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Supplement Article  |   November 2014
Physician Implementation of Asthma Management Guidelines and Recommendations: 2 Case Studies
Author Affiliations & Notes
  • D. Parker Jonathan, DO, MS
    Timothy J. Craig, DO, is professor of medicine and pediatrics in the Division of Pulmonary, Allergy, and Immunology and a distinguished educator at Pennsylvania State University in Hershey. He is also chief of the Allergy/Immunology Section, director of Allergy and Respiratory Clinical Research, and program director of Allergy, Asthma, and Immunology.
  •  *Address correspondence to Timothy J. Craig, DO, Pennsylvania State University, Division of Allergy, Asthma, and Immunology, 500 University Dr, UPC II, Suite 1300, Hershey, PA 17033-2360. Email: tcraig@psu.edu
     
Article Information
Pulmonary Disorders
Supplement Article   |   November 2014
Physician Implementation of Asthma Management Guidelines and Recommendations: 2 Case Studies
The Journal of the American Osteopathic Association, November 2014, Vol. 114, eS4-eS15. doi:10.7556/jaoa.2014.165
The Journal of the American Osteopathic Association, November 2014, Vol. 114, eS4-eS15. doi:10.7556/jaoa.2014.165
Abstract

Despite the development and availability of new treatments and prescription medications, asthma remains a widespread chronic health problem in the United States. Achieving asthma control in patients is a resource-intensive enterprise that requires close assessment and personalized management. Asthma is simply not a disease that can be remedied with prescription medications alone. In 2007, the National Asthma Education and Prevention Program released their Guidelines for the Diagnosis and Management of Asthma. The guidelines provide assistance and direction to health care professionals in the assessment and treatment of patients with asthma. Two cases are presented to illustrate the treatment process in light of the Guidelines and the outcomes of these patients, who have varying degrees of support, education, and assessment of adherence to an asthma treatment plan. J Am Osteopath Assoc. 2014;114(11 suppl 3):eS4-eS15 doi:10.7556/jaoa.2014.165

This supplement is supported by independent educational grants from AstraZeneca and Merck & Co, Inc. 
A total of 18.7 million adults (8.0%) in the United States currently have asthma,1 and 14.2 million patient visits to physicians' offices result in a primary diagnosis of asthma.2 Moreover, 1.3 million visits to hospital outpatient departments and 1.8 million visits to emergency departments occur as a result of complications caused by asthma.3,4 In 439,000 hospitalizations, asthma is the first-listed discharge diagnosis (average length of stay, 3.6 days),5 and 3404 deaths are caused by asthma annually (1.1 per 100,000). The vast majority of these deaths are preventable.6 
Asthma is a disease not easily controlled by medication alone. It has been determined that to achieve the highest degree of control possible, physicians should actively engage with their asthmatic patients, conducting appropriate testing for accurate diagnosis, teaching and observing therapy techniques, encouraging adherence, and remaining in close contact throughout treatment. 
The purpose of this activity is to highlight important diagnostic considerations and management strategies and to illustrate these processes as they are applied to 2 patients who presented with nearly identical asthma symptoms and medical histories. The primary difference in the patients' experiences correlates with the level of physician adherence to the Guidelines for the Diagnosis and Management of Asthma from the National Asthma Education and Prevention Program (NAEPP).7 The 2 cases reported herein demonstrate the value of incorporating these guidelines into the asthma management paradigm. 
Overview of Asthma Diagnosis and Management
The recommended methods to establish a diagnosis of asthma include a detailed medical history, physical examination, and spirometry. Spirometry is an important objective method to establish the diagnosis of asthma; patient history and physical examination are not reliable methods to assess lung function or to exclude other diagnoses.7 
For the diagnosis of asthma to be established, the following presenting features are required: 
  • recurrent episodes of airflow obstruction or airway hyperresponsiveness
  • wheezing, cough, shortness of breath, and chest tightness
  • onset or worsening of symptoms in the presence of the following triggers: respiratory irritants, exercise, respiratory tract infection, allergens or irritants, changes in the weather, stress or strong emotional expression, and menstruation, with exclusion of alternative diagnoses
  • airflow obstruction that is at least partially reversible (reversibility should be determined by an increase in forced expiratory volume in 1 second [FEV1] of greater than 200 mL and 12% or more from baseline measured after inhalation of a short-acting β2-agonist)
In some patients who are older than 40 years, it can be difficult to differentiate asthma from other respiratory disorders, such as chronic obstructive pulmonary disease (COPD). Typical features of COPD include midlife onset, symptoms that progress slowly, and a long history of smoking. Exceptions occur, and patients with a1-antitrypsin deficiency can have obstructive lung disease before the age of 40 years even without smoking. In certain cases, patients with chronic asthma cannot be differentiated from those with COPD using currently available imaging and lung function testing. The patients should therefore be treated for both conditions; the management of asthma and COPD should be similar to that of asthma alone.8 
Studies that may be useful when considering asthma and related diagnoses include the following7: 
  • Spirometry. An increase of FEV1 back to normal after inhalation of a short-acting β2-agonist and a course of prednisone or inhaled corticosteroids may differentiate patients who have asthma from those who have COPD.
  • Bronchoprovocation with methacholine, histamine, cold air, or exercise challenge. A positive test result is indicative of airway hyperresponsiveness and asthma; however, methacholine often causes false-positive test results because it is nonspecific.
  • Chest radiography. Other differential diagnoses, such as a paralyzed diaphragm, should be excluded.
  • Laboratory analyses. Biomarkers of inflammation include total and differential white blood cell count and mediator assays of sputum, blood, urine, and exhaled air; however, at this time, total blood immunoglobulin E (IgE), blood eosinophil count, and exhaled nitric oxide are the recommended clinical tests; these levels are usually high in patients with asthma.
  • Skin test for positive allergens. Most patients with asthma are expected to have positive results.8
When asthma assessment and management guidelines7 are implemented, many patients with asthma demonstrate positive clinical outcomes, including improved control of asthma and health status, better quality of life, reduced limitation of activities, and fewer urgent-care visits and hospitalizations. 
In 2007, the NAEPP, coordinated by the National Heart, Lung, and Blood Institute, released its most recent report, titled Expert Panel Report-3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma.7 The guidelines provide recommendations for the individualized treatment of patients with asthma and guidance for maintaining treatment based on the extent of asthma control. The National Asthma Control Initiative, also by the National Heart, Lung, and Blood Institute, focuses on 6 priority messages. Selected by the Guidelines Implementation Panel, these messages reinforce the above-mentioned clinical practice recommendations, which are vital for asthma control and high-quality, patient-centered care. These priority messages are as follows9: assess asthma severity at the initial visit to determine initial treatment; use inhaled corticosteroids to control asthma; control environmental exposures that worsen asthma; use written asthma action plans to guide patient self-management; schedule follow-up visits at periodic intervals; and assess and monitor asthma control and adjust treatment if needed. 

The Expert Panel applied a system to describe the level of evidence for each of their recommendations as follows: Evidence Category A is described as randomized controlled trials, rich body of data; B, randomized controlled trials, limited body of data; C, nonrandomized trials and observational studies; and D, panel consensus judgment.7

 
Guidelines for the Diagnosis and Management of Asthma: Six Key Messages for 2 Patients
Two male patients with a history of asthma and a similar presentation received care in 2 different clinics. Henry, a 32-year-old paving contractor, and Lou, a 30-year-old construction worker, have asthma characterized by dyspnea, coughing, wheezing, and chest tightness that occasionally limit their ability to perform work duties that require intense physical labor. Their symptoms have become more frequent during the past year; each patient experiences symptoms more than 2 days per week (but not daily), and symptoms wake them 3 times per month. Each patient has had minor limitations in activity. 
Henry and Lou smoke cigarettes, with a 1.5 pack-per-day habit and a history of unsuccessful attempts at nicotine replacement therapy for smoking cessation. They are currently taking a short-acting β2-agonist (SABA), as needed. In the past year, 2 exacerbations have required oral systemic corticosteroid treatment. Henry's physical examination results showed congested nasal mucosa and normal heart and lungs. His physician also ordered pulmonary function tests (spi-rometry). His prebronchodilator (short-acting) test showed an FEV1 level of 4.07 L, which is 87% of the predicted value,10 and an FEV1/FVC (forced vital capacity) of 81%, which is normal for his age.10 The postbronchodilator test showed an FEV1 of 4.60 L, which represents a 13% (530 mL) improvement vs the prebronchodilator FEV1. The predicted FEV1 value for Henry (4.68 L) was based on his age and height (183 cm). Lou's physical examination results showed congested nasal mucosa and normal heart and lungs, like Henry. However, his physician did not order spirometric testing. On allergan assessment, both patients were positive for dust mite hypersensitivity. 
Asthma Severity: Determining Initial Treatment
As the National Asthma Control Initiative states: 

All patients should have an initial severity assessment based on measures of current impairment and future risk in order to determine type and level of initial therapy needed.11(p14)

 
Table 17 shows the recommended methods for classifying asthma severity and initiating treatment in adults. 
Table 1.
Classifying Asthma Severity and Initiating Treatment in Patients Aged >12 y
  Classification of Asthma Severity
    Persistent
Components of Severity Intermittent Mild Moderate Severe
Impairmenta
Symptoms ≤2 d/wk >2 d/wk but not daily daily throughout the day
Nighttime awakenings ≤2/m 3-4/mo >1/wk but not nightly often 7/wk
SABA use for symptom control (not prevention of EIB) ≤2 d/wk >2 d/wk but not daily, and not more that 1 on any d daily several times per day
Interference with normal activity none minor limitation some limitation extreme limitation
Lung function
FEV1 Normal between exacerbations; >80% predicted >80% predicted >60% but <80% predicted <60% predicted
FEV1/FEV normal normal reduced 5% reduced >5%
Risk
Exacerbations requiring oral systemic corticosteroids 0-1/yd (see note) ≥2/yb    
  Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV1.
Recommended Step for Initiating Treatmentc Step 1 Step 2 Step 3d Step 4 or 5d
  In 2-6 wk, evaluate level of asthma control that is achieved and adjust therapy accordingly.      
a Normal FEV1/FVC by age: 8-19 y, 85%; 20-39 y, 80%; 40-59 y, 75%; 60-80 y, 70%.b The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Level of severity is determined by assessment of both impairment and risk. Assess impairment domain by patient's or caregivers' recall of previous 2-4 weeks and spirometry. Assign severity to the most severe category in which any feature occurs. At present, there are inadequate data to correspond frequencies of exacerbations (eg, requiring urgent, unscheduled care; hospitalization; intensive care unit admission) with greater underlying disease severity. For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.c See Figure 2 for steps.d And consider short course of oral systemic corticosteroids.Abbreviations: FEV, forced expiratory volume; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity.Source: Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007.7
Table 1.
Classifying Asthma Severity and Initiating Treatment in Patients Aged >12 y
  Classification of Asthma Severity
    Persistent
Components of Severity Intermittent Mild Moderate Severe
Impairmenta
Symptoms ≤2 d/wk >2 d/wk but not daily daily throughout the day
Nighttime awakenings ≤2/m 3-4/mo >1/wk but not nightly often 7/wk
SABA use for symptom control (not prevention of EIB) ≤2 d/wk >2 d/wk but not daily, and not more that 1 on any d daily several times per day
Interference with normal activity none minor limitation some limitation extreme limitation
Lung function
FEV1 Normal between exacerbations; >80% predicted >80% predicted >60% but <80% predicted <60% predicted
FEV1/FEV normal normal reduced 5% reduced >5%
Risk
Exacerbations requiring oral systemic corticosteroids 0-1/yd (see note) ≥2/yb    
  Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV1.
Recommended Step for Initiating Treatmentc Step 1 Step 2 Step 3d Step 4 or 5d
  In 2-6 wk, evaluate level of asthma control that is achieved and adjust therapy accordingly.      
a Normal FEV1/FVC by age: 8-19 y, 85%; 20-39 y, 80%; 40-59 y, 75%; 60-80 y, 70%.b The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Level of severity is determined by assessment of both impairment and risk. Assess impairment domain by patient's or caregivers' recall of previous 2-4 weeks and spirometry. Assign severity to the most severe category in which any feature occurs. At present, there are inadequate data to correspond frequencies of exacerbations (eg, requiring urgent, unscheduled care; hospitalization; intensive care unit admission) with greater underlying disease severity. For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.c See Figure 2 for steps.d And consider short course of oral systemic corticosteroids.Abbreviations: FEV, forced expiratory volume; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity.Source: Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007.7
×
Henry
His physician determined the level of Henry's asthma severity to be mild persistent, per the NAEPP asthma guidelines.7 This assessment was based on Henry's current impair-ment7: (1) symptoms occurring more than twice per week (but not daily), (2) 3 to 4 nighttime awakenings per month, and (3) minor limitation in normal activity. The diagnosis was also made based on (4) Henry's spirometry results (FEV1 >80% predicted; FEV1/FVC normal), with reversibility in FEV1 demonstrated after the administration of a short-acting bronchodilator (>12% improvement in FEV1 and a >200-mL increase). Relative to future risk7 and on the basis of his recent history, the physician determined that Henry was at risk for 2 or more exacerbations per year, which would require oral systemic corticosteroids. 
Current impairment was assessed by determining the frequency and intensity of his symptoms, the functional limitations experienced recently, and his spirometry results. Future risk was assessed by considering the frequency (within the past year) and severity of his asthma exacerbations that required oral systemic corticosteroid therapy. 
Lou
In contrast, Lou's physician did not assess the severity of his asthma—neither his current impairment nor his level of future risk. 
ICS: Effective for the Long-term
According to the National Asthma Control Initiative: 

Inhaled corticosteroids are the most effective medications for long-term management of persistent asthma and should be utilized by patients and clinicians as is recommended in the guidelines for treatment of asthma.12

 
Asthma is a chronic inflammatory condition; thus, persistent asthma is most effectively controlled with daily asthma control medication that minimizes inflammation.12 Inhaled corticosteroids are anti-inflammatory medications that work by reducing airway hyperresponsive-ness, inhibiting inflammatory cell migration and activation, and blocking late-phase reaction to allergens.12 As the National Asthma Control Initiative states: "The benefits of inhaled corticosteroids outweigh the possible adverse effects."12 These treatments are generally well tolerated and safe when used at recommended doses.12 Figure 1 shows the available methods for asthma management.7 
Figure 1.
Long-term control and quick-relief medications, listed in alphabetical order. Medications for asthma are categorized into 2 general classes: (1) long-term control medications used to achieve and maintain control of persistent asthma and (2) quick-relief medications used to manage acute symptoms and exacerbations. Adapted from the National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma 2007.7 Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; Ig, immunoglobulin; LABA; long-acting β-agonist; LTRA, leukotriene receptor agonist; SABA, short-acting β-agonist.
Figure 1.
Long-term control and quick-relief medications, listed in alphabetical order. Medications for asthma are categorized into 2 general classes: (1) long-term control medications used to achieve and maintain control of persistent asthma and (2) quick-relief medications used to manage acute symptoms and exacerbations. Adapted from the National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma 2007.7 Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; Ig, immunoglobulin; LABA; long-acting β-agonist; LTRA, leukotriene receptor agonist; SABA, short-acting β-agonist.
Figure 2.
Stepwise approach for managing asthma in patients aged ≥12 years. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up. Step 1, 2, and 3 preferred therapies are based on Evidence A; step 3 alternative therapy is based on Evidence A for LTRA, Evidence B for theophylline, and Evidence D for zileuton. Step 4 preferred therapy is based on Evidence B, and alternative therapy is based on Evidence B for LTRA and theophylline and Evidence D zileuton. Step 5 preferred therapy is based on Evidence B. Step 6 preferred therapy is based on Expert Panel Report 2 (1997) and Evidence B for omalizumab. Immunotherapy for steps 2-4 is based on Evidence B for house-dust mites, animal dander, and pollens; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults. Footnotes: aTheophylline requires monitoring of serum concentration levels. bZileuton is a less desirable alternative because of limited studies as adjunctive therapy and the need to monitor liver function. cClinicians who administer immunotherapy or omalizumab should be prepared and equipped to identify and manage anaphylaxis that may occur. dIn step 6, before oral corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or zileuton may be considered, although this approach has not been studied in clinical trials. Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting β-agonist; LTRA, leukotriene receptor agonist; SABA, short-acting β-agonist.
Figure 2.
Stepwise approach for managing asthma in patients aged ≥12 years. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up. Step 1, 2, and 3 preferred therapies are based on Evidence A; step 3 alternative therapy is based on Evidence A for LTRA, Evidence B for theophylline, and Evidence D for zileuton. Step 4 preferred therapy is based on Evidence B, and alternative therapy is based on Evidence B for LTRA and theophylline and Evidence D zileuton. Step 5 preferred therapy is based on Evidence B. Step 6 preferred therapy is based on Expert Panel Report 2 (1997) and Evidence B for omalizumab. Immunotherapy for steps 2-4 is based on Evidence B for house-dust mites, animal dander, and pollens; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults. Footnotes: aTheophylline requires monitoring of serum concentration levels. bZileuton is a less desirable alternative because of limited studies as adjunctive therapy and the need to monitor liver function. cClinicians who administer immunotherapy or omalizumab should be prepared and equipped to identify and manage anaphylaxis that may occur. dIn step 6, before oral corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or zileuton may be considered, although this approach has not been studied in clinical trials. Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting β-agonist; LTRA, leukotriene receptor agonist; SABA, short-acting β-agonist.
Henry
After discussing his treatment options with his physician, Henry expressed reluctance toward the long-term use of ICSs, citing concerns about thrush and eye problems. His physician explained the facts about low-dose ICSs vs oral corticoste-roids, and Henry agreed to try a low-dose ICS to be used twice per day, with continuation of a SABA as needed for symptoms per the NAEPP asthma guidelines (step 2 therapy; Figure 2).7 The physician also prescribed a spacer to be used with the inhalers to optimize inhaler safety and efficacy. Spacers enhance delivery of medication to the lungs by decreasing oropharyngeal deposition of ICSs, thus decreasing risk of local adverse events (such as thrush7) and increasing deposition of the ICS into the lungs. 
Per the NAEPP asthma guidelines, the physician also taught Henry the appropriate inhaler/spacer technique using the teach-back method and counseled him on rinsing his mouth after inhaler use.7 Henry's physician also stressed adherence and discussed tobacco cessation and dust mite avoidance. If the physician had less time available during the visit, he would have had an allied health professional (AHP) educate Henry on asthma action plan adherence, mite avoidance, and inhaler technique. 
Lou
After discussing treatment options with his physician, Lou expressed hesitancy about the long-term use of ICSs, citing concerns about thrush and his belief that ICSs increase blood glucose level (Lou's parents have type 2 diabetes mellitus). His physician prescribed another course of oral corticosteroids and advised Lou to continue using the SABA as needed. Lou's physician did not counsel Lou on his technique, adherence, mite avoidance, or tobacco cessation. 
Allergen and Irritant Exposure Control: Managing the Environment
The National Asthma Control Initiative advises the following: 

Clinicians should review each patient's exposure to allergens and irritants and provide a multipronged strategy to reduce exposure to those allergens and irritants to which a patient is sensitive and exposed, that is, that make a patient's asthma worse.13

 
Substantially decreasing exposure to allergens and irritants, such as first-and secondhand cigarette smoke, may significantly reduce inflammation, symptoms, and the need for medications.13 
Henry
Based on Henry's history, his physician determined that the asthma worsened when Henry was exposed to tobacco through smoking or inhaling secondhand smoke. Furthermore, Henry reported that his asthma improved during previous short-term periods of smoking cessation and when he avoided passive smoke exposure. Henry's physician discussed the importance of smoking cessation and avoiding passive smoke to optimize asthma control, and he asked the AHP in the clinic to discuss with Henry, in layperson language, various smoking-cessation methods. 
Lou
The physician neither mentioned the importance of smoking cessation to Lou, nor did he educate his patient on smoking-cessation methods. 
Asthma Action Plan: Self-Management
The National Asthma Control Initiative states that "All people with asthma should receive a written asthma action plan to guide their self-management efforts."14 
A written asthma action plan should be tailored to the needs of the patient and provide instructions and information on how to self-manage asthma daily,14 including taking medications appropriately, identifying and avoiding exposure to allergens and irritants that can cause asthma symptoms, and recognizing and managing worsening asthma, including when, how, and whom to contact in an emergency. The action plan should also educate patients on how to adjust their therapy based on symptoms or peak flow. A sample asthma action plan is shown in Figure 3.7 
Figure 3.
Sample asthma action plan. Reprinted with permission from the Regional Asthma Management and Prevention website. Available at http://www.rampasthma.org/info-resources/asthma-action-plans/.
Figure 3.
Sample asthma action plan. Reprinted with permission from the Regional Asthma Management and Prevention website. Available at http://www.rampasthma.org/info-resources/asthma-action-plans/.
Henry
The AHP developed a tailored, written asthma action plan that was easy to follow and presented in layperson's language for optimal usability and reviewed it with Henry. The action plan included elements recommended by the asthma guidelines,7 including information and instructions on how to self-manage his asthma daily, such as when to use his inhalers and how much to use, and reminders about avoiding exposure to tobacco smoke (active or passive). The asthma action plan also included instructions to help Henry use symptoms to assess his asthma control, to know what to do in an emergency situation, to know when and how to step up therapy, and to know when to start taking oral corticosteroids. 
Lou
The physician sent an electronic prescription for the oral corticosteroids to Lou's pharmacy. He did not provide Lou with a written asthma action plan. 
Follow-up Visits: Monitoring and Maintaining Asthma Control
According to the National Asthma Control Initiative, "Patients who have asthma should be scheduled for planned follow-up visits at periodic intervals in order to assess their asthma control and modify treatment if needed,"17 and it further advises: 

At planned follow-up visits, asthma patients should review their level of asthma control with their healthcare provider based on multiple measures of current impairment and future risk in order to guide physician decisions to either maintain or adjust therapy.18

 
Asthma symptoms and response to asthma therapy can vary; thus, periodic monitoring of asthma control through clinical visits is essential to maintain asthma control with the optimal amount of medication.17 The frequency of monitoring should be determined by the physician's judgment and will vary depending on several factors, including the level of asthma control.17 
In general, patient visits should be scheduled at 2- to 6-week intervals while initiating therapy or stepping up therapy to achieve control; 1- to 6-month intervals after asthma control is achieved to monitor whether asthma control is maintained; and at 3-month intervals if a step-down in therapy is anticipated.17 Table 27 shows the recommended methods for assessing asthma control and adjusting therapy in adults. At follow-up visits, the physician should teach and reinforce self-monitoring techniques (eg, symptom and peak flow result assessment) to enable patients to assess their level of asthma control and to recognize signs of worsening asthma.18 
Table 2.
Assessing Asthma Control and Adjusting Therapy in Patients Aged ≥12 y
  Classification of Asthma Control
Components of Control Well Controlled Not Well Controlled Very Poorly Controlled
Impairmenta
Symptoms ≤2 d/wk >2 d/wk Throughout the day
Nighttime awakenings ≤2/mo 1-3/wk >4/wk
Interference with normal activity None Some limitation Extremely limited
SABA use for symptom control (not prevention of EIB) ≤2 d/wk >2 d/wk Several times per day
FEV1 or peak flow >80% predicted/ personal best 60%-80% predicted/ personal best <60% predicted/ personal best
Validated questionnaires'
ATAQ 0 1-2 3-4
ACQ ≤0.75 ≥1.5 NA
ACT ≥20 16-19 ≤15
Risk
Exacerbations requiring oral systemic corticosteroids 0-1/y ≥2/yc ≥2/yc
Consider severity and interval since last exacerbation
Progressive loss of lung function Evaluation requires long-term follow-up care
Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Recommended Action for Treatmentd Maintain current step. Regular follow-up every 1-6 mo to maintain control. Consider step down if well controlled for ≥3 mo Step upe 1 step and reevaluate in 2-6 wk. For side effects, consider alternative treatment options. Consider short course or oral systemic corticosteroids. Step upe 1-2 steps, and reevaluate in 2 wk. For side effects, consider alternative treatment options.
a Assess impairment domain by patient's recall of previous 2-4 wk and by spirometry or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit.b Minimal important difference for these questionnaires is as follows: 1.0 for the ATAQ (Asthma Therapy Assessment Questionnaire); 0.5 for the ACQ (Asthma Control Questionnaire); not determined for the ACT (Asthma Control Test).c At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care; hospitalization; intensive care unit admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma.d See Figure 2 for steps. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Level of control is based on the most severe impairment or risk.e Before step up in therapy, review adherence to medication, inhaler technique, environmental control, and comorbid conditions. If an alternative treatment option was used in a step, discontinue and use the preferred treatment for that step.Abbreviations: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second; NA, not applicable; SABA, short-acting β-agonist.Source: Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007.7
Table 2.
Assessing Asthma Control and Adjusting Therapy in Patients Aged ≥12 y
  Classification of Asthma Control
Components of Control Well Controlled Not Well Controlled Very Poorly Controlled
Impairmenta
Symptoms ≤2 d/wk >2 d/wk Throughout the day
Nighttime awakenings ≤2/mo 1-3/wk >4/wk
Interference with normal activity None Some limitation Extremely limited
SABA use for symptom control (not prevention of EIB) ≤2 d/wk >2 d/wk Several times per day
FEV1 or peak flow >80% predicted/ personal best 60%-80% predicted/ personal best <60% predicted/ personal best
Validated questionnaires'
ATAQ 0 1-2 3-4
ACQ ≤0.75 ≥1.5 NA
ACT ≥20 16-19 ≤15
Risk
Exacerbations requiring oral systemic corticosteroids 0-1/y ≥2/yc ≥2/yc
Consider severity and interval since last exacerbation
Progressive loss of lung function Evaluation requires long-term follow-up care
Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Recommended Action for Treatmentd Maintain current step. Regular follow-up every 1-6 mo to maintain control. Consider step down if well controlled for ≥3 mo Step upe 1 step and reevaluate in 2-6 wk. For side effects, consider alternative treatment options. Consider short course or oral systemic corticosteroids. Step upe 1-2 steps, and reevaluate in 2 wk. For side effects, consider alternative treatment options.
a Assess impairment domain by patient's recall of previous 2-4 wk and by spirometry or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit.b Minimal important difference for these questionnaires is as follows: 1.0 for the ATAQ (Asthma Therapy Assessment Questionnaire); 0.5 for the ACQ (Asthma Control Questionnaire); not determined for the ACT (Asthma Control Test).c At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care; hospitalization; intensive care unit admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma.d See Figure 2 for steps. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Level of control is based on the most severe impairment or risk.e Before step up in therapy, review adherence to medication, inhaler technique, environmental control, and comorbid conditions. If an alternative treatment option was used in a step, discontinue and use the preferred treatment for that step.Abbreviations: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second; NA, not applicable; SABA, short-acting β-agonist.Source: Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007.7
×
The level of asthma control achieved in response to treatment dictates whether a treatment regimen can be maintained, stepped up (increasing dose, frequency, or number of medications, or a combination), or stepped down (decreasing dose, frequency, or number of medications, or a combination).18 
Henry
Henry's physician had him schedule a follow-up appointment within 2 to 6 weeks after the initial visit per the NAEPP asthma guidelines.7 At the 2-week follow-up visit, Henry reported that he had 1 mild occurrence of wheezing while performing intense labor at work, and he controlled the symptom with the assistance of his asthma action plan and, as instructed, used his SABA. He was able to fully participate in work activities, began a smoking cessation program (he had not smoked for the past week), and had ensured a mite-free home environment. 
As requested by his physician, Henry brought his ICS canister to the appointment, and the physician confirmed his inhaler adherence by verifying that half of the 30-day supply was gone. Using the teach-back method to reinforce proper use of his inhaler and spacer, Henry once again demonstrated the technique per the NAEPP asthma guidelines.7 
The physician used this recent history to assess Henry's asthma control (both current impairment and future risk) and decided to maintain the current therapy (step 2). He had Henry schedule follow-up appointments at 4 weeks, 3 months, and 6 months, per the NAEPP guidelines.7 
3-WEEK FOLLOW-UP 
Henry continued to follow his asthma action plan. Having the plan at hand allowed him to return to his normal activities, including performing his regular duties at work. 
3- AND 6-MONTH FOLLOW-UP 
Henry reported continued asthma control and medication adherence and stated that he had not smoked since his quit date. He completed the 5-question, validated Asthma Control Test (Quality Metric, Inc),15,16 and scored 25 out of 25, indicating that his asthma was controlled. 
The physician assessed Henry's asthma (impairment and risk), concluding that his patient's asthma had been well controlled for 6 months. Therapy could be stepped down to step 1, and Henry could discontinue ICS use, per the NAEPP asthma guidelines.7 The physician reviewed with Henry his action plan and inhaler/spacer technique and had him schedule a follow-up appointment in 3 months, per the guidelines.7 The education included a discussion on when ICS should be restarted if necessary. 
Lou
3-WEEK FOLLOW-UP 
After a visit to the emergency department for an acute exacerbation of asthma symptoms, Lou returned to his physician's office. He reported that shortly after the oral corticosteroid regimen, his daytime and nighttime symptoms returned, and his activities, including his work duties, had become increasingly limited. His physician advised him to call the office if the symptoms persisted or to make another appointment. He did not recommend any follow-up visits, but he did refer Lou to an asthma specialist. Lou was subsequently lost to follow-up. 
New Treatments on the Horizon
In addition to the medications previously discussed, numerous agents are currently being investigated for the management of asthma. Ultra-long-acting inhaled β2-agonists (eg, olodat-erol, indacaterol)19,20 provide 24-hour bronchodilation that allow for once-daily dosing19,20 and are being investigated in combination with ICSs.19,20 Vilanterol, also a once-per-day LABA, in combination with fluticasone furoate was recently approved for a once-per-day inhalent.19,20 
Long-acting inhaled anticholiner-gic bronchodilators (eg, tiotropium, aclidinium),21-23 which have been approved for use in patients with COPD,21,22 provide sustained broncho-dilation, improve pulmonary function, decrease asthma exacerbations, and reduce corticosteroid requirements in patients with poorly controlled asthma. Published reports have demonstrated their effectiveness in patients with asthma as an additional agent to ICS or in addition to the combination of ICS and long-acting β2-agonists; however, they are not yet approved by the US Food and Drug Administration for use in patients with asthma.21-23 
Monoclonal antibodies (reslizumab [anti-interleukin 5 (IL-5)], mepolizumab [anti-IL-5], lebrikizumab [anti-IL-13], Medi-528 [anti-IL-9], Medi-563 [anti-IL-5 receptor], daclizumab [anti-CD25], lumi-liximab [anti-CD23], AMG-317 [anti-IL-4 a receptor], anti-IL-4, and tralokinumab [anti-IL-13]) are parenterally administered agents being researched,25-27 and they mainly provide reduction in exacerbations in patients with poorly controlled asthma despite high-dose ICS therapy.25-27 The benefit of these agents is limited to a small number of patients with similar phenotypes, but the above monoclonal antibodies are not yet approved for therapy. 
The only approved monoclonal antibody is omalizumab. Omalizumab is anti-IgE and is indicated, according to the guidelines, for severe refractory asthma not controlled with high doses of inhaled corticosteroids. Omalizumab has been demonstrated to reduce asthma exacerbations and improve asthma control.28 
Conclusion
In patients with suspected asthma, spiro-metric testing is important in establishing the diagnosis.7 The proper assessment and management of asthma is essential to patients' quality of life and well-being.7 Most patients can control their asthma with appropriate care.9 Follow-up appointments should be scheduled within 2 to 6 weeks after treatment initiation, with subsequent follow-up appointments at 3-month intervals once asthma control is achieved. At each follow-up visit, physicians should review the patients' level of asthma control (based on current impairment and future risk), success and adherence with inhaler/spacer techniques, and use of the asthma action plan. The science behind ideal management strategies for asthma control is robust and has been translated into evidence-based asthma guidelines, which, if implemented, can improve patient care.7,9 The use of the 6 priority messages selected by the Guidelines Implementation Panel can help physicians efficiently optimize patient outcomes.9 
References
Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: national health interview survey, 2012. Vital Health Stat 10. 2014;(260): 1-161. [PubMed]
Table 13: Twenty leading primary diagnosis groups for office visits: United States, 2010. National Ambulatory Medical Care Survey: 2010 Summary Tables. Atlanta, GA: Centers for Disease Control and Prevention; 2010. September 16, 2014.
Table 11: Twenty leading primary diagnosis groups for outpatient department visits: United States, 2010. National Hospital Ambulatory Medical Care Survey: 2010 Outpatient Department Summary Tables. Atlanta, GA: Centers for Disease Control and Prevention: 2010. http://www.cdc.gov/nchs/data/ahcd/nhamcs_outpatient/2010 _opd_web_tables.pdf. September 16, 2014.
Table 12: Twenty leading primary diagnosis groups and presence of chronic disease at emergency department visits: United States, 2010. National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables. Atlanta, GA: Centers for Disease Control and Prevention; 2010. http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf. Accessed September 16, 2014.
Average length of stay and days of care -number and rate of discharges by first-listed diagnostic categories [table]. National Hospital Discharge Survey. Hyattsville, MD: National Center for Health Statistics; 2010. http://www.cdc.gov/nchs/data/nhds/2average/2010ave2_dischargesage.pdf. Accessed October 2, 2014.
Murphy SL , Xu J, Kochanek KD. Deaths: final data for 2010. Natl Vital Stat Rep. 2013;61(4): 1-117. [PubMed]
National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120(5 suppl): S94-S138. [CrossRef] [PubMed]
Differential diagnosis of COPD. American Thoracic Society website. http://www.thoracic.org/clinical/copd-guidelines/for-health-professionals/clinical-assessment-testing-and-differential-diagnosis/differential-diagnosis.php. Accessed September 16, 2014.
Dexheimer JW, Borycki EM, Chiu KW, et al. A systematic review of the implementation and impact of asthma protocols. BMC Med Inform Decis Mak. 2014;14(1): 82. doi:10.1186/1472-6947-14-82. [CrossRef] [PubMed]
Putting guideline priorities into action. National Heart, Lung, and Blood Institute website. www.nhlbi.nih.gov/health/prof/lung/asthma/naci/discover/priorities.htm. Updated January 2013. Accessed September 16, 2014.
Spirometry training program: NHANES III reference values for men. Centers for Disease Control and Prevention website. http://www.cdc.gov/niosh/topics/spirometry/pdfs/CMale20_40_All.pdf. Accessed September 16, 2014.
Asthma severity: know where to start. National Heart, Lung, and Blood Institute website. http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/discover/asthma-severity.htm. Accessed September 16, 2014.
Inhaled corticosteroids: keep airways open. National Heart, Lung, and Blood Institute website. http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/discover/corticosteriods.htm. Accessed September 16, 2014.
Environmental exposures: avoid asthma triggers. National Heart, Lung, and Blood Institute website. http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/discover/environmental-exposure.htm. Accessed September 16, 2014.
Asthma action plans: help patients take control. National Heart, Lung, and Blood Institute website. http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/discover/action-plans.htm. Accessed September 16, 2014.
Nathan RA, Sorkness CA, Kosinski M, et al.  . Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004;113(1): 59-65. [CrossRef] [PubMed]
Asthma Control Test (ACT). QualityMetric website. http://www.qualitymetric.com/WhatWeDo/DiseasespecificHealthSurveys/AsthmaControlTestACT/tabid/190/Default.aspx. Accessed September 16, 2014.
Follow-up Visits: Stay on Track. National Heart, Lung, and Blood Institute website. http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/discover/follow-up-visits.htm. Accessed September 16, 2014.
Asthma control: keep it going. National Heart, Lung, and Blood Institute website. http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/discover/asthma-control.htm. Accessed September 16, 2014.
Cazzola M, Calzetta L, Mater MG. β2~adrenoceptor agonists: current and future direction. Br J Pharmacol. 2011;163(1): 4-171. [CrossRef] [PubMed]
Cazzola M, Page CP, Rogliani P, Matera MG. β2-agonist therapy in lung disease. Am J Respir Crit Care Med. 2013; 187(7): 690-696. doi:10.1164/rccm.201209-1739PP. [CrossRef] [PubMed]
Kerstjens HA, Engel M, Dahl R, et al. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med. 2012;367(13): 1198-1207. [CrossRef] [PubMed]
Reid DJ, Carlson AA. Clinical use of aclidinium in patients with COPD. Int J Chron Obstruct Pulmon Dis. 2014;28(9): 369-379. doi:10.2147/COPD.S40193. [CrossRef]
Adams KS, Lowe DK. Tiotropium for adults with inadequately controlled persistent asthma. Ann Pharmacother. 2013;47(1): 117-123. [CrossRef] [PubMed]
Castro M, Mathur S, Hargreave F, et al; Res-5-0010 Study Group. Reslizumab for poorly controlled, eosinophilic asthma: a randomized, placebo-controlled study. Am J Respir Crit Care Med. 2011;184(10): 1125-1132. doi:10.1164/rccm.201103-0396OC. [CrossRef] [PubMed]
Corren J, Lemanske RF, Hanania NA, et al. Lebrikizumab treatment in adults with asthma. N Engl J Med. 2011;365(12):1088-1098. doi:10.1056/NEJMoa1106469. [CrossRef] [PubMed]
Piper E, Brightling C, Niven R, et al. A phase II placebo-controlled study of tralokinumab in moderate-to-severe asthma. Eur Respir J. 2013;41(2):330-338. doi:10.1183/09031936.00223411. [CrossRef] [PubMed]
Busse WW, Morgan WJ, Gergen PJ, et al. Randomized trial of omalizumab (anti-IgE) for asthma in inner-city children. N Engl J Med. 2011;364(11):1005-1015. doi:10.1056/NEJMoa1009705. [CrossRef] [PubMed]
Figure 1.
Long-term control and quick-relief medications, listed in alphabetical order. Medications for asthma are categorized into 2 general classes: (1) long-term control medications used to achieve and maintain control of persistent asthma and (2) quick-relief medications used to manage acute symptoms and exacerbations. Adapted from the National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma 2007.7 Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; Ig, immunoglobulin; LABA; long-acting β-agonist; LTRA, leukotriene receptor agonist; SABA, short-acting β-agonist.
Figure 1.
Long-term control and quick-relief medications, listed in alphabetical order. Medications for asthma are categorized into 2 general classes: (1) long-term control medications used to achieve and maintain control of persistent asthma and (2) quick-relief medications used to manage acute symptoms and exacerbations. Adapted from the National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma 2007.7 Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; Ig, immunoglobulin; LABA; long-acting β-agonist; LTRA, leukotriene receptor agonist; SABA, short-acting β-agonist.
Figure 2.
Stepwise approach for managing asthma in patients aged ≥12 years. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up. Step 1, 2, and 3 preferred therapies are based on Evidence A; step 3 alternative therapy is based on Evidence A for LTRA, Evidence B for theophylline, and Evidence D for zileuton. Step 4 preferred therapy is based on Evidence B, and alternative therapy is based on Evidence B for LTRA and theophylline and Evidence D zileuton. Step 5 preferred therapy is based on Evidence B. Step 6 preferred therapy is based on Expert Panel Report 2 (1997) and Evidence B for omalizumab. Immunotherapy for steps 2-4 is based on Evidence B for house-dust mites, animal dander, and pollens; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults. Footnotes: aTheophylline requires monitoring of serum concentration levels. bZileuton is a less desirable alternative because of limited studies as adjunctive therapy and the need to monitor liver function. cClinicians who administer immunotherapy or omalizumab should be prepared and equipped to identify and manage anaphylaxis that may occur. dIn step 6, before oral corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or zileuton may be considered, although this approach has not been studied in clinical trials. Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting β-agonist; LTRA, leukotriene receptor agonist; SABA, short-acting β-agonist.
Figure 2.
Stepwise approach for managing asthma in patients aged ≥12 years. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up. Step 1, 2, and 3 preferred therapies are based on Evidence A; step 3 alternative therapy is based on Evidence A for LTRA, Evidence B for theophylline, and Evidence D for zileuton. Step 4 preferred therapy is based on Evidence B, and alternative therapy is based on Evidence B for LTRA and theophylline and Evidence D zileuton. Step 5 preferred therapy is based on Evidence B. Step 6 preferred therapy is based on Expert Panel Report 2 (1997) and Evidence B for omalizumab. Immunotherapy for steps 2-4 is based on Evidence B for house-dust mites, animal dander, and pollens; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults. Footnotes: aTheophylline requires monitoring of serum concentration levels. bZileuton is a less desirable alternative because of limited studies as adjunctive therapy and the need to monitor liver function. cClinicians who administer immunotherapy or omalizumab should be prepared and equipped to identify and manage anaphylaxis that may occur. dIn step 6, before oral corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or zileuton may be considered, although this approach has not been studied in clinical trials. Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting β-agonist; LTRA, leukotriene receptor agonist; SABA, short-acting β-agonist.
Figure 3.
Sample asthma action plan. Reprinted with permission from the Regional Asthma Management and Prevention website. Available at http://www.rampasthma.org/info-resources/asthma-action-plans/.
Figure 3.
Sample asthma action plan. Reprinted with permission from the Regional Asthma Management and Prevention website. Available at http://www.rampasthma.org/info-resources/asthma-action-plans/.
Table 1.
Classifying Asthma Severity and Initiating Treatment in Patients Aged >12 y
  Classification of Asthma Severity
    Persistent
Components of Severity Intermittent Mild Moderate Severe
Impairmenta
Symptoms ≤2 d/wk >2 d/wk but not daily daily throughout the day
Nighttime awakenings ≤2/m 3-4/mo >1/wk but not nightly often 7/wk
SABA use for symptom control (not prevention of EIB) ≤2 d/wk >2 d/wk but not daily, and not more that 1 on any d daily several times per day
Interference with normal activity none minor limitation some limitation extreme limitation
Lung function
FEV1 Normal between exacerbations; >80% predicted >80% predicted >60% but <80% predicted <60% predicted
FEV1/FEV normal normal reduced 5% reduced >5%
Risk
Exacerbations requiring oral systemic corticosteroids 0-1/yd (see note) ≥2/yb    
  Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV1.
Recommended Step for Initiating Treatmentc Step 1 Step 2 Step 3d Step 4 or 5d
  In 2-6 wk, evaluate level of asthma control that is achieved and adjust therapy accordingly.      
a Normal FEV1/FVC by age: 8-19 y, 85%; 20-39 y, 80%; 40-59 y, 75%; 60-80 y, 70%.b The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Level of severity is determined by assessment of both impairment and risk. Assess impairment domain by patient's or caregivers' recall of previous 2-4 weeks and spirometry. Assign severity to the most severe category in which any feature occurs. At present, there are inadequate data to correspond frequencies of exacerbations (eg, requiring urgent, unscheduled care; hospitalization; intensive care unit admission) with greater underlying disease severity. For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.c See Figure 2 for steps.d And consider short course of oral systemic corticosteroids.Abbreviations: FEV, forced expiratory volume; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity.Source: Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007.7
Table 1.
Classifying Asthma Severity and Initiating Treatment in Patients Aged >12 y
  Classification of Asthma Severity
    Persistent
Components of Severity Intermittent Mild Moderate Severe
Impairmenta
Symptoms ≤2 d/wk >2 d/wk but not daily daily throughout the day
Nighttime awakenings ≤2/m 3-4/mo >1/wk but not nightly often 7/wk
SABA use for symptom control (not prevention of EIB) ≤2 d/wk >2 d/wk but not daily, and not more that 1 on any d daily several times per day
Interference with normal activity none minor limitation some limitation extreme limitation
Lung function
FEV1 Normal between exacerbations; >80% predicted >80% predicted >60% but <80% predicted <60% predicted
FEV1/FEV normal normal reduced 5% reduced >5%
Risk
Exacerbations requiring oral systemic corticosteroids 0-1/yd (see note) ≥2/yb    
  Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV1.
Recommended Step for Initiating Treatmentc Step 1 Step 2 Step 3d Step 4 or 5d
  In 2-6 wk, evaluate level of asthma control that is achieved and adjust therapy accordingly.      
a Normal FEV1/FVC by age: 8-19 y, 85%; 20-39 y, 80%; 40-59 y, 75%; 60-80 y, 70%.b The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Level of severity is determined by assessment of both impairment and risk. Assess impairment domain by patient's or caregivers' recall of previous 2-4 weeks and spirometry. Assign severity to the most severe category in which any feature occurs. At present, there are inadequate data to correspond frequencies of exacerbations (eg, requiring urgent, unscheduled care; hospitalization; intensive care unit admission) with greater underlying disease severity. For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.c See Figure 2 for steps.d And consider short course of oral systemic corticosteroids.Abbreviations: FEV, forced expiratory volume; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity.Source: Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007.7
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Table 2.
Assessing Asthma Control and Adjusting Therapy in Patients Aged ≥12 y
  Classification of Asthma Control
Components of Control Well Controlled Not Well Controlled Very Poorly Controlled
Impairmenta
Symptoms ≤2 d/wk >2 d/wk Throughout the day
Nighttime awakenings ≤2/mo 1-3/wk >4/wk
Interference with normal activity None Some limitation Extremely limited
SABA use for symptom control (not prevention of EIB) ≤2 d/wk >2 d/wk Several times per day
FEV1 or peak flow >80% predicted/ personal best 60%-80% predicted/ personal best <60% predicted/ personal best
Validated questionnaires'
ATAQ 0 1-2 3-4
ACQ ≤0.75 ≥1.5 NA
ACT ≥20 16-19 ≤15
Risk
Exacerbations requiring oral systemic corticosteroids 0-1/y ≥2/yc ≥2/yc
Consider severity and interval since last exacerbation
Progressive loss of lung function Evaluation requires long-term follow-up care
Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Recommended Action for Treatmentd Maintain current step. Regular follow-up every 1-6 mo to maintain control. Consider step down if well controlled for ≥3 mo Step upe 1 step and reevaluate in 2-6 wk. For side effects, consider alternative treatment options. Consider short course or oral systemic corticosteroids. Step upe 1-2 steps, and reevaluate in 2 wk. For side effects, consider alternative treatment options.
a Assess impairment domain by patient's recall of previous 2-4 wk and by spirometry or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit.b Minimal important difference for these questionnaires is as follows: 1.0 for the ATAQ (Asthma Therapy Assessment Questionnaire); 0.5 for the ACQ (Asthma Control Questionnaire); not determined for the ACT (Asthma Control Test).c At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care; hospitalization; intensive care unit admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma.d See Figure 2 for steps. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Level of control is based on the most severe impairment or risk.e Before step up in therapy, review adherence to medication, inhaler technique, environmental control, and comorbid conditions. If an alternative treatment option was used in a step, discontinue and use the preferred treatment for that step.Abbreviations: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second; NA, not applicable; SABA, short-acting β-agonist.Source: Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007.7
Table 2.
Assessing Asthma Control and Adjusting Therapy in Patients Aged ≥12 y
  Classification of Asthma Control
Components of Control Well Controlled Not Well Controlled Very Poorly Controlled
Impairmenta
Symptoms ≤2 d/wk >2 d/wk Throughout the day
Nighttime awakenings ≤2/mo 1-3/wk >4/wk
Interference with normal activity None Some limitation Extremely limited
SABA use for symptom control (not prevention of EIB) ≤2 d/wk >2 d/wk Several times per day
FEV1 or peak flow >80% predicted/ personal best 60%-80% predicted/ personal best <60% predicted/ personal best
Validated questionnaires'
ATAQ 0 1-2 3-4
ACQ ≤0.75 ≥1.5 NA
ACT ≥20 16-19 ≤15
Risk
Exacerbations requiring oral systemic corticosteroids 0-1/y ≥2/yc ≥2/yc
Consider severity and interval since last exacerbation
Progressive loss of lung function Evaluation requires long-term follow-up care
Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Recommended Action for Treatmentd Maintain current step. Regular follow-up every 1-6 mo to maintain control. Consider step down if well controlled for ≥3 mo Step upe 1 step and reevaluate in 2-6 wk. For side effects, consider alternative treatment options. Consider short course or oral systemic corticosteroids. Step upe 1-2 steps, and reevaluate in 2 wk. For side effects, consider alternative treatment options.
a Assess impairment domain by patient's recall of previous 2-4 wk and by spirometry or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit.b Minimal important difference for these questionnaires is as follows: 1.0 for the ATAQ (Asthma Therapy Assessment Questionnaire); 0.5 for the ACQ (Asthma Control Questionnaire); not determined for the ACT (Asthma Control Test).c At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care; hospitalization; intensive care unit admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma.d See Figure 2 for steps. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Level of control is based on the most severe impairment or risk.e Before step up in therapy, review adherence to medication, inhaler technique, environmental control, and comorbid conditions. If an alternative treatment option was used in a step, discontinue and use the preferred treatment for that step.Abbreviations: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second; NA, not applicable; SABA, short-acting β-agonist.Source: Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007.7
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