Classification of asthma symptom severity and therapy

DAYTIME SYMPTOMS
Continual symptoms Limited physical activity Frequent exacerbations

NIGHTTIME SYMPTOMS
Frequent

LUNG FUNCTION

LONG TERM CONTROL

(see reverse side for drugs and dosage)

QUICK RELIEF

Daily high dose inhaled steroid FEV1/PEF 60% predicted PEF variability >30%3

Consideration for infants and children <5 years

Corticosteroids: Inhaled: high dose Long acting bronchodilator 4

Severe Persistent

Long acting bronchodilator 4 +/- oral steroid

AND

Short-acting B 2 -agonist prn

And And

Daily symptoms Daily use of inhaled shortacting B2 agonist Exacerbations affect activity Exacerbations 2 times/wk, may last days

1 night/wk FEV1/PEF >60% - <80% predicted PEF variability >30%3

Daily low/ medium dose

+/- Systemic steroid only if needed Medium dose ICS Short-acting B 2 -agonist prn

Moderate Persistent

inhaled steroid

OR, once controlled

Lower dose ICS Long acting bronchodilator 4

AND
Long acting bronchodilator4 Daily low/ medium dose inhaled steroid

AND OR

OR

Lower dose ICS

AND
Consider leukotriene modifier or theophylline Daily low dose inhaled steroid FEV1/PEF 80% predicted PEF variability 20 - 30% 3 2 nights/month FEV1/PEF 80% predicted PEF variability <20%3

AND
Theophylline

OR
leukotriene modifier Low dose inhaled corticosteroids

Symptoms >2/wk but <1 time/day

>2 nights/month

Exacerbations may affect activity

Mild Persistent

OR
Daily Cromolyn

Short-acting B 2 -agonist prn

OR
Alternative treatment: cromolyn, leukotriene, nedocromil, OR sustained release theophylline None

OR
Daily Leukotriene modifier None

Symptoms 2 times/wk Asymptomatic and normal PEF between exacerbations Exacerbations brief (hrs-days), variable intensity
1 2 3

Mild Intermittent

Short-acting B 2 -agonist prn

Adapted from Expert Panel Report 2 Guidelines for the Diagnosis and Management of Asthma , National Institutes of Health, National Heart, Lung and Blood Institute

For infants and children use SPACER AND MASK Infants and young children consistently requiring symptomatic treatment more than twice a week should be given daily anti-inflammatory therapy. Assessment of diurnal variation in peak expiratory flow over 1-2 weeks is recommended when patients have asthma symptoms but normal spirometry. PEF should be measured before taking a short-acting inhaled beta 2 agonist in the morning and after taking one in the afternoon. A 20% difference between the morning and afternoon measurements suggest asthma. Theophylline, sustained release / Salmeterol / Albuterol, sustained release.

If a patient has seasonal asthma on a predictable basis, daily, long-term anti-inflammatory therapy (inhaled corticosteroids, cromolyn, or nedocromil) should be initiated prior to the anticipated onset of symptoms and continued through the season.
Revised: March, 6 2003

HIPPO: Helping Improve Pediatric Practice Outcomes