STEPwise Treatment of Asthma - Adults and Children > 5 yo

Classify Severity: Clinical Features Before Treatment or Adequate Control Medications Required to Maintain Long-Term Control



PEF variability
Daily Medications
Mild Intermittent
<= 2 days/week
<= 2 nights/month
>= 80%
< 20%
  • No daily medication needed
  • Severe exacerbations may occur, separated by long periods of normal lung function and no symptoms. A course of systemic corticosteroids is recommended.
Mild Persistent
> 2/week but < 1x/day
> 2 nights/month
>= 80%
  • Preferred treatment:
    • Low-dose inhaled corticosteroids.
  • Alternative treatment (listed alphabetically): cromolyn, leukotriene modifier, nedocromil, OR sustained release theophylline to serum concentrations of 5-15 mcg/ml.
Moderate Persistent
> 1 night/week
>60% - < 80%
> 30%
  • Preferred treatment:
    • Low-to-medium dose inhaled corticosteroids and long-acting inhaled beta2-agonists.
  • Alternative treatment (listed alphabetically):
    • Increase inhaled corticosteroids within medium-dose range


    • Low-to-medium dose inhaled corticosteroids and either leukotriene modifier or theophylline

If needed (particularly in patients with recurring severe exacerbations):

  • Preferred treatment:
    • Increase inhaled corticosteroids within medium-dose range and add long-acting inhaled beta2-agonists.
  • Alternative treatment:
    • Increase inhaled corticosteroids within medium-dose range and add either leukotriene modifier or theophylline.
Severe Persistent
<= 60%
> 30%
  • Preferred treatment:
    • High-dose inhaled corticosteroids


    • Long-acting inhaled beta2-agonists

    AND, if needed

    • Corticosteroid tablets or syrup long term (2 mg/kg/day, generally do not exceed 60mg per day). (Make repeat attempts to reduce systemic corticosteroids and maintain control with high-dose inhaled corticosteroids.)
National Asthma Education and Prevention Program Expert Panel Report 2:  Guidelines for the Diagnosis and Management of Asthma


Quick Relief

All Patients

  • Short-acting bronchodilator: 2-4 puffs short-acting inhaled beta2-agonists as needed for symptoms.
  • Intensity of treatment will depend on severity of exacerbations; up to 3 treatments at 20-minute intervals or a single nebulizer as needed. Course of systemic corticosteroid may be needed.
  • Use of short-acting beta2-agonists >2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term therapy.
Step Down:
    Review treatment every 1 to 6 months; a gradual stepwise reduction in treatment may be possible.


  • The stepwise approach is intended to assist, not replace, the clinical decisionmaking required to meet individual patient needs.
  • Classify severity: assign patient to most severe step in which any feature occurs (PEF is % of personal best; FEV1 is % predicted).
  • Gain control as quickly as possible (a course of short systemic corticosteroids may be required); then step down to the least medication necessary to maintain control
  • Provide education on self-management and controlling environmental factors that make asthma worse (e.g. allergies and irritants)
  • Refer to an asthma specialist if there are difficulties controlling asthma or if step 4 care is required. Referral may be considered if step 3 care is required.
Step Up:
    If control is not achieved, consider step up.  First, review patient medication technique, adherence, and environmental control.

Goals of Therapy: Asthma Control

  • Minimal or no chronic symptoms day or night
  • Minimal or no exacerbations
  • No limitations on activities; no school/work missed
  • Maintain (near) normal pulmonary function
  • Minimal use of short-acting inhaled beta2-agonist (< 1x per day, < 1 canister/month)
  • Minimal or no side effects from medication