NATIONAL INSTITUTES OF HEALTH

NATIONAL HEART, LUNG, AND BLOOD INSTITUTE

Practical Guide 

for the 

Diagnosis and 

Management of Asthma

Based on the Expert Panel Report 2:

Guidelines for the Diagnosis and 

Management of Asthma

National Asthma Education and Prevention
*Shirley Murphy, M.D., Chair

University of New Mexico

Eugene R. Bleecker, M.D.

University of Maryland

*Homer Boushey, M.D.

University of California at San Francisco

*A. Sonia Buist, M.D.

Oregon Health Sciences University

*William Busse, M.D.

University of Wisconsin

Noreen M. Clark, Ph.D.

University of Michigan 

Howard Eigen, M.D.

Riley Hospital for Children

Jean G. Ford, M.D.

Columbia University

*Susan Janson, D.N.Sc., R.N.

University of California, San Francisco

*H. William Kelly, Pharm.D.

University of New Mexico

Robert F. Lemanske, Jr., M.D.

University of Wisconsin

Carolyn C. Lopez, M.D.

Rush Medical College

Fernando Martinez, M.D.

University of Arizona

*Harold S. Nelson, M.D.

National Jewish Medical and Research 

Center

Richard Nowak, M.D., M.B.A.

Henry Ford Hospital

Thomas A.E. Platts-Mills, M.D., Ph.D.

University of Virginia

Gail G. Shapiro, M.D.

University of Washington

Stuart Stoloff, M.D.

Private Family Practice

and 

University of Nevada

Kevin Weiss, M.D., M.P.H.

Rush Primary Care Institute

Federal Liaison Representatives

Clive Brown, M.B.B.S., M.P.H.

Centers for Disease Control and Prevention

Peter J. Gergen, M.D.

(formerly with the National Institute of 

Allergy and Infectious Diseases)

Agency for Health Care Policy and Research

Edward L. Petsonk, M.D.

National Institute for Occupational Safety 

and Health

National Heart, Lung, and 

Blood Institute Staff

Ted Buxton, M.P.H.

Robinson Fulwood, M.S.P.H.

Michele Hindi-Alexander, Ph.D.

Suzanne S. Hurd, Ph.D.

Virginia S. Taggart, M.P.H.

R.O.W. Sciences, Inc., Support Staff

Ruth Clark

Daria Donaldson

Lisa Marcellino

Donna Selig

Keith Stanger

Eileen Zeller, M.P.H.

Second Expert Panel on the Management of Asthma

Allergy and Asthma Network/Mothers of

Asthmatics, Inc.

American Academy of Allergy, Asthma,

and Immunology

American Academy of Family

Physicians

American Academy of Pediatrics

American Academy of Physician

Assistants

American Association for 

Respiratory Care

American Association of 

Occupational Health Nurses

American College of Allergy, Asthma,

and Immunology

American College of Chest Physicians

American College of Emergency

Physicians

American Lung Association

American Medical Association

American Nurses Association, Inc.

American Pharmaceutical Association

American Public Health Association

American School Health Association

American Society of Health-System

Pharmacists

American Thoracic Society

Association of State and Territorial 

Directors of Health Promotion and

Public Health Education

Asthma and Allergy Foundation of

America

Centers for Disease Control and 

Prevention

National Association of School Nurses

National Black Nurses Association, Inc.

National Center for Environmental

Health

National Center for Health Statistics

NHLBI Ad Hoc Committee on 

Minority Populations

National Heart, Lung, and Blood

Institute

National Institute for Occupational

Safety and Health

National Institute of Allergy and 

Infectious Diseases

National Institute of Environmental 

Health Sciences

National Medical Association

Society for Public Health Education

U.S. Environmental Protection Agency

U.S. Food and Drug Administration

U.S. Public Health Service

National Asthma Education and Prevention Program Coordinating Committee Organizations

* Executive Committee Member
U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES

PUBLIC HEALT H SE RVICE

NATIONAL INSTITUTES O F HEALT H

National Heart, Lung, 

and Blood Institute

NIH PUBLICATION NO. 97-4053 

OC TOBER 1997

Practical Guide

for the 

Diagnosis and 

Management 

of Asthma

Based on the Expert Panel Report 2:

Guidelines for the Diagnosis and 

Management of Asthma
Contents

1.

2.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Practical and Effective Asthma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Asthma Care in the United States Can Be Improved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Airway Inflammation Plays a Central Role in Asthma and Its Management . . . . . . . . . . . . . . . . . . . . . . . . 1

Asthma Changes Over Time, Requiring Active Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Four Key Components for Long-Term Control of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Major Recommendations From the Expert Panel Report 2: Guidelines for the Diagnosis 

and Management of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Figure 1. Mechanisms Underlying the Definition of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Figure 2. Asthma Changes Over Time: Patient Monitoring and Followup Required . . . . . . . . . . . . . . . . . . 2

Initial Assessment and Diagnosis of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Diagnosis of Asthma in Adults and Children Over 5 Years of Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Diagnosis in Infants and Children Younger Than 5 Years of Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Additional Tests for Adults and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Patient Education After Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Assessment of Asthma Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

General Guidelines for Referral to an Asthma Specialist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Pharmacologic Therapy: Managing Asthma Long Term . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Establish the Goals of Asthma Therapy With the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

The Asthma Medications: Long-Term Control and Quick Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Inhaled Steroids: The Most Effective Long-Term-Control Medication for Asthma . . . . . . . . . . . . . . . . 8

Stepwise Approach to Managing Asthma in Adults and in Children Over 5 Years of Age . . . . . . . . . . . . . . 9

Gaining Control of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Maintaining Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Step Down Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Step Up Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Special Considerations for Infants, Children, and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Infants and Preschool Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

School-Age Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Inhaled Steroids and Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Action Plan for Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Managing Asthma in Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Managing Special Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Managing Exercise-Induced Bronchospasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Managing Seasonal Asthma Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Managing Asthma in Patients Undergoing Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Managing Asthma in Pregnant Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

ii
Figure 3. Classification of Asthma Severity: Clinical Features Before Treatment . . . . . . . . . . . . . . . . . . . .10

Figure 4. Stepwise Approach for Managing Asthma in Adults and Children 

Over 5 Years Old: Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Figure 5. Stepwise Approach for Managing Infants and Young Children (5 Years 

of Age and Younger) With Acute or Chronic Asthma Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Figure 6. Indicators of Poor Asthma Control—Consider Increasing Long-Term Medications . . . . . . . . . . .13

Figure 7. Assess Reasons for Poor Asthma Control Before Increasing Medications—ICE . . . . . . . . . . . . .13

Control of Factors Contributing to Asthma Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Patient Assessment and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Inhaled Allergens and Persistent Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Allergy Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Control Measures for Factors Contributing to Asthma Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Immunotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Figure 8. Allergen Control Significantly Improves Even Mild Asthma: An Illustrative Study 

with House-Dust Mites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Figure 9. Determining the Need for Allergen Control in Patients With Persistent Asthma . . . . . . . . . . . . . .18

Periodic Assessment and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Working Within the Time Constraints of the Typical Office Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Patient Self-Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Clinician Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Identify Patient Concerns and Expectations of the Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Assess Achievement of the Goals of Asthma Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Review Medications Usage and Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Education for a Partnership in Asthma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

How To Increase the Likelihood of Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 

Teach Use of Inhaler and Peak Flow Meter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Tips for Replacing Metered-Dose Inhalers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Figure 10. Example of Delivery of Asthma Education by Clinicians During Patient Care Visits . . . . . . . . .24

Figure 11. How Often To Change Long-Term-Control Canisters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

3.

4.

5.

iii
iv

Managing Asthma Exacerbations at Home, in the Emergency Department, 

and in the Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Home Management: Prompt Treatment Is Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Risk Factors for Death From Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Prehospital Emergency Medicine/Ambulance Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Emergency Department and Hospital Management of Exacerbations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Treat Without Delay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Repeat Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Special Considerations for Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Therapies Not Recommended for Treating Exacerbations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Hospital Asthma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Patient Discharge From the Emergency Department or Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Figure 12. Management of Asthma Exacerbations: Home Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Figure 13. Management of Asthma Exacerbations: Emergency Department and 

Hospital-Based Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Appendices

Dosages for Medications

Usual Dosages for Long-Term-Control Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Estimated Comparative Daily Dosages for Inhaled Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Dosages of Drugs for Asthma Exacerbations in Emergency Medical Care or Hospital . . . . . . . . . .39

Glossary

Asthma Long-Term-Control Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Asthma Quick-Relief Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Patient Handouts

What Everyone Should Know About Asthma Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

How To Control Things That Make Your Asthma Worse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

How To Use Your Metered-Dose Inhaler the Right Way . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

Asthma Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

School Self-Management Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

How To Use Your Peak Flow Meter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

Patient Self-Assessment Forms

Patient Self-Assessment Form for Environmental and Other Factors That Can Make Asthma Worse . .50

Patient Self-Assessment Form for Followup Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

6.
Practical and Effective 

Asthma Care

This Practical Guide for the Diagnosis and

Management of Asthma describes how primary care

clinicians can improve the asthma care they provide

within the time constraints of their current clinical

practice. More than 130 primary care professionals

reviewed this guide to help assure that it is relevant and

practical for primary care practitioners.

The recommendations in the Practical Guide are 

summarized from the National Asthma Education 

and Prevention Program, Expert Panel Report 2:

Guidelines for the Diagnosis and Management of

Asthma (EPR-2).1 See page 3 for a summary of some

major recommendations from EPR-2.

Asthma Care in the United States 

Can Be Improved

Undertreatment and inappropriate therapy are major

contributors to asthma morbidity and mortality in the

United States. A few examples of data that support this

assertion are presented below.

■ Hospitalizations due to asthma are preventable or

avoidable when patients receive appropriate primary

care.2

— Asthma is the third leading cause of preventable

hospitalizations in the United States.2

— There are about 470,000 hospitalizations and 

more than 5,000 deaths a year from asthma.

■ Studies from two metropolitan areas of children 

with asthma who used the emergency department3

and adults hospitalized with asthma4 found that:

— Less than half of these patients were receiving 

anti-inflammatory therapy as recommended in 

the EPR-2.1

— Only 28 percent of the adult patients hospitalized for asthma had written action plans that 

told how to manage their asthma and control 

an exacerbation.4

The Practical Guide will help clinicians improve the

asthma care they provide and reduce the hospitalizations and emergency department visits needed by their

patients.

Airway Inflammation Plays a Central Role

in Asthma and Its Management 

The management of asthma needs to be responsive to 

the characteristics that define asthma. The relationships between these characteristics are illustrated in 

figure 1.

■ Asthma is a chronic inflammatory disorder of

the airways. Many cells and cellular elements play

a role, in particular, mast cells, eosinophils, T-lymphocytes, macrophages, neutrophils, and epithelial

cells.

■ Environmental and other factors “cause” or

provoke the airway inflammation in people with

asthma. Examples of these factors include inhaled

allergens to which the patient is sensitive, some 

irritants, and viruses. This inflammation is always 

present to some degree, regardless of the level of 

asthma severity.

1

Introduction
■ Airway inflammation causes recurrent episodes

in asthma patients of wheezing, breathlessness, chest

tightness, and coughing, particularly at night and in the

early morning.

■ These episodes of asthma symptoms are usually

associated with widespread but variable airflow

obstruction that is often reversible either spontaneously or with treatment. Airflow obstruction is

caused by a variety of changes in the airway, including bronchoconstriction, airway edema, chronic

mucus plug formation, and airway remodeling.

■ Inflammation causes an associated increase in

the existing airway hyperresponsiveness to a variety of stimuli, such as allergens, irritants, cold air,

and viruses. These stimuli or precipitants result in 

airflow obstruction and asthma symptoms in the

patient with asthma.

Asthma Changes Over Time, 

Requiring Active Management

The condition of a patient’s asthma will change

depending on the environment, patient activities, 

management practices, and other factors (see figure 2).

Thus, even when patients have their asthma under 

control, monitoring and treatment are needed to 

maintain control.

Four Key Components for

Long-Term Control of Asthma

The four components of asthma therapy respond to the

basic nature of asthma described previously. The four 

components are listed below and will be described in

this guide.

References

In EPR-2, the Expert Panel cites the scientific literature

to support its recommendations or clearly indicates

they are “based on the opinion of the Expert Panel.”

The Panel submitted multiple drafts of EPR-2 for

review by more than 140 outside reviewers, including

members of the NAEPP Coordinating Committee.

This Practical Guide summarizes the recommendations

in EPR-2, provides practical information to aid the

implementation of those recommendations, and cites

selected references from EPR-2. For complete documentation of the recommendations, refer to EPR-2.

Copies of the full report can be accessed through the

Internet (http://www.nhlbi.nih.gov/nhlbi/lung/asthma/

prof/asthgdln.htm) or purchased from the NHLBI

Information Center, P.O. Box 30105, Bethesda, MD

20824-0105 (phone 301-251-1222; fax 301-251-1223).

This guide presents basic recommendations for the diagnosis and

management of asthma that will help clinicians and patients make

appropriate decisions about asthma care. Of course, the clinician

and patient need to develop an individual treatment plan that is 

tailored to the specific needs of the patient. This report is not an

official regulatory document of any Government agency.

2

Practical Guide for the Diagnosis and Management of Asthma

Figure 1.

Mechanisms Underlying the Definition of Asthma

Figure 2.

Asthma Changes Over Time: Patient Monitoring

and Followup Required

INFLAMMATION

Environmental risk factors (causes)

Airway

hyperresponsiveness

Airflow

obstruction

Precipitants

Symptoms

Date 4/22

Janie Doe Height 49” Patient’s Personal Best 280

200

PEF (L/min)

100

300

4/23 4/24 4/25 4/26 4/27 4/28 4/29 4/30 5/1 5/2 5/3 5/4

Visited

friend

with

cat Beta2-

agonist

Upper

respiratory

infection

Burst

of oral

steroids

Adapted with permission from Stephen T. Holgate, M.D., D.Sc.

Assessment and monitoring

Pharmacologic therapy

Control of factors contributing to asthma severity

Patient education for a partnership
3

Introduction

■ Diagnose asthma by establishing:

— A history of recurrent symptoms, 

— Reversible airflow obstruction using spirometry, and 

— The exclusion of alternative diagnoses.

■ Establish patient-clinician partnership.

— Address patient’s concerns.

— Agree upon the goals of asthma therapy.

— Agree upon a written action plan for patient self-management.

■ Prescribe anti-inflammatory medications to patients with mild, moderate, or

severe persistent asthma (i.e., inhaled steroids, cromolyn, or nedocromil).

■ Reduce exposures to precipitants of asthma symptoms.

— Assess patient’s exposure and sensitivity to individual precipitants 

(e.g., allergens, irritants).

— Provide written and verbal instructions on how to avoid or reduce factors that 

make the patient’s asthma worse.

■ Train all patients to monitor their asthma.

— All patients should monitor symptoms.

— Patients with moderate-to-severe persistent asthma should also monitor their 

peak flow.

■ See patients at least every 1 to 6 months

— Assess attainment of goals of asthma therapy and patient’s concerns, 

— Adjust treatment, if needed,

— Review the action plan with patient, and 

— Check patient’s inhaler and peak flow technique.

■ Prompt use of short-acting inhaled beta2-agonists and, if episode is moderate 

to severe, a 3- to 10-day course of oral steroids.

■ Prompt communication and followup with clinician.

Major Recommendations From the Expert Panel Report 2: Guidelines for the Diagnosis and

Management of Asthma1

Diagnose asthma and initiate partnership with patient.

Reduce inflammation, symptoms, and exacerbations.

Monitor and manage asthma over time.

Treat asthma episodes promptly.

Summary
4

Initial Assessment 

and Diagnosis 1. of Asthma

Diagnosis of Asthma in Adults 

and Children Over 5 Years of Age

Recurrent episodes of coughing or wheezing are

almost always due to asthma in both children

and adults. Cough can be the sole symptom.

Findings that increase the probability of asthma

include:

Medical history:

■ Episodic wheeze, chest tightness, shortness of 

breath, or cough.

■ Symptoms worsen in presence of aeroallergens, 

irritants, or exercise.

■ Symptoms occur or worsen at night, awakening 

the patient.

■ Patient has allergic rhinitis or atopic dermatitis.

■ Close relatives have asthma, allergy, sinusitis, or 

rhinitis.

Physical examination of the upper

respiratory tract, chest, and skin:

■ Hyperexpansion of the thorax

■ Sounds of wheezing during normal breathing or 

a prolonged phase of forced exhalation

■ Increased nasal secretions, mucosal swelling, 

sinusitis, rhinitis, or nasal polyps

■ Atopic dermatitis/eczema or other signs of allergic 

skin problems

Assessment and monitoring

Pharmacologic therapy

Control of factors contributing to asthma severity

Patient education for a partnership

▲

▲

To establish an asthma diagnosis, determine

the following:

1. History or presence of episodic symptoms of

airflow obstruction (i.e., wheeze, shortness of

breath, tightness in the chest, or cough). Asthma

symptoms vary throughout the day; absence of

symptoms at the time of the examination does not

exclude the diagnosis of asthma.

2. Airflow obstruction is at least partially

reversible. Use spirometry to:

Establish airflow obstruction: FEV1 <80 

percent predicted; FEV1/FVC* <65 percent or

below the lower limit of normal. (If obstruction is

absent, see Additional Tests, page 5.)

Establish reversibility: FEV1 increases _>12 percent and at least 200 mL after using a short-acting

inhaled beta2-agonist (e.g., albuterol, terbutaline). 

NOTE: Older adults may need to take oral steroids for 2 to 3

weeks and then take the spirometry test to measure the degree of

reversibility achieved. Chronic bronchitis and emphysema may

coexist with asthma in adults. The degree of reversibility indicates

the degree to which asthma therapy may be beneficial. 

3. Alternative diagnoses are excluded (e.g., vocal

cord dysfunction, vascular rings, foreign bodies, 

or other pulmonary diseases). See page 5 for 

additional tests that may be needed.

In general, FEV1 predicted norms or reference values

used for children should also be used for adolescents. 

*FEV1, forced expiratory volume in 1 second 

FVC, forced vital capacity
Initial Assessment and Diagnosis

5

Diagnosis in Infants and Children 

Younger Than 5 Years of Age

Because children with asthma are often 

mislabeled as having bronchiolitis, bronchitis,

or pneumonia, many do not receive adequate

therapy.

■ The diagnostic steps listed previously are the same for

this age group except that spirometry is not possible. 

A trial of asthma medications may aid in the eventual

diagnosis. 

■ Diagnosis is not needed to begin to treat wheezing

associated with an upper respiratory viral infection,

which is the most common precipitant of wheezing

in this age group. Patients should be monitored 

carefully. 

■ There are two general patterns of illness in infants and

children who have wheezing with acute viral upper respiratory infections: a remission of symptoms in the

preschool years and persistence of asthma throughout

childhood. The factors associated with continuing

asthma are allergies, a family history of asthma, and

perinatal exposure to aeroallergens and passive smoke.

Reasons for Additional Tests The Tests

■ Patient has symptoms but spirometry is normal or

near normal

■ Suspect infection, large airway lesions, 

heart disease, or obstruction by foreign object

■ Suspect coexisting chronic obstructive 

pulmonary disease, restrictive defect, 

or central airway obstruction

■ Suspect other factors contribute to asthma 

(These are not diagnostic tests for asthma.)

■ Assess diurnal variation of peak flow over 

1 to 2 weeks.

■ Refer to a specialist for bronchoprovocation with

methacholine, histamine, or exercise; negative test

may help rule out asthma.

■ Chest x-ray

■ Additional pulmonary function studies

■ Diffusing capacity test

■ Allergy tests—skin or in vitro

■ Nasal examination

■ Gastroesophageal reflux assessment

Additional tests may be needed when asthma is suspected but spirometry is normal, when coexisting conditions

are suspected, or for other reasons. 

These tests can aid diagnosis or confirm suspected 

contributors to asthma morbidity (e.g., allergens 

and irritants).

Additional Tests for Adults and Children
6

Practical Guide for the Diagnosis and Management of Asthma

Patient Education After Diagnosis 

Identify the concerns the patient has about being diagnosed with asthma by asking: “What worries you most

about having asthma? What concerns do you have

about your asthma?”

Address the patient’s concerns and make at least

these key points (see patient handout, “What Everyone

Should Know About Asthma Control”):

■ Asthma can be managed and the patient can live a

normal life.

■ Asthma can be controlled when the patient works

together with the medical staff. The patient plays a

big role in monitoring asthma, taking medications,

and avoiding things that can cause asthma episodes.

■ Asthma is a chronic lung disease characterized by

inflammation of the airways. There may be periods

when there are no symptoms, but the airways are

swollen and sensitive to some degree all of the time.

Long-term anti-inflammatory medications are important to control airway inflammation.

■ Many things in the home, school, work, or elsewhere can cause asthma attacks (e.g., secondhand

tobacco smoke, allergens, irritants). An asthma attack

(also called episodes, flareups, or exacerbations)

occurs when airways narrow, making it harder to

breathe. 

■ Asthma requires long-term care and monitoring.

Asthma cannot be cured, but it can be controlled.

Asthma can get better or worse over time and

requires treatment changes. 

Patient education should begin at the time of diagnosis

and continue at every visit.

Assessment of Asthma Severity

See figure 3 on page 10 to estimate the severity of

chronic asthma in patients of all age groups. These 

levels of severity correspond to the “steps” of 

pharmacologic therapy discussed later.

General Guidelines for Referral 

to an Asthma Specialist

Based on the opinion of the Expert Panel, referral

for consultation or care to a specialist in asthma care

is recommended if assistance is needed for:

■ Diagnosis and assessment (e.g., differential diagnosis is problematic, other conditions aggravate asthma,

or confirmation is needed on the contribution of

occupational or environmental exposures)

■ Specialized treatment and education (e.g., considering patient for immunotherapy or providing additional education for allergen avoidance)

■ Other cases:

— Patient is not meeting the goals of asthma 

therapy (defined in next section) after 3 to 6 

months. An earlier referral or consultation is 

appropriate if the physician concludes that the 

patient is unresponsive to therapy.

— Life-threatening asthma exacerbation occurred.

— Patient requires step 4 care (see figure 4 on 

page 11) or has used more than two bursts 

of oral steroids in 1 year. (Referral may be 

considered for patients requiring step 3 care.)

— Patient is younger than age 3 and requires step 3 

or 4 care. Referral should be considered for 

patients under age 3 who require step 2 care 

(see figure 5 on page 12).

An asthma specialist is usually a fellowship-trained

allergist or pulmonologist or, occasionally, a physician

with expertise in asthma management developed

through additional training and experience.

Patients with significant psychiatric, psychosocial, 

or family problems that interfere with their asthma

therapy should be referred to an appropriate mental

health professional for counseling or treatment.
7

Establish the Goals of Asthma 

Therapy With the Patient

The goals of asthma therapy provide the 

criteria that the clinician and patient will use 

to evaluate the patient’s response to therapy.

The goals will provide the focus for all subsequent interactions with the patient.

First, determine the patient’s personal goals of therapy by asking a few questions, such as: “What would

you like to be able to do that you can’t do now or can’t

do well because of your asthma?” “What would you

like to accomplish with your asthma treatment?”

Then, share the general goals of asthma therapy

with the patient and the family.

Finally, agree on the goals you and the patient will set 

as the foundation for the patient’s treatment plan.

The Asthma Medications: 

Long-Term Control and Quick Relief

■ Long-term-control asthma medications are taken

daily to achieve and maintain control of persistent asthma (for dosage information, see pages 

36-38). The most effective long-term-control medications for asthma are those that reduce inflammation. Inhaled steroids are the most potent inhaled

anti-inflammatory medication currently available

(see next page).

Inhaled steroids are generally well tolerated 

and safe at recommended doses. To reduce the

potential for adverse effects, patients taking

inhaled steroids should:

— Use a spacer/holding chamber. 

— Rinse and spit following inhalation.

— Use the lowest possible dose to maintain 

control. Consider adding a long-acting inhaled 

beta2-agonist to a low-to-medium dose of 

inhaled steroid rather than using a higher dose 

of inhaled steroid.17,18

■ Quick-relief medications are used to provide

prompt treatment of acute airflow obstruction

and its accompanying symptoms such as cough,

chest tightness, shortness of breath, and wheezing.

These medications include short-acting inhaled

beta2-agonists and oral steroids. Anticholinergics 

are included in special circumstances.

Pharmacologic

Therapy: Managing 2.Asthma Long Term

Assessment and monitoring

Pharmacologic therapy

Control of factors contributing to asthma severity

Patient education for a partnership

▲

▲

General Goals of Asthma Therapy

■ Prevent chronic asthma symptoms and asthma exacerbations during the day and night.

(Indicators: No sleep disruption by asthma. 

No missed school or work due to asthma. No or

minimal need for emergency department visits or

hospitalizations.)

■ Maintain normal activity levels—including 

exercise and other physical activities.

■ Have normal or near-normal lung function.

■ Be satisfied with the asthma care received.

■ Have no or minimal side effects while receiving 

optimal medications.
8

Practical Guide for the Diagnosis and Management of Asthma

Inhaled Steroids: The Most Effective Long-Term-Control Medication for Asthma

The daily use of inhaled steroids results in the following:5,6,10-16

■ Asthma symptoms will diminish. Improvement will continue gradually (see study 1).

■ Occurrence of severe exacerbations is greatly reduced.

■ Use of quick-relief medication decreases (see study 2).

■ Lung function improves significantly, as measured by peak flow, FEV1, and airway 

hyperresponsiveness.

Problems due to asthma may return if patients stop taking inhaled steroids.

Frequency of dosing 

Once-daily dosing with inhaled steroids for patients with mild asthma and twice-a-day dosing for many

other patients, even with high doses of some preparations, have been effective.

7-9

Study 1. 

Daily Inhaled Steroids Control Moderate Persistent

Asthma in Children 7 to 16 Years Old: Reduced

Symptomatic Days*

4

3

2

1

2 mo

IS

P

IS

P

IS

P

12 mo 22 mo 0

Study 2.

Inhaled Steroids Control Asthma in Adults: Significant

Reduction in Need for Quick-Relief Medicine*

No Steroids

21%

20

10

0

–10

–20

–30

–40

–50

–60

–70

Steroids

–70%

*Other endpoints—FEV1, peak flow, airway hyperresponsiveness, and symptoms—significantly improved relative to

the placebo group over 22 months of the children’s study (N=116)5 and over 2 years in the adult study (N=103).6

IS-Inhaled steroids

P- Placebo

Median Days With

Symptoms in Past 2 Weeks

Percentage Change in Beta2-Agonist Use 

After 12 Weeks

The effect of the inhaled steroids persisted during the 2 years of the study.
Pharmacologic Therapy: Managing Asthma Long Term

9

Stepwise Approach to Managing

Asthma in Adults and in

Children Over 5 Years of Age

All patients need to have a short-acting inhaled

beta2-agonist to take as needed for symptoms.

Patients with mild, moderate, or severe persistent asthma require daily long-term-control

medication to control their asthma. 

See figure 4 for the recommended pharmacologic 

therapy at each level of asthma severity and pages 36-

38 for dosage information. Also, see the glossary for

the brand names of the medications mentioned in 

this guide. 

Gaining Control of Asthma

The physician’s judgment of an individual patient’s

needs and circumstances will determine at what step to

initiate therapy. There are two appropriate approaches

to gaining control of asthma:

■ Start treatment at the step appropriate to the severity

of the patient’s asthma at the time of evaluation. 

If control is not achieved, gradually step up therapy

until control is achieved and maintained.

OR

■ At the onset, give therapy at a higher level to

achieve rapid control and then step down to the 

minimum therapy needed to maintain control. 

A higher level of therapy can be accomplished by

either adding a course of oral steroids to inhaled

steroids, cromolyn, or nedocromil or using a higher

dose of inhaled steroids.

■ In the opinion of the Expert Panel, the preferred

approach is to start with more intensive therapy

in order to more rapidly suppress airway inflammation and thus gain prompt control. 

If control is not achieved with initial therapy (e.g.,

within 1 month), the step selected, the therapy in the

step, and possibly the diagnosis should be reevaluated.

Maintaining Control 

Increases or decreases in medications may be needed as

asthma severity and control vary over time. The Expert

Panel’s opinion is that followup visits every 1 to 6

months are essential for monitoring asthma. In

addition, patients should be instructed to monitor their

symptoms (and peak flow if used) and adjust therapy as

described in the action plan (see Patient Handouts).

STEP DOWN THERAPY

Gradually reduce or “step down” long-term-control

medications after several weeks or months of controlling persistent asthma (i.e., the goals of asthma

therapy are achieved). In general, the last medication

added to the medical regimen should be the first medication reduced.

Inhaled steroids may be reduced about 25 percent

every 2 to 3 months until the lowest dose required to

maintain control is reached. For patients with persistent asthma, anti-inflammatory medications should be

continued. 

For patients who are taking oral steroids daily on a

long-term basis, referral for consultation or care by an

asthma specialist is recommended. Patients should be

closely monitored for adverse side effects. Continuous

attempts should be made to reduce daily use of oral

steroids when asthma is controlled: 

■ Maintain patients on the lowest possible dose of 

oral steroids (single dose daily or on alternate days).

■ Use high doses of inhaled steroids to eliminate or

reduce the need for oral steroids.
10

Practical Guide for the Diagnosis and Management of Asthma

STEP UP THERAPY

The presence of one or more indicators of poor

asthma control (see figure 6) may suggest a need to

increase or “step up” therapy. Before increasing 

therapy, alternative reasons for poorly controlled asthma

should be considered (see figure 7). Referral to a 

specialist for comanagement or consultation may be

appropriate.

The addition of a 3- to 10-day course of oral steroids

may be needed to reestablish control during a period

of gradual deterioration or a moderate-to-severe

exacerbation (see Managing Asthma Exacerbations,

page 26). If symptoms do not recur after the course of

steroids (and peak flow remains normal), the patient

should continue in the same step. However, if the

steroid course controls symptoms for less than 1 to 2

weeks, or if courses of steroids are repeated frequently,

the patient should move to the next higher step in 

therapy.

Special Considerations for

Infants, Children, and Adolescents

Infants and Preschool Children

Treatment of acute or chronic wheezing or cough should

follow the stepwise approach presented in figure 5. 

In general, physicians should do the following when

infants and young children consistently require treatment for symptoms more than two times per week:

■ Prescribe daily inhaled anti-inflammatory medication

(inhaled steroids, cromolyn, or nedocromil) as longterm-control asthma therapy. A trial of cromolyn 

or nedocromil is often given to patients with mild

persistent asthma.

■ Monitor the response to therapy carefully 

(e.g., frequency of symptoms over 2 to 4 weeks).

■ If benefits are sustained for at least 3 months, 

a step down in therapy should be attempted.

* Percent predicted values for forced expiratory volume in 1 second (FEV1) and percent of personal best for peak expiratory flow (PEF) (relevant for

children 6 years old or older who can use these devices).

NOTES:

■ Patients should be assigned to the most severe step in which any feature occurs. Clinical features for individual patients may overlap across steps. ■ An individual’s classification may change over time. ■ Patients at any level of severity of chronic asthma can have mild, moderate, or severe exacerbations of asthma. Some patients with intermittent 

asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. ■ Patients with two or more asthma exacerbations per week (i.e., progressively worsening symptoms that may last hours or days) tend to have 

moderate-to-severe persistent asthma.

Figure 3. 

Classification of Asthma Severity: Clinical Features Before Treatment

PEF or 

FEV1* 

Step 4

Severe 

Persistent

Step 3 

Moderate 

Persistent

Step 2

Mild 

Persistent

Step 1 

Mild 

Intermittent 

Continual

Daily

3-6/week 

≤2/week 

Frequent

≥5/month

3-4/month

≤2/month 

≤60%

>60%- <80%

≥80%

≥80%

Days With

Symptoms

Nights With

Symptoms PEF Variablity

>30%

>30%

20-30%

<20%
Pharmacologic Therapy: Managing Asthma Long Term

11

Figure 4.

Stepwise Approach for Managing Asthma in Adults and Children Over 5 Years Old: Treatment

Step Care: >5 

Years Old

Step 4 

Severe 

Persistent

Step 3 

Moderate

Persistent

Step 2 

Mild 

Persistent

Step 1 

Mild

Intermittent 

All Patients

Long-Term Control

Daily medications:

■ Anti-inflammatory: inhaled steroid (high dose)* AND

■ Long-acting bronchodilator: either long-acting inhaled beta2-agonist

(adult: 2 puffs q 12 hours; child: 1-2 puffs q 12 hours), sustained-release theophylline, 

or long-acting beta2-agonist tablets AND

■ Steroid tablets or syrup long term; make repeated attempts to reduce systemic steroid and maintain 

control with high-dose inhaled steroid.

Daily medication:

■ Either

—Anti-inflammatory: inhaled steroid (medium dose)*

OR

—Inhaled steroid (low-to-medium dose)* and add a long-acting bronchodilator, especially for nighttime 

symptoms: either long-acting inhaled beta2-agonist (adult: 2 puffs q 12 hours; child: 1-2 puffs q 12 hours),

sustained-release theophylline, or long-acting beta2-agonist tablets.

■ If needed

—Anti-inflammatory: inhaled steroids (medium-to-high dose)*

AND

—Long-acting bronchodilator, especially for nighttime symptoms; either long-acting inhaled beta2-agonist, 

sustained-release theophylline, or long-acting beta2-agonist tablets.

Daily medication:

■ Anti-inflammatory: either inhaled steroid (low dose)* or cromolyn (adult: 2-4 puffs tid-qid; child: 1-2 puffs

tid-qid) or nedocromil (adult: 2-4 puffs bid-qid; child: 1-2 puffs bid-qid) (children usually begin with a trial of

cromolyn or nedocromil).

■ Sustained-release theophylline to serum concentration of 5-15 mcg/mL is an alternative, but not preferred, 

therapy. Zafirlukast or zileuton may also be considered for those ≥12 years old, although their position in 

therapy is not fully established.

■ No daily medication needed.

Short-acting bronchodilator: inhaled beta2-agonist (2-4 puffs) as needed for symptoms. Intensity of treatment will

depend on severity of exacerbation.

Preferred treatments are in bold print.

Quick-Relief

*See Estimated Comparative Daily Dosages for Inhaled Steroids on page 38.

NOTES:

■ The stepwise approach presents general guidelines to assist clinical decisionmaking. Asthma is highly variable; clinicians should tailor medication plans to the needs of individual patients.

■ Gain control as quickly as possible. Either start with aggressive therapy (e.g., add a course of oral steroids or a higher dose of inhaled steroids to

the therapy that corresponds to the patient’s initial step of severity); or start at the step that corresponds to the patient’s initial severity and step up

treatment, if necessary. ■ Step down: Review treatment every 1 to 6 months. Gradually decrease treatment to the least medication necessary to maintain control.

■ Step up: If control is not maintained, consider step up. Inadequate control is indicated by increased use of short-acting beta2-agonists and in:

step 1 when patient uses a short-acting beta2-agonist more than two times a week; steps 2 and 3 when patient uses short-acting beta2-agonist on a

daily basis or more than three to four times in 1 day. But before stepping up: Review patient inhaler technique, compliance, and environmental

control (avoidance of allergens or other precipitant factors). 

■ A course of oral steroids may be needed at any time and at any step.

■ Patients with exercise-induced bronchospasm should take two to four puffs of an inhaled beta2-agonist 5 to 60 minutes before exercise.

■ Referral to an asthma specialist for consultation or comanagement is recommended if there is difficulty maintaining control or if the patient

requires step 4 care. Referral may be considered for step 3 care.

■ For a list of brand names, see glossary.
12

Practical Guide for the Diagnosis and Management of Asthma

Figure 5.

Stepwise Approach for Managing Infants and Young Children 

(5 Years of Age and Younger) With Acute or Chronic Asthma Symptoms

Step 4 

Severe 

Persistent

Step 3 

Moderate

Persistent

Step 2 

Mild 

Persistent

Step 1 

Mild 

Intermittent 

All Patients

Long-Term Control

■ Daily anti-inflammatory medication

— High-dose inhaled steroid* with spacer and face mask

— If needed, add oral steroids (2 mg/kg/day); reduce to lowest daily or alternate-day dose that 

stabilizes symptoms

■ Daily anti-inflammatory medication. Either:

— Medium-dose inhaled steroid* with spacer and face mask

Once control is established, consider:

— Lower medium-dose inhaled steroid* with spacer and face mask and nedocromil (1-2 puffs bid-qid)

OR

— Lower medium-dose inhaled steroid* with spacer and face mask and theophylline

(10 mg/kg/day up to 16 mg/kg/day for children ≥1 year of age, to a serum concentration of

5-15 mcg/mL)**

■ Daily anti-inflammatory medication. 

— Infants and young children usually begin with a trial of cromolyn (nebulizer is preferred—

1 ampule tid-qid; or MDI—1-2 puffs tid-qid) or nedocromil (MDI only—1-2 puffs bid-qid)

OR

— Low-dose inhaled steroid* with spacer and face mask

■ No daily medication needed.

Bronchodilator as needed for symptoms: Short-acting inhaled beta2-agonist by nebulizer (0.05 mg/kg in

2-3 cc of saline) or inhaler with face mask and spacer (2-4 puffs; for exacerbations, repeat q 20 minutes

for up to 1 hour) or oral beta2-agonist.

With viral respiratory infection, use short-acting inhaled beta2-agonist q 4 to 6 hours up to 24 hours

(longer with physician consult) but, in general, if repeated more than once every 6 weeks, consider moving to next step up. Consider oral steroids if the exacerbation is moderate to severe or at the onset of the

infection if the patient has a history of severe exacerbations.

Quick-Relief

* See Estimated Comparative Dosages for Inhaled Steroids on page 38.

** For children <1 year of age: usual max mg/kg/day = 0.2 (age in weeks) + 5.

NOTES:

■ The stepwise approach presents general guidelines to assist clinical decisionmaking. Asthma is highly variable; clinicians should tailor medication plans to the needs of individual patients.

■ Gain control as quickly as possible. Either start with aggressive therapy (e.g., add a course of oral steroids or a higher dose of inhaled

steroids to the therapy that corresponds to the patient’s initial step of severity); or start at the step that corresponds to the patient’s initial severi- ty and step up treatment, if necessary.

■ Step down. Review treatment every 1 to 6 months. If control is sustained for at least 3 months, a gradual stepwise reduction in treatment may

be possible.

■ Step up. If control is not achieved, consider step up. Inadequate control is indicated by increased use of short-acting beta2-agonists and in:

step 1 when patient uses a short-acting beta2-agonist more than two times a week; steps 2 and 3 when patient uses short-acting beta2-agonist on

a daily basis OR more than three to four times a day. But before stepping up: review patient inhaler technique, compliance, and environmental control (avoidance of allergens or other precipitant factors). 

■ A course of oral steroids (prednisolone) may be needed at any time and step.

■ Referral to an asthma specialist for consultation or comanagement is recommended for patients requiring step 3 or 4 care. Referral may be

considered for step 2 care.

■ For a list of brand names, see glossary.
Pharmacologic Therapy: Managing Asthma Long Term

13

■ If clear benefit is not observed, treatment should be

stopped. Alternative therapies or diagnoses should

be considered.

■ Consider oral steroids if an exacerbation caused by

a viral respiratory infection is moderate to severe. 

If the patient has a history of severe exacerbations,

consider steroids at the onset of the viral infection.

Medication delivery devices should be selected

according to the child’s ability to use them. Be

aware that the dose received can vary considerably

among delivery devices:

■ Children aged 2 or less—nebulizer therapy is preferred for administering cromolyn or high doses of

short-acting inhaled beta2-agonists. A metered-dose

inhaler (MDI) with a spacer/holding chamber that

has a face mask may be used to take inhaled

steroids.

■ Children 3 to 5 years of age—MDI plus spacer/ 

holding chamber may be used by many children 

of this age. If the desired therapeutic effects are not

achieved, a nebulizer or an MDI plus spacer/holding

chamber with a face mask may be required.

Spacers/holding chambers are devices that hold the

aerosol medication so the patient can inhale it easily.

This reduces the problem of coordinating the actuation

of the MDI with the inhalation. Spacers/holding chambers come in many different shapes. These devices are

not simply tubes that put space between the patient’s

mouth and the MDI. Examples of spacers/holding

chambers are illustrated in the box on page 14. 

Parents or caregivers need to be instructed in the proper use of appropriately sized face masks, spacers with

face masks, and holding chamber devices. Acceptable

use of the delivery device should be demonstrated in

the office before the patient leaves. The ability of

children to use the devices may vary widely.

Figure 6.

Indicators of Poor Asthma Control—Consider

Increasing Long-Term Medications*

Figure 7.

Assess Reasons for Poor Asthma Control

Before Increasing Medications—ICE

■ Inhaler technique Check patient’s technique.

■ Compliance Ask when and how much 

medication the patient is 

taking.

■ Environment Ask patient if something 

in his or her environment 

has changed.

Also consider:

■ Alternative Assess patient for 

diagnosis presence of concomitant 

upper respiratory disease 

or alternative diagnosis.

■ Awakened at night with symptoms

■ An urgent care visit

■ Patient has increased need for short-acting

inhaled beta2-agonists (excludes use for upper 

respiratory viral infections and exercise-induced 

bronchospasm) OR 

— At step 1: Used short-acting inhaled beta2-

agonists more than two times in a week

— At steps 2-3: Used short-acting inhaled 

beta2-agonists more than three to four 

times a day OR used this medication on a 

daily basis for a week or less 

— Patient used more than one canister of shortacting inhaled beta2-agonist in one month

* This may mean a temporary increase in anti-inflammatory 

medication to regain control or a “step up” in long-term 

therapy. This will depend on the frequency of the above events,

reasons for poor control (see figure 7), and the clinician’s 

judgment.
14

Practical Guide for the Diagnosis and Management of Asthma

School-Age Children and Adolescents

The pharmacologic management of school-age 

children and adolescents follows the same basic

principles as those for adults, but with special

consideration of growth, school, and social

development. 

■ Cromolyn or nedocromil is often tried first in

children with mild or moderate persistent asthma. This is because these medications are often

effective anti-inflammatory therapies and have no

known long-term systemic effects.

■ For children with severe persistent asthma, and

for many with moderate persistent asthma,

inhaled steroids are necessary for long-termcontrol therapy. Cromolyn and nedocromil 

do not provide adequate control for these patients. 

See stepwise approach to pharmacotherapy (figure 4

on page 11) for treatment recommendations.

INHALED STEROIDS AND GROWTH

The potential but small risk of adverse effects on

linear growth from the use of inhaled steroids is

well balanced by their efficacy. Poor asthma control

itself can result in retarded linear growth. Most studies

do not demonstrate a negative effect on growth with

dosages of 400 to 800 mcg a day of beclomethasone,21-23

although a few short-term studies have.24,25 Adverse

effects on linear growth appear to be dose dependent.

High doses of inhaled steroids have greater potential

for growth suppression, but less potential than the alternative of oral steroids. Some caution (e.g., monitoring

growth, stepping down therapy when possible) is suggested while this issue is studied further.

ACTION PLAN FOR SCHOOLS

The clinician should prepare a written action plan for

the student’s school that explains when medications

may be needed to treat episodes and to prevent exercise-induced bronchospasm. Recommendations to

limit exposures to offending allergens or irritants and

a written request for the child to carry quick-relief

medications at school could be helpful. When possible, schedule daily medications so they do not need

to be taken at school. (See patient handout, “School

Self-Management Plan”)

Managing Asthma in Older Adults

■ Make adjustments or avoid asthma medications that

can aggravate other conditions:

— Inhaled steroids. Give supplements of calcium 

(1,000 to 1,500 mg per day), vitamin D 

(400 units a day), and, where appropriate, 

estrogen replacement therapy, especially for 

women using high doses of inhaled steroids. 

— Oral steroids may provoke confusion, agitation,

and changes in glucose metabolism.

— Theophylline and epinephrine may exacerbate 

underlying heart conditions. Also, the risk of 

theophylline overdose may be higher because of 

reduced theophylline clearance in older patients.

Examples of Spacer/Holding Chamber Devices 
Pharmacologic Therapy: Managing Asthma Long Term

15

■ Inform patients about potential adverse effects 

on their asthma from medications used for other

conditions, for example:

— Aspirin and other oral nonsteroidal antiinflammatory medications (arthritis, pain relief)

— Nonselective beta-blockers (high blood 

pressure)

— Beta-blockers in some eye drops (glaucoma)

■ Chronic bronchitis and emphysema may coexist with

asthma. A 2- to 3-week trial with oral steroids can

help determine the presence of reversibility of airway obstruction and indicate the extent of potential

benefit from asthma therapy.

Managing Special Situations 

Managing Exercise-Induced Bronchospasm

Exercise-induced bronchospasm generally begins during exercise and reaches its peak 5 to 10 minutes after

stopping. The symptoms often spontaneously resolve

in another 20 to 30 minutes. 

A diagnosis of exercise-induced bronchospasm is 

suggested by a history of cough, shortness of breath,

chest pain or tightness, wheezing, or endurance problems during and after vigorous activity. The diagnosis

can be confirmed by an objective measure of the problem (i.e., a 15 percent decrease in peak flow or FEV1

between measurements taken before and after vigorous

activity at 5-minute intervals for 20 to 30 minutes.)

For the vast majority of patients, exercise-induced 

bronchospasm should not limit either participation or

success in vigorous activities. The following are the

recommended control measures:

■ Two to four puffs of short-acting beta2-agonist 

5 to 60 minutes before exercise, preferably as close

to the start of exercise as possible. The effects of

this pretreatment should last approximately 2 to 3

hours. A long-acting inhaled beta2-agonist taken at

least 30 minutes before exercise will last 10 to 12

hours.26 Cromolyn or nedocromil can also be used

before exercise with a duration of effect of 1 to 2

hours.

27-29

■ A 6- to 10-minute warmup period before exercise

may benefit patients who can tolerate continuous

exercise with minimal symptoms. The warmup may

preclude a need for repeated medications.

■ Increase in long-term-control medications, if

appropriate. If symptoms occur with usual activities or exercise, a step up in long-term-control 

therapy may be warranted. Long-term control of

asthma with anti-inflammatory medication (i.e.,

inhaled steroid, cromolyn, or nedocromil) can 

reduce the frequency and severity of exerciseinduced bronchospasm.30

Teachers and coaches need to be notified that a child

has exercise-induced bronchospasm. They should be

told that the child is able to participate in activities but

may need inhaled medication before activity. Athletes

should disclose the medications they use and adhere 

to standards set by the U.S. Olympic Committee.31

A complete, easy-to-use list of prohibited and approved

medications can be obtained from the U.S. Olympic

Committee’s Drug Control Hotline (1-800-233-0393).

Managing Seasonal Asthma Symptoms

■ During the allergy season: Use the stepwise

approach to the long-term management of asthma to

control symptoms.

■ Before the season: If symptoms during a season are

predictable, start daily anti-inflammatory therapy

(inhaled steroids, cromolyn, or nedocromil) just

before the anticipated onset of symptoms and 

continue this throughout the season. 
16

Practical Guide for the Diagnosis and Management of Asthma

Managing Asthma in Patients Undergoing

Surgery

■ Evaluate the patient’s asthma over the past 

6 months.

■ Improve lung function to predicted values before

surgery, possibly with a short course of oral steroids. 

■ Give patients who have received oral steroids for

longer than 2 weeks during the past 6 months 100

mg of hydrocortisone every 8 hours intravenously

during the surgical period. Reduce the dose rapidly

within 24 hours following surgery.

Managing Asthma in Pregnant Women

Management of asthma in pregnant women is essential and is achieved with basically the same treatment as for nonpregnant women. Poorly controlled

asthma during pregnancy can result in reduced oxygen

supply to the fetus, increased perinatal mortality,

increased prematurity, and low birth weight.32 There is

little to suggest an increased risk to the fetus for most

drugs used to treat asthma. 

Drugs or drug classes with potential risk to the fetus

include brompheniramine, epinephrine, and alphaadrenergic compounds (other than pseudoephedrine),33-35

decongestants (other than pseudoephedrine), antibiotics

(tetracycline, sulfonamides, and ciprofloxacine), live

virus vaccines, immunotherapy (initiation or increase 

in doses), and iodides.
17

Control of Factors 

Contributing to 3.Asthma Severity

Assessment and monitoring

Pharmacologic therapy

Control of factors contributing to asthma severity

Patient education for a partnership

▲

▲

Avoiding or controlling factors that contribute

to asthma severity will reduce symptoms 

and the need for medications. (See figure 8).

Patient Assessment and Education

Have each patient complete the “Patient SelfAssessment Form for Environmental and Other

Factors That Can Make Asthma Worse” to assess

exposures and identify factors that may contribute to

asthma severity. 

Educate patients in how to reduce their exposures to

these factors (see patient handout, “How To Control

Things That Make Your Asthma Worse,” and box on

page 19). Confirm suspected occupational exposures by

having the patient record over 2 to 3 weeks symptoms,

exposures, bronchodilator use, and peak flow at and away

from work.

Inhaled Allergens and Persistent Asthma

To reduce the effects of specific allergens on a patient

with persistent asthma (see figure 9):

■ Identify the specific allergens to which patient is

exposed (use “Patient Self- Assessment Form for

Environmental and Other Factors That Can Make

Asthma Worse”).

■ Determine and confirm sensitivity to the 

allergens (skin or in vitro tests, medical history).

■ Obtain agreement with the patient to initiate one

or two simple control measures (see patient handout, “How To Control Things That Make Your

Asthma Worse,” and box on page 19).

40

50 Wheezing

30

20

10

Treatment

0

Control

Medication use

Peak flow drops below 80% predicted

and car e

Many studies support the effectiveness of allergen control in

improving asthma and reducing the need for medication.36-39

The controlled study of 20 children with mild asthma and housedust mite allergy illustrates the effect control measures can have.39

■ Major components of treatment used in the study:

— Encased pillows, mattresses, and box springs in 

allergen-impermeable covers.

— Washed blankets and mattress pads every 2 weeks 

in hot water.

— Removed toys, upholstered furniture, and carpets 

from bedroom.

■ After 1 month, the treatment group had:

— Symptom days and days needing medicine 

significantly reduced to a minimal number 

— Airway hyperresponsiveness reduced significantly 

relative to the control group.

Allergen Control Significantly Improves Even Mild Asthma: An Illustrative Study With House-Dust Mites

Figure 8.

Percentage of days (± standard error) in which wheezing was noticed, 

medication was used, or peak flow dropped below 80% predicted.39

Reproduced with permission. Percentage of Days 
18

Practical Guide for the Diagnosis and Management of Asthma

■ Follow up with patient, adding control measures

after first ones are implemented. 

Let the patient know that the benefits of many control

measures will take some time to be felt. For dust-mite

control it can take less than a month, whereas the benefits from removing an animal from the home may take

6 months or longer to become apparent. This is how

long it may take before all the dander is out of the 

environment. 

Allergy Testing

Skin or in vitro (e.g., RAST) tests are alternative

methods to assess the sensitivity to the year-round

allergens to which patients with persistent asthma

are exposed (i.e., animal, house-dust mite, cockroach,

or indoor mold allergens). Allergy testing is the only

reliable way to determine sensitivity to year-round

indoor allergens40,41 and is important for justifying the

expense and effort involved in implementing environmental controls. Allergy tests also reinforce for the

patients the need to take environmental control measures. Whether skin or in vitro tests are used will probably depend on whether the physician is knowledgeable

about skin testing technique. 

Order tests only for those substances to which you

have determined the patient is exposed (i.e., do not

order a panel of tests). When allergy tests are positive, ask patients about the onset of symptoms when

they are in contact with the allergen. Positive

answers to these questions confirm the likelihood that

the allergy is contributing to asthma symptoms. However, lack of a positive response to these questions does

not exclude the possibility that the allergen may be

contributing to the patient’s symptoms.

Figure 9.

Determining the Need for Allergen Control in Patients With Persistent Asthma

Year-Round Symptoms

Determine exposure to:

• Warm-blooded animals

• Cockroaches

• Indoor molds

• House-dust mites

(assume present in all but arid regions)

Confirm exposure leads to symptoms.

(e.g., Do symptoms increase after

vacuuming? See text.)

Plan allergen control with patient.

Yes No

Positive Negative

No year-round allergen

control may be needed.

Perform skin or in vitro tests

for each type allergen exposure.

Seasonal Symptoms

Identify allergen by season:

• Early spring → tree pollens

• Late spring → grass pollens

• Late summer to autumn → weed pollens

• Summer and fall → Alternaria or 

Cladosporium (outdoor mold)

Plan ways to control asthma during

season.
19

■ For animals and dust mites: “Do nasal, eye, or

chest symptoms occur in a room where carpets are

being or have just been vacuumed?”

■ For indoor mold: “Do nasal, eye, or chest symptoms appear when in damp or moldy rooms, such as

basements?”

Immunotherapy

In the opinion of the Expert Panel and based on the evidence,42-46 allergen immunotherapy may be considered

for asthma patients when (1) there is clear evidence of a

relationship between symptoms and exposure to an

unavoidable allergen to which the patient is sensitive,

(2) symptoms occur all year or during a major portion

of the year, and (3) there is difficulty controlling symptoms with pharmacologic management because multiple medications are required or medications are ineffective or not accepted by the patient. The course of allergen immunotherapy is typically of 3 to 5 years’ duration. If use of allergen immunotherapy is elected, it

should be administered only in a medical office where

facilities and trained personnel are available to treat any

life-threatening reaction that can, but rarely does,

occur.

47,48 In the Expert Panel’s opinion, referral to an

allergist should be made when patients are being considered for immunotherapy.

See patient handout, “How To Control Things That Make Your Asthma Worse.” 

Strongly advise patient and others living in the home to stop smoking. Discuss ways 

to reduce exposure to other sources of tobacco smoke, such as from day care providers

and the workplace.

Intranasal steroids. Antihistamine/decongestant combinations may also be used.

Medical measures to promote drainage. Antibiotic therapy is appropriate when 

complicating acute bacterial infection is present.

No eating within 3 hours of bedtime, head of bed elevated 6 to 8 inches, and 

appropriate medications (e.g., H2-antagonist).

No eating of shrimp, dried fruit, processed potatoes. No drinking of beer or wine.

No beta-blockers (including ophthalmological preparations).

Aspirin and other nonsteroidal anti-inflammatory medications. Inform adult patients

with severe persistent asthma, nasal polyps, or a history of aspirin sensitivity about the

risk of severe and even fatal episodes from using these drugs. Usually safe alternatives

are acetaminophen or salsalate.

Discuss with asthma patients the importance of avoidance, ventilation, respiratory 

protection, and a tobacco smoke-free environment. If occupationally induced asthma, 

recommend complete cessation of exposure to initiating agent. Obtain permission

from patient before contacting management or onsite health professionals about workplace exposure.

Annual influenza vaccinations should be given to patients with persistent asthma.

Control Measures for Factors Contributing to Asthma Severity

Factors Contributing to 

Asthma Severity Control Measures: Instructions to Patients

Allergens

Tobacco smoke

Rhinitis

Sinusitis

Gastroesophageal reflux

Sulfite sensitivity

Medication interactions

Occupational exposures

Viral respiratory infections

Control Measures 

Control of Factors Contributing to Asthma Severity
20

Periodic clinical assessments every 1 to 6

months and patient self-monitoring are 

essential for asthma care because: 

■ Asthma symptoms and severity change, requiring

changes in therapy.

■ Patients’ exposure to precipitants of asthma will

change.

■ Patients’ memories and self-management practices

fade with time. Reinforcement, review, and

reminders are needed.

The frequency of patient visits depends on the severity

of the asthma and the patient’s ability to control and

monitor symptoms. The first followup visit usually

needs to be sooner than 1 month.

Working Within the Time Constraints 

of the Typical Office Visit

Each physician develops his or her own way of accomplishing the periodic assessment and patient education

(see box on page 21 for an example). Here are ways

some primary care physicians have been able to perform the recommended periodic assessment and patient

education within the time constraints of routine office

visits:

■ Give patients an assessment questionnaire to

complete in the waiting room. The answers to

these questions determine the issues to be addressed

during that visit. See “Patient Self-Assessment

Form for Followup Visits” on page 50 for such an

assessment questionnaire. This helps set priorities 

to be addressed.

■ Have patients come back to the office more often,

especially at the beginning. Break the assessment

and education the patient needs into segments and

perform these over a number of visits. For example,

after the diagnosis of asthma, a patient could be

given the “Patient Self-Assessment Form for

Environmental and Other Factors That Can Make

Asthma Worse” to be completed at home. A visit in

a week or so could be set to review the form and

your recommendations to the patient. Similarly, initial education on the use of a peak flow meter and

action plan might be scheduled for a separate visit.

An example of how the necessary patient education

can be divided and conducted across visits is outlined in figure 10 on page 24. Review this and make

adjustments, as needed, for your own practice.

■ Use nurses or office staff to do some of the tasks,

like checking MDI technique.

■ Some managed care organizations have a home case

manager to do followup assessments and education.

Periodic Assessment 4.and Monitoring

Assessment and monitoring

Pharmacologic therapy

Control of factors contributing to asthma severity

Patient education for a partnership
21

Patient Self-Monitoring

All patients should be taught to recognize symptoms

and what to do when symptoms occur (see patient

handout, “Asthma Action Plan”). Review the information in the Asthma Action Plan often, optimally at each

office visit.

Long-term daily peak flow monitoring is recommended for those with moderate or severe persistent

asthma or patients with a history of severe exacerbations. If long-term daily peak flow monitoring is not

used by these patients, short-term monitoring (2 to 3

weeks) can be used to evaluate the severity of exacerbations to guide treatment decisions, evaluate response to

changes in long-term treatment, and identify environmental or occupational exposures. 

Educate patients on how to use the peak flow meter to

help monitor and manage their asthma (see patient handout, “How To Use Your Peak Flow Meter,” for details).

Ask patients to demonstrate the use of their peak flow 

meter at every visit and use the reading as part of the

clinical assessment. This will take less than a minute and

should become a routine component of the clinic visit. 

Specific recommendations regarding peak flow 

monitoring include:

■ Use the patient’s own personal best peak flow 

(see patient handout, “How To Use Your Peak Flow

Meter”) as the standard against which peak flow 

measurements should be compared.

■ Use the same peak flow meter and, when needed,

replace with same brand.

■ Measure peak flow first thing in the morning 

before medications.

■ A drop in peak flow below 80 percent of personal 

best indicates a need for added medications.

■ A drop in peak flow below 50 percent of personal 

best indicates a severe exacerbation.

How I Organized My Visits To Accomplish the Periodic Assessment and Patient Education

■ My staff gives asthma patients a self-assessment form to complete in the 

waiting room.

■ My nurse evaluates the patients’ inhaler technique and checks their peak 

flow before they see me. 

■ I am then able to direct my care to the patients’ and families’ concerns,

problems in achieving the goals of therapy, medication issues, and other

concerns I may identify with open-ended questions.

I feel my office has been very successful with this organized approach to the asthma office visit. It obviously

required energy to organize the system and practice on the part of myself and my staff to make it work. But the 

routine periodic assessment and patient education needed for good asthma care are doable in the typical office visit.

Stuart Stoloff, MD

Private Family Practice

Carson City, Nevada

Periodic Assessment and Monitoring

Spirometry and Peak Flow Measurement at Office Visits

The Expert Panel recommends that spirometry tests be done (1) at the initial assessment, (2) after treatment has stabilized 

symptoms and peak flow (to document a baseline of “normal” airway function), and (3) at least every 1 to 2 years when asthma

is stable, more often when asthma is unstable, or at other times the clinician believes it is needed.
22

Practical Guide for the Diagnosis and Management of Asthma

Clinician Assessment

At each visit, (1) identify patient’s concerns about

asthma and expectations for the visit, (2) assess

achievement of the patient’s goals and the general

goals of asthma therapy, (3) review medications

usage, and (4) teach and reinforce patient’s self-management activities (the latter is addressed in the next

chapter on “Education for a Partnership in Asthma

Care”). These four activities can be achieved within 

the time constraints of routine medical visits, particularly

when the patient completes the “Patient Self-Assessment

Form for Followup Visits” in the waiting room.

Identify Patient Concerns and 

Expectations of the Visit

Review the self-assessment questionnaire and 

address the patient’s concerns during the visit. 

Assess Achievement of the Goals of 

Asthma Therapy

If the patient is not meeting the following goals of 

asthma therapy, assess the reasons (see figure 7 on page

13) and consider increasing the patient’s medications.

Prevent chronic asthma symptoms and asthma

exacerbations during the day and night.

■ Perform physical examination 

(respiratory tract).

■ Review patient’s symptom history at each visit:

—Daytime symptoms in the past 2 weeks

—Nighttime symptoms in the past 2 weeks

—Symptoms while exercising

—Cause(s) of the symptoms

—What the patient did to control the symptoms

■ Use of quick-relief medications:

—Number of times short-acting inhaled 

beta2-agonists are used per week

—Number of short-acting inhaled beta2-agonist 

inhalers used in past month

■ Emergency or hospital care.

■ Missed any work or school due to asthma.

Maintain normal activity levels—including 

exercise and other physical activities.

■ Reduction in usual activities or exercise.

■ Disruption of caregivers’ or parents’ routine by 

their child’s asthma.

Have normal or near-normal lung function.

■ Objective measure of lung function—either 

spirometry or peak flow at each visit (see box 

on page 21).

■ Number of times peak flow went below 

80 percent personal best in past 2 weeks, 

if peak flow monitoring is performed.

Be satisfied with the asthma care received and the 

level of control—ask patient about this.

Have no or minimal side effects—shakiness, nervousness, bad taste, sore throat, cough, upset 

stomach—while receiving optimal medications.

Review Medications Usage and Skills

■ Ask patients to review for you what medications they

are taking, when they take them, and how often.

■ Identify any problems patients have had taking medications as prescribed (e.g., missed doses). Note:

Patients should bring all of their medications to each

office visit.

■ Ask patients to demonstrate their use of a placebo

inhaler at each followup visit. Assess their performance using the checklist in the patient handout (see

patient handout, “How To Use Your Metered-Dose

Inhaler the Right Way”). Ask patients to demonstrate use of their peak flow meter, if used.
23

The goal of all patient education is to help

patients take the actions needed to control

their asthma.

These actions are listed below and are described more

fully in the patient handouts. See figure 10 on page 24

for an example of how to address these issues during

routine office visits.

■ Taking daily medications for long-term control as

prescribed

■ Using delivery devices effectively—metereddose inhalers, spacers, nebulizers

■ Identifying and controlling factors that make 

asthma worse

■ Monitoring peak flow and/or symptoms

■ Following the written action plan when 

symptoms or episodes occur

How To Increase the 

Likelihood of Compliance

Patients cannot be expected to perform a task they

never agreed to do or one that is only mentioned once

to them. Thus, two essential clinician activities for successful patient education are:

1. Asking the patient for a verbal, sometimes written, agreement to take specific action(s). You will

need to explain the recommended action(s) and the

benefits the patient can expect from doing them.

2. Following up and reinforcing the patient for the

actions during subsequent visits or phone calls.

Other ways to increase compliance are: 

■ Develop an Asthma Action Plan with the patient

(see patient handout). Involve adolescents and

school-age children in developing their plan, as

appropriate. Minimize the number of medications

and daily doses to the fewest clinically possible.

Give parents additional copies of the plan to give to

day care providers and schools. 

■ Fit the daily medication regimen into the

patient’s and family’s routine. Explain the difference between long-term-control and quick-relief

medicines and how to use them. Ask patients (and

parents) when would be the easiest times for them to

take their daily medicines.

■ Identify and address obstacles and concerns. Ask

patients about problems they think they might

have doing the recommended action(s). Ask questions that start with “what” or “how” to identify the

obstacles (e.g., “What are things that might make it

hard for you to take the action each day?”). 

Discuss ways to address the problems or provide

alternative actions.

■ Ask for agreement/plans to act. Ask patients to

summarize what recommended action(s) they plan to

take, especially at the end of each visit. 

■ Encourage or enlist family involvement.

■ Follow up. At each visit, review the performance

of the agreed-upon actions. Praise appropriate

actions and discuss how to improve other actions.

Share evidence of the patient’s improvement in lung

function and symptoms. Remain encouraging when

patients do not take the agreed-upon actions. 

Education for a

Partnership in 5.Asthma Care

Assessment and monitoring

Pharmacologic therapy

Control of factors contributing to asthma severity

Patient education for a partnership ▲
24

Practical Guide for the Diagnosis and Management of Asthma

Recommendations for Initial Visit

Assessment Questions Teach information in simple language Teach and demonstrate skills

Focus on: ■ Concerns ■ Goals of Therapy

■ Quality of Life ■ Expectations

“What worries you most about your 

asthma?”

“What do you want to accomplish at 

this visit?”

“What do you want to be able to do that 

you can’t do now because of your 

asthma?”

“What do you expect from treatment?”

“What medicines have you tried?”

“What other questions do you have for 

me today?”

What is asthma? A chronic lung disease.

The airways are very sensitive. They

become inflamed and narrow; breathing

becomes difficult.

Two types of medicines are needed:

■ Long-term control: medications that 

prevent symptoms, often by reducing

inflammation

■ Quick relief: short-acting bronchodilator

relaxes muscles around airways

Bring all medications to every appointment.

When to seek medical advice. Provide

appropriate telephone number.

Inhaler (see patient handout) and spacer/

holding chamber use. Check performance.

Self-monitoring skills tied to action plan:

■ Recognize intensity and frequency of

asthma symptoms

■ Review the signs of deterioration and the

need to reevaluate therapy:

— Waking at night with asthma

— Increased medication use

— Decreased activity tolerance

Use of an action plan (see patient handout)

Recommendations for First Followup Visit (2 to 4 weeks or sooner as needed)

Ask relevant questions from previous visit

and also ask:

“What medications are you taking?”

“How and when are you taking them?”

“What problems have you had using 

your medications?”

“Please show me how you use your 

inhaled medications.”

Use of two types of medications. Remind

patient to bring all medications and the peak

flow meter to every appointment for review.

Self-evaluation of progress in asthma control using symptoms and peak flow as a

guide.

Use of an action plan. Review and adjust as

needed.

Peak flow monitoring (see patient handout)

and daily diary recording.

Correct inhaler and spacer/holding chamber

technique.

Figure 10.

Example of Delivery of Asthma Education by Clinicians During Patient Care Visits

Ask relevant questions from previous visits

and also ask:

“How have you tried to control things 

that make your asthma worse?”

“Please show me how you use your 

inhaled medication.”

Review and reinforce all:

■ Educational messages

■ Environmental control strategies at

home, work, or school

■ Medications

Review and interpret peak flow and symptom scores from daily diary. 

Inhaler/spacer/holding chamber 

technique.

Peak flow monitoring technique.

Review use of action plan. Confirm that

patient knows what to do if asthma gets

worse. Periodically review and adjust 

written action plan.

Recommendations for Second Followup Visit

Recommendations for All Subsequent Visits

Ask relevant questions from previous visits

and also ask:

“Have you noticed anything in your 

home, work, or school that makes 

your asthma worse?”

“Describe for me how you know when 

to call your doctor or go to the hospital for asthma care.”

“What questions do you have about the 

action plan?” “Can we make it easier?”

“Are your medications causing you any 

problems?”

Relevant environmental control/avoidance

strategies (see patient handout).

■ How to identify and control home, work,

or school exposures that can cause or

worsen asthma

■ How to avoid cigarette smoke (active

and passive)

Review all medications and review and

interpret peak flow and symptom scores

from daily diary 

Inhaler/spacer/holding chamber 

technique.

Peak flow monitoring technique.

Review use of action plan. Confirm that

patient knows what to do if asthma gets

worse.
Education for a Partnership in Asthma Care

25

MDI Replacement

■ Assess the influence of the patient’s cultural

beliefs and practices that might affect asthma

care. Ask open-ended questions (e.g., “What

will your friends and family think when you tell

them you have asthma? What advice might they

give to you?”) If harmless or potentially beneficial folk remedies are mentioned by the patients,

consider incorporating them into the treatment

plan. 

Teach Use of Inhaler and Peak Flow Meter

Most patients use their inhalers incorrectly, and this skill

deteriorates over time. Patients’ poor technique results

in less medication getting to the airways. The initial

inhaler training can be done in minutes with the simple

skills-training method described below. Note that different inhalers may require different inhalation techniques.

The necessary reviews at each visit are quick and easy

and can be done by other staff members in the office. 

Effective skills-training steps for teaching inhaler

techniques are as follows:

1. Tell the patient the steps and give written instructions. (For written instructions, see patient handouts.)

2. Demonstrate how to use the inhaler following each

of these steps.

3. Ask the patient to demonstrate how to use the

inhaler. Let the patient refer to the handout on the

first training. Subsequently, use the handout as a

checklist to assess the patient’s technique.

4. Tell patients what they did right and what they need

to improve. Have them demonstrate their technique

again, if needed. Focus the patient on improving

one or two key steps (e.g., timing of actuation and

inhalation) if the patient made multiple errors.

At each subsequent visit, perform the last two steps:

patient demonstration and telling what they did right

and what they need to improve. Train patients to use

their peak flow meter using the same four skills-training

steps above and the patient handout, “How To Use Your

Peak Flow Meter.”

Tips for Replacing Metered-Dose Inhalers

The only reliable way to determine whether a

metered-dose inhaler is empty is to count the number

of puffs used and subtract that number from the

total number of sprays in the canister. Unfortunately,

many patients believe they know when their inhalers are

empty by floating the canister, spraying into the air, or

tasting the medicine. 

Clinicians and pharmacists can help patients determine

the life of their long-term-control canisters by referring

to the chart in figure 11 (“How Often To Change LongTerm-Control Canisters”) or by dividing the number of

sprays per canister (written on the canister and listed in

the dosage chart on page 36) by the number of puffs

prescribed per day. Determine the corresponding

calendar date. Make an appointment before that date or

make refills available after that date.

Figure 11.

How Often To Change Long-Term-Control Canisters

# Sprays 2 Sprays/Day 4 Sprays/Day 6 Sprays/Day 8 Sprays/Day 9 Sprays/Day 12 Sprays/Day 16 Sprays/Day

60 30 days 15 days n/a n/a n/a n/a n/a

100 n/a 25 days 16 days 12 days n/a n/a n/a

104 n/a 26 days 17 days 13 days n/a n/a n/a

112 n/a 28 days 18 days 14 days n/a n/a n/a

120 60 days 30 days 20 days 15 days n/a n/a n/a

200 n/a 50 days 33 days 25 days 22 days 16 days 12 days

240 n/a 60 days 40 days 30 days 26 days 20 days 15 days

* If the medication is taken as prescribed, the canister should be discarded as indicated above. Otherwise, the remaining puffs 

may not contain sufficient medication.
Home Management: 

Prompt Treatment Is Key

Educating patients to recognize and treat

exacerbations early is the best strategy.

Education and preparation of patients to manage their 

exacerbations* are essential and should include:

■ A written action plan and clear instructions on how

to follow it. (See patient handout, “Asthma Action

Plan,” and figure 12).

■ Instructions on how to recognize signs of worsening

asthma and signs that indicate the need to call the

doctor or seek emergency care.

■ Prompt use of short-acting beta2-agonists 

(two puffs every 20 minutes for 1 hour) and, for

moderate-to-severe exacerbations, the addition of 

oral steroids. Increased therapy should be maintained for several days to stabilize symptoms and

peak flow.

■ Monitoring the response to the medications.

■ Followup with patients to assess overall asthma 

control, the need to increase long-term-control medications, and the need to remove or withdraw from

allergens or irritants that precipitated the exacerbation.

Patients at high risk of asthma-related death

(see box below) require special attention—intensive

education, monitoring, and care. They should be counseled to seek medical care early during an exacerbation

and instructed about when and how to call for an ambulance. Patients with moderate-to-severe persistent asthma or a history of severe exacerbations should have the

medication (e.g., steroid tablets or liquid) and equipment

(e.g., peak flow meter, compressor-driven nebulizer for

young children) for assessing and treating exacerbations

at home.

Managing Asthma

Exacerbations at Home, 

in the Emergency Department, 6.and in the Hospital

Assessment and monitoring

Pharmacologic therapy

Control of factors contributing to asthma severity

Patient education for a partnership

26

* Asthma exacerbations are episodes of progressively worsening shortness of

breath, cough, wheezing, chest tightness, or some combination of these

symptoms.

Risk Factors for Death From Asthma

History of Severe Exacerbations

■ Past history of sudden severe exacerbations

■ Prior intubation for asthma

■ Prior admission for asthma to an intensive care unit

Asthma Hospitalizations and Emergency Visits

■ ≥ 2 hospitalizations in the past year

■ ≥ 3 emergency care visits in the past year

■ Hospitalization or emergency visit in past month

Beta2-Agonist and Oral Steroid Usage

■ Use of >2 canisters per month of short-acting

inhaled beta2-agonist

■ Current use of oral steroids or recent 

withdrawal from oral steroids

Complicating Health Problems

■ Comorbidity (e.g., cardiovascular diseases or

COPD)

■ Serious psychiatric disease, including depression, 

or psychosocial problems

■ Illicit drug use

Other Factors

■ Poor perception of airflow obstruction or its severity

■ Sensitivity to Alternaria (an outdoor mold)

■ Low socioeconomic status and urban residence

Sources: See references 19, 49-52.
27

Assess Symptoms/Peak Flow*

( g ), g

Mild-to-Moderate Exacerbation

PEF 50-80% predicted or personal best

or 

Signs and Symptoms:

• Cough, breathlessness, wheeze, or chest

 tightness (correlate imperfectly with severity 

 of exacerbation), or

• Waking at night due to asthma, or

• Decreased ability to perform usual activities

Good Response (Mild Exacerbation)

PEF >80% predicted or personal best

and/or

Signs and Symptoms:

• No wheezing, shortness of breath, cough,

 or chest tightness, and

• Response to beta2-agonist sustained for 

 4 hours

Incomplete Response (Moderate

Exacerbation)

PEF 50-80% predicted or personal best

or

Signs and Symptoms:

Persistent wheezing, shortness of breath, 

cough, or chest tightness

Poor Response (Severe Exacerbation)

PEF <50% predicted or personal best

or

Signs and Symptoms:

• Marked wheezing, shortness of breath,

 cough, or chest tightness

• Distress is severe and nonresponsive

• Response to beta2-agonist lasts <2 hours

Severe Exacerbation

PEF <50% predicted or personal best

or

Signs and Symptoms:

• Marked wheezing and shortness of breath

• Cyanosis

• Trouble walking or talking due to asthma

• Accessory muscle use

• Suprasternal retractions

Instructions to Patient

Inhaled short-acting beta2-agonist:

• Up to three treatments of 2-4 puffs by MDI

 at 20-minute intervals, or

• Single nebulizer treatment

Assess symptoms and/or peak flow after 1 hour

Instructions to Patient

• May continue 2-4 puffs beta2-agonist every 

 3-4 hours for 24-48 hours prn

• For patients on inhaled steroids, double

 dose for 7-10 days

• Contact clinician within 48 hours for

 instructions

* Patients at high risk for asthma-related death (see box on page 26) should receive immediate clinical attention after initial treatment. More intensive therapy 

may be required.

** Oral steroid dosages: 

 Adult: 40-60 mg, single or 2 divided doses for 3-10 days.

 Child: 1-2 mg/kg/day, maximum 60 mg/day, for 3-10 days

Instructions to Patient

• Take 2-4 puffs beta2-agonist every 2-4 hours

 for 24-48 hours prn

• Add oral steroid**

• Contact clinician urgently (same day) 

 for instructions

Instructions to Patient

IMMEDIATELY:

• Take up to 3 treatments of 4-6 puffs 

beta2-agonist every 20 minutes prn 

• Start oral steroid**

• Contact clinician

• Proceed to emergency department, or

 call ambulance or 9-1-1

Figure 12.

Management of Asthma Exacerbations: Home Treatment

Give patients the Asthma Action Plan (page 45), which corresponds to this figure.

Managing Asthma Exacerbations at Home, in the Emergency Department, and in the Hospital

Home 

Treatment
28

Practical Guide for the Diagnosis and Management of Asthma

Prehospital Emergency

Medicine/Ambulance Management

It is recommended that emergency workers administer short-acting inhaled beta2-agonists and supplemental oxygen to patients who have signs or symptoms of asthma.53 Subcutaneous epinephrine or terbutaline are NOT recommended but can be used if inhaled

medication is not available (see dosage information on

page 39).

Emergency Department and Hospital

Management of Exacerbations

Treat Without Delay

Assess patient’s peak flow or FEV1 and administer

medication(s) upon patient’s arrival without delay.

After therapy is initiated, obtain a brief, focused history

and physical examination pertinent to the exacerbation.

Perform a more detailed history, physical, and lab studies only after therapy has started.

The goals for treating asthma exacerbations are

rapid reversal of airflow obstruction, reduction in

the likelihood of recurrence, and correction of significant hypoxemia. To achieve these goals, the management of asthma exacerbations in the emergency department and hospital (see figure 13 and dosage chart on

page 39) includes:

■ Oxygen for most patients to maintain SaO2 ≥90 percent (>95 percent in pregnant women, infants, and

patients with coexistent heart disease). Monitor oxygen saturation until a significant clinical improvement has occurred.

■ Short-acting inhaled beta2-agonists every 20 to 

30 minutes for three treatments for all patients

(see box on page 30). The onset of action is about 

5 minutes. Subsequent therapy depends on response

(see figure 13). Subcutaneous beta2-agonists provide

no proven advantage over inhaled medication. 

NOTE: Anticholinergics added to albuterol may be considered.

Adding high doses of ipratropium bromide (0.5 mg in adults,

0.25 mg in children) to albuterol in a nebulizer has been shown to

cause additional bronchodilation in some but not all studies,54-56

particularly in patients with severe airflow obstruction.

■ Oral steroids should be given to most patients—

those with moderate-to-severe exacerbations, patients

who fail to respond promptly and completely to an

inhaled beta2-agonist, and patients admitted into the

hospital. Oral steroids speed recovery and reduce the

likelihood of recurrence. Onset of action is greater

than 4 hours.57-59 Often, a 3- to 10-day course of oral

steroids at discharge is useful.

— For patients who take oral steroids long term, 

give supplemental doses, even if the 

exacerbation is mild.

— In infants and children, give oral steroids early 

in the course of an asthma exacerbation.

— Oral administration of prednisone is usually 

preferred to intravenous methylprednisolone 

because it is less invasive and the effects are 

equivalent.60,61

Repeat Assessment

The Expert Panel recommends repeat assessments of

patients with severe exacerbations after the first dose

and the third dose (about 60 to 90 minutes after

initiating treatment) of short-acting inhaled beta2-

agonists. Evaluate the patient’s subjective response,

physical findings, and lung function. Consider arterial

blood gas measurement for evaluating arterial carbon

dioxide (PCO2

) in patients with suspected hypoventilation, severe distress, or with FEV1 or peak flow ≤30 

percent of predicted after treatment.

Effectiveness of MDI Plus Spacer/Holding

Chamber vs. Nebulizer

Equivalent bronchodilation can be achieved by a

beta2-agonist given by MDI with a spacer/holding

chamber under the supervision of trained personnel

or by nebulizer therapy.

62-64 Continuous administration with a nebulizer may be more effective in children and severely obstructed adults65-68 and patients

who have difficulty with an MDI plus spacer/holding chamber. 
Managing Asthma Exacerbations at Home, in the Emergency Department, and in the Hospital

29

Initial Assessment

 History, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate), PEF or FEV1, oxygen saturation, and other tests as indicated

Repeat Assessment

Symptoms, physical examination, PEF, O2 saturation, other tests as needed

Moderate Exacerbation

 FEV1 or PEF 50-80% predicted/personal best

 Physical exam: moderate symptoms

• Inhaled short-acting beta2-agonist every 60 minutes

• Systemic steroid

• Continue treatment 1-3 hours, provided there is improvement

Good Response

• FEV1 or PEF >70%

• Response sustained 60 minutes after last 

 treatment

• No distress

• Physical exam: normal

Impending or Actual Respiratory 

Arrest

• Intubation and mechanical ventilation 

 with 100% O2

• Nebulized beta2-agonist and anticholinergic

• Intravenous steroid

Admit to Hospital Intensive Care

(see below)

FEV1 or PEF >50% 

• Oxygen to achieve O2 saturation >90%

• Inhaled beta2-agonist by metered-dose inhaler or 

 nebulizer, up to three treatments in first hour

• Oral steroids if no immediate response or if patient 

 recently took oral steroid

FEV1 or PEF <50% (Severe Exacerbation)

• Oxygen to achieve O2 saturation >90%

• Inhaled high-dose beta2-agonist and

 anticholinergic by nebulization every

 20 minutes or continuously for 1 hour

• Oral steroid

Severe Exacerbation

 FEV1 or PEF <50% predicted/personal best

 Physical exam: severe symptoms at rest, accessory muscle use, chest retraction

 History: high-risk patient

 No improvement after initial treatment

• Oxygen

• Inhaled short-acting beta2-agonist hourly or continuously + inhaled anticholinergic

• Systemic steroid

Incomplete Response

• FEV1 or PEF >50% but <70%

• Mild-to-moderate symptoms

Poor Response

• FEV1 or PEF <50%

• PCO2 >42 mm Hg

• Physical exam: symptoms severe, 

 drowsiness, confusion

Admit to Hospital Ward

• Inhaled beta2-agonist + inhaled

 anticholinergic

• Systemic steroid

• Oxygen

• Monitor FEV1 or PEF, O2 saturation

Admit to Hospital Intensive Care

• Inhaled beta2-agonist hourly or 

 continuously + inhaled anticholinergic

• Intravenous steroid

• Oxygen

• Possible intubation and mechanical 

 ventilation

Improve

Individualized decision re:

hospitalization 

Discharge Home

• Continue treatment with inhaled beta2-agonist

• Continue course of oral steroid

• Patient education

 — Review medicine use

 — Review/initiate action plan

 — Recommend close medical followup

Discharge Home

• Continue treatment with inhaled beta2-agonist

• Continue course of oral steroid

• Patient education

 — Review medicine use

 — Review/initiate action plan

 — Recommend close medical followup

Figure 13.

Management of Asthma Exacerbations: Emergency Department and Hospital-Based Care

E.D./Hospital Care
Special Considerations for Infants

Infants require special attention due to their greater risk

for respiratory failure. 

■ Use oral steroids early in the episode.

■ Monitor oxygen saturation by pulse oximetry. 

SaO2 should be >95 percent at sea level. 

■ Assess infants for signs of serious distress, including

use of accessory muscles, paradoxical breathing,

cyanosis, a respiratory rate >60, or oxygen saturation <91 percent. 

■ Assess response to therapy. A lack of response 

to beta2-agonist therapy noted by physical 

exam or oxygen saturation is an indication for 

hospitalization.

Therapies Not Recommended for

Treating Exacerbations

Theophylline/aminophylline is NOT recommended

therapy in the emergency department because it

appears to provide no additional benefit to shortacting inhaled beta2-agonists and may produce

adverse effects.69-73 In hospitalized patients, intravenous methylxanthines are not beneficial in children

with severe asthma74-76 and their addition remains controversial for adults.77,78

Chest physical therapy and mucolytics are not recommended. Anxiolytic and hypnotic drugs are contraindicated. Antibiotics are NOT recommended for asthma

treatment but may be needed for comorbid conditions

(e.g., patients with fever and purulent sputum or with

evidence of bacterial pneumonia). Aggressive hydration is NOT recommended for older children and

adults. Assess fluid status and make appropriate 

corrections for infants and young children to reduce

their risk of dehydration.

Hospital Asthma Care

In general, the principles of care in the hospital are

similar to those for care in the emergency department and involve treatment with aerosolized bronchodilators, systemic steroids, oxygen, and frequent

assessments (see figure 13). Clinical assessment of respiratory distress and fatigue and objective measurement

of airflow (peak flow or FEV1) and oxygen saturation

with pulse oximetry should be performed. Most

patients respond well to therapy; however, a small

minority will show signs of worsening ventilation.

Signs of impending respiratory failure include declining

mental clarity, worsening fatigue, and a PCO2 of 

≥42 mm Hg. Respiratory failure tends to progress

rapidly and is hard to reverse. The decision to intubate

is based on clinical judgment; however, intubation is

best done semi-electively, before the crisis of respiratory arrest. Therefore, the Expert Panel recommends that

intubation should not be delayed once it is deemed necessary. Intubation should be performed by physicians

with extensive experience in intubation and airway

management. Consultation or comanagement by 

a physician expert in ventilator management is 

appropriate.

Patient Discharge From the 

Emergency Department or Hospital

Patients can be discharged from the emergency

department and hospital when peak flow or FEV1

is ≥70 percent of predicted or personal best and

symptoms are minimal. Patients should be assessed

for discharge on an individual basis if they have a peak

flow or FEV1 of ≥ 50 but <70 percent of predicted or

personal best and mild symptoms. Take into consideration the risk factors for asthma-related death (see box

on page 26). Hospitalized patients should have their

medications changed to an oral or inhaled regimen and

then be observed for 24 hours before discharge. 

30

Practical Guide for the Diagnosis and Management of Asthma
Managing Asthma Exacerbations at Home, in the Emergency Department, and in the Hospital

31

Before Discharge, Provide Patients With 

the Following:

■ Sufficient short-acting inhaled beta2-agonist

and oral steroids to complete the course of 

therapy or to continue therapy until the followup

appointment. Patients given oral steroids should

continue taking them for 3 to 10 days. Patients

may be asked to start taking or to increase

inhaled steroids in an attempt to improve the

patient’s long-term-control regimen. 

■ Written and verbal instructions on when to

increase medications or return for care should

asthma worsen. The plan provided in the emergency department can be quite simple. Before

discharge from the hospital, patients should

receive a more complete written action plan 

(see patient handout, page 45) on when to 

take their medicines.

■ Training on how to monitor peak flow should 

be provided in the hospital and considered for

patients in the emergency department. Also, consider issuing peak flow meters. Patients in both

settings should receive instruction on monitoring

their symptoms.

■ Training on necessary environmental control

measures and inhaler technique, whenever

possible.

■ Referral for a followup medical appointment.

Tell patients from the emergency department to

go to a followup appointment within 3 to 5 days

or set up an appointment for them. When possible, phone or fax a notice to the patient’s physician that the patient came to the emergency

department. For both emergency department and

hospital patients, emphasize the need for continual, regular care in an outpatient setting. If

patients do not have a physician, refer them or

arrange a followup visit with a primary care

physician, a clinic, or an asthma specialist.
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1993;123:313-7.

65. Lin RY, Sauter D, Newman T, Sirleaf J, Walters J, Tavakol M. Continuous

versus intermittent albuterol nebulization in the treatment of acute asthma.

Ann Emerg Med 1993;22:1847-53.

66. Rudnitsky GS, Eberlein RS, Schoffstall JM, Mazur JE, Spivey WH.

Comparison of intermittent and continuously nebulized albuterol for treatment of asthma in an urban emergency department. Ann Emerg Med

1993;22:1842-6.

67. Papo MC, Frank J, Thompson AE. A prospective, randomized study of

continuous versus intermittent nebulized albuterol for severe status asthmaticus in children. Crit Care Med 1993;21:1479-86.

68. Kelly HW, Murphy S. Beta-adrenergic agonists for acute, severe asthma.

Ann Pharmacother 1992;26:81-91.

69. Fanta CH, Rossing TH, McFadden ER Jr. Treatment of acute asthma: is

combination therapy with sympathomimetics and methylxanthines indicated? Am J Med 1986;80:5-10.

70. Rossing TH, Fanta CH, Goldstein DH, Snapper JR, McFadden ER Jr.

Emergency therapy of asthma: comparison of the acute effects of parenteral and inhaled sympathomimetics and infused aminophylline. Am Rev

Respir Dis 1980;122:365-71.

71. Murphy DG, McDermott MF, Rydman RJ, Sloan EP, Zalenski RJ.

Aminophylline in the treatment of acute asthma when beta2-adrenergics

and steroids are provided. Arch Intern Med 1993;153:1784-88.

72. Rodrigo C, Rodrigo G. Treatment of acute asthma. Lack of therapeutic

benefit and increase of the toxicity from aminophylline given in addition

to high doses of salbutamol delivered by metered-dose inhaler with a

spacer. Chest 1994;106:1071-6.

73. Coleridge J, Cameron P, Epstein J, Teichtahl H. Intravenous aminophylline confers no benefit in acute asthma treated with intravenous

steroids and inhaled bronchodilators. Aust N Z J Med 1993;23:348-54.

74. Strauss RE, Wertheim DL, Bonagura VR, Valacer DJ. Aminophylline therapy does not improve outcome and increases adverse effects in children

hospitalized with acute asthmatic exacerbations. Pediatrics 1994;93:

205-10.

75. Carter E, Cruz M, Chesrown S, Shieh G, Reilly K, Hendeles L. Efficacy

of intravenously administered theophylline in children hospitalized with

severe asthma. J Pediatr 1993;122:470-6.

76. DiGiulio GA, Kercsmar CM, Krug SE, Alpert SE, Marx CM. Hospital

treatment of asthma: lack of benefit from theophylline given in addition to

nebulized albuterol and intravenously administered corticosteroid. J

Pediatr 1993;122:464-9.

77. Huang D, O’Brien RG, Harman E, et al. Does aminophylline benefit

adults admitted to the hospital for an acute exacerbation of asthma? Ann

Intern Med 1993;119:1155-60.

78. Self TH, Abou-Shala N, Burns R, et al. Inhaled albuterol and oral prednisone therapy in hospitalized adult asthmatics. Does aminophylline add

any benefit? Chest 1990;98:1317-21.

35

Appendices

Dosages for Medications

Usual Dosages for Long-Term-Control Medications . . . . . . . . . . .36

Estimated Comparative Daily Dosages for Inhaled Steroids . . . . .38

Dosages of Drugs for Asthma Exacerbations in Emergency 

Medical Care or Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Glossary

Asthma Long-Term-Control Medications . . . . . . . . . . . . . . . . . . . .40

Asthma Quick-Relief Medications . . . . . . . . . . . . . . . . . . . . . . . . .40

Patient Handouts

What Everyone Should Know About Asthma Control . . . . . . . . . .41

How To Control Things That Make Your Asthma Worse . . . . . . . .42

How To Use Your Metered-Dose Inhaler the Right Way . . . . . . . .44

Asthma Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

School Self-Management Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

How To Use Your Peak Flow Meter . . . . . . . . . . . . . . . . . . . . . . . .48

Patient Self-Assessment Forms

Patient Self-Assessment Form for Environmental and 

Other Factors That Can Make Asthma Worse* . . . . . . . . . . . .50

Patient Self-Assessment Form for Followup Visits* . . . . . . . . . . . .52

* These questions are examples and do not represent a 

standardized assessment or diagnostic instrument. 

The validity and reliability of these questions have not 

been assessed. 
36

Usual Dosages for Long-Term-Control Medications* Medication Inhaled Steroids Oral Steroids Methylprednisolone Prednisolone Prednisone

Cromolyn andNedocromilCromolynNedocromilLong-Acting BronchodilatorsSalmeterolSustained-release albuterol

Dosage Form2, 4, 8, 16, 32 mg tablets5 mg tabs, 5 mg/5 cc, 15 mg/5 cc1, 2.5, 5, 10, 20, 25 mgtabs; 5 mg/cc, 5 mg/5 ccMDI 1 mg/puff (200sprays/canister)Nebulizer solution 20mg/ampuleMDI 1.75 mg/puff(104 sprays/canister)InhaledMDI 21 mcg/puff, 60 or120 puffs (120 sprays/ 

canister)

DPI 50 mcg/blisterTablet4 mg tablet

Adult Dose■ 7.5-60 mg daily in a 

single dose or qod asneeded for control

■ Short-course “burst”: 

40-60 mg per day as single or 2 divided dosesfor 3-10 days

2-4 puffs tid-qid1 ampule tid-qid2-4 puffs bid-qid2 puffs q 12 hours1 blister q 12 hours4 mg q 12 hours

Child Dose■ 0.25-2 mg/kg daily in 

single dose or qod asneeded for control

■ Short course “burst”: 

1-2 mg/kg/day, maximum 60 mg/day,for 3-10 days

1-2 puffs tid-qid1 ampule tid-qid1-2 puffs bid-qid1-2 puffs q 12 hours1 blister q 12 hours0.3-0.6 mg/kg/day, not to exceed 8 mg/day

Comments■ Most effective anti-inflamm■ For long-term treatment of 

administer single dose in a.nate days (which may lessestudy suggests improved efadrenal suppression when a

■ Short courses or “bursts” ar

control when initiating thergradual deterioration.

■ The burst should be continu

80% of peak flow personal This usually requires 3-10 There is no evidence that taimprovement prevents relap

■ An initial trial in children w

tent asthma is often given d

■ Can usually see therapeutic 

2 weeks; takes 4 to 6 weekeffect.

■ Dose of cromolyn by MDI 

nebulizer may be preferred

■ Should not be used in place 

therapy. 

■ Use with inhaled steroids in ■ May use one dose nightly f■ Duration of bronchodilation ■ Should not be used for sy

exacerbations.

(see Estimated Comparative Daily Dosages for Inhaled Steroids, page 38)
37

Usual Dosages for Long-Term-Control Medications* CONTINUED

MedicationTheophyllineLeukotriene ModifiersZafirlukastZileuton

Dosage FormLiquidsSustained-release tablets 

and capsules

20 mg tablet300 mg tablet600 mg tablet

Adult DoseStarting dose 10 mg/kg/day up to 300 mg max; usual max 800 mg/day40 mg daily (1 tablet bid)2,400 mg daily (two 300-mg tablets or one 600-mg tablet, qid)

Child DoseStarting dose 10 mg/kg/day; usual max:■ ≥1 year of age: 

16 mg/kg/day

■ <1 year: 0.2 (age in 

weeks) + 5 = mg/kg/day

Comments■ Adjuvant to inhaled steroid■ Alternative, but not preferr

at step 2.

■ Adjust dosage to achieve p

5-15 mcg/mL at steady-stadosage).

■ Due to wide interpatient v

metabolic clearance, routimonitoring is important.

■ May be considered at step 

age, although their position fully established.

■ For zafirlukast, administra

bioavailability; take at leas2 hours after meals.

■ For patients taking zafirluk

monitor prothrombin and a

■ For zileuton, monitor hepa

NOTE: All chlorofluorocarbon (CFC)-propelled inhalers are being phased out. The new non-CFC products should have similar effectiveness and safety levels as the 

* For a list of brand names, see glossary, page 40.

Dosages
Practical Guide for the Diagnosis and Management of Asthma

Inhaled Steroid

Beclomethasone 

dipropionate 

42 mcg/puff

84 mcg/puff

Budesonide DPI

200 mcg/dose

Flunisolide

250 mcg/puff

Fluticasone

MDI: 

44, 110, 220 mcg/puff

DPI:

50, 100, 250 mcg/dose

Triamcinolone 

acetonide

100 mcg/puff

Low Dose

168-504 mcg

4-12 puffs—42 mcg

2-6 puffs—84 mcg

200-400 mcg

1-2 inhalations 

500-1,000 mcg

2-4 puffs

88-264 mcg

2-6 puffs—44 mcg or

2 puffs—110 mcg

2-6 inhalations—50 mcg

400-1,000 mcg

4-10 puffs

Medium Dose

504-840 mcg

12-20 puffs—42 mcg

6-10 puffs—84 mcg 

400-600 mcg

2-3 inhalations

1,000-2,000 mcg

4-8 puffs

264-660 mcg

2-6 puffs—110 mcg

3-6 inhalations—100 mcg

1,000-2,000 mcg

10-20 puffs

High Dose

>840 mcg

>20 puffs—42 mcg

>10 puffs—84 mcg

>600 mcg

>3 inhalations

>2,000 mcg

>8 puffs

>660 mcg

>6 puffs—110 mcg or

>3 puffs—220 mcg

>6 inhalations—100 mcg

or

>2 inhalations—250 mcg

>2,000 mcg

>20 puffs

Estimated Comparative Daily Dosages for Inhaled Steroids 

Adults

Children ≤12 years 

Inhaled Steroid

Beclomethasone 

dipropionate 

42 mcg/puff

84 mcg/puff

Budesonide DPI

200 mcg/dose

Flunisolide

250 mcg/puff

Fluticasone

MDI: 

44, 110, 220 mcg/puff

DPI:

50, 100, 250 mcg/dose

Triamcinolone 

acetonide

100 mcg/puff

Low Dose

84-336 mcg

2-8 puffs—42 mcg

1-4 puffs—84 mcg

100-200 mcg

500-750 mcg

2-3 puffs

88-176 mcg

2-3 puffs—44 mcg 

2-4 inhalations—50 mcg

400-800 mcg

4-8 puffs

Medium Dose

336-672 mcg

8-16 puffs—42 mcg

4-8 puffs—84 mcg 

200-400 mcg

1-2 inhalations—200 mcg

1,000-1,250 mcg

4-5 puffs

176-440 mcg

4-10 puffs—44 mcg or

2-4 puffs—110 mcg

2-4 inhalations—100 mcg

800-1,200 mcg

8-12 puffs

High Dose

>672 mcg

>16 puffs—42 mcg

>8 puffs—84 mcg

>400 mcg

>2 inhalations—200 mcg

>1,250 mcg

>5 puffs

>440 mcg

>4 puffs—110 mcg or

>2 puffs—220 mcg

>4 inhalations—100 mcg

or

>2 inhalations—250 mcg

>1,200 mcg

>12 puffs

• Clinician judgment of patient response is essential to appropriate dosing. 

Once asthma is controlled, medication doses should be carefully titrated to the 

minimum dose required to maintain control, thus reducing the potential for 

adverse effect. 

• Data from in vitro and clinical trials suggest that different inhaled corticosteroid preparations are not equivalent on a per puff or microgram basis. However, few data

directly compare the preparations. The Expert Panel developed recommended dose

ranges for different preparations based on available data.

• Inhaled corticosteroid safety data suggest dose ranges for children equivalent to

beclomethasone dipropionate 200-400 mcg/day (low dose), 400-800 mcg/day (medium dose), and >800 mcg/day (high dose).

38
39

Dosages of Drugs for Asthma Exacerbations in Emergency Medical Care or Hospital*

MedicationInhaled short-acting beta2-agonistsAlbuterol

Nebulizer solution (5 mg/mL)Metered-dose inhaler (90 mcg/puff)

Bitolterol and pirbuterol

Systemic (injected) beta2-agonistsEpinephrine1:1000 (1 mg/mL)Terbutaline(1 mg/mL)AnticholinergicsIpratropium bromide

Nebulizer solution (0.25 mg/mL)Metered-dose inhaler (18 mcg/puff)

SteroidsPrednisoneMethylprednisolonePrednisolone

Adults2.5-5 mg every 20 min for 3 doses,then 2.5-10 mg every 1-4 hours asneeded, or 10-15 mg/hour continuously.4-8 puffs every 20 min up to 4 hours, then every 1-4 hours asneeded.0.3-0.5 mg every 20 min for 3 doses SQ.0.25 mg every 20 min for 3 doses SQ.0.5 mg every 30 min for 3 dosesthen every 2-4 hours as needed.4-8 puffs as needed.120-180 mg/day in 3 or 4 divideddoses for 48 hours, then 60-80mg/day until PEF reaches 70% ofpredicted or personal best.

Children0.15 mg/kg (minimum dose 2.5 mg) every20 min for 3 doses, then 0.15-0.3 mg/kg upto 10 mg every 1-4 hours as needed, or 0.5mg/kg/hour by continuous nebulization.4-8 puffs every 20 min for 3 doses, thenevery 1-4 hours as needed.0.01 mg/kg up to 0.3-0.5 mg every 20 min for 3 doses SQ.0.01 mg/kg every 20 min for 3 doses thenevery 2-6 hours as needed SQ.0.25 mg every 20 min for 3 doses, thenevery 2 to 4 hours.4-8 puffs as needed.1 mg/kg every 6 hours for 48 hours then 1-2mg/kg/day (maximum = 60 mg/day) in 2divided doses until PEF 70% of predicted orpersonal best.

CommentsOnly selective bet

mended. For optimto minimum of 4 mL/min.As effective as nebable to coordinate spacer/holding chaHave not been stuexacerbations.No proven advantover aerosol.No proven advantover aerosol.May mix in same Should not be useshould be added to 

Dose delivered frobeen studied in asAdult “burst” at dsingle or 2 divided Child “burst” at di

maximum 60 mg/d

Dosages

* For a list of brand names, see glossary page 40.

Dosages
40

Asthma Long-Term-Control Medications

Generic name Brand name

Corticosteroids: Inhaled

beclomethasone Beclovent®

Vanceril®, Vanceril®—Double Strength

budesonide Pulmicort Turbuhaler®

flunisolide AeroBid®, AeroBid-M®

fluticasone Flovent®

triamcinolone Azmacort®

Cromolyn and Nedocromil: Inhaled

cromolyn sodium Intal®

nedocromil sodium Tilade®

Leukotriene Modifiers: Oral

zafirlukast Accolate®

zileuton Zyflo®

Long-Acting Beta2-Agonists

salmeterol (inhaled) Serevent®

albuterol (extended release) Volmax®

Proventil Repetabs®

Theophylline: Oral

Aerolate® III

Aerolate® JR

Aerolate® SR

Choledyl® SA

Elixophyllin®

Quibron®-T

Quibron®-T/SR 

Slo-bid®

Slo-Phyllin®

Theo-24®

Theochron®

Theo-Dur®

Theolair®

Theolair®-SR

T-Phyl®

Uni-Dur®

Uniphyl®

Asthma Quick-Relief Medications

Generic name Brand name

Short-Acting Beta2-Agonists**: Inhaled

albuterol Airet®

Proventil®

Proventil HFA®

Ventolin®

Ventolin® Rotacaps

bitolterol Tornalate®

pirbuterol Maxair®

terbutaline Brethaire®

Brethine® (tablet only)

Bricanyl® (tablet only)

** This list does not include metaproterenol, which is not recommended for relief of acute bronchospasm due to its potential for excessive

cardiac stimulation, especially in high doses. 

Anticholinergics: Inhaled

ipratropium bromide Atrovent®

Corticosteroids: Oral

methylprednisolone Medrol®

prednisone Prednisone

Deltasone®

Orasone®

Liquid Pred®

Prednisone Intensol®

prednisolone Prelone®

Pediapred®

* This glossary is a complete list of brand names associated with the

appropriate generic names of asthma medications, as listed in the

United States Pharmacopeial Convention, Inc., Approved Drug

Products and Legal Requirements, Volume III, 17th edition, 1997,

and the USP DI Drug Information for Health Care Professionals,

Volume I, 17th edition, 1997. This list does not constitute an

endorsement of these products by the National Heart, Lung, and

Blood Institute.

Glossary*
41

You will learn to take care of your asthma

over time. For now, you will be off to a

good start if you know just five key things.

These five things should guide your efforts

to take care of your asthma.

Asthma can be managed so that you can live a

normal life. 

Your asthma should not keep you from

doing what you want. It should not keep

you from going to work or school. If it

does, talk to your doctor about your treatment.

Asthma is a disease that makes the airways in

your lungs inflamed. 

This means your airways are swollen and 

sensitive. The swelling is there all of the

time, even when you feel just fine. The

swelling can be controlled with medicine

and by staying away from things that bother your airways.

Many things in your home, school, work, and

other places can cause asthma attacks. 

An asthma attack occurs when your airways narrow, making it harder to breathe.

Asthma attacks are sometimes called flareups, exacerbations, or episodes. 

Things in the air that you are allergic to

(like pollen) can cause an asthma attack.

So can things that bother your airways like

tobacco smoke. You can learn to stay away

from the things that cause you to have asthma attacks.

Asthma needs to be watched and cared

for over a very long time. 

Asthma cannot be cured, but it can be 

treated. You can become free of symptoms

all or most of the time. But your asthma

does NOT go away when your symptoms 

go away. You will need to keep taking care 

of your asthma. 

Also, over the years your asthma may

change. Your asthma could get worse so

you need more medicine. That’s why you

need to keep in touch with your doctor. 

Asthma can be controlled when you 

manage your asthma and work with 

your doctor. 

You play a big role in taking care of your 

asthma with your doctor’s help. Your job is

to:

■ Take your medicines as your doctor 

suggests,

■ Watch for signs that your asthma is getting worse and act quickly to stop the

attack,

■ Stay away from things that can bother 

your asthma,

■ Ask your doctor about any concerns you

have about your asthma, and 

■ See your doctor at least every 6 months. 

When you do these things, you will gain—

and keep—control of your asthma.

WHAT EVERYONE SHOULD KNOW ABOUT ASTHMA CONTROL
42

You can help prevent asthma attacks by staying away

from things that make your asthma worse. This guide

suggests many ways to help you do this. 

You need to find out what makes your asthma

worse. Some things that make asthma worse for

some people are not a problem for others. You do

not need to do all of the things listed in this guide.

Look at the things listed in dark print below. Put a

check next to the ones that you know make your asthma worse. Ask your doctor to help you find out what

else makes your asthma worse. Then, decide with

your doctor what steps you will take. Start with the

things in your bedroom that bother your asthma. Try

something simple first.

■ Tobacco Smoke

■ If you smoke, ask your doctor for ways to help 

you quit. Ask family members to quit 

smoking, too.

■ Do not allow smoking in your home or 

around you. 

■ Be sure no one smokes at a child’s day care 

center.

■ Dust Mites

Many people with asthma are allergic to dust mites.

Dust mites are like tiny “bugs” you cannot see that

live in cloth or carpet. 

Things that will help the most:

■ Encase your mattress in a special dust-proof 

cover.*

■ Encase your pillow in a special dust-proof 

cover* or wash the pillow each week in hot 

water. Water must be hotter than 1300

F to 

kill the mites.

■ Wash the sheets and blankets on your bed 

each week in hot water.

Other things that can help:

■ Reduce indoor humidity to less than 

50 percent. Dehumidifiers or central air 

conditioners can do this.

■ Try not to sleep or lie on cloth-covered 

cushions or furniture.

■ Remove carpets from your bedroom and 

those laid on concrete, if you can.

■ Keep stuffed toys out of the bed or wash the 

toys weekly in hot water. 

■ Animal Dander

Some people are allergic to the flakes of skin or

dried saliva from animals with fur or feathers.

The best thing to do:

■ Keep furred or feathered pets out of your 

home.

If you can’t keep the pet outdoors, then:

■ Keep the pet out of your bedroom and keep 

the bedroom door closed.

■ Cover the air vents in your bedroom with 

heavy material to filter the air.* 

■ Remove carpets and furniture covered with 

cloth from your home. If that is not possible,

keep the pet out of the rooms where these 

are.

■ Cockroach

Many people with asthma are allergic to the dried

droppings and remains of cockroaches.

■ Keep all food out of your bedroom. 

■ Keep food and garbage in closed containers 

(never leave food out).

■ Use poison baits, powders, gels, or paste 

(for example, boric acid). You can also use 

traps.

■ If a spray is used to kill roaches, stay out of 

the room until the odor goes away.

HOW TO CONTROL THINGS THAT MAKE YOUR ASTHMA WORSE
43

■ Vacuum Cleaning

■ Try to get someone else to vacuum for you 

once or twice a week, if you can. Stay out

of rooms while they are being vacuumed

and for a short while afterward.

■ If you vacuum, use a dust mask (from a 

hardware store), a double-layered or micro

filter vacuum cleaner bag,* or a vacuum

cleaner with a HEPA filter.* 

■ Indoor Mold

■ Fix leaky faucets, pipes, or other sources of 

water.

■ Clean moldy surfaces with a cleaner that has

bleach in it.

■ Pollen and Outdoor Mold

What to do during your allergy season (when

pollen or mold spore counts are high):

■ Try to keep your windows closed.

■ Stay indoors with windows closed during the 

midday and afternoon, if you can. Pollen and 

some mold spore counts are highest at that time.

■ Ask your doctor whether you need to take or

increase anti-inflammatory medicine before 

your allergy season starts.

■ Smoke, Strong Odors, and Sprays

■ If possible, do not use a wood-burning

stove, kerosene heater, or fireplace.

■ Try to stay away from strong odors and sprays,

such as perfume, talcum powder, hair spray, 

and paints.

■ Exercise, Sports, Work, or Play

■ You should be able to be active without 

symptoms. See your doctor if you have 

asthma symptoms when you are active—like

when you exercise, do sports, play, or work 

hard.

■ Ask your doctor about taking medicine before

you exercise to prevent symptoms.

■ Warm up for about 6 to 10 minutes before

you exercise.

■ Try not to work or play hard outside when the

air pollution or pollen levels (if you are

allergic to the pollen) are high.

■ Other Things That Can Make 

Asthma Worse

■ Flu: Get a flu shot.

■ Sulfites in foods: Do not drink beer or wine

or eat shrimp, dried fruit, or processed 

potatoes if they cause asthma symptoms.

■ Cold air: Cover your nose and mouth with a

scarf on cold or windy days.

■ Other medicines: Tell your doctor about all

the medicines you may take. Include cold 

medicines, aspirin, and even eye drops. 

*To find out where to get products mentioned in this guide,

call:

Asthma and Allergy Foundation of America 

(800-727-8462)

Allergy and Asthma Network/Mothers of 

Asthmatics, Inc. (800-878-4403)

American Academy of Allergy, Asthma, and Immunology 

(800-822-2762)

National Jewish Medical and Research Center 
44

HOW TO USE YOUR METERED-DOSE INHALER THE RIGHT WAY

Using an inhaler seems simple, but most patients do not use it the right way. When you use your inhaler the 

wrong way, less medicine gets to your lungs. (Your doctor may give you other types of inhalers.) 

For the next 2 weeks, read these steps aloud as you do them or ask someone to read them to you. Ask your 

doctor or nurse to check how well you are using your inhaler. 

Use your inhaler in one of the three ways pictured below (A or B are best, but C can be used if you have 

trouble with A and B).

A. Hold inhaler 1 to 2 

inches in front of your 

mouth (about the width 

of two fingers).

B. Use a spacer/holding 

chamber. These come in 

many shapes and can be 

useful to any patient. 

C. Put the inhaler in your 

mouth. Do not use for 

steroids.

Steps for Using Your Inhaler

Getting ready

Breathe in slowly

Hold your breath

1. Take off the cap and shake the inhaler.

2. Breathe out all the way.

3. Hold your inhaler the way your doctor said (A, B, or C below).

4. As you start breathing in slowly through your mouth, press down

on the inhaler one time. (If you use a holding chamber, first press 

down on the inhaler. Within 5 seconds, begin to breathe in slowly.)

5. Keep breathing in slowly, as deeply as you can.

6. Hold your breath as you count to 10 slowly, if you can. 

7. For inhaled quick-relief medicine (beta2-agonists), wait about 

1 minute between puffs. There is no need to wait between puffs 

for other medicines.

Clean Your Inhaler as Needed

Look at the hole where the medicine

sprays out from your inhaler. If you

see “powder” in or around the hole,

clean the inhaler. Remove the metal

canister from the L-shaped plastic

mouthpiece. Rinse only the mouthpiece and cap in warm water. Let

them dry overnight. In the morning,

put the canister back inside. Put the

cap on.

Know When To Replace 

Your Inhaler

For medicines you take each day 

(an example):

Say your new canister has 200 puffs

(number of puffs is listed on canister) and you are told to take 8 puffs 

per day.

 25 days 

8 puffs per day ) 200 puffs in canister 

So this canister will last 25 days. 

If you started using this inhaler on 

May 1, replace it on or before May 25.

You can write the date on your canister.

For quick-relief medicine take as

needed and count each puff.

Do not put your canister in water to

see if it is empty. This does not

work.
45 National Asthma Education and Prevention Program; National Heart, Lung, and Blood Institute; NIH Publication No. 97-4053

■ No cough, wheeze, chest tightness, or 

 shortness of breath during the day or night

■ Can do usual activities

And, if a peak flow meter is used,Peak flow: more than ___________________ (80% or more of my best peak flow)My best peak flow is:____________________

GREEN ZONE: Doing Well

Take this medicine:

Then call your doctor NOW.

■ Cough, wheeze, chest tightness, or shortness 

 of breath, or

■ Waking at night due to asthma, or■ Can do some, but not all, usual activities

-OrPeak flow: ______ to ______ (50% - 80% of my best peak flow)

YELLOW ZONE: Asthma Is Getting Worse

■ Very short of breath, or■ Quick-relief medicines have not helped, or■ Cannot do usual activities, or■ Symptoms are same or get worse after 24 hours 

 in Yellow Zone-OrPeak flow: less than_______  (50% of my best peak flow)

RED ZONE: Medical Alert!

■ Trouble walking and talking due to shortness of breath

■ Take 

❏ 4 or 

❏ 6 puffs of your quick-relief medicine AND

■ Lips or fingernails are blue 

■ Go to the hospital or call for an ambulance ( _________________

 ❏

_____________________________________________________ 

❏ 4 or 

❏ 

(short-acting beta2-agonist) 

 ❏ _________________________________________ _________ mg. 

(oral steroid) 

DANGER SIGNS

Add: Quick-Relief Medicine 

– and keep taking your GREEN ZONE m

_________________________________________ 

❏ 2 or

❏ 4 puffs, every 20 

(short-acting beta2-agonist)

❏ Nebulizer, once

If your symptoms (and peak flow, if used) return to GREEN ZONE after 1 hour of abov

❏ Take the quick-relief medicine every 4 hours for 1 to 2 days.❏ Double the dose of your inhaled steroid for ____________ (7-10) days.

-Or-

 If your symptoms (and peak flow, if used) do not return to GREEN ZONE after 1 hour 

❏ Take: ________________________________________________ 

❏ 2 or 

❏ 

(short-acting beta2-agonist)

❏ Add: _____________________________________ _________ mg. per da

(oral steroid)

❏ Call the doctor 

❏ before/ 

❏ within _____________ hours after taking the ora

FIRST

Go to the hospital or call for an ambula

 ■ You are still in the red zone after 15 minutes AND  ■ You have not reached your doctor.

Take These Long-Term-Control Medicines Each Day (include an anti-inflamm

Before exercise ❏ 

__________________________________ 

❏ 2 or 

❏ 4 puffs 5 to 

SECOND

ASTHMA

ACTION

PLAN FOR

__________________________

Doctor’s Name

_______________________________

Doctor’s Phone Number

______________________________________Hospital/Emergency Room Phone Number

Medicine How much to take W
46

SCHOOL SELF-MANAGEMENT PLAN
47

SCHOOL SELF-MANAGEMENT PLAN (CONTINUED)
48

HOW TO USE YOUR PEAK FLOW METER

A peak flow meter helps you check how well your asthma is controlled. Peak flow meters 

are most helpful for people with moderate or severe asthma. 

This guide will tell you (1) how to find your personal best peak flow number, (2) how to

use your personal best number to set your peak flow zones, (3) how to take your peak flow, 

and (4) when to take your peak flow to check your asthma each day.

To find your personal best

peak flow number, take your

peak flow each day for 2 to 3

weeks. Your asthma should

be under good control during

this time. Take your peak

flow as close to the times listed below as you can. (These

times for taking your peak

flow are only for finding your

personal best peak flow. To

check your asthma 

each day, you will take your

peak flow in the morning.

This is discussed on the next

page.)

• Between noon and 2:00 p.m.

each day.

• Each time you take your

quick-relief medicine to

relieve symptoms.

(Measure your peak flow

after you take your medicine.)

• Any other time your doctor 

suggests.

Write down the number you get

for each peak flow reading. 

The highest peak flow number 

you had during the 2 to 3 

weeks is your personal best. 

Your personal best can change

over time. Ask your doctor

when to check for a new 

personal best. 

Your peak flow zones are based on your personal best peak flow

number. The zones will help you check your asthma and take the

right actions to keep it controlled. The colors used with each

zone come from the traffic light. 

Green Zone (80 to 100 percent of your personal best) signals good 

control. Take your usual daily long-term-control medicines, if

you take any. Keep taking these medicines even when you are in the

yellow or red zones.

Yellow Zone (50 to 79 percent of your personal best) signals

caution: your asthma is getting worse. Add quick-relief medicines. You might need to increase other asthma medicines as

directed by your doctor.

Red Zone (below 50 percent of your personal best) signals medical

alert! Add or increase quick-relief medicines and call your doctor now.

• The peak flow numbers for your green, yellow, and red zones. Mark

the zones on your peak flow meter with colored tape or a marker.

• The medicines you should take while in each peak flow zone.

Starting Out: Find Your Personal Best Peak Flow Number

Your Peak Flow Zones

Ask your doctor to write an action plan for you that tells you:
49

1.Move the marker to the bot- tom of the numbered scale.

2.Stand up or sit up straight.

3.Take a deep breath. Fill

your lungs all the way.

4.Hold your breath while you

place the mouthpiece in your

mouth, between your teeth.

Close your lips around it. 

Do not put your tongue 

inside the hole. 

5.Blow out as hard and fast as

you can. Your peak flow

meter will measure how fast

you can blow out air. 

6.Write down the number you

get. But if you cough or

make a mistake, do not

write down the number. Do

it over again.

7.Repeat steps 1 through 6

two more times. Write

down the highest of the

three numbers. This is your

peak flow number.

8.Check to see which peak

flow zone your peak flow

number is in. Do the

actions your doctor told you

to do while in that zone. 

Your doctor may ask you to 

write down your peak flow 

numbers each day. You can do 

this on a calendar or other 

paper. This will help you and 

your doctor see how your 

asthma is doing over time. 

• Every morning when you

wake up, before you take

medicine. Make this part of

your daily routine. 

• When you are having

asthma symptoms or an

attack. And after taking

medicine for the attack.

This can tell you how bad

your asthma attack is and

whether your medicine 

is working. 

• Any other time your doctor

suggests. 

If you use more than one peak

flow meter (such as at home

and at school), be sure that

both meters are the same

brand.

• Your peak flow meter. 

• Your peak flow numbers if

you have written them

down each day.

Also, ask your doctor or nurse

to check how you use your

peak flow meter—just to be

sure you are doing it right.

How To Take Your Peak Flow 

Checking Your Asthma: When To Use Your Peak Flow Meter

Bring to Each of Your Doctor’s Visits:
50

Do you cough, wheeze, have chest tightness, or feel short of breath 

year-round? (If no, go to next question) 

If yes:

■ Are there pets or animals in your home, school, or day care? 

■ Is there moisture or dampness in any room of your home?

■ Have you seen mold or smelled musty odors any place in your home?

■ Have you seen cockroaches in your home?

■ Do you use a humidifier or swamp cooler in your home?

Does your coughing, wheezing, chest tightness, or shortness of breath get

worse at certain times of the year? (If no, go to next question)

If yes: 

Do your symptoms get worse in the:

■ Early spring? (Trees)

■ Late spring? (Grasses)

■ Late summer to autumn? (Weeds)

■ Summer and fall? (Alternaria, Cladosporium)

Do you smoke?

Does anyone smoke at home, work, or day care?

Is a wood-burning stove or fireplace used in your home?

Are kerosene, oil, or gas stoves or heaters used without vents in your home?

Are you exposed to fumes or odors from cleaning agents, 

sprays, or other chemicals? 

Do you cough or wheeze during the week, but not on weekends when away 

from work or school?

Do your eyes and nose get irritated soon after you get to work or school?

Do your coworkers or classmates have symptoms like yours?

Are isocyanates, plant or animal products, smoke, gases, or fumes 

used where you work?

Is it cold, hot, dusty, or humid where you work?

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

PATIENT SELF-ASSESSMENT FORM FOR ENVIRONMENTAL AND

OTHER FACTORS THAT CAN MAKE ASTHMA WORSE

Patient Name: Date:
51

Do you have a stuffy nose or postnasal drip, either at certain 

times of the year or year-round?

Do you sneeze often or have itchy, watery eyes?

Do you have heartburn?

Does food sometimes come up into your throat?

Have you had coughing, wheezing, or shortness of breath at 

night in the past 4 weeks?

Does your infant vomit then cough or have wheezy cough at night?

Are these symptoms worse after feeding?

Have you had wheezing, coughing, or shortness of breath after eating

shrimp, dried fruit, or canned or processed potatoes?

After drinking beer or wine? 

Are you taking any prescription medicines or over-the-counter medicines?

If yes, which ones?

Do you use eye drops?

Do you use any medicines that contain beta-blockers 

(e.g., blood pressure medicine)?

Do you ever take aspirin or other nonsteroidal anti-inflammatory drugs 

(like ibuprofen)? 

Have you ever had coughing, wheezing, chest tightness, or shortness of 

breath after taking any medication?

Do you cough, wheeze, have chest tightness, or feel short of 

breath during or after exercising?

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 
52

PATIENT SELF-ASSESSMENT FORM FOR FOLLOWUP VISITS

Please answer the questions below in the space provided on the right.

Since your last visit:

1. Has your asthma been any worse?

2. Have there been any changes in your home, work, or school environment 

(such as a new pet, someone smoking)?

3. Have you had any times when your symptoms were a lot worse than usual?

4. Has your asthma caused you to miss work or school or reduce or change 

your activities?

5. Have you missed any regular doses of your medicines for any reason?

6. Have your medications caused you any problems? 

(shakiness, nervousness, bad taste, sore throat, cough, upset stomach)

7. Have you had any emergency room visits or hospital stays for asthma?

8. Has the cost of your asthma treatment kept you from getting the 

medicine or care you need for your asthma?

In the past 2 weeks, 

9. Have you had a cough, wheezing, shortness of breath, 

or chest tightness during: 

■ the day 

■ night

■ exercise or play?

10. (If you use a peak flow meter) Did your peak flow go below 80 percent of 

your personal best? 

11. How many days have you used your inhaled quick-relief medicine?

12. Have you been satisfied with the way your asthma has been?

13. What are some concerns or questions you would like us to 

address at this visit?

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

For staff use.

■ Peak Flow Technique

■ MDI Technique

■ Reviewed Action Plan: ■ Daily meds ■ Emergency meds

Number of days 

Patient Name: Date:
Discrimination Prohibited: Under provisions

of applicable public laws enacted by

Congress since 1964, no person in the

United States shall, on the grounds of race,

color, national origin, handicap, or age, be

excluded from participation in, be denied

the benefits of, or be subjected to discrimination under any program or activity (or, on

the basis of sex, with respect to any education program or activity) receiving Federal

financial assistance. 

In addition, Executive Order 11141 prohibits 

discrimination on the basis of age by contractors and subcontractors in the performance of Federal contracts, and Executive

Order 11246 states that no federally funded

contractor may discriminate against any

employee or applicant for employment

because of race, color, religion, sex, or

national origin. Therefore, the National
U.S. DEPARTMENT OF HEALTH AND 

HUMAN SERVICES

Public Health Service

National Institutes of Health

National Heart, Lung, and Blood Institute

NIH Publication No. 97-4053

October 1997