Stepwise Management of Asthma

Patients 5 Years and Younger

Step 4: Severe Persistent	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
Step 3: Moderate Persistent	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 old or older, to a serum concentration of 5-15 mcg/mL)
Step 2: Mild Persistent	Daily anti-inflammatory medication Infants and young children usually begin with a trial of cromolyn (nebulizer is preferred: one 20 mg ampule tid-qid) or nedocromil (MDI only -- 1 to 2 puffs bid-qid) OR Low-dose inhaled steroid with space and face-mask
Step 1: Mild Intermittent	No Daily medication needed.
All Patients	Bronchodilator as needed for symptoms: Short-acting inhaled beta₂ agonist by nebulizer (0.05 mg/kg albuterol in 2-3 cc saline) or inhaler with face mask and spacer (2-4 puffs; for exacerbations repeat q 20 minutes for up to one 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.

Also see chart of steroid strengths.

The stepwise approach presents general guidelines to assist clinical decision making. 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 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. If control is sustained for at least 3 months, a gradual stepwise reduction in treatment may be possible.
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 more that 3 to 4 times in one day. But before stepping up, review patient inhaler technique, compliance, and environmental control (allergen and irritant avoidance)
A course of oral steroids may be needed at any time and at any step.
Referral to an asthma specialist for consultation of comanagement is recommended if there is difficulty maintaining control or if the patient requires step 3 or 4 care. Referral may be considered for step 2 care.

This page is based on the Practical Guide for the Diagnosis and Management of Asthma, a publication of the National Heart, Lung and Blood Institute of the National Institutes of Health of the United States
NIH Publication No. 97-4053, October 1997

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