2. Infants and Young Children— When
to Start Controllers
• >3 episodes of wheezing in the last year and
• Parental history of asthma or physician diagnosis of eczema
Or 2 of the following
• Physician diagnosis of allergic rhinitis, wheezing apart from
colds, peripheral eosinophilia
• Courses of oral steroids more often than every 6 wk
• Symptoms >2x/wk, nocturnal symptoms >2x/mo
3. Principles of Maintenance Therapy
• Start high.
• Step down once control is achieved.
• Maintain at lowest dose of medication that
controls asthma.
• Step up and down as indicated.
4. Step-down Therapy
Step down once control is achieved.
• After 2–3 mo.
• 25% reduction over 2–3 mo.
Follow-up monitoring
• Every 1–6 mo.
• Assess symptoms.
• Review medication use.
• Objective monitoring (PEFR or spirometery).
• Review medication.
5. Step-up Therapy
• Indications: symptoms, need for quick-relief
medication, exercise intolerance, decreased
lung function.
• May need short course of oral steroids.
• Continue to monitor.
• Follow and reassess every 1–6 mo.
• Step down when appropriate.
6. Acute Exacerbations
Principle: Gain control as quickly as possible.
Treat all asthma exacerbations promptly
and aggressively.
• Inhaled ß2-agonist inhalants for quick relief
• Access to quick relief medication
• Written action plan
• Indications
• Medications
• When to contact physician or emergency medical services
• Short course of oral corticosteroids
7. Acute Exacerbations
Office Management
Assess severity.
• Symptoms, signs, lung function, pulse oximetry (if available)
↓
• Oxygen recommended
• Short acting ß2-agonist inhalant every 20–30 min
• ± Ipratropium—metered-dose inhaler, inhalation solution
• ± Corticosteroid—orally, intravenous if vomiting
• Intravenous favored if dehydrated
• Follow-up—hours (phone) to 1–7 d
8. Step 1
Mild Intermittent
No Daily
Medication
Step 2
Mild Persistent
Preferred:
Low-dose ICS
Step 3
Moderate Persistent
Step 4
Severe Persistent
Alternative:
Cromolyn
or LTRA
Preferred:
Low-dose ICS +
LABA or
Medium-dose ICS
(+ LABA if needed)
Alternative:
Low- to Med-dose ICS
+ LTRA or
Theophylline
High-dose ICS +
LABA
(+ systemic
corticosteroids
if needed)
Stepwise Approach to Therapy
for Children ≤5 Years
ICS = inhaled corticosteroid; LABA = long-acting β2-agonist; LTRA = leukotriene receptor antagonist
NIH/NHLBI Guideline Update. June 2002. NIH Publication No. 02-5075.
9. ICS = inhaled corticosteroid; LABA = long-acting β2-agonist; LTM =
leukotriene modifier; SR = sustained release.
Stepwise Approach to Therapy
for Adults and Children >5 Years
Alternative:
Cromolyn, LTM,
Nedocromil, or
SR Theophylline
Step 1
Mild Intermittent
No Daily
Medication
Step 2
Mild Persistent
Preferred:
Low-dose ICS
Step 3
Moderate Persistent
Step 4
Severe Persistent
High-dose ICS +
LABA
(+ systemic
corticosteroids
if needed)
Preferred:
Alternative:
↑ ICS With No LABA
or Low- to Med-dose
ICS + LTM or
Theophylline
Low- to Med-dose
ICS + LABA
(↑ to med-dose ICS+
LABA if needed)
NIH/NHLBI Guideline Update. June 2002. NIH Publication No. 02-5075.
