1. Adults and Children over 12
Asthma
Adults and Children over 12

2. 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

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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

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

21. 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.

22. 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

23. 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: Accessed January 8, 2009.

24. 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

25. 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

26. 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 %
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 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.

27. 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 – ) 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.

28. 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 or
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.

29. 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.

30. 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

31. 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

32. 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.

33. 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.