Stepwise Approach for Asthma Staging and Management
Asthma management requires a structured stepwise approach based on both severity classification and control assessment, with treatment adjustments guided by patient response to achieve optimal control of symptoms and minimize future risk of exacerbations.
Asthma Severity Classification
Asthma severity is classified into four categories based on both impairment and risk domains:
| Components of Severity | Intermittent | Mild Persistent | Moderate Persistent | Severe Persistent |
|---|---|---|---|---|
| Symptoms | ≤2 days/week | >2 days/week but not daily | Daily | Throughout the day |
| Nighttime awakenings | ≤2x/month | 3-4x/month | >1x/week but not nightly | Often 7x/week |
| SABA use for symptom control | ≤2 days/week | >2 days/week but not daily | Daily | Several times per day |
| Interference with normal activity | None | Minor limitation | Some limitation | Extreme limitation |
| Lung function | FEV1 >80% predicted, FEV1/FVC normal | FEV1 >80% predicted, FEV1/FVC normal | FEV1 60-80% predicted, FEV1/FVC reduced | FEV1 <60% predicted, FEV1/FVC reduced >5% |
| Exacerbations requiring oral corticosteroids | 0-1/year | ≥2/year | ≥2/year | ≥2/year |
Important note: Patients who have had ≥2 exacerbations requiring oral corticosteroids in the past year should be considered to have persistent asthma, even if their impairment levels suggest intermittent asthma 1.
Stepwise Treatment Approach
Step 1: Intermittent Asthma
- Preferred: As-needed SABA
- Alternative: Consider low-dose ICS-formoterol as needed
Step 2: Mild Persistent Asthma
- Preferred: Daily low-dose ICS plus as-needed SABA, OR as-needed ICS-formoterol
- Alternative: LTRA, cromolyn, nedocromil, or theophylline
Step 3: Moderate Persistent Asthma
- Preferred: Low-dose ICS-LABA plus as-needed SABA, OR low-dose ICS-formoterol as both maintenance and reliever (SMART approach)
- Alternative: Medium-dose ICS plus as-needed SABA, OR low-dose ICS plus LTRA
- Consider: Specialist consultation at this step 1
Step 4: Moderate-to-Severe Persistent Asthma
- Preferred: Medium-dose ICS-LABA plus as-needed SABA, OR medium-dose ICS-formoterol as both maintenance and reliever
- Alternative: Medium-dose ICS plus LTRA or theophylline
Step 5: Severe Persistent Asthma
- Preferred: High-dose ICS-LABA plus as-needed SABA
- Add-on options: Consider tiotropium, LTRA, or theophylline
Step 6: Very Severe Persistent Asthma
- Preferred: High-dose ICS-LABA plus oral corticosteroids
- Add-on options: Consider biologic agents (omalizumab for allergic asthma, others based on phenotype)
- Specialist care required
Monitoring and Adjusting Treatment
Assessing Control
Control should be assessed at regular intervals (2-6 weeks when initiating therapy; 1-6 months when control is achieved) 2:
| Components of Control | Well Controlled | Not Well Controlled | Very Poorly Controlled |
|---|---|---|---|
| Symptoms | ≤2 days/week | >2 days/week | Throughout the day |
| Nighttime awakenings | ≤2x/month | 1-3x/week | ≥4x/week |
| Interference with normal activity | None | Some limitation | Extreme limitation |
| SABA use | ≤2 days/week | >2 days/week | Several times per day |
| FEV1 or PEF | >80% predicted/personal best | 60-80% predicted/personal best | <60% predicted/personal best |
| Exacerbations requiring oral corticosteroids | 0-1/year | ≥2/year | ≥2/year |
Step-Up and Step-Down Decisions
Step-Up:
- If asthma is not well-controlled, step up 1-2 steps
- Before stepping up, check:
- Inhaler technique
- Adherence
- Environmental control measures
- Comorbid conditions
- Re-evaluate in 2-6 weeks 2
Step-Down:
- If asthma is well-controlled for at least 3 months, consider stepping down
- Reduce medication gradually to find minimum effective dose
- Maintain ICS therapy even when symptoms improve 1, 2
Special Considerations
Long-Acting Beta-Agonists (LABAs):
- Never use as monotherapy
- Always combine with ICS
- Daily use should not exceed 100 mcg salmeterol or 24 mcg formoterol 1
Immunotherapy:
- Consider subcutaneous allergen immunotherapy for patients with persistent allergic asthma (Steps 2-4) 1
Exacerbations:
- For acute exacerbations: SABA every 4-6 hours up to 24 hours
- Consider short course of oral corticosteroids for severe exacerbations 1
Children:
- Different dosing considerations apply for children 0-4 years and 5-11 years 2
Common Pitfalls to Avoid
Underestimating severity: Patients who have had ≥2 exacerbations requiring oral corticosteroids in the past year should be considered to have persistent asthma, regardless of symptom frequency 1
Relying on symptoms alone: Assessment should include both impairment (symptoms, activity limitation, lung function) and risk (exacerbations, medication side effects) domains 1
Overlooking comorbidities: Conditions like GERD, sinusitis, and allergies can worsen asthma control 2
Inadequate follow-up: Regular monitoring is essential to adjust therapy appropriately 2
Overuse of SABA: Frequent use may indicate the need to step up treatment with daily long-term control therapy 1
The stepwise approach is meant to assist clinical decision-making but should be tailored to meet individual patient needs. Regular assessment of both symptom control and exacerbation risk is necessary to optimize asthma management and improve quality of life.