alternative: Medium-dose ICS+either LTRA, Theophylline, or Zileuton Step 3 Preferred: Low dose ICS + LABA OR medium-dose ICS Alternative: low-dose ICS + either LTRA, Theophylline, or Zileuton Step2 Preferred: Low-dose ICS Alternative: Cromolyn, LTRA, Nedocromil, or Theophylline Step 1 Preferred: SABA PRN Assess control Each step: Patient education, environmental control, and management of comorbidities. Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma * The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up. Zileuton is a less desirable alternative due to limited studies as adjunctive therapy and the need to monitor liver function. Theophylline requires monitoring of serum concentration levels. In step 6, before oral systemic corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or zileuton may be considered, although this approach has not been studied in clinical trials. Step 1,2, and 3 preferred therapies are based on Evidence A; step 3 alternative therapy is based on Evidence A for LTRA, Evidence B for theophylline, and Evidence D for zileuton. Step 4 preferred therapy is based on Evidence B, and alternative therapy is based on Evidence B for LTRA and theophylline and Evidence D for zileuton. Step 5 preferred therapy is based on Evidence B. Step 6 preferred therapy is based on (EPR – 2 1997) and Evidence B for omalizumab. Immunotherapy for steps 2-4 is based on Evidence B for house-dust mites, animal danders, and pollens; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults. Clinicians who administer immunotherapy should be prepared and equipped to identify and treat anaphylaxis that may occur. The text below is a narration of the table for the visually impaired using an electronic reading device: Title of table is Stepwise approach for managing asthma in youths greater than or equal to 12 years of age and adults. The key for the table is EIB, is exercise induced bronchospasm; ICS is inhaled corticosteroid; LABA is inhaled long acting beta 2 agonist; LTRA is leukotriene receptor antagonist; SABA is inhaled short acting beta 2 agonist. Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. The slide is organized into six distinct steps for patient education and environmental control. Quick relief medication for all patients is SABA, as needed for symptoms. Intensity of treatment depends on severity of symptoms. Up to 3 treatments at 20 minute intervals as needed. Short course of oral systemic corticosteroids may be needed. Caution: Increasing use of SABA or use more than 2 days a week for symptom relief, not prevention of EIB, generally indicates inadequate control and the need to step up treatment. For intermittent asthma, step 1 is recommended. The preferred treatment of step 1 is SABA PRN. Persistent Asthma, which requires daily medication, corresponds with steps 2 through 6. If step 4 care or higher is required, consult with asthma specialist. Consultation should be considered at step 3. Step 2, preferred treatment is Low dose ICS. Alternative is cromolyn, LTRA, Nedocromil, or theophylline. For step 3, preferred treatment is low dose ICS plus LABA, or medium dose ICS. Alternative is low dose ICS plus either LTRA, theophylline, or zileuton. For Step 4, preferred treatment is medium dose ICS plus LABA. Alternative is medium dose ICS plus either LTRA, theophylline, or zileuton. For step 5, preferred treatment is High dose ICS plus LABA and consider omalizumab for patients who have allergies. For step 6, preferred treatment is high dose ICS plus LABA plus oral systemic corticosteroid, and consider omalizumab for patients who have allergies. For all asthma management, step up if needed. First, however, assess control. Check adherence, environmental control, and comorbid conditions.. Step down if possible, and asthma is well controlled at least 3 months. Note that for each step, include patient education, environmental control, and management of comorbidities. For steps 2-4, consider subcutaneous allergen immunotherapy for patients who have allergic asthma. Immunotherapy for steps 2-4 is based on Evidence B for house-dust mites, animal danders, and pollens; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults. Clinicians who administer immunotherapy should be prepared and equipped to identify and treat anaphylaxis that may occur. Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment.

ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTH ≥ 12 YEARS OF AGE AND ADULTS Components of Control Classification of Asthma Control ( ≥ 12 years of age) Well Controlled Not Well Controlled Very Poorly Controlled Impairment Symptoms ≤ 2 days/week >2 days/week Throughout the day Nighttime awakenings ≤ 2x/month 1-3x/week ≥ 4x/week Interference with normal activity None Some limitation Extremely limited Short-acting beta2-agonist use for symptom control (not prevention of EIB) Several times per day FEV1 or peak flow >80% predicted/ personal best 60-80% predicted/ personal best <60% predicted/ personal best Validated Questionnaires ATAQ ACQ ACT ≤ 0.75* ≥ 20 1-2 ≥ 1.5 16-19 3-4 N/A ≤ 15 Risk Exacerbations requiring oral systemic corticosteroids 0-1/year ≥ 2/year Progressive loss of lung function Evaluation requires long-term follow-up care. Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. Recommended Action for Treatment Maintain current step. Regular follow ups every 1-6 months to maintain control. Consider step down if well controlled for at least 3 months. Step up 1 step and Reevaluate in 2-6 weeks. For side effects, consider alternative treatment options. Consider short course of oral systemic corticosteroids, Step up 1-2 steps, and Reevaluate in 2 weeks. Consider severity and interval since last exacerbation The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient’s recall of previous 2-4 weeks and by spirometry/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment such as inquiring whether the patient's asthma is better or worse since the last visit. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had ≥ 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma. Validated Questionnaires for the impairment domain (the questionnaires do not assess lung function or the risk domain) ATAQ=Asthma Therapy Assessment Questionnaire© (See sample in “Component 1: Measures of Asthma Assessment and Monitoring.”) ACQ=Asthma Control Questionnaire © (user package may be obtained at www.qoltech.co.uk or juniper@qoltech.co.uk) ACT=Asthma Control Test™ (See sample in “Component 1: Measures of Asthma Assessment and Monitoring.”) Minimal Importance Difference: 1.0 for the ATAQ; 0.5 for the ACQ; not determined for the ACT. Before step up in therapy: Review adherence to medications, inhaler technique, environmental control, and comorbid conditions. If alternative treatment option was used in a step, discontinue and use the preferred treatment for that step. The text below is a narration of the table for the visually impaired using an electronic reading device: Title of table is assessing asthma control and adjusting therapy in youth greater than or equal to 12 years of age and adults. The Key for this table is: EIB is exercise induced bronchospasm; ICU is intensive care unit. The components of control are impairment and risk. Impairment is subdivided into symptoms, nighttime awakenings, interference with normal activity, short-acting beta two agonist use for symptom control not including the prevention of exercise induced bronchospasm, FEV1 or peak flow and validated questionnaires. Risk involves the number of exacerbations requiring oral systemic corticosteroids, progressive loss of lung function, and treatment-related adverse effects. For a classification of "Well Controlled," symptoms are less than or equal to 2 days per week.. Nighttime awakenings are less than or equal to 2 times per month. No interference with normal activity. Short acting beta 2 agonist use for symptom control (not prevention of exercise induced bronchospasm) is less than or equal to 2 days per week. FEV1 or peak flow is greater than 80% predicted or personal best. The ATAQ validated questionnaire is 0. The ACQ validated questionnaire is less than or equal to .75, note that ACQ values of .76 thru 1.4 are indeterminate regarding well controlled asthma. The ACT validated questionnaire is greater than or equal to 20. Risk is classified as well controlled if exacerbations requiring oral systemic corticosteroids occur 0-1 times per year. For the risk of reduction in lung growth, evaluation requires long term follow up. In regards to treatment related adverse effects, medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. The recommended action for treatment is maintain current treatment, regular follow up every 1 to 6 months, consider step down if well controlled for at least 3 months. For a classification of "Not Well Controlled, " symptoms are greater than 2 days per week. Nighttime awakenings are greater than or equal to 1 to 3 times per week. Some limitation with normal activity. Short acting beta 2 agonist use for symptom control (not prevention of exercise induced bronchospasm) is greater than two days per week. FEV1 or peak flow is greater than 60 to 80% predicted or personal best. The ATAQ validated questionnaire is 1 to 2. The ACQ validated questionnaire is greater than or equal to 1.5. The ACT validated questionnaire is 16 to 19. Risk is classified as not well controlled if exacerbations requiring oral systemic corticosteroids occurs greater than or equal to 2 times per year. Severity and interval since last exacerbation should be considered. Recommended action for treatment is to step up one step and reevaluate in 2 to 6 weeks. For side effects, consider alternative treatment options. For a classification of asthma control "Very Poorly Controlled," symptoms are throughout the day. Nighttime awakenings are greater than or equal to 4 times per week. Extreme limitation with normal activity. Short acting beta 2 agonist use for symptom control (not prevention of exercise induced bronchospasm) is several times per day. FEV1 or peak flow is less than 60% predicted or personal best. The ATAQ validated questionnaire is 3 to 4. The ACQ validated questionnaire is not available. The ACT validated questionnaire is less than or equal to 15. Risk is classified as very poorly controlled if exacerbations requiring oral systemic corticosteroids occur greater than or equal to 2 times per year. . Severity and interval since last exacerbation should be considered. For the risk of reduction in lung growth, evaluation requires long term follow up Treatment related adverse effects, medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. Recommended action for treatment is to consider short course of oral systemic corticosteroids. Step up 1 to 2 steps, and reevaluate in 2 weeks. For side effects, consider alternative treatment options. Note: At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (for example, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had greater than or equal to 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.

Asthma Action Plan Examples Here are two examples. This treatment plan is popular because the simple analogy (traffic light) is easy to understand. Directions are clear.

SAMPLE LONG TERM TREATMENT PLAN FOR MILD PERSISTENT ASTHMA CLINICAL CONDITION Baseline Plan & When asthma is under control At the FIRST sign of a cold or mild asthma attack For rapidly worsening asthma (severe attack) When there is no cough or wheeze for 3 months For cough or wheeze with exercise PEAK FLOW (% predicted) FEV1/FVC Over 80% for 3 months Above 80% 75 to 80% Below 75% MEDICATION Reliever: Inhaled short-acting beta2-agonist Albuterol 2 puffs as needed Controller: 1) Inhaled low dose corticosteroid Beclomethasone, 42 mcg 1-4 puffs 2x/day or 2) Leukotriene modifier Corticosteroid Tablet or Syrup

SAMPLE LONG TERM TREATMENT PLAN FOR MILD PERSISTENT ASTHMA CLINICAL CONDITION Baseline Plan & When asthma is under control At the FIRST sign of a cold or mild asthma attack For rapidly worsening asthma (severe attack) When there is no cough or wheeze for 3 months For cough or wheeze with exercise PEAK FLOW (% predicted) FEV1/FVC Over 80% for 3 months Above 80% 75 to 80% Below 75% MEDICATION Reliever: Inhaled short-acting beta2-agonist Albuterol 2-6 puffs every 20 minutes for 3 doses then 2-4 puffs every 4 hr 2 puffs as needed 2 puffs every 4 hr 2 puffs as needed 2 puffs 5-10 minutes before exercise Controller: 1) Inhaled low dose corticosteroid Beclomethasone, 42 mcg 1-4 puffs 2x/day 1-4 puffs 2x/day 1-4 puffs 2x/day or 2) Leukotriene modifier 1 tablet* per day Begin with 1-2 mg/kg/day NOTIFY MD Corticosteroid Tablet or Syrup * If patients develops symptoms when corticosteroid discontinued, either resume corticosteroids or try leukotriene modifier

Exercise–Induced Bronchospasm (EIB) Physical activity should be encouraged. Teach patients to take treatment before exercise. SABAs (short–acting beta2–agonist) LTRAs (leukotriene receptor antagonist), cromolyn, or LABAs (long–acting beta2–agonist) also are protective. Frequent or chronic use of LABA to prevent EIB is discouraged, as it may disguise poorly controlled persistent asthma. Consider long–term control medication. EIB often is a marker of inadequate asthma control and responds well to regular anti–inflammatory therapy. Encourage a warm–up period or mask or scarf over the mouth for cold–induced EIB.

Pregnancy Maintain asthma control through pregnancy. ICSs (inhaled corticosteroids) are the preferred long–term control medication. Check asthma control at all prenatal visits. Asthma can worsen or improve during pregnancy; adjust medications as needed. Treating asthma with medications is safer for the mother and fetus than having poorly controlled asthma. Maintaining lung function is important to ensure oxygen supply to the fetus. Remind patients to avoid exposure to tobacco smoke.