Stepwise approach for managing asthma

Like impairment evaluation and risk assessment, the Guidelines offer recommendations for asthma management in three age ranges: children aged 0-4 years, children aged 5-11 years, and youths older than 12 years and adults. Previously, there were two age ranges: children aged 5 years and younger and children older than 5 years through adults. The goal of management is to reduce impairment as well the risk of exacerbation and disease progression with the least amount of medication. The stepwise approach for managing asthma now consists of six steps rather than four.

Instead of having multiple actions within each of four steps, the new Guidelines have simplified the actions so that each step represents only one action. Step 1 for all age groups is use of a short-acting beta agonist to control intermittent symptoms.

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In children aged 0-4 years, long-term control therapy with low-dose inhaled corticosteroids (Step 2) should be started in those “who had four or more episodes of wheezing in the past year that lasted more than one day and affected sleep and who have a positive asthma predictive index.” A positive asthma predictive index comprises one of the following major criteria:

• A parental history of asthma
• A physician’s diagnosis of atopic dermatitis
• Evidence of sensitization to aeroallergens

Or two of the following minor criteria:
• Evidence of sensitization to foods
• >4% peripheral blood eosinophilia
• Wheezing apart from colds

For infants and young children in this age category whose symptoms are not well controlled on low-dose inhaled corticosteroids, the Guidelines suggest increasing to medium-dose inhaled corticosteroids before adding any additional therapy.

In the second age range (children aged 5-11 years), inhaled corticosteroids are also the preferred medication in Step 2. However, in Step 3 of the asthma-management approach, the clinician may choose to add another medication (long-acting beta2-agonist, leukotriene receptor antagonist, or theophylline) to the low-dose inhaled corticosteroid. Alternatively, he may prescribe step-up to a medium dose of inhaled corticosteroids. Either change in therapy may be considered an equal option.

For youths older than 12 years and adults, the preferred treatment for Step 3 of the stepwise approach is a combination of an inhaled steroid and long-acting beta2-agonist or stepping up to a medium dose of inhaled corticosteroids. If the patient has severe-persistent asthma (Step 5 or Step 6) and allergic rhinitis, the clinician should consider omalizumab.

Follow-up schedule

The Expert Panel has made specific recommendations regarding the schedule for follow-up. If the patient’s asthma is not well controlled or if long-term control therapy has just been started, the patient should return within two to six weeks. If the patient’s asthma is very poorly controlled and a short course of oral systemic corticosteroids was given, the Guidelines recommend re-evaluation in two weeks. Once asthma is well controlled, intervals between visits can range from one to six months. Patients being considered for a step down in therapy should return in three months. If there are problems controlling asthma symptoms despite appropriate therapy, or if immunotherapy or omalizumab is being considered, further testing is warranted. Patients who have had two severe exacerbations in the past year or who have been hospitalized should be referred to an asthma specialist.


A stronger emphasis has been placed on educating patients throughout all points of care, including hospitals, emergency departments, pharmacies, schools, and even in the patient’s home. Another point of emphasis is teaching patients to control environmental factors and comorbid conditions that affect asthma.

The clinician should provide all patients with a written action plan that includes both daily management instructions (long-term control medication) and direction on how to recognize and handle worsening asthma.

Ms. Dale is a pediatric nurse practitioner who works with a traveling asthma clinic that serves school districts in Los Angeles.