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An overview of asthma management

Author: Christopher H Fanta, MD
Section Editors: Robert A Wood, MD, Bruce S Bochner, MD
Deputy Editors: Helen Hollingsworth, MD, Elizabeth TePas, MD, MS

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Nov 2020. | This topic last updated: Nov 23, 2020.

INTRODUCTION

The main goals of asthma management are to optimize control of asthma symptoms and reduce the risk of asthma
exacerbations, while minimizing medication adverse effects. The four essential components of asthma management are patient
education, control of asthma triggers, monitoring for changes in symptoms or lung function, and pharmacologic therapy. This
overview topic presents the goals and components of asthma management. It is applicable to both children and adults. The
recommendations that follow are based upon major published asthma guidelines [1-3], additional therapies added as they
become available, and approaches modified based upon subsequently published data.

The diagnosis of asthma and more detailed management issues are reviewed separately. (See "Asthma in adolescents and
adults: Evaluation and diagnosis" and "Asthma in children younger than 12 years: Initial evaluation and diagnosis" and "Asthma
in children younger than 12 years: Management of persistent asthma with controller therapies" and "Treatment of intermittent
and mild persistent asthma in adolescents and adults" and "Treatment of moderate persistent asthma in adolescents and
adults" and "Treatment of severe asthma in adolescents and adults".)

ADVICE RELATED TO COVID-19 PANDEMIC

Asthma does not appear to be a strong risk factor for acquiring coronavirus disease 2019 (COVID-19; SARS-CoV-2) or to increase
the risk of more severe disease or death for the majority of patients [4-10]. However, it is still important to maintain good asthma
control, as poorly-controlled asthma may lead to a more complicated COVID-19 disease course, and some studies have found a
higher rate of intubation and prolonged mechanical ventilation in adults with asthma [5,11,12].

We concur with expert groups that every effort should be made to avoid exposure to the SARS-CoV-2 virus and that all regular
medications necessary to maintain asthma control, including inhaled glucocorticoids, oral glucocorticoids, and biologic agents
(eg, omalizumab, mepolizumab, and others), should be continued during the COVID-19 pandemic [2,13-15]. Maintaining good
asthma control helps minimize risk of an asthma exacerbation. There is no good evidence that inhaled glucocorticoids or the
biologic agents used for asthma have an adverse effect on the course of COVID-19 infection [6,16]. For those taking long-term
oral glucocorticoids, abruptly stopping this medication can have a number of serious consequences. Furthermore, the usual
guidelines for prompt initiation of systemic glucocorticoids for asthma exacerbations should be followed, as delaying therapy
can increase the risk of a life-threatening exacerbation [17]. For patients with COVID-19 infection, inhaled asthma medications
should be given by inhaler rather than nebulizer when possible to avoid aerosolizing the virus and enhancing disease spread.

Additional information about COVID-19 is provided separately. (See "Coronavirus disease 2019 (COVID-19): Questions and
answers" and "Coronavirus disease 2019 (COVID-19): Clinical features" and "Coronavirus disease 2019 (COVID-19): Management
in hospitalized adults" and "Coronavirus disease 2019 (COVID-19): Management in children" and "Patient education: Coronavirus
disease 2019 (COVID-19) overview (The Basics)" and "Patient education: Coronavirus disease 2019 (COVID-19) vaccines (The
Basics)".)

GOALS OF ASTHMA TREATMENT

The goals of chronic asthma management may be divided into two domains: achieving good control of asthma-related
symptoms and minimizing future risk (asthma exacerbations, suboptimal lung function, adverse effects of medication) [1,2]. The
patient’s own goals should be incorporated into decision-making regarding asthma management.
 ● Optimizing control of asthma symptoms – Good control of asthma means reducing the intensity and frequency of asthma
symptoms and maintaining normal or near normal activity levels. Specific goals for asthma control include:

• Freedom from frequent or troublesome symptoms of asthma (cough, chest tightness, wheezing, or shortness of breath)
• Few night-time awakenings (≤2 nights per month) due to asthma
• Minimal need (≤2 days per week) for medication for acute relief of asthma symptoms
• Optimized lung function
• Maintenance of normal daily activities, including work or school attendance and participation in athletics and exercise
• Satisfaction with asthma care on the part of patients and families

● Reducing future risk – The concept of risk encompasses the various adverse outcomes associated with asthma and its
treatment [1]. These include asthma exacerbations, suboptimal lung development (children), loss of lung function over time
(adults), and adverse effects from asthma medications. A history of ≥1 exacerbation(s) in the past year is an independent risk
factor for future exacerbations, as are poor adherence to asthma medication, incorrect inhaler technique, low lung function,
smoking (eg, tobacco, cannabis) or vaping, and blood eosinophilia [2].

Specific goals for reducing risk include:

• Prevention of recurrent exacerbations and need for emergency department or hospital care
• Prevention of reduced lung growth in children and loss of lung function in adults (due to poor asthma control)
• Optimization of pharmacotherapy with minimal or no adverse effects

PATIENT EDUCATION

A key component of optimizing asthma control is to engage patients in becoming active partners in their asthma management
[2]. A successful partnership depends on robust and ongoing asthma education; a well-informed and motivated patient can
assume a large measure of control over his or her asthma care.

The effectiveness of direct one-on-one education by the primary clinician, in particular, is well supported by evidence [1].
Numerous additional resources are available for asthma education, such as asthma educators, pharmacists, respiratory
therapists, organized programs in the community, and online sources (eg, Asthma and Allergy Foundation, American Academy
of Allergy, Asthma & Immunology, American College of Allergy, Asthma & Immunology, American Lung Association, National
Jewish Health) [3]. Patient education information from UpToDate is listed below. (See 'Information for patients' below.)

Patient education decreases asthma exacerbations and hospitalizations and improves daily function and patient satisfaction in
many, but not all, studies [18-22]. Based on limited evidence, culturally-specific asthma education may improve asthma
outcomes in minority groups [23].

Components of asthma education and self-management — The important components of asthma education are described in
detail separately and include responses to the following questions (see "Asthma education and self-management"):

● What is asthma and what are its symptoms?

● What are the asthma triggers for the individual patient and how can they be mitigated?
● Which medications should be used for quick relief of asthma symptoms and which are used for asthma control?
● What is the correct technique for each inhaler that the patient uses ( table 1 and table 2 and table 3 and table 4
and table 5)?
● Are there barriers that prevent the patient from taking medications regularly? If so, what methods would help improve
adherence?

Asthma action plan — A personalized “asthma action plan” is a written document that provides instructions for the patient to
follow at home. Although supportive data are limited [1,2], many asthma specialists, including ourselves, believe that written
asthma action plans are useful in clarifying the medication regimen, helping patients to identify declines in asthma control, and
guiding treatment adjustments in response to changes in symptoms and peak expiratory flow (PEF).

Symptom-based action plans are used for the majority of patients. PEF monitoring can be incorporated into the asthma action
plan for patients with moderate to severe asthma, particularly if they are poor perceivers of asthma control. (See 'Home
monitoring' below and "Peak expiratory flow monitoring in asthma".)

Several asthma action plan forms are available:

 ● National Asthma Education and Prevention Program (NAEPP) Asthma action plan ( form 1)
● NAEPP Asthma action plan for children ( form 2)
● American Academy of Allergy Asthma & Immunology - School based asthma management program
● Asthma Society of Canada
● Asthma UK
● National Asthma Council Australia

Instructions for the use of asthma action plans are presented separately. (See "Asthma education and self-management".)

Controlling asthma triggers — The identification and avoidance of asthma "triggers" is an important component of successful
asthma management, and successful avoidance or remediation may reduce the patient's need for medication. Directed
questions can help identify specific triggers (eg, allergens, cigarette smoke exposure) and comorbid conditions ( table 6).
Similarly, children should be questioned about symptoms that occur in school [2]. (See "Trigger control to enhance asthma
management" and "Allergen avoidance in the treatment of asthma and allergic rhinitis".)

Adults should be questioned about symptoms not only in the home, but also in the workplace, as asthma can be exacerbated by
both irritant and allergen exposures in occupational settings. Patterns of symptoms that suggest occupational triggers are
presented in the table ( table 7) [1]. (See "Occupational asthma: Definitions, epidemiology, causes, and risk factors".)

For triggers that are more difficult to avoid or should not be avoided, such as upper respiratory tract illnesses, physical exertion,
hormonal fluctuations, and extreme emotion, patients should be taught how to adjust their asthma management to mitigate
potential exacerbation of their symptoms.

INITIAL ASSESSMENT

The initial assessment of asthma severity typically occurs around the time of diagnosis. (See "Asthma in children younger than 12
years: Initial evaluation and diagnosis" and "Asthma in adolescents and adults: Evaluation and diagnosis".)

Besides noting the frequency of symptoms and risk factors for exacerbations, evaluation should include assessment (and
documentation) of lung function in persons old enough to perform testing [2]. If the patient has an exacerbation at the time of
the initial evaluation, assessment of lung function should be repeated following resolution of the exacerbation.

The National Asthma Education and Prevention Program (NAEPP) and the Global Initiative for Asthma (GINA) base initial therapy
on assessment of asthma symptoms (frequency and intensity), respiratory impairment, and risk of poor asthma outcomes,
although the specific categories vary ( table 8) [1,2]. NAEPP includes spirometric values in determining asthma severity. In
contrast, GINA does not use spirometric values to guide medication selection after the diagnosis of asthma is confirmed, except
for a forced expiratory volume in one second (FEV1) <60 percent of predicted.

Asthma control is determined by considering the following factors ( table 9) [1,2]:

● Reported frequency and severity of daytime symptoms and nocturnal awakening over the previous four weeks
● Number of exacerbations requiring oral glucocorticoids in the previous year
● Current level of lung function, if able to perform this testing (FEV1 and FEV1/forced vital capacity [FVC] values, or peak
expiratory flow [PEF] if spirometry not available)

GINA defines the severity of a patient’s asthma based upon the level of treatment required to control symptoms and
exacerbations, assessed retrospectively, but incorporates symptom frequency and severity and risk of exacerbation in the
approach to initiation of therapy [2].

The use of these elements to determine severity in adults and adolescents over the age of 12 years is presented in the table (
table 8). The classification of severity in children aged 5 to 11 years is similar to that in adults. Severity in children under the
age of five years, however, is classified somewhat differently.

Intermittent — Intermittent asthma is characterized by the following features in adults and adolescents ( table 8) [1]:

● Daytime asthma symptoms occurring two or fewer days per week

● Two or fewer nocturnal awakenings per month
● Use of short-acting beta agonists (SABAs) to relieve symptoms two or fewer days per week
● No interference with normal activities between exacerbations
● FEV1 measurements between exacerbations that are consistently within the normal range (ie, ≥80 percent of predicted)
 ● FEV1/FVC ratio between exacerbations that is normal (based on age-adjusted values)
● One or no exacerbations requiring oral glucocorticoids per year

If any of the features of a patient’s asthma is more severe than those listed here, the asthma should be categorized as
persistent, with its severity based on the most severe element.

In addition, a person using a SABA to prevent exercise-induced asthmatic symptoms might fit into this category of intermittent
asthma even if exercising more than twice per week. (See "Exercise-induced bronchoconstriction".)

Equivalent tables for classifying asthma in children 0 to 4 years and 5 to 11 years are provided.

Mild persistent — Mild persistent asthma is characterized by the following ( table 8):

● Symptoms more than twice weekly (although less than daily)

● Approximately three to four nocturnal awakenings per month due to asthma (but fewer than every week)
● Use of SABAs to relieve symptoms more than two days out of the week (but not daily)
● Minor interference with normal activities
● FEV1 measurements within normal range (≥80 percent of predicted)

Asthma is considered to be mild persistent if any of the above features is present (lung function measured in the absence of an
asthmatic exacerbation may be normal in both intermittent and mild persistent asthma). A patient with symptoms and lung
function suggesting intermittent asthma but with two or more exacerbations per year requiring oral glucocorticoids is
considered to have mild persistent asthma. If any of the features of a patient’s asthma is more severe than those listed here,
their asthma should be categorized according to the most severe element.

Equivalent tables for asthma in children 0 to 4 years and 5 to 11 years are provided. (See "Asthma in children younger than 12
years: Management of persistent asthma with controller therapies".)

Moderate persistent — The presence of any of the following features is considered an indication of moderate disease severity (
table 8):

● Daily symptoms of asthma

● Nocturnal awakenings as often as once per week
● Daily need for SABAs for symptom relief
● Some limitation in normal activity
● FEV1 ≥60 and <80 percent of predicted and FEV1/FVC below normal

Equivalent figures for asthma in children 0 to 4 years and 5 to 11 years are provided. (See "Asthma in children younger than 12
years: Management of persistent asthma with controller therapies".)

Severe persistent — Severe persistent asthma is manifest by the presence of asthma symptoms throughout the day, nocturnal
awakening due to asthma nightly, reliever medication needed for symptoms several times/day, or activity limitation due to
asthma [1]. Such patients need prompt initiation of asthma therapy [1,2]. The term “severe asthma,” as defined by the European
Respiratory Society/American Thoracic Society guideline [24], describes patients whose symptoms and lung function impairment
are severe enough that they will require high-dose inhaled or near continuous oral glucocorticoid therapy (step 4 or 5) to achieve
asthma control or may not achieve control with this therapy ( table 8) [2,24]. (See "Evaluation of severe asthma in adolescents
and adults", section on 'Definition'.)

Equivalent parameters for asthma in children 0 to 4 years and 5 to 11 years are provided. (See "Asthma in children younger than
12 years: Management of persistent asthma with controller therapies".)

INITIATING PHARMACOLOGIC TREATMENT

Pharmacologic treatment is the mainstay of management in most patients with asthma [25]. National and international
guidelines advise initiating pharmacologic therapy based on the frequency and severity of symptoms, and then adjusting
therapy up or down, as needed, according to a stepwise approach, although some of the details differ among guidelines [1,2].

The choice of medication is based on age of the patient (eg, ≥12 years, 5 to 11 years, 0 to 4 years), symptoms, lung function, risk
factors for exacerbations, patient preference, and practical issues (eg, ability to use the medication delivery device, accessibility
of medication).
The approach outlined here focuses on treatment of adolescent and adult patients. While management of children with asthma
is similar, the details related to initiating long-term controller medications in children under the age of 12 years are reviewed
separately. (See "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies".)

Initiating therapy during an acute exacerbation — For all patients with symptoms of an asthma exacerbation, we
recommend prompt administration of an inhaled short-acting beta-agonist (SABA; eg, albuterol or equivalent). Patients who
present with an acute exacerbation of asthma often require an initial, brief course of systemic glucocorticoids, at the same time
that long-term controller medication is initiated. Selection of the specific controller medication(s) is based on recent symptoms
but may need to be “stepped down” once asthma control improves. Treatment of asthma exacerbations is reviewed separately.
(See "Acute exacerbations of asthma in adults: Home and office management" and "Acute asthma exacerbations in children
younger than 12 years: Home/office management and severity assessment" and "Acute asthma exacerbations in children
younger than 12 years: Emergency department management".)

Initiating therapy in previously untreated patients — All patients with asthma should have immediate access to an inhaled
bronchodilator with a rapid onset of action for prompt relief of asthma symptoms. The traditional (and our preferred) choice is a
short-acting beta agonist (SABA; eg, albuterol or levalbuterol); an alternative is to use a combination low-dose glucocorticoid-
formoterol inhaler (eg, budesonide-formoterol 160 mcg-4.5 mcg), 1 inhalation as needed for asthma symptoms (off-label). (See
'Intermittent (Step 1)' below.)

Initiation of controller therapy for asthma in a stable patient who is not already receiving asthma medication or who is being
treated with a short-acting beta agonist (SABA) alone is based upon the severity of the individual's asthma ( table 8). (See
'Initial assessment' above.)

Initiating long-term controller medications in children younger than 12 years of age is reviewed separately. (See "Asthma in
children younger than 12 years: Management of persistent asthma with controller therapies".)

Intermittent (Step 1) — Patients with intermittent asthma have traditionally been treated with a SABA, taken as needed for
relief of symptoms, which is our preference ( figure 1) [1]. A novel strategy has been recommended by the Global Initiative for
Asthma (GINA): use of a combination inhaler that contains low-dose glucocorticoid and the fast-acting long-acting beta agonist
(LABA), formoterol, taken as needed for symptom relief (off-label in the United States) [2]. Formoterol has both a rapid onset of
action and is long-acting (up to 12 hours of bronchodilation). Alternatively, GINA recommends use of a low-dose glucocorticoid
inhaler whenever a SABA is used for symptom relief. In the United States this latter strategy requires carrying two separate
inhalers for intermittent, as-needed use [2]. These novel approaches seek to treat the chronic airway inflammation that is
thought to be present even in intermittent asthma and to reduce the risk of severe and potentially life-threatening asthma
attacks that can occur in patients with intermittent asthma who rely on treatment with a SABA alone. More extensive discussion
of the rationale behind these options is addressed separately. (See "Treatment of intermittent and mild persistent asthma in
adolescents and adults" and "Asthma in children younger than 12 years: Quick relief (rescue) treatment for acute symptoms".)

When triggering of asthma symptoms can be predicted (eg, exercise-induced bronchoconstriction), pretreatment with a SABA (2
inhalations) or an inhaler containing the fast-acting LABA, formoterol, and a glucocorticoid (eg, budesonide-formoterol)
approximately 5 to 20 minutes prior to exposure is recommended to blunt or prevent the onset of symptoms. (See "Exercise-
induced bronchoconstriction".)

Mild persistent (Step 2) — For patients with mild persistent asthma, we recommend using a regimen that includes a low-
dose inhaled glucocorticoid ( figure 1 and table 10). We suggest regular (daily) use of a low-dose inhaled glucocorticoid or a
combination glucocorticoid-LABA inhaler, because regular use of inhaled glucocorticoids reduces the frequency of symptoms
(and the need for SABAs for symptom relief), improves the overall quality of life, and decreases the risk of serious exacerbations
[26-28]. An alternative, as proposed by GINA, is as-needed use of a combination budesonide-formoterol inhaler (off-label) [2].

Leukotriene modifiers are an alternative when avoidance of inhaled glucocorticoids is preferred, but efficacy is generally less (
table 8 and figure 1). The US Food and Drug Administration (FDA) has placed a boxed warning on montelukast regarding
potential behavior and mood-related changes. (See "Antileukotriene agents in the management of asthma", section on 'Adverse
effects'.)

Patients receiving long-term controller therapy should continue to use their SABA as needed for relief of symptoms and prior to
exposure to known triggers of their symptoms. Alternatively, for those using a combination low-dose glucocorticoid-formoterol
inhaler (eg, budesonide-formoterol 160 mcg-4.5 mcg) on a daily basis, 1 inhalation can also be used for symptom relief, a
strategy referred to as Single-Inhaler for Maintenance and Reliever Therapy or SMART. (See "Treatment of intermittent and mild
persistent asthma in adolescents and adults" and "Asthma in children younger than 12 years: Quick relief (rescue) treatment for
acute symptoms".)

The pharmacologic management of mild persistent asthma is presented in greater detail elsewhere. (See "Treatment of
intermittent and mild persistent asthma in adolescents and adults" and "Asthma in children younger than 12 years:
Management of persistent asthma with controller therapies".)

Moderate persistent (Step 3) — For moderate persistent asthma, the preferred controller therapies are either low-doses of
an inhaled glucocorticoid plus a LABA, or medium doses of an inhaled glucocorticoid ( figure 1 and table 10). The former
combination has proven more effective in controlling asthmatic symptoms than an increased dose of inhaled glucocorticoids.
While potential risks of adverse outcomes were initially reported in association with LABAs, subsequent safety data regarding
the use of combination inhalers containing inhaled glucocorticoid and a LABA are reassuring. (See "Beta agonists in asthma:
Controversy regarding chronic use", section on 'Long–acting beta-agonists'.)

Addition of an inhaled long-acting muscarinic antagonist (LAMA; tiotropium) to an inhaled glucocorticoid has proven equally
effective compared to the combination of an inhaled glucocorticoid and LABA. This option is appropriate for any patient
intolerant of LABAs or in whom even limited sympathomimetic stimulation is contraindicated, but it requires two separate
inhaler devices with distinct inhaler techniques.

An alternative, but overall less effective, strategy is addition of a leukotriene modifier (eg, montelukast, zafirlukast) to low-dose
inhaled glucocorticoids. We rarely initiate theophylline in the modern treatment of asthma. The pharmacologic management of
moderate asthma is presented in more detail elsewhere. (See "Treatment of moderate persistent asthma in adolescents and
adults".)

Severe persistent (Step 4 or 5) — For severe persistent asthma, the preferred controller treatments are medium (Step 4) or
high (Step 5) doses of an inhaled glucocorticoid in combination with a LABA ( figure 1 and table 10). Additional therapy with
a leukotriene modifier, tiotropium, or biologic agent may be needed, guided by the treatment response. These options are
discussed in greater detail separately. (See 'Stepping up therapy in poorly controlled asthma' below and "Treatment of severe
asthma in adolescents and adults".)

FOLLOW-UP MONITORING

Effective asthma management requires a proactive, preventive approach, similar to the treatment of hypertension or diabetes.

Approach to monitoring — Routine follow-up visits for patients with active asthma are recommended, at a frequency of every
one to six months, depending upon the severity of asthma. Follow-up visits should be used to assess asthma control, lung
function, exacerbations, inhaler technique, adherence, medication adverse effects, quality of life, and patient satisfaction with
care [3].

By consensus from panels of asthma experts, well-controlled asthma is characterized by daytime symptoms no more than twice
per week and nighttime awakening due to asthma no more than twice per month [2]. Asthma symptoms requiring reliever
medication (eg, short-acting beta agonist [SABA]) should occur at most two days out of the week (not including pretreatment
before exercise), and there should be no interference with normal activity. Pretreatment with a SABA to prevent exercise-induced
bronchoconstriction is generally not counted, although the need for daily SABA to prevent exercise-induced bronchoconstriction
suggests suboptimal control that often warrants addition of controller medication [2,29]. (See "Exercise-induced
bronchoconstriction", section on 'Refractory EIB due to poor asthma control'.)

Peak expiratory flow and spirometry should remain normal or near-normal (or at or close to the individual’s personal best peak
flow or forced expiratory volume in one second [FEV1], when a patient’s optimal baseline lung function is abnormal). Oral
glucocorticoid courses and/or urgent care visits should be needed no more than once per year [30]. An approach to assessment
of asthma control is summarized in the table and figure ( table 9 and figure 1).

Symptom assessment — Symptoms over the past four weeks should be assessed at each visit. Assessment should address
daytime symptoms, nighttime awakening due to asthma symptoms, frequency of use of SABAs to relieve symptoms, and
difficulty in performing normal activities and exercise ( table 9). Several quick and validated questionnaires, like the Asthma
Control Test for children ( figure 2) and adults ( form 3), provide a standardized method for scoring asthma control and
recording changes over time [2,31-41].
 ● Assessment of impairment – The following questions are representative of those used in validated questionnaires to
assess asthma control:

• How often has your asthma awakened you at night or in the early morning?

• How often have you been needing to use your quick-acting relief medication for symptoms of cough, shortness of
breath, or chest tightness?

• Have you needed any unscheduled care for your asthma, including calling in, an office visit, or an emergency
department visit?

• Have you been able to participate in school/work and recreational activities as desired?

• If you are measuring your peak flow, has it been lower than your personal best? Home monitoring of peak flow
measurements is reviewed in detail separately. (See "Peak expiratory flow monitoring in asthma".)

● Assessment of risk – The following questions can be used to address the most important risk factors for future
exacerbations [1]. A discussion of the risk factors for fatal and near-fatal asthma is provided separately. (See "Identifying
patients at risk for fatal asthma", section on 'Identifying high-risk patients'.)

• Have you taken oral glucocorticoids ("steroids") for your asthma in the past year?

• Have you been hospitalized for your asthma? If yes, how many times have you been hospitalized in the past year?

• Have you been admitted to the intensive care unit or been intubated because of your asthma? If yes, did this occur
within the past five years?

• Do you currently vape or smoke cigarettes or does anyone in your household? If so, how many each day?

• Have you ever noticed an increase in asthma symptoms after taking aspirin or a nonsteroidal anti-inflammatory agent
(NSAID)? Patients with aspirin-exacerbated respiratory disease are vulnerable to severe asthma attacks following
ingestion of any cyclooxygenase-1 inhibitor (aspirin or NSAID).

Other factors that are more weakly associated with fatal asthma (eg, aeroallergen exposure, food allergy, illicit drug use) may
increase risk in individual patients. (See "Identifying patients at risk for fatal asthma", section on 'Minor risk factors'.)

Follow-up visits should also include inquiry about any adverse effects from or concerns about asthma medications.

Pulmonary function — Spirometry is the preferred method for monitoring pulmonary function in children older than five years
of age and adults; assessing peak expiratory flow (PEF) with a peak flow meter is an alternative. Guidelines prefer use of
spirometry over peak flow in medical offices, when available, due to greater accuracy of the measurement, when carefully
performed by skilled technical staff [1]. Spirometry is not obtainable predictably from children younger than six years.

Office monitoring — Spirometry, which measures FEV1 and forced vital capacity (FVC), is a sensitive and reproducible method
for assessing airflow limitation, defined as a reduced FEV1/FVC ratio. Spirometry can detect reductions in lung function,
indicating loss of asthma control and risk of a severe asthma exacerbation, in patients who have few symptoms or physical
findings of asthma [42,43]. We typically obtain spirometry approximately every one to two years when asthma is stable, but
more frequently if asthma is not well-controlled or medications are being adjusted. (See "Office spirometry" and "Pulmonary
function testing in asthma" and "Overview of pulmonary function testing in children", section on 'Use in asthma'.)

As an alternative, PEF can be a useful indicator of airflow obstruction and can be measured with handheld peak flow meters.
Reliable PEF measurements can be made with little training; the costs in terms of equipment, staff, and time are minimal. PEF
monitoring is best used in patients in whom the diagnosis of asthma has been previously established with spirometry.
Periodically, PEF values should be correlated with spirometry. Normal values for men, women, and adolescents are listed in the
table or can be calculated ( table 11 and table 12) (calculator 1 and calculator 2); normal values for children can be
calculated (calculator 3 and calculator 4).

It is important to understand the limitations of PEF. A reduced peak flow is not synonymous with airway obstruction; spirometry
is needed to differentiate an obstructive from restrictive abnormality [44]. Also, the accuracy of a single peak flow measurement
to detect the presence of airflow obstruction is limited, given the large variability of PEF among healthy individuals of the same
age, height, and sex (±20 percent) [44]. The use of PEF monitoring and its limitations are presented in more detail separately. Its
greatest value is monitoring for changes over time and for detecting severe obstruction in a patient who may not have wheezing
or complain of troublesome symptoms. It is our practice to obtain a measurement of lung function (peak flow or spirometry) at
every visit in our patients with asthma. (See "Peak expiratory flow monitoring in asthma".)

Home monitoring — Home monitoring with repeated measurements of PEF or FEV1 over time may be useful for determining
relative changes or trends in asthma control in adults and adolescents with moderate to severe asthma, but is rarely used for
children [1,2]. PEF monitoring may be particularly helpful in patients who have poor perception of airflow limitation. These
individuals cannot be easily identified at the outset of care, although over time they display a lack of awareness of increasing
impairment, and typically seek care for exacerbations only after symptoms have become severe [45,46]. (See "Identifying
patients at risk for fatal asthma".)

Peak flow meters for individual use are widely available, inexpensive (approximately $20), and easy to use. However,
measurements are highly dependent upon the patient's technique. It is therefore important that the patient's technique be
assessed in the office and any mistakes in technique corrected. Instructions for use of a PEF meter are provided separately. (See
"Patient education: How to use a peak flow meter (Beyond the Basics)".)

Ideally, the patient should establish a baseline measure of peak flow, using morning and evening measurements over the course
of a week or two when feeling entirely well: the "personal best" peak flow value. A chart for recording PEF values at home is
available for download. The personal best PEF is then used to determine the normal PEF range, which is between 80 and 100
percent of the patient's personal best. Readings below this normal range indicate airway narrowing, a change that may occur
before symptoms are perceived by the patient. (See 'Asthma action plan' above.)

Other

● Airway inflammation – Methods to assess airway inflammation, such as blood and sputum eosinophil counts and fraction
of exhaled nitric oxide (FENO), are less widely employed for disease monitoring. These tests are used in selected patients to
determine the likelihood of response to a change in inhaled glucocorticoid dose or candidacy for one of the biologic
therapies (eg, monoclonal antibodies targeting interleukin [IL]-5 or its receptor, or the alpha subunit of the IL-4 receptor).
Studies have reached conflicting conclusions about whether regularly measuring these markers could help optimize asthma
management. The use of expectorated sputum eosinophilia and exhaled nitric oxide analysis in the management of asthma
are discussed in more detail separately. (See "Evaluation of severe asthma in adolescents and adults", section on 'Airway
inflammation' and "Exhaled nitric oxide analysis and applications".)

● Comorbid conditions – Comorbid conditions can contribute to asthma symptoms, depending on the specific condition. In
adults, these conditions include rhinitis/sinusitis, chronic obstructive pulmonary disease (COPD)/emphysema, allergic
bronchopulmonary aspergillosis, gastroesophageal reflux, obesity, obstructive sleep apnea, inducible laryngeal obstruction
(also called vocal cord dysfunction), and depression/chronic stress. These conditions are reviewed separately. (See "An
overview of rhinitis" and "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis" and "Chronic
obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging" and "Clinical manifestations and
diagnosis of allergic bronchopulmonary aspergillosis" and "Gastroesophageal reflux and asthma" and "Obesity and asthma"
and "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Inducible laryngeal obstruction
(paradoxical vocal fold motion)".)

ADJUSTING CONTROLLER MEDICATION

For patients already taking one or more controller medications, therapy is adjusted in a stepwise fashion, increasing medication
until asthma is controlled and then decreasing medication when possible to minimize adverse effects ( table 8).

Therapy should be reassessed at each visit, because asthma is an inherently variable condition, and the management of asthma
is a dynamic process that changes in accordance with the patient's needs over time ( table 9).

Asthma control is assessed based on impairment over the past two to four weeks (as determined by history or a validated
questionnaire), current forced expiratory volume in one second (FEV1) or peak flow, and estimates of risk ( table 9) [1,47].
Adjusting therapy in children younger than 12 years is reviewed in more detail separately. (See 'Follow-up monitoring' above and
"Asthma in children younger than 12 years: Initiating therapy and monitoring control", section on 'Monitoring and dosing
adjustment' and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies".)

Stepping up therapy in poorly controlled asthma — In patients with poorly controlled asthma, treatment should be "stepped
up" ( figure 1 and table 8) [2]. In patients with very poorly controlled asthma, it may be necessary to escalate therapy more
than one step, and then "step-down" again once good control is achieved.

In treating severe asthma, many providers add a long-acting muscarinic antagonist (LAMA; eg, tiotropium) and/or a leukotriene
modifier to the combination inhaled glucocorticoid and long-acting beta agonist (LABA). When severe asthma remains poorly
controlled, oral glucocorticoids may be needed on a daily or alternate-day basis. Consultation with an asthma specialist and
consideration of biologic therapy are recommended actions in glucocorticoid-dependent patients. Severe asthma is reviewed in
more detail separately. (See "Treatment of severe asthma in adolescents and adults".)

For patients whose asthma is inadequately controlled on high-dose inhaled glucocorticoids and LABAs, the anti-IgE therapy
omalizumab may be considered if there is objective evidence of sensitivity to a perennial allergen (by allergy skin tests or in vitro
measurements of allergen-specific IgE) and if the serum IgE level is within the established target range. (See "Anti-IgE therapy".)

Interleukin 4 (IL-4) and 5 (IL-5) are potent chemoattractants for eosinophils. Monoclonal antibodies against IL-5 (mepolizumab
and reslizumab), IL-5 receptor alpha (benralizumab), and IL-4 receptor alpha subunit (dupilumab) are available for treatment of
severe eosinophilic asthma that is poorly-controlled with conventional therapy. (See "Treatment of severe asthma in adolescents
and adults", section on 'Anti-IL-5 therapy' and "Treatment of severe asthma in adolescents and adults", section on 'Anti-lL-4
receptor alpha subunit antibody'.)

Bronchial thermoplasty is a device-based intervention available in specialized centers to treat severe asthma. Using a special
catheter introduced via a fiberoptic bronchoscope, thermal energy is applied to bronchial walls in an effort to impair bronchial
smooth muscle contractility. The role of bronchial thermoplasty in managing severe asthma remains debated. (See "Treatment
of severe asthma in adolescents and adults", section on 'Bronchial thermoplasty'.)

Stepping down therapy — For patients whose asthma has been well-controlled for three to six months on a stable regimen,
controller medications can be reduced in a step-wise fashion ( table 8). Besides minimizing expense, inconvenience, and
potential immediate adverse effects, the purpose of stepping down therapy in some patients is reducing long-term exposure to
high doses of inhaled glucocorticoids, with their potential for systemic absorption and adverse effects on organs such as bones,
eyes, and skin. Careful monitoring as therapy is stepped down is needed to identify, and respond to, any deterioration in control.
Complete cessation of inhaled glucocorticoids should be approached with caution, as it is likely to lead to clinical deterioration in
patients with persistent asthma [48]. Alternatively, in follow-up of well-controlled asthma, medications can be continued
unchanged, especially if history reveals serious exacerbations in the past or a high risk of future exacerbation.

WHEN TO REFER

Both pulmonologists and allergists/immunologists have specialty training in asthma care. Referral for consultation or
comanagement depends on the level of experience and comfort of the primary care provider with asthma care, but is generally
advisable when any of the following circumstances arise [1,2]:

● Difficulty confirming a diagnosis of asthma

● History of a life-threatening asthma exacerbation (eg, intensive care unit admission, mechanical ventilation for asthma)
● Hospitalization for asthma, more than two courses of oral glucocorticoids in a year, or inability to discontinue oral
glucocorticoids
● Need for step 5 care or higher
● Poor asthma control after three to six months of active therapy and appropriate monitoring
● Anaphylaxis or confirmed food allergy in a patient with asthma
● Presence of complicating comorbidity (eg, aspirin-exacerbated respiratory disease (AERD), nasal polyposis, chronic
rhinosinusitis, allergic bronchopulmonary aspergillosis (ABPA), chronic obstructive pulmonary disease (COPD), inducible
laryngeal obstruction [also called vocal cord dysfunction])
● Need for additional diagnostic tests (eg, allergy skin testing, bronchoscopy complete pulmonary function tests)
● Patient may be a candidate for allergen immunotherapy (see "Subcutaneous immunotherapy for allergic disease:
Indications and efficacy")
● Patient is a potential candidate for therapy with biologics (benralizumab, dupilumab, mepolizumab, omalizumab,
reslizumab) or bronchial thermoplasty.

Other possible indications for referral include [1,2]:

● Need for step 4 care in an adult or child older than five years
● Need for step 2 care or higher in a child under five years
 ● Evaluate potential occupational triggers
● Patients in whom psychosocial or psychiatric problems are interfering with asthma management and in whom referral to
other appropriate specialists may be required

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided
separately. (See "Society guideline links: Asthma in adolescents and adults" and "Society guideline links: Severe asthma in
adolescents and adults" and "Society guideline links: Asthma in children" and "Society guideline links: Exercise-induced
bronchoconstriction".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education
pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who want a general overview and who prefer short,
easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your
patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s)
of interest.)

● Basics topics (see "Patient education: How to use your child's dry powder inhaler (The Basics)" and "Patient education:
Asthma in children (The Basics)" and "Patient education: How to use your child's metered dose inhaler (The Basics)" and
"Patient education: Asthma and pregnancy (The Basics)" and "Patient education: How to use your dry powder inhaler
(adults) (The Basics)" and "Patient education: How to use your metered dose inhaler (adults) (The Basics)" and "Patient
education: How to use your soft mist inhaler (adults) (The Basics)" and "Patient education: Asthma in adults (The Basics)" and
"Patient education: Avoiding asthma triggers (The Basics)" and "Patient education: Medicines for asthma (The Basics)" and
"Patient education: Coping with high drug prices (The Basics)" and "Patient education: Inhaled corticosteroid medicines (The
Basics)")

● Beyond the Basics topics (see "Patient education: Asthma inhaler techniques in children (Beyond the Basics)" and "Patient
education: Asthma treatment in children (Beyond the Basics)" and "Patient education: Asthma and pregnancy (Beyond the
Basics)" and "Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)" and "Patient education:
How to use a peak flow meter (Beyond the Basics)" and "Patient education: Inhaler techniques in adults (Beyond the Basics)"
and "Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)" and "Patient education: Exercise-
induced asthma (Beyond the Basics)" and "Patient education: Trigger avoidance in asthma (Beyond the Basics)" and "Patient
education: Coping with high drug prices (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● The goals of asthma treatment are to reduce impairment from symptoms, attenuate the risk of adverse outcomes
associated with asthma (eg, hospitalizations, loss of lung function), and minimize adverse effects from asthma medications.
(See 'Goals of asthma treatment' above.)

● Effective asthma management requires a preventive approach, with regularly scheduled visits during which symptoms are
assessed, pulmonary function monitored, control of exposure to asthma triggers and impact of comorbid conditions
reviewed, medications adjusted, and ongoing education provided. (See 'Follow-up monitoring' above.)

● Patients should learn to monitor asthma control at home, including the frequency and severity of dyspnea, cough, chest
tightness, and the need for use of reliever medication (eg, short-acting beta agonist [SABA]). Adult and adolescent patients
with moderate to severe asthma and those with poor perception of increasing asthma symptoms may also benefit from
measurement of their peak expiratory flow (PEF) at home. A personalized asthma action plan should be provided with
 detailed instructions about adjusting asthma medications based upon changes in symptoms and/or lung function. (See
'Patient education' above.)

● Environmental triggers and coexisting conditions that interfere with asthma management should be identified and
addressed for each patient. (See 'Controlling asthma triggers' above and 'Other' above.)

● Pharmacologic therapy is determined by the degree of asthma severity and asthma control ( table 9 and figure 1).

• All patients with asthma should have immediate access to an inhaled bronchodilator with a rapid onset of action for
prompt relief of asthma symptoms. The traditional and our preferred choice is a short-acting beta agonist (SABA; eg,
albuterol or levalbuterol); an alternative approach is to use a combination low-dose glucocorticoid-formoterol inhaler
(eg, budesonide-formoterol 160 mcg-4.5 mcg), 1 inhalation as needed for quick relief of asthma symptoms (off-label).
(See 'Initiating therapy in previously untreated patients' above.)

• Initial therapy is based on assessment of asthma severity ( table 8), whereas adjustment of therapy is based on
asthma control, which includes components of current impairment and future risk ( table 9). Asthma control can be
judged, irrespective of medication use, based on the current level of symptoms, forced expiratory volume in one second
(FEV1) or PEF values, and number of exacerbations requiring oral glucocorticoids per year. (See 'Initial assessment'
above and 'Initiating pharmacologic treatment' above.)

• The patient's asthma control ( table 9) is evaluated at each return visit, and therapy is adjusted up or down as needed,
based on a stepwise approach. (See 'Adjusting controller medication' above.)

● Guidelines for specialist referral to a pulmonologist or allergist/immunologist include uncertainty about the diagnosis of
asthma, poorly-controlled asthma, an episode of near-fatal asthma, and need for specialized diagnostic studies (eg, allergy
skin testing, bronchoscopy, evaluation for use of biologic agents), or treatment of comorbid conditions. (See 'When to refer'
above.)

Use of UpToDate is subject to the Subscription and License Agreement.

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33. Boulet LP, Boulet V, Milot J. How should we quantify asthma control? A proposal. Chest 2002; 122:2217.

34. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the asthma control test: a survey for assessing asthma control. J
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35. Patino CM, Okelo SO, Rand CS, et al. The Asthma Control and Communication Instrument: a clinical tool developed for
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36. Schatz M, Kosinski M, Yarlas AS, et al. The minimally important difference of the Asthma Control Test. J Allergy Clin Immunol
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45. Kikuchi Y, Okabe S, Tamura G, et al. Chemosensitivity and perception of dyspnea in patients with a history of near-fatal
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challenge and threshold loading tests. Chest 2000; 117:954.

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systematic review and meta-analysis of randomized controlled trials. J Allergy Clin Immunol 2013; 131:724.

Topic 547 Version 57.0

GRAPHICS

Technique for use of a pressurized metered dose inhaler (MDI) without a spacer or chamber

Remove the cover of the mouthpiece.

Prime your inhaler if this is the first time you are using it, if you have not used it for several days, or if you have dropped it. Priming an MDI usually involves shaking it and spraying
it into the air (away from your face) a total of up to 4 times. See the information that came with your inhaler for exact instructions.

Shake MDI canister vigorously for 5 seconds.

Hold the MDI upright with your index finger on the top of the medication canister and your thumb supporting the bottom of the inhaler.

Breathe out normally.

Put the mouthpiece between your teeth and close your lips around mouthpiece or position mouthpiece approximately 4 cm (approximately width of 2 fingers) from your mouth.

Keep your tongue away from the opening of the mouthpiece.

Press down the top of the canister with the index finger to release the medication.

At the same time as the canister is pressed, breathe in deeply and slowly through your mouth until your lungs are completely filled; this should take 4 to 6 seconds.

Hold the medication in your lungs for as long as comfortable (approximately 5 to 10 seconds) before breathing out.

If you need a second puff, wait approximately 15 to 30 seconds between puffs. Shake canister again before the next puff.

When finished, recap mouthpiece.

If your inhaler contains a steroid medicine (sometimes called glucocorticoid or corticosteroid), rinse your mouth and gargle with water after you use it. Then spit out the water. Do
not swallow it.

These instructions do NOT apply to dry powder or soft mist inhalers. Cleaning instructions are provided separately.
More detailed information about individual medication formulations can be found at http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm.

Graphic 103302 Version 6.0

Technique for use of a pressurized metered dose inhaler (MDI) with a spacer or chamber*

Uncap mouthpiece and check for loose objects in the device.

Prime your inhaler if this is the first time you are using it, if you have not used it for several days, or if you have dropped it. Priming an MDI usually involves shaking it and spraying
it into the air (away from your face) a total of up to 4 times. See the information that came with your inhaler for exact instructions.

Insert MDI into spacer.

Shake canister vigorously for approximately 5 seconds.

Hold the MDI upright with your index finger on the top of the medication canister and your thumb supporting the bottom of the inhaler. You may need to use the other hand to
hold the spacer.

Breathe out normally through your mouth.

Put the mouthpiece between your teeth and close your lips tightly around mouthpiece of spacer. (If using a mask attached to the chamber, place the mask completely over your
nose and mouth.)

Make sure your tongue does not block the opening of the mouthpiece of the spacer.

Press down the top of the canister with your index finger to release the medicine.

At the same time, breathe in deeply and slowly through your mouth until your lungs are completely filled; this should take 3 to 5 seconds.

Hold the medicine in your lungs for approximately 5 to 10 seconds. If you did not get a full breath or cannot hold your breath long enough, you can inhale a second time to fully
empty the chamber and hold your breath again for approximately 5 seconds. For infants and young children, or if unable to cooperate with a deep breath or breath-holding, 5 to 6
normal breaths will allow complete emptying of the chamber.

If you need more than one puff, wait approximately 15 to 30 seconds between puffs. Shake canister again before the next puff. Do not load both puffs into the chamber and then
empty the chamber with a single inhalation.

When finished, recap mouthpiece.

If your inhaler contains a steroid medicine (sometimes called glucocorticoid or corticosteroid), rinse your mouth and gargle with water after you use it. Then spit out the water. Do
not swallow it.

You can use your spacer for more than 1 medication. Just remove the first MDI and insert the other one.

These instructions do NOT apply to dry powder or soft mist inhalers. Cleaning instructions are provided separately.

* We prefer to use a "valved holding chamber" for the spacer (eg, AeroChamber, Easivent, Optichamber, Vortex). The valve holds the medicine in the chamber until you take your deep
breath in. This helps get the medicine into your lungs. Also, when you breathe out into the mouthpiece, the valve prevents your breath from going into the chamber. If your spacer does
not have this valve, you should breathe out through your nose or remove the spacer from your mouth before breathing out.

Graphic 103303 Version 8.0

Technique for use of various dry powder inhalers

Diskhaler (available in Canada)

Remove the mouthpiece cover and pull tray out from device.

Place disk on wheel with numbers facing up.

Rotate the disk by sliding tray out and in.

Lift the back of the lid until fully upright, so the needle pierces both sides of the blister.

Keep the device level while inhaling the dose with a rapid and steady flow.

Breathe in rapidly and steadily, as deeply as possible, then hold your breath.

Remove the device from your mouth and exhale outside the device.

Brush off any powder remaining within the device once every week. Store the device in a cool, dry place.

Diskus
Open the device and slide the lever until it clicks.

Keep the device level while inhaling the dose.

Breathe in rapidly and steadily, as deeply as possible, then hold your breath.

Remove the device from your mouth and exhale outside device. Store the device in a cool, dry place.

Ellipta
Remove the inhaler from the foil tray. Do not open the cover of the inhaler until you are ready to use it.

Write the "Tray opened" and "Discard" dates on the inhaler label. The "Discard" date should be 6 weeks from the date you open the tray.

Check the dose counter on the inhaler. Before you use the inhaler for the first time, the counter should show the number 30. This is the number of doses in the inhaler.

Open the cover of the inhaler. Each time you fully open the cover it should produce a clicking sound, and the number on the counter should go down by one. This means a
dose is ready to be inhaled. (If you open and close the cover without inhaling the medicine, you will lose the dose. The lost dose will be held in the inhaler, but it will no
longer be available to be inhaled. It is not possible to accidentally take a double dose or an extra dose in 1 inhalation.)

If the counter does not count down as you hear the click, the inhaler will not deliver the medicine. Call your healthcare provider or pharmacist if this happens.

While holding the inhaler away from your mouth, breathe out (exhale) fully. Do not exhale into the mouthpiece.

Hold the inhaler in a horizontal position. You do not need to shake it. Do not block the air vent in the inhaler with your fingers.

Put the mouthpiece between your lips, and close your lips tightly around it. Your lips should fit over the curved shape of the mouthpiece.

Take one long, steady, deep breath in through your mouth. Do not breathe in through your nose. You might not taste or feel the medicine, even when you are using the
inhaler correctly.

Remove the mouthpiece from your mouth and hold your breath for about 3 to 4 seconds (or as long as you comfortably can).

Breathe out slowly and gently.

Slide the cover up and over the mouthpiece as far as it will go to close the inhaler.

Clean the mouthpiece if needed, using a dry tissue, before you close the cover. Regular cleaning is not required.

When you have less than 10 doses remaining in your inhaler, the left half of the counter shows red as a reminder to get a refill. After you have inhaled the last dose, the
counter will show "0" and the inhaler should be thrown away.

HandiHaler
Capsules should be stored in sealed blisters and only removed immediately before use.

Peel back the foil using the tab until one capsule is fully visible.

Open the dust cap by pulling it upwards, then open the mouthpiece.

Place the capsule in the center chamber. (It does not matter which end of the capsule is placed in the chamber.)

Close the mouthpiece firmly until you hear a click, leaving the dust cap open.

Hold the HandiHaler with the mouthpiece upwards, then press the piercing button completely in 1 time and release.

Breathe out completely. Do not breathe into the mouthpiece at any time.

Close your lips tightly around the mouthpiece.

Breathe in rapidly and steadily, as deeply as possible, then hold your breath.

To ensure you get the full dose, repeat the inhalation from the HandiHaler as described.

After the dose, open the mouthpiece, tip out the used capsule, and throw it away. Do not handle used capsules.

Close the mouthpiece and dust cap for storage. Store the device in a cool, dry place.

Neohaler/Breezhaler
Capsules should be stored in sealed blisters and removed immediately before use.

Remove cap and tilt mouthpiece to open inhaler.

Separate one blister from card, and peel away backing to expose the foil. Remove one capsule by pushing it through the foil.

Place the capsule in the chamber.

Close the mouthpiece firmly until you hear a click.

Hold the inhaler with the mouthpiece upwards. Press the piercing buttons on both sides at the same time, then release. You should hear a click. Do not press the buttons
 more than once.

Breathe out completely away from the mouthpiece.

Hold the inhaler so the buttons are facing left and right, not up and down, and your fingers are not on the buttons. Close your lips tightly around the mouthpiece.

Breathe in rapidly and steadily, and as deeply as possible. As you breathe, you should hear a whirring noise as the capsule spins. (If you do not hear this, open the inhaler
and tap it on the bottom to loosen the capsule. Then repeat the steps of breathing out then inhaling the medicine.)

Remove the inhaler from your mouth, and hold your breath for 5 to 10 seconds (or as long as you comfortably can). Then breathe out.

Open the inhaler to make sure the capsule is empty. If there is still powder in the capsule, close the inhaler and repeat the steps above to breathe out and then inhale the
medicine.

Tip out the empty capsule, and throw it away.

Replace the cap. Store the device in a cool, dry place.

Pressair/Genuair
Remove the cap by gently squeezing the arrows on each side of cap.

Hold the inhaler with the green button pointing up.

Before you put the inhaler in your mouth, press the green button all the way down 1 time and release it.

Look at the small window above the mouthpiece to see if the color changed from red to green. If it is still red, press and release green button again.

Breathe out completely.

Close your lips tightly around the mouthpiece.

Breathe in rapidly and as deeply as possible.

You will hear a click. This means you are inhaling correctly. Do not stop breathing until your lungs are full.

Remove the inhaler from your mouth, and hold your breath for as long as is comfortable.

The window above the mouthpiece should now be red. (If window is still green, you might not have inhaled correctly or might have forgotten to release the green button.
Close your lips tightly around the mouthpiece and take another rapid, deep breath. Now the window should be red.)

Once the window has turned red, replace the cap.

RespiClick
Make sure the cap is closed before use.

Hold the inhaler upright and open the cap all the way, until you hear it click.

Breathe out as much air as you can from your lungs.

Close your lips tightly around the mouthpiece. Do not let your fingers or lips block the vents above the mouthpiece.

Breathe in as deeply as possible, then hold your breath for about 10 seconds (or as long as you comfortably can).

Remove the inhaler from your mouth.

Close the cap. Repeat steps above if you need another dose.

Keep inhaler clean and dry. If the mouthpiece needs cleaning, use a clean, dry cloth or tissue.

Turbuhaler
Twist and remove the cover.

Hold the inhaler upright with mouthpiece facing up.

Turn the grip right then left until it clicks.

Inhaler may be held upright or horizontal.

Breathe in rapidly and steadily, as deeply as possible, then hold your breath.

Remove the device from your mouth and exhale outside the device.

Replace the cover and twist to close. Store the device in a cool, dry place.

Twisthaler
Hold the inhaler straight up with the pink part (the base) on the bottom.

Remove the cap while it is in the upright position to make sure you get the right amount of medicine with each dose.

Hold the pink base and twist the cap in a counter-clockwise direction to remove it.

As you lift off the cap, the dose counter on the base will count down by 1. This action loads the medicine that you are now ready to inhale.

Make sure the indented arrow located on the white part (directly above the pink base) is pointing to the dose counter.

Breathe out normally. Do not exhale into the device.

Place the mouthpiece into your mouth, with the mouthpiece facing towards you, and close your lips tightly around it.

Inhale dose with a rapid and steady flow while holding the Twisthaler horizontal.

Remove the mouthpiece from your mouth and hold your breath for 5 to 10 seconds (or as long as you comfortably can).

When you exhale, be sure that you are not exhaling into the device.

Replace the cap right away, and turn it in a clockwise direction as you gently press down, until you hear a click.

Firmly close the Twisthaler to assure that your next dose is properly loaded.

Be sure that the arrow is in line with the dose-counter window.

 Store the device in a cool, dry place.

The dose counter displays the number of doses remaining. When the unit reads 01, this indicates the last remaining dose. When the counter reads 00, the unit must then be
discarded.

Graphic 51020 Version 8.0

Techniques for use of various dry powder inhalers in children

Digihaler
Hold the inhaler in an upright position and open the cap. A "click" sound means that the next dose is ready.

Breathe out fully - do not exhale into the device.

Place the mouthpiece into your mouth and close your lips tightly around it.

Breathe in rapidly and steadily, as deeply as possible; remove the inhaler from your mouth and hold your breath for 10 seconds.

Close the cap after each dose.

Store device in a cool, dry place.

The dose counter displays the number of doses remaining.

Diskhaler
Remove mouthpiece cover and pull tray out from device.

Place disk on wheel with numbers facing up.

Rotate disk by sliding tray out and in.

Lift back of lid until fully upright so that needle pierces both sides of blister.

Keep device level while inhaling dose with a rapid and steady flow.

Breathe in rapidly and steadily, as deeply as possible; hold your breath for 5 to 10 seconds.

Remove device from mouth and exhale outside device.

Brush off any powder remaining within device once every week; store device in cool, dry place.

Diskus
Open the device and slide the lever until it clicks.

Keep device level while inhaling dose.

Breathe in rapidly and steadily, as deeply as possible; hold your breath for 5 to 10 seconds.

Remove device from mouth and exhale outside device; store device in cool, dry place.

Flexhaler
Prime the inhaler: This is done only with the initial dose. Holding the inhaler in the upright position, twist the brown grip as far as it will go in one direction, then twist it all the
way back in the other direction. A click will be heard during one of the turns. This step should be repeated to complete the priming of the device.

Load a dose: Holding the inhaler in an upright position, twist the brown grip as far as it will go in one direction, then twist it all the way back in the other direction.

Inhale the dose: Turn away from the inhaler and breathe out. Then place the mouthpiece in your mouth, close your lips, and inhale deeply.

Twisthaler
Hold the inhaler straight up with the pink portion (the base) on the bottom.

Remove the cap while it is in the upright position to make sure you get the right amount of medicine with each dose.

Hold the pink base and twist the cap in a counter-clockwise direction to remove it.

As you lift off the cap, the dose counter on the base will count down by one. This action loads the medicine that you are now ready to inhale.

Make sure the indented arrow located on the white portion (directly above the pink base) is pointing to the dose counter.

Breathe out normally - do not exhale into the device.

Place the mouthpiece into your mouth, with the mouthpiece facing towards you, and close your lips tightly around it.

Inhale dose with a rapid and steady flow while holding the Twisthaler horizontal.

Remove the mouthpiece from your mouth and hold your breath for 5 to 10 seconds (or as long as you comfortably can).

When you exhale, be sure that you are not exhaling into the device.

Immediately replace the cap and turn in a clockwise direction as you gently press down until you hear a click.

Firmly close the Twisthaler to assure that your next dose is properly loaded.

Be sure that the arrow is in line with the dose-counter window.

Store device in a cool, dry place.

The dose counter displays the number of doses remaining. When the unit reads 01, this indicates the last remaining dose. When the counter reads 00, the unit must then be
discarded.

Graphic 58951 Version 7.0

Technique for use of soft mist inhalers (SMIs)

The first time you use a soft mist inhaler,* you will need to insert the cartridge.
Press the safety catch on the side and pull off the clear plastic base.

Push the narrow end of the cartridge into the inhaler until it clicks.

Push the cartridge against a firm surface or table top to be sure it has gone all the way in.

Do not remove the cartridge after it has been inserted.

Put the clear base back on. Press until you hear a click.

Do not remove the clear base again.

Prime the inhaler before the first dose.

Hold the inhaler upright. Turn the clear base clockwise (to the right) until it clicks.

Open the cap and point the inhaler towards the floor.

Press the button on the side until you see a mist or cloud.

Repeat 3 more times.

If you do not use the inhaler for more than 3 days, repeat 1 time.

If you do not use the inhaler for more than 3 weeks, repeat 4 times.

To take a dose of medicine, hold inhaler upright with the cap closed. There is no need to shake it.
Hold the top of the inhaler with 1 hand. With the other hand, turn the clear base clockwise (to the right) until it clicks. This prepares the dose of medicine.

Open the cap.

Breathe out slowly and fully.

Put the mouthpiece in your mouth, and hold the inhaler horizontally, pointing toward the back of your throat.

Seal your lips around the inhaler, but do not cover the air vents on the side.

As you take a slow deep breath in, press and hold the button on the side of the inhaler. This releases the medicine in a soft mist.

Breathe in to a full deep breath to get all the medicine into your lungs.

Hold your breath for a count of 10.

Remove inhaler from your mouth and breathe out slowly.

The inhaler has a dose indicator on the side. When the arrow is in the red zone, the inhaler is almost empty. When the inhaler is completely
empty, the arrow will point to "0," and you will not be able to turn the base of the inhaler.

* Soft mist inhalers are also known as Respimat inhalers.

Graphic 93600 Version 4.0

Asthma action plan

Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and
Management of Asthma. NIH Publication no. 08-4051, 2007.

Graphic 55900 Version 4.0

Child asthma action plan

Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and
Management of Asthma. NIH Publication no. 08-4051, 2007.

Graphic 71958 Version 4.0

Questions to help identify asthma triggers*

Allergen exposures
Do you have asthma symptoms year-round or only certain times of year?

Do you have pets? Or birds? Are they indoors or outdoors most of the time?

Have you seen cockroaches at home/school/work in the past month? How about rodents?

Is there moisture, dampness, moldy odor, or visible mold in your home? ¶

For patients who live in dry climates, do you use an evaporative cooler (also known as a swamp cooler)? These coolers are associated with increased humidity and increased
mold/dust mites.

Do your asthma symptoms get worse during pollen seasons (eg, tree pollen in early spring in New England) or more humid times of year (suggests molds and dust mites)?

Have you ever had allergy skin or IgE testing? If so, do you have the results?

Irritant exposures
Do you smoke cigarettes? If so, how many/day and how long have you smoked?

Does anyone at home/work/daycare smoke?

Do you smoke cannabis (marijuana), use electronic cigarettes, or vape?

Do you use a wood-burning stove or fireplace at home?

Do you have any unvented/open fire stoves or heaters at home?

Are you exposed regularly to smells or fumes from perfumes, cleaning agents, or sprays?

Work and school

Do you cough, wheeze or need your inhaler more during the week at work/school than on weekends or times away from work/school?

Do your eyes or nose itch or feel irritated at work/school?

Do coworkers or other students have similar symptoms?

Are you exposed to fumes, dusts, or vapors at work? If so, what?

Nasal problems
Do you have seasonal or persistent nasal congestion, runny nose, postnasal drip, or decreased sense of smell?

Are your nasal symptoms worse at home/school/work?

Gastroesophageal reflux
Do you have heartburn (burning sensation in the chest); does food come back up into your mouth; or do you sense/taste sour stomach acid coming up into your throat?

Medications that can worsen asthma

Do you use eye drops? If so, which? Do your asthma symptoms worsen after taking them?

Do you use any medications that contain beta-blockers or ACE inhibitors? Has your asthma worsened since you started taking this medication?

Do you take aspirin or other NSAIDs? Do your asthma symptoms flare when you take them?

Possible sulfite sensitivity Δ

Do you have wheezing, coughing, or shortness of breath after eating shrimp, dried fruit, or processed potatoes or after drinking beer or wine?
IgE: immunoglobulin E; ACE: angiotensin-converting enzyme; NSAID: nonsteroidal anti-inflammatory drug.
* These questions are examples and do not represent a standardized assessment or diagnostic instrument. The validity and reliability of these questions have not been assessed.
¶ Higher humidity makes mold and mite exposure more likely. Visible mold suggests significant mold exposure.
Δ Rare issue in children.

Adapted from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.

Graphic 80507 Version 12.0

Evaluation and management of work aggravated asthma and occupational asthma

Evaluation
Potential for workplace-related symptoms:

Recognized sensitizers (eg, isocyanates, plant or animal products).

Irritants* or physical stimuli (eg, cold/heat, dust, humidity).

Coworkers may have similar symptoms.

Patterns of symptoms (in relation to work exposures):

Improvement occurs during vacations or days off (may take a week or more).

Symptoms may be immediate (<1 hour), delayed (most commonly, 2-8 hours after exposure), or nocturnal.

Initial symptoms may occur after high-level exposure (eg, spill).

Documentation of work-relatedness of airflow limitation:

Serial charting for 2-3 weeks (2 weeks at work and up to 1 week off work, as needed to identify or exclude work-related changes in PEF):

Record when symptoms and exposures occur.

Record when a bronchodilator is used.

Measure and record peak flow (or FEV 1 ) every 2 hours while awake.

Immunologic tests.

Referral for further confirmatory evaluation (eg, bronchial challenges).

Management
Work-aggravated asthma:

Work with onsite health care providers or managers/supervisors.

Discuss avoidance, ventilation, respiratory protection, tobacco smoke-free environment.

Occupationally induced asthma:

Recommend complete cessation of exposure to initiating agent.

FEV 1 : forced expiratory volume in 1 second; PEF: peak expiratory flow.

* Material Safety Data Sheets may be helpful for identifying respiratory irritants, but many sensitizers are not listed.

Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.

Graphic 69644 Version 1.0

Approaches to asthma controller therapy in adolescents and adults

National Asthma Education and Prevention Program: Expert Panel

Global Initiative for Asthma (GINA; 2019)
Report 3 (NAEPP-EPR 3; 2007)

Asthma symptoms/lung function Therapy* Asthma symptoms Therapy

Intermittent asthma/step 1 Step 1

Daytime symptoms ≤2 days/week SABA, as needed Infrequent asthma symptoms (eg, <2 Low-dose ICS with rapid onset LABA
Nocturnal awakenings ≤2/month times/week) (eg, budesonide-formoterol
Normal FEV 1 combination MDI 160 mcg-4.5
mcg/inhalation or DPI 200 mcg-6
Exacerbations ≤1/year
mcg/inhalation) 1 inhalation, as
needed
or

Low-dose ICS whenever SABA used

Mild persistent asthma/step 2 Step 2

Daytime symptoms >2 but <7 SABA as needed for symptom relief Asthma symptoms or need for reliever Daily low-dose ICS, with SABA as
days/week plus inhaler ≥2 times/week needed
Nocturnal awakenings 3 to 4 or
Daily low dose ICS (preferred)
nights/month
or Low dose ICS-formoterol, as needed
Minor interference with activities
or
FEV 1 within the normal range Daily LTRA
Take ICS whenever SABA taken, as
Exacerbations ≥2/year
needed
or (less preferred)

Daily LTRA, with SABA as needed

Moderate persistent asthma/step 3 Step 3

Daily symptoms SABA as needed for symptom relief Troublesome asthma symptoms most Low-dose ICS-LABA daily and as
Nocturnal awakenings >1/week plus days, nocturnal awakening due to reliever therapy (ie, budesonide-
Daily need for SABA asthma ≥1 time/month, risk factors for formoterol)
Daily low-dose ICS-LABA combination
exacerbations ¶ or
Some activity limitation or
FEV 1 60 to 80% predicted Daily low-dose ICS -LABA combination,
Daily medium-dose ICS
Exacerbations ≥2/year with SABA as needed
or
or
Daily low-dose ICS plus LTRA
Daily medium-dose ICS, with SABA as
needed
or

Daily low-dose ICS plus LTRA, with

SABA as needed

Severe persistent asthma/steps 4 to 6 Steps 4 to 5

Symptoms all day Step 4: Severely uncontrolled asthma with ≥3 SABA as needed for symptom relief
Nocturnal awakenings nightly of the following: daytime asthma and
Daily medium-dose ICS-LABA
Need for SABA several times/day symptoms >2 times/week; nocturnal
Possible addition of LTRA, zileuton
awakening due to asthma; reliever
Extreme limitation in activity Step 4:
needed for symptoms >2 times/week,
FEV 1 <60% predicted
Step 5: or activity limitation due to asthma Daily medium-dose ICS-LABA
Exacerbations ≥2/year
Daily high-dose ICS-LABA or or
Possible addition of omalizumab for An acute exacerbation Daily high-dose ICS-May need short
patients with allergies course of oral glucocorticoids
Possible add-on tiotropium, LTRA
Step 6:
Step 5:
Daily high-dose ICS-LABA
Daily high-dose ICS-LABA
May need short course of oral
glucocorticoids Assess for possible add-on therapy
(eg, tiotropium, zileuton, anti-IgE,
Possible addition of omalizumab for
anti-IL5/5R, anti-IL4R)
patients with allergies
May need short course of oral
glucocorticoids

Initial therapies are noted above. A higher level of initial therapy, sometimes with concurrent use of oral glucocorticoids, may be chosen if the patient presents with an acute
exacerbation. Treatment may be stepped down if asthma is well controlled for at least 3 months, or stepped up 1 or 2 steps if asthma is not well controlled or is very poorly
controlled.

FEV 1 : forced expiratory volume in one second; SABA: short-acting beta agonist; ICS: inhaled corticosteroid (glucocorticoid); LABA: long-acting beta agonist; MDI: metered dose inhaler;
DPI: dry powder inhaler; LTRA: leukotriene receptor antagonist; IgE: immunoglobulin E; IL: interleukin.
* Theophylline and cromolyn are not included in the table even though they were included in NAEPP-EPR 3 (2007). They are rarely used now, due to availability of more effective options.
¶ Risk factors for exacerbations include: smoking, allergen exposure if sensitized, previous intubation or intensive care unit stay for asthma, low FEV 1 (especially <60% predicted),
obesity, food allergy, chronic rhinosinusitis, and poor adherence/inhaler technique.

References:
1. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood
Institute, 2007. (NIH publication no. 08-4051). www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
2. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA). www.ginasthma.org

Graphic 127798 Version 1.0

Assessment of asthma symptom control and risk of exacerbations

A. Level of asthma symptom control

In the past 4 weeks, has the patient had: Well controlled Partly controlled Uncontrolled

Daytime symptoms more than twice/week? Yes No None of these 1 to 2 of these 3 to 4 of these

Any night waking due to asthma? Yes No

Reliever needed more than twice/week? Yes No

Any activity limitation due to asthma? Yes No

B. Risk factors for poor asthma outcomes

Assess risk factors at diagnosis and periodically, at least every 1 to 2 years, particularly for patients experiencing exacerbations.
Measure FEV 1 at start of treatment, after 3 to 6 months of controller treatment to record personal best lung function, then periodically for ongoing risk assessment.

Having uncontrolled asthma symptoms is an important risk factor for exacerbations. Having any of these risk
Additional potentially modifiable risk factors for exacerbations, even in patients with few asthma symptoms, include: factors increases the
patient's risk of
Medications: ICS not prescribed; poor adherence; incorrect inhaler technique; high SABA use (with increased mortality if >1×200-dose
exacerbations even if
canister/month)
they have few asthma
Comorbidities: obesity; chronic rhinosinusitis; gastroesophageal reflux disease; confirmed food allergy; anxiety; depression; pregnancy
symptoms.
Exposures: smoking; allergen exposure if sensitized; air pollution
Setting: major socioeconomic problems
Lung function: low FEV 1 , especially if <60% predicted; higher reversibility
Other tests: sputum/blood eosinophilia; elevated FE NO in allergic adults on ICS

Other major independent risk factors for flare-ups (exacerbations) include:

Ever being intubated or in intensive care for asthma
Having 1 or more severe exacerbations in the last 12 months

Risk factors for developing fixed airflow limitation include preterm birth, low birth weight, and greater infant weight gain; lack of ICS treatment; exposure to tobacco smoke,
noxious chemicals, or occupational exposures; low FEV 1 ; chronic mucus hypersecretion; and sputum or blood eosinophilia

Risk factors for medication side-effects include:

Systemic: frequent OCS; long-term, high dose and/or potent ICS; also taking cytochrome P450 inhibitors
Local: high-dose or potent ICS; poor inhaler technique

Asthma control has two domains: symptom control and risk of future exacerbations. Assess the symptom control domain by patient's recall of previous 4 weeks; assess risk
of future exacerbations by the presence of risk factors and by spirometry/or peak flow measures.

FEV 1 : forced expiratory volume in one second; ICS: inhaled corticosteroids; SABA: short-acting beta-2 agonist; FE NO : fraction of expired nitric oxide; OCS: oral corticosteroid.

Reproduced with permission from: Global Initiative for Asthma. Asthma Management and Prevention (for Adults and Children Older than 5 Years): A Pocket Guide for Health Professionals, Updated
2019. Available at: https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/ (Accessed on July 19, 2019).

Graphic 53233 Version 6.0

GINA strategy for asthma treatment in adults and adolescents

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, change to the preferred treatment before stepping up. Refer to UpToDate content on asthma management for more information about the decision-making that
supports the various treatment options.
Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy.

ICS: inhaled corticosteroid (glucocorticoid); SABA: inhaled short-acting beta 2 -agonist; LTRA: leukotriene receptor antagonist; LABA: long-acting inhaled beta 2 -agonist; IgE: immunoglobulin E;
IL-5: interleukin 5; IL-5R: interleukin 5 receptor; IL-4R: interleukin 4 receptor; OCS: oral corticosteroid (glucocorticoid); BDP: beclomethasone dipropionate; HDM: house dust mite; SLIT:
sublingual immunotherapy; FEV 1 : forced expiratory volume in one second.
* Off-label; data only with budesonide-formoterol (bud-form).
¶ Off-label; separate or combination ICS and SABA inhalers.
Δ Consider adding HDM SLIT for sensitized patients with allergic rhinitis and FEV 1 >70% predicted.
◊ Low-dose ICS-formoterol is the reliever for patients prescribed budesonide-formoterol or beclomethasone-formoterol maintenance and reliever therapy.

Reproduced with permission from: Global Initiative for Asthma. Asthma Management and Prevention (for Adults and Children Older than 5 Years): A Pocket Guide for Health Professionals, Updated 2019.
Available at: https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/ (Accessed on July 19, 2019).

Graphic 56729 Version 10.0

Estimated comparative daily doses for inhaled glucocorticoids in adolescents and adults

Drug Low dose Medium dose High dose

Beclomethasone HFA 80 to 160 mcg >160 to 320 mcg >320 mcg
(Qvar and Qvar RediHaler products available in United States)*

40 mcg per puff 2 to 4 puffs ¶ ¶

80 mcg per puff 1 to 2 puffs 3 to 4 puffs >4 puffs

Beclomethasone HFA Δ 100 to 200 mcg >200 to 400 mcg >400 mcg
(Qvar product available in Canada, Europe, and elsewhere)

50 mcg per puff 2 to 4 puffs ¶ ¶

100 mcg per puff 1 to 2 puffs 3 to 4 puffs >4 puffs

Budesonide DPI 180 to 360 mcg >360 to 720 mcg >720 mcg
(Pulmicort Flexhaler product available in United States)*

90 mcg per inhalation 2 to 4 inhalations ¶ ¶

180 mcg per inhalation 1 to 2 inhalations 3 to 4 inhalations >4 inhalations

Budesonide DPI Δ 200 to 400 mcg >400 to 800 mcg >800 mcg
(Pulmicort Turbuhaler product available in Canada, Europe, and
elsewhere)

100 mcg per inhalation 2 to 4 inhalations ¶ ¶

200 mcg per inhalation 1 to 2 inhalations 3 to 4 inhalations ¶

400 mcg per inhalation 1 inhalation 2 inhalations >2 inhalations

Ciclesonide HFA 80 to 160 mcg >160 to 320 mcg >320 mcg

(Alvesco product available in United States, Europe, and elsewhere)*

80 mcg per puff 1 to 2 puffs 3 to 4 puffs ¶

160 mcg per puff 1 puff 2 puffs >2 puffs

Ciclesonide HFA Δ 100 to 200 mcg >200 to 400 mcg >400 mcg
(Alvesco product available in Canada)

100 mcg per puff 1 to 2 puffs 3 to 4 puffs ¶

200 mcg per puff 1 puff 2 puffs >2 puffs

Flunisolide MDI 320 mcg >320 to 640 mcg Insufficient data

(Aerospan product available in United States)*

80 mcg per puff 4 puffs 5 to 8 puffs Insufficient data

Fluticasone propionate HFA 88 to 220 mcg >220 to 440 mcg >440 mcg
(Flovent HFA product available in United States)*

44 mcg per puff 2 to 5 puffs ¶ ¶

110 mcg per puff 1 to 2 puffs 3 to 4 puffs ¶

220 mcg per puff ◊ 2 puffs >2 puffs

Fluticasone propionate HFA Δ 100 to 250 mcg >250 to 500 mcg >500 mcg
(Flovent HFA product available in Canada, Europe, and elsewhere)

50 mcg per puff 2 to 5 puffs ¶ ¶

125 mcg per puff 1 to 2 puffs 3 to 4 puffs ¶

250 mcg per puff ◊ 2 puffs >2 puffs

Fluticasone propionate DPI 100 to 250 mcg >250 to 500 mcg >500 mcg
(Flovent Diskus product available in United States and Canada)*

50 mcg per inhalation 2 to 5 inhalations ¶ ¶

100 mcg per inhalation 1 to 2 inhalations 3 to 5 inhalations ¶

250 mcg per inhalation 1 inhalation 2 inhalations >2 inhalations

500 mcg per inhalation (strength not available in United States) ◊ 1 inhalation >1 inhalation

Fluticasone propionate DPI 100 to 250 mcg >250 to 500 mcg >500 mcg
(Armonair Respiclick product available in United States)*

55 mcg per inhalation 2 to 4 inhalations ¶ ¶

113 mcg per inhalation 1 to 2 inhalations 3 to 4 inhalations >4 inhalations

232 mcg per inhalation 1 inhalation 2 inhalation >2 inhalations

Fluticasone furoate DPI 50 mcg (by use of pediatric DPI, 100 mcg 200 mcg
(Arnuity Ellipta product available in United States)* which is off-label in adolescents
and adults)
NOTE: Inhaled fluticasone furoate has a greater anti-inflammatory
potency per microgram than fluticasone propionate inhalers. Thus,
fluticasone furoate is administered at a lower daily dose and used
only once daily.

50 mcg per inhalation 1 inhalation ¶ ¶

100 mcg per inhalation ◊ 1 inhalation 2 inhalations

200 mcg per actuation ◊ ◊ 1 inhalation

Mometasone DPI § 110 to 220 mcg >220 to 440 mcg >440 mcg
(Asmanex Twisthaler product available in United States)*

110 mcg per inhalation 1 to 2 inhalations ¶ ¶

220 mcg per inhalation 1 inhalation 2 inhalations >2 inhalations

Mometasone HFA § 100 to 200 mcg >200 to 400 mcg >400 mcg
 (Asmanex HFA product available in United States)*

100 mcg per actuation 1 to 2 inhalations ¶ ¶

200 mcg per actuation 1 inhalation 2 inhalations >2 inhalations

Mometasone DPI Δ § 200 mcg >200 to 400 mcg >400 mcg

(Asmanex Twisthaler product available in Canada, Europe, and
elsewhere)

200 mcg per inhalation 1 inhalation 2 inhalations >2 inhalations

400 mcg per inhalation ◊ 1 inhalation >1 inhalation

The most important determinant of appropriate dosing is the clinician's judgment of the patient's response to therapy. The clinician must monitor the patient's
response on several clinical parameters and adjust the dose accordingly. The stepwise approach to therapy emphasizes that once control of asthma is achieved, the dose
of medication should be carefully titrated to the minimum dose required to maintain control, thus reducing the potential for adverse effects.
Depending on the specific product, total daily doses are administered once or twice daily.
Some doses are outside the approved product information recommendations.

DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant metered dose inhaler.
* Doses shown and strengths (ie, mcg per puff or inhalation) are based upon product descriptions approved in the United States which may differ from how strengths are described for
products available in other countries. Consult local product information before use.
¶ Select alternate preparation with higher mcg/puff to improve convenience.
Δ Products shaded in light blue color are not available in the United States but are available widely elsewhere.
◊ Select preparation with fewer mcg/puff.
§ Approved for once-daily dosing in mild asthma in some countries.

National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma; 2007. NIH Publication 08-4051 available at
http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report; updated with additional data from Global Initiative for Asthma (GINA); Global Strategy for Asthma
Management and Prevention; 2017. Available at www.ginasthma.org.

Graphic 78011 Version 15.0

Childhood Asthma Control Test for children aged 4 to 11 years

Reproduced with permission from: Liu AH, Zeiger R, Sorkness C, et al. Development and cross-sectional validation of the Childhood
Asthma Control Test. J Allergy Clin Immunol 2007; 119:817. Copyright © 2007 Elsevier.

Graphic 81872 Version 6.0

Asthma Control Test®

For information on the interpretation and scoring of the Asthma Control Test® (ACT®), visit
https://www.asthmacontroltest.com.

Reproduced with permission from: Kosinski, M, Bayliss, MS, Turner-Bowker, DM, Fortin, EW. Asthma Control
Test: A User's Guide, Lincoln (RI): QualityMetric, Incorporated, 2004. Copyright ©2004 QualityMetric.

Graphic 50620 Version 3.0

Predicted peak expiratory flow (PEF; liters/minute) for females age 20 to 70 years

Age Height
(years) 55 inches/140 cm 60 inches/152 cm 65 inches/165 cm 70 inches/178 cm 75 inches/190 cm

20 333 372 418 468 517

25 340 379 425 475 524

30 344 383 429 479 528

35 344 383 430 479 529

40 342 381 427 477 526

45 336 376 422 471 521

50 328 367 413 463 512

55 316 323 401 451 501

60 301 341 387 436 486

65 283 323 369 419 468

70 263 302 348 398 447

For patients who do not know their personal best PEF, this table can help estimate an expected "personal best." This table uses a prediction equation for Caucasian women.
Refer to UpToDate calculator for values for additional age, height, and race/ethnicity parameters.

Reference:
1. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med. 1999; 159(1):179.

Graphic 62839 Version 9.0

Predicted peak expiratory flow (PEF; liters/minute) for males age 20 to 70 years

Age Height
(years) 60 inches/152 cm 65 inches/165 cm 70 inches/178 cm 75 inches/191 cm 80 inches/203 cm

20 477 539 606 678 748

25 484 546 613 685 756

30 488 550 616 688 759

35 487 549 616 688 758

40 483 545 611 683 754

45 474 536 603 675 746

50 462 436 591 663 733

55 446 508 575 646 717

60 426 488 554 626 697

65 402 464 530 602 673

70 374 436 503 574 645

For patients who do not know their personal best PEF, this table can help estimate an expected "personal best." This table uses a prediction equation for Caucasian men.
Refer to UpToDate calculator for values for additional age, height, and race/ethnicity parameters.

Reference:
1. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med. 1999; 159(1):179.

Graphic 57257 Version 9.0

Contributor Disclosures
Christopher H Fanta, MD Grant/Research/Clinical Trial Support: Samsung Research of America [Asthma and COPD]. Robert A Wood,
MD Grant/Research/Clinical Trial Support: NIAID; DBV Technologies; Aimmune; Astellas; HAL-Allergy; Sanofi; Regeneron [Food allergy]. Bruce S
Bochner, MD Grant/Research/Clinical Trial Support: NIAID; NHLBI, Acerta Pharma [Siglec-6, Siglec-8, Siglec-9, asthma, COPD, anaphylaxis,
imaging, eosinophilic granulomatosis with polyangiitis, food allergy, Bruton's tyrosine kinase, mastocytosis]. Consultant/Advisory Boards: GSK;
Genentech; Allakos; Regeneron; Third Harmonic Bio [Eosinophil and mast cell-related diseases]. Patent Holder: Siglec-8 and its ligand; anti-
Siglec-8 antibodies [Eosinophil and mast cell-associated disease (Licensed by Johns Hopkins University to Allakos and being developed as
antibody AK002 [in clinical trials; not yet FDA-approved])]. Equity Ownership/Stock Options: Allakos [Eosinophil and mast cell-related diseases
(AK002 [in clinical trials; not yet FDA-approved])]. Other Financial Interest: Elsevier [Publication royalties (Allergy and Immunology)]. Helen
Hollingsworth, MD Nothing to disclose Elizabeth TePas, MD, MS Nothing to disclose

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