Asthma classification: Difference between revisions

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Latest revision as of 20:30, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Asthma is classified into atopic and non-atopic types based on the onset of symptoms. Atopic refers to early-onset whereas non-atopic refers to late-onset. Despite the differentiation, a significant degree of overlap exists between the two types. The severity of symptoms is further classified based on the GINA severity grades into mild intermittent, mild persistent, moderate persistent and severe persistent asthma.

Classification

Based on Symptom Onset

Early-onset Asthma (Atopic, Allergic, Extrinsic)

Early-age of onset
Atopic individuals have an increased predisposition
Environmental allergens play a strong role in the pathogenesis
Positive personal and/or family history of atopic diseases such as allergic rhinitis, urticaria and eczema
Laboratory tests may reveal increased serum IgE levels, positive skin test to specific aero-allergens and a positive bronchoprovocation test

Late-onset Asthma (Non-Atopic, Idiosyncratic, Intrinsic)

Late-age of onset
Non- atopic individuals have an increased predisposition
Indoor allergens play a strong role in the pathogenesis
Negative personal and/or family history of allergic diseases
Laboratory tests may reveal normal serum IgE levels and a negative bronchoprovocation test

Based on GINA Severity Grade

Asthma is classified into four subgroups: mild intermittent, mild persistent, moderate persistent and severe persistent based on the Global Initiative for Asthma - GINA severity grades.^[1]

Mild Intermittent Asthma

Symptoms per day	Symptoms at night	PEF or FEV1	PEF variability
Less than once a week Brief exacerbations Asymptomatic and normal PEFR between exacerbations	Less than or equal to twice a month	≥ 80% of predicted normal	< 20%

Mild Persistent Asthma

Symptoms per day	Symptoms at night	PEF or FEV1	PEF variability
Symptoms more than twice a week but less than once a day Exacerbations may affect activity and sleep.	Greater than or equal to twice a month	≥ 80%	20-30%

Moderate Persistent Asthma

Symptoms per day	Symptoms at night	PEF or FEV1	PEF variability
Daily symptoms Exacerbations more than twice a week Exacerbations may affect activity and sleep Daily use of bronchodilators	More than once a month	60-80%	≥ 30%

Severe Persistent Asthma

Symptoms per day	Symptoms at night	PEF or FEV1	PEF variability
Continued symptoms Frequent exacerbations Limited physical activity	Frequent	≤ 60%	≥ 30%

Guidelines for Diagnosis and Management of Asthma Based On The National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR3) ^[2]

Severity Components	Intermittent	Persistent Asthma
Severity Components	Intermittent	Mild	Moderate	Severe
Symptoms	Less than 1 day/week	More than 2 days/week Not daily	Daily	Daily Throughout the day
Nocturnal Symptoms	Less than 2 times/month	3 to 4 times/month	More than 1 time/week Not every night	Every night
Interference w/ Activity	Minimal to none	Minor limitation of activity	Some limitation of activity	Severe limitation of activity
Short-Acting Beta-Agonist Use	Less than 2 days/week	More than 2 days/week but not daily Not more than once/day	Daily	Several times/day
Pulmonary Function Test	Normal FEV₁ between exacerbations FEV₁ > 80% predicted FEV₁/FVC normal	FEV₁ > 80% predicted FEV₁/FVC normal	FEV₁ > 60% but < 80% predicted FEV₁/FVC reduced by 5%	FEV₁ < 60% predicted FEV₁/FVC reduced by > 5%
Recommended Treatment Strategy	STEP 1 Preferred: Short-acting beta-agonist PRN	STEP 2 Preferred: Low-dose inhaled corticosteroids Alternative: Cromolyn, Leukotriene receptor antagonist, Nedocromil, or Theophylline	STEP 3 Preferred: Either low-dose inhaled corticosteroids + long-acting beta-agonist OR Medium-dose inhaled corticosteroid Alternative: Low-dose inhaled corticosteroid + either Leukotriene receptor antagonist, Theophylline, or Zileuton	STEP 4 Preferred: Medium-dose inhaled corticosteroid + long-acting beta-agonist Alternative: Medium-dose inhaled corticosteroids + either Leukotriene receptor antagonist, Theophylline, or Zileuton STEP 5 Preferred: High-dose inhaled corticosteroids + long-acting beta-agonist Consider adding Omalizumab for patients with allergies STEP 6 Preferred: High-dose inhaled corticosteroids + long-acting beta-agonist + oral corticosteroids Consider adding Omalizumab for patients with allergies
Step down if possible and asthma is controlled for at least 3 months Step-up if needed, but first check adherence, environmental control, and comorbidities
In each step, patient education, environmental control, and management of comorbidities are important. In STEP 2 - 4, consider subcutaneous allergen immunotherapy for patients with allergic asthma
Short-acting beta-agonist as needed for symptoms. Up to 3 treatments at 20 minute intervals as needed. A short course of oral systemic corticosteroids may be needed. Use of a short-acting beta agonist for >2 days a week for symptom control indicates inadequate control and the need to step up therapy.

References

↑ Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M et al. (2008) Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J 31 (1):143-78. DOI:10.1183/09031936.00138707 PMID: 18166595
↑ Urbano FL (2008) Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines. J Manag Care Pharm 14 (1):41-9. PMID: 18240881

Template:WH Template:WS

[pmid18166595-1] Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M et al. (2008) Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J 31 (1):143-78. DOI:10.1183/09031936.00138707 PMID: 18166595

[pmid18240881-2] Urbano FL (2008) Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines. J Manag Care Pharm 14 (1):41-9. PMID: 18240881

[1]

[2]

@@ Line 4: / Line 4: @@
 ==Overview==
-Asthma is classified into atopic and non-atopic types based on the onset of symptoms. Atopic refers to early-onset whereas non-atopic refers to late-onset. Despite the differentiation, a significant degree of overlap exists between the two types. The severity of symptoms is further classified based on the GINA severity grades into mild intermittent, mild persistent, moderate persistent and severe persistent asthma.
+Asthma is classified into [[atopic]] and non-atopic types based on the onset of [[symptoms]]. Atopic refers to early-onset whereas non-atopic refers to late-onset. Despite the differentiation, a significant degree of overlap exists between the two types. The severity of symptoms is further classified based on the GINA severity grades into mild intermittent, mild persistent, moderate persistent and severe persistent asthma.
 ==Classification==
@@ Line 23: / Line 23: @@
 ===Based on GINA Severity Grade===
-Asthma is classified into four subgroup, namely, mild intermittent, mild persistent, moderate persistent and severe persistent based on the ''Global Initiative for Asthma - GINA severity grades''.<ref name="pmid18166595">Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18166595 Global strategy for asthma management and prevention: GINA executive summary.] ''Eur Respir J'' 31 (1):143-78. [http://dx.doi.org/10.1183/09031936.00138707 DOI:10.1183/09031936.00138707] PMID: [http://pubmed.gov/18166595 18166595]</ref>
+Asthma is classified into four subgroups: mild intermittent, mild persistent, moderate persistent and severe persistent based on the ''Global Initiative for Asthma - GINA severity grades''.<ref name="pmid18166595">Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18166595 Global strategy for asthma management and prevention: GINA executive summary.] ''Eur Respir J'' 31 (1):143-78. [http://dx.doi.org/10.1183/09031936.00138707 DOI:10.1183/09031936.00138707] PMID: [http://pubmed.gov/18166595 18166595]</ref>
-===Mild Intermittent Asthma===
+====Mild Intermittent Asthma====
-{| align="center" style="border: 0px; font-size: 90%; margin: 3px;"
+{| align="center" style="border: 0px; font-size: 90%; margin: 3px; width:70%;"
 |-
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
+| style="width: 55%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per night'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms at night'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" | Less than once a week. Brief exacerbations. Asymptomatic and normal PEFR between exacerbations.
+| style="background: #DCDCDC; padding: 5px; text-align: left;" |
+*Less than once a week
+*Brief exacerbations
+*Asymptomatic and normal PEFR between exacerbations
 | style="background: #DCDCDC; padding: 5px; text-align: center;" | Less than or equal to twice a month
 | style="background: #DCDCDC; padding: 5px; text-align: center;" | ≥ 80% of predicted normal
@@ Line 39: / Line 42: @@
 |}
-====Step 1 Therapy:====
+====Mild Persistent Asthma====
-Short-acting inhaled [[Bronchodilator#Short-acting β2-agonists|β2-agonists]] on need basis.<ref name="pmid7436160">Shim C, Williams MH (1980) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7436160 Bronchial response to oral versus aerosol metaproterenol in asthma.] ''Ann Intern Med'' 93 (3):428-31. PMID: [http://pubmed.gov/7436160 7436160]</ref><ref name="pmid7282733">Shim C, Williams MH (1981) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7282733 Comparison of oral aminophylline and aerosol metaproterenol in asthma.] ''Am J Med'' 71 (3):452-5. PMID: [http://pubmed.gov/7282733 7282733]</ref>
+{| align="center" style="border: 0px; font-size: 90%; margin: 3px; width:70%;"
-===Mild Persistent Asthma===
-{| align="center" style="border: 0px; font-size: 90%; margin: 3px;"
 |-
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
+| style="width: 55%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per night'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms at night'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" | Symptoms more than twice a week but less than once a day. Exacerbations may affect activity and sleep.
+| style="background: #DCDCDC; padding: 5px; text-align: left;" |
+*Symptoms more than twice a week but less than once a day
+*Exacerbations may affect activity and sleep.
 | style="background: #DCDCDC; padding: 5px; text-align: center;" | Greater than or equal to twice a month
 | style="background: #DCDCDC; padding: 5px; text-align: center;" | ≥ 80%
@@ Line 56: / Line 58: @@
 |}
-====Step 2 Therapy:====
+====Moderate Persistent Asthma====
-*Preferred drug of choice is once a day [[steroid|low-dose steroid]] inhalation.
+{| align="center" style="border: 0px; font-size: 90%; margin: 3px; width:70%;"
-*Alternative therapies include:
-:*Use of anti-inflammatory drugs such as [[cromolyn]] or [[nedocromil]], ''OR''
-:*[[Theophylline]], [[montelukast]], [[zafirlukast]] along with a short-acting inhaled [[Bronchodilator#Short-acting β2-agonists|β2-agonists]].<ref name="pmid11037987">Berridge MS, Lee Z, Heald DL (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11037987 Pulmonary distribution and kinetics of inhaled [11C]triamcinolone acetonide.] ''J Nucl Med'' 41 (10):1603-11. PMID: [http://pubmed.gov/11037987 11037987]</ref>
-===Moderate Persistent Asthma===
-{| align="center" style="border: 0px; font-size: 90%; margin: 3px;"
 |-
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
+| style="width: 55%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per night'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms at night'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" | Daily symptoms. Exacerbations more than twice a week. Exacerbations may affect activity and sleep. Daily use of [[Bronchodilators#Short-acting β2-agonists|bronchodilators]].
+| style="background: #DCDCDC; padding: 5px; text-align: left;" |
+*Daily symptoms
+*Exacerbations more than twice a week
+*Exacerbations may affect activity and sleep
+*Daily use of [[Bronchodilators#Short-acting β2-agonists|bronchodilators]]
 | style="background: #DCDCDC; padding: 5px; text-align: center;" | More than once a month
 | style="background: #DCDCDC; padding: 5px; text-align: center;" | 60-80%
@@ Line 76: / Line 76: @@
 |}
-====Step 3 Therapy:====
+====Severe Persistent Asthma====
-*Preferred drug of choice:
+{| align="center" style="border: 0px; font-size: 90%; margin: 3px; width:70%;"
-:*Moderate dose of inhaled [[steroid]], ''OR''
-:*Low dose inhaled [[steroid]] along with inhaled [[Bronchodilators#Long-acting β2-agonists|long-acting β2-agonists]] <ref name="pmid11174215">Nelson HS (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11174215 Advair: combination treatment with fluticasone propionate/salmeterol in the treatment of asthma.] ''J Allergy Clin Immunol'' 107 (2):398-416. [http://dx.doi.org/10.1067/mai.2001.112939 DOI:10.1067/mai.2001.112939] PMID: [http://pubmed.gov/11174215 11174215]</ref> or [[Bronchodilators#Theophylline|sustained-release theophylline]] for nocturnal symptoms,
-*Alternative strategy includes the use of low-dose of inhaled [[steroid]] along with long-acting bronchodilators (either [[Bronchodilators#Long-acting β2-agonists|inhaled long-acting β2-agonists]] or [[Bronchodilators#Theophylline|sustained-release theophylline]]) and/or a short-acting inhaled [[Bronchodilator#Short-acting β2-agonists|β2-agonists]] on need basis.
-===Severe Persistent Asthma===
-{| align="center" style="border: 0px; font-size: 90%; margin: 3px;"
 |-
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
+| style="width: 55%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per night'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms at night'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
-| style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
+| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" | Continued symptoms. Frequent exacerbations. Limited physical activity.
+| style="background: #DCDCDC; padding: 5px; text-align: left;" |
+*Continued symptoms
+*Frequent exacerbations
+*Limited physical activity
 | style="background: #DCDCDC; padding: 5px; text-align: center;" | Frequent
 | style="background: #DCDCDC; padding: 5px; text-align: center;" | ≤ 60%
 | style="background: #DCDCDC; padding: 5px; text-align: center;" | ≥ 30%
 |}
-====Step 4 Therapy:====
-*Preferred drug of choice: Medium-dose of inhaled [[steroid]] along with  [[Bronchodilators#Long-acting β2-agonists|inhaled long-acting β2-agonists]]
-*Alternative strategy includes the use of medium-dose inhaled [[steroids]] along with long-acting [[bronchodilators]] (such as [[Bronchodilators#Long-acting β2-agonists|inhaled β2-agonists]] or [[Bronchodilators#Theophylline|sustained-release theophylline]] used alone or in combination) and/or short-acting inhaled [[Bronchodilator#Short-acting β2-agonists|β2-agonists]] may be used on need basis.
-====Step 5 Therapy:====
-*Preferred drug of choice: High-dose of inhaled [[steroid]] along with  [[Bronchodilators#Long-acting β2-agonists|inhaled long-acting β2-agonists]] and [[omalizumab]] in patients who have allergies.
 ==Guidelines for Diagnosis and Management of Asthma Based On The National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR3) <ref name="pmid18240881">Urbano FL (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18240881 Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines.] ''J Manag Care Pharm'' 14 (1):41-9. PMID: [http://pubmed.gov/18240881 18240881]</ref>==
 {| style="border: 0px; font-size: 90%; margin: 3px;"
-! rowspan="2" style="text-align: center; background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Severity Components}}
+! rowspan="2" style="text-align: center; background: #4479BA; text-align: center; width: 12%;" | {{fontcolor|#FFF|Severity Components}}
-! rowspan="2" style="text-align: center; background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Intermittent}}
+! rowspan="2" style="text-align: center; background: #4479BA; text-align: center; width: 22%;" | {{fontcolor|#FFF|Intermittent}}
 ! colspan="3" style="text-align: center; background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Persistent Asthma}}
 |-
-| style="text-align: center; background: #7d7d7d; text-align: center;" | {{fontcolor|#FFF|'''Mild'''}}
+| style="text-align: center; background: #7d7d7d; text-align: center; width: 22%;" | {{fontcolor|#FFF|'''Mild'''}}
-| style="text-align: center; background: #7d7d7d; text-align: center;" | {{fontcolor|#FFF|'''Moderate'''}}
+| style="text-align: center; background: #7d7d7d; text-align: center; width: 22%;" | {{fontcolor|#FFF|'''Moderate'''}}
-| style="text-align: center; background: #7d7d7d; text-align: center;" | {{fontcolor|#FFF|'''Severe'''}}
+| style="text-align: center; background: #7d7d7d; text-align: center; width: 22%;" | {{fontcolor|#FFF|'''Severe'''}}
 |-
 | style="background: #DCDCDC; padding: 5px;" |'''Symptoms'''
-| style="background: #F5F5F5; padding: 5px;" |Less than 1 day/week
+| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |More than 2 days/week
+* Less than 1 day/week
-Not daily
+| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |Daily
+* More than 2 days/week
-| style="background: #F5F5F5; padding: 5px;" |Daily
+* Not daily
-Throughout the day
+| style="background: #F5F5F5; padding: 5px;" |
+* Daily
+| style="background: #F5F5F5; padding: 5px;" |
+* Daily
+* Throughout the day
 |-
 | style="background: #DCDCDC; padding: 5px;" |'''Nocturnal Symptoms'''
-| style="background: #F5F5F5; padding: 5px;" |Less than 2 times/month
+| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |3 to 4 times/month
+* Less than 2 times/month
-| style="background: #F5F5F5; padding: 5px;" |More than 1 time/week
+| style="background: #F5F5F5; padding: 5px;" |
-Not every night
+* 3 to 4 times/month
-| style="background: #F5F5F5; padding: 5px;" |Every night
+| style="background: #F5F5F5; padding: 5px;" |
+* More than 1 time/week
+* Not every night
+| style="background: #F5F5F5; padding: 5px;" |
+* Every night
 |-
 | style="background: #DCDCDC; padding: 5px;" |'''Interference w/ Activity'''
-| style="background: #F5F5F5; padding: 5px;" |Minimal to none
+| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |Minor limitation of activity
+* Minimal to none
-| style="background: #F5F5F5; padding: 5px;" |Some limitation of activity
+| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |Severe limitation of activity
+* Minor limitation of activity
+| style="background: #F5F5F5; padding: 5px;" |
+* Some limitation of activity
+| style="background: #F5F5F5; padding: 5px;" |
+* Severe limitation of activity
 |-
-| style="background: #DCDCDC; padding: 5px;" |'''Short Acting Beta-Agonist Use'''
+| style="background: #DCDCDC; padding: 5px;" |'''Short-Acting Beta-Agonist Use'''
-| style="background: #F5F5F5; padding: 5px;" |Less than 2 days/week
+| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |More than 2 days/week but not daily
+* Less than 2 days/week
-Not more than once/day
+| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |Daily
+* More than 2 days/week but not daily
-| style="background: #F5F5F5; padding: 5px;" |Several times/day
+* Not more than once/day
+| style="background: #F5F5F5; padding: 5px;" |
+* Daily
+| style="background: #F5F5F5; padding: 5px;" |
+* Several times/day
 |-
 | style="background: #DCDCDC; padding: 5px;" |'''Pulmonary Function Test'''
-| style="background: #F5F5F5; padding: 5px;" |Normal FEV<sub>1</sub> between exacerbations
+| style="background: #F5F5F5; padding: 5px;" |
-FEV<sub>1</sub> > 80% predicted
+* Normal FEV<sub>1</sub> between exacerbations
+* FEV<sub>1</sub> > 80% predicted
-FEV<sub>1</sub>/FVC normal
+* FEV<sub>1</sub>/FVC normal
-| style="background: #F5F5F5; padding: 5px;" |FEV<sub>1</sub> > 80% predicted
+| style="background: #F5F5F5; padding: 5px;" |
-FEV<sub>1</sub>/FVC normal
+* FEV<sub>1</sub> > 80% predicted
-| style="background: #F5F5F5; padding: 5px;" |FEV<sub>1</sub> > 60% but < 80% predicted
+* FEV<sub>1</sub>/FVC normal
-FEV<sub>1</sub>/FVC reduced by 5%
+| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |FEV<sub>1</sub> < 60% predicted
+* FEV<sub>1</sub> > 60% but < 80% predicted
-FEV<sub>1</sub>/FVC reduced by > 5%
+* FEV<sub>1</sub>/FVC reduced by 5%
+| style="background: #F5F5F5; padding: 5px;" |
+* FEV<sub>1</sub> < 60% predicted
+* FEV<sub>1</sub>/FVC reduced by > 5%
 |-
 | style="background: #DCDCDC; padding: 5px;" |'''Recommended Treatment Strategy'''
-| style="background: #F5F5F5; padding: 5px;" |STEP 1
+| style="background: #F5F5F5; padding: 5px; vertical-align:top;" |'''STEP 1'''
-Preferred: Short-acting beta-agonist PRN
+* ''Preferred:'' Short-acting beta-agonist PRN
-| style="background: #F5F5F5; padding: 5px;" |STEP 2
+| style="background: #F5F5F5; padding: 5px; vertical-align:top;" |'''STEP 2'''
-Preferred: Low-dose inhaled corticosteroids
+* ''Preferred:'' Low-dose inhaled corticosteroids
-Alternative: Cromolyn, Leukotriene receptor antagonist, Nedocromil, or Theophylline
+* ''Alternative:'' Cromolyn, Leukotriene receptor antagonist, Nedocromil, or Theophylline
-| style="background: #F5F5F5; padding: 5px;" |STEP 3
+| style="background: #F5F5F5; padding: 5px; vertical-align:top;" |'''STEP 3'''
-Preferred: Low-dose inhaled corticosteroids + Long-acting beta-agonist
+* ''Preferred:'' '''Either''' low-dose inhaled corticosteroids + long-acting beta-agonist '''OR''' Medium-dose inhaled corticosteroid
-OR
-Medium-dose inhaled corticosteroid
-Alternative: Low-dose inhaled corticosteroid + either Leukotriene receptor antagonist, Theophylline, or Zileuton
+* ''Alternative:'' Low-dose inhaled corticosteroid + either Leukotriene receptor antagonist, Theophylline, or Zileuton
-| style="background: #F5F5F5; padding: 5px;" |STEP 4
+| style="background: #F5F5F5; padding: 5px;" |'''STEP 4'''
+* ''Preferred:'' Medium-dose inhaled corticosteroid + long-acting beta-agonist
+* ''Alternative:'' Medium-dose inhaled corticosteroids + either Leukotriene receptor antagonist, Theophylline, or Zileuton
+'''STEP 5'''
+* ''Preferred:'' High-dose inhaled corticosteroids + long-acting beta-agonist
+* Consider adding Omalizumab for patients with allergies
-STEP 5
+'''STEP 6'''
+* ''Preferred:'' High-dose inhaled corticosteroids + long-acting beta-agonist + oral corticosteroids
+* Consider adding Omalizumab for patients with allergies
-STEP 6
 |-
-| colspan="5" style="text-align: center;" | Step down if possible and asthma is controlled for at least 3 months                                                                                             Step-up if needed
+| colspan="5" style="text-align: center; background: #4479BA; padding: 5px;" | {{fontcolor|#FFF|'''Step down if possible and asthma is controlled for at least 3 months'''}} [[File:Dualarrow.png|200px]] {{fontcolor|#FFF|'''Step-up if needed, but first check adherence, environmental control, and comorbidities'''}}
 |-
-| colspan="5" |
+| colspan="5" style="background: #F5F5F5; padding: 5px;" |
 * In each step, patient education, environmental control, and management of comorbidities are important.
 * In STEP 2 - 4, consider subcutaneous allergen immunotherapy for patients with allergic asthma
 |-
-| colspan="5" |
+| colspan="5" style="background: #F5F5F5; padding: 5px;" |
-* Short-acting beta agonist as needed for symptoms. Up to 3 treatments at 20 minute intervals as needed.
+* Short-acting beta-agonist as needed for symptoms. Up to 3 treatments at 20 minute intervals as needed.
 * A short course of oral systemic corticosteroids may be needed. Use of a short-acting beta agonist for >2 days a week for symptom control indicates inadequate control and the need to step up therapy.
 |}
-<br clear="left" />
 ==References==
 {{reflist|2}}
+{{WH}}
+{{WS}}
-[[Category:Disease]]
-[[Category:Overview complete]]
-[[Category:Template complete]]
 [[Category:Pulmonology]]
 [[Category:Immunology]]
 [[Category:Emergency medicine]]
-[[Category:Intensive care medicine]]
-[[Category:Allergology]]
-[[Category:Asthma]]
-[[Category:Primary care]]
-[[Category:Up-To-Date]]
-[[Category:Up-To-Date pulmonology]]
 [[Category:Mature chapter]]
-{{WH}}
-{{WS}}