Asthma Management: 5-11 Years of Age

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ASTHMA MANAGEMENT: 5−11 YEARS OF AGE
Classifying Asthma Severity and Initiating Treatment
Assessing severity and initiating therapy in children who
are not currently taking long-term control medication
Components of Severity Classification of Asthma Severity
Intermittent Persistent
Mild Moderate Severe
Impair-
ment
Symptoms ≤2 days/week >2 days/week but not daily Daily Throughout the day
Nighttime awakenings ≤2×/month 3−4×/month >1×/week but not nightly Often 7×/week
Short-acting β2-agonist use for symptom control (not prevention of EIB) ≤2 days/week >2 days/week but not daily Daily Several times per day
Interference with
normal activity
None Minor limitation Some limitation Extremely limited
Lung function

• Normal FEV1 between exacerbations

• FEV1 >80% predicted

• FEV1/FVC >85%

• FEV1 ≥80% predicted

• FEV1/FVC >80%

• FEV1 = 60%−80% predicted

• FEV1/FVC = 75%−80%

• FEV1 <60% predicted

• FEV1/FVC <75%

Risk Exacerbations requiring oral systemic corticosteroids 0−1/year ≥2/year
• Consider severity and interval since last exacerbation
• Frequency and severity may fluctuate over time for patients in any severity category
• Relative annual risk of exacerbations may be related to FEV1
Recommended Step
for Initiating Therapy
Step 1 Step 2 Step 3, medium-dose ICS option Step 3, medium-dose ICS option, or Step 4
and consider short course of oral systemic corticosteroids
In 2−6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.
Stepwise Approach for Managing Asthma
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if Step 4 care or higher is required.
Consider consultation at Step 3.

 
Step up if
needed

(first, check
adherence, inhaler
technique,
environmental
control, and
comorbid
conditions)
————————
Assess
control

————————
Step down if
possible

(and asthma is
well controlled
at least
3 months)
 
  Step 6
Preferred:
High-dose ICS +
LABA +
oral systemic
corticosteroid
Alternative:
High-dose ICS +
either LTRA or
Theophylline
and
oral systemic
corticosteroid
  Step 5
Preferred:
High-dose ICS +
LABA
Alternative:
High-dose ICS +
either LTRA or
Theophylline
  Step 4
Preferred:
Medium-dose
ICS + LABA
Alternative:
Medium-dose ICS
+ either LTRA or
Theophylline
  Step 3
Preferred:
EITHER:
Low-dose ICS +
either LABA,
LTRA, or
Theophylline
OR
Medium-dose ICS
  Step 2
Preferred:
Low-dose ICS
Alternative:
Cromolyn,
LTRA,
or
Theophylline
Step 1
Preferred:
SABA PRN
 
 
 
 
 
Each Step: Patient education, environmental control, and management of comorbidities
Steps 2−4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma.

Quick-Relief Medication for All Patients

• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20‑minute intervals as needed. Short course of oral systemic corticosteroids may be needed

• Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment

Assessing Asthma Control and Adjusting Therapy
Components of Control Classification of Asthma Control
Well Controlled Not Well Controlled Very Poorly Controlled
Impair-
ment
Symptoms ≤2 days/week but not more than once on each day >2 days/week or multiple times on ≤2 days/week Throughout the day
Nighttime awakenings ≤1×/month ≥2×/month ≥2×/week
Interference with normal activity None Some limitation Extremely limited
Short-acting β2-agonist use for symptom control (not prevention of EIB) ≤2 days/week >2 days/week Several times per day
Lung function
• FEV1 or peak flow
 
• FEV1/FVC
 
>80% predicted/
personal best
>80%
 
60%−80% predicted/
personal best
75%−80%
 
<60% predicted/
personal best
<75%
Risk Exacerbations requiring oral systemic corticosteroids 0−1/year ≥2/year
Consider severity and interval since last exacerbation
Reduction in lung growth Evaluation requires long‑term follow‑up
Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Recommended Action
for Treatment

• Maintain current step

• Regular follow-up every 1−6 months

• Consider step down if well controlled for at least 3 months

• Step up at least 1 step and

• Reevaluate in 2−6 weeks

• For side effects, consider alternative treatment options

• Consider short course of oral systemic corticosteroids

• Step up 1−2 steps, and

• Reevaluate in 2 weeks

• For side effects, consider alternative treatment options

NOTES

Key: EIB = exercise-induced bronchospasm; FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity; ICS = inhaled corticosteroid; LABA = inhaled long-acting β2‑agonist; LTRA = leukotriene receptor antagonist; SABA = inhaled short-acting β2‑agonist

REFERENCES

Adapted from National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma 2007.
U.S. Department of Health and Human Services. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed on: November 26, 2012.

(Rev. 8/2016)

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