From the Guidelines
To determine the appropriate step in an asthma action plan, a comprehensive assessment of the patient's current symptoms, medication use, and asthma control is necessary, as outlined in the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma 1. The assessment should include:
- Current symptoms: frequency of daytime symptoms, nighttime awakenings, rescue inhaler use, and activity limitations due to asthma
- Recent exacerbations: oral steroids, emergency department visits, or hospitalizations within the past year
- Current medications: controller therapies, dosages, and adherence patterns
- Inhaler technique and environmental trigger exposures
- Pulmonary function testing results: FEV1, FEV1/FVC ratio, and bronchodilator response
- Comorbidities: allergic rhinitis, GERD, obesity, or anxiety
- Asthma control: validated measures of well-controlled, not well-controlled, or very poorly controlled based on symptom frequency, rescue medication use, and functional limitations This comprehensive assessment allows for the determination of the appropriate step in the asthma action plan, ranging from Step 1 (intermittent asthma requiring as-needed SABA only) through Step 6 (severe persistent asthma requiring high-dose ICS-LABA plus additional controllers or biologics) 1. A written asthma action plan should be provided to all patients, including instructions for daily management and actions to manage worsening asthma, as recommended by the EPR-3 guidelines 1.
From the Research
HPI Template for Asthma
To determine the step of action plan needed for asthma, the following template can be used:
- Chief Complaint: Patient's main symptom, such as shortness of breath, cough, or wheezing 2
- History of Present Illness:
- Onset and duration of symptoms
- Severity of symptoms (mild, moderate, severe)
- Triggers for symptoms (e.g. exercise, allergens)
- Previous treatments and responses to treatment
- Past Medical History:
- Previous asthma exacerbations
- Comorbidities (e.g. allergies, sinusitis)
- Medications currently being taken
- Medication Use:
- Current asthma medications (e.g. inhaled corticosteroids, long-acting beta-agonists)
- Dosages and frequencies of medications
- Adherence to medication regimen
- Symptom Assessment:
- Frequency and severity of symptoms
- Impact of symptoms on daily activities
- Use of rescue medications (e.g. short-acting beta-agonists)
- Lung Function:
- Results of spirometry or peak flow measurements
- Comparison to previous measurements
- Treatment Goals:
- Control symptoms
- Improve lung function
- Reduce risk of exacerbations
- Minimize side effects of medications
Determining Step of Action Plan
Based on the information gathered, the step of action plan needed can be determined using the following guidelines:
- Mild Asthma: Patients with mild asthma may be managed with inhaled corticosteroids alone or in combination with long-acting beta-agonists 3, 4
- Moderate Asthma: Patients with moderate asthma may require step-up therapy with additional medications, such as combination inhalers (e.g. fluticasone/salmeterol) 5, 6
- Severe Asthma: Patients with severe asthma may require more intensive treatment, including oral corticosteroids and hospitalization if necessary 2