Classifying Asthma Severity and Initiating 

Treatment in Children 0‐4

Treatment in Children 0 4 Years of Age  
Years of Age
Classification of Asthma Severity (0‐4 years of age)
Components of Severity Persistent
Intermittent
Mild Moderate Severe
> 2 days/week 
≤ 2 days/week Daily Throughout the day  
Symptoms but not daily

Nighttime awakenings 0 1‐2x/month 3‐4x/month >1x/week

Impairment
Short‐acting beta
Short acting beta2‐
agonist use for  ≤ 2 days/week > 2 days/week 
Daily Several times per day
symptom control (not  but not daily
prevention of EIB)
Interference with 
None Minor limitation Some limitation Extremely limited
normal activityy
≥ 2 exacerbations in 6 months requiring oral systemic corticosteroids, 
0‐1/year  or ≥ 4 wheezing episodes/1 year lasting > 1 day AND risk factors for 
persistent asthma
Exacerbations 
Risk requiring oral systemic  Consider severity and interval since last exacerbation
corticosteroids F
Frequency and severity may fluctuate over time
d it fl t t ti
Exacerbations of any severity may occur in patients in any severity category

Step 3 and consider short course of oral systemic 
Step 1 Step 2
Recommended Step  corticosteroids

for Initiating Treatment
g In 2‐6
In 2 6 weeks, depending on severity, evaluate level of asthma control that is achieved. If no clear benefit is 
weeks depending on severity evaluate level of asthma control that is achieved If no clear benefit is
observed in 4‐6 weeks, consider adjusting therapy or alternative diagnosis

EIB = exercise‐induced bronchospasm
National Asthma Education and Prevention Program. Publication No. 07‐4051. Available from: 
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
 Classifying Asthma Severity and Initiating 
Treatment in Children 5‐11 Years of Age
Classification of Asthma Severity (5‐11 years of age)
Components of Severity Persistent
Intermittent
Mild Moderate Severe

S
Symptoms
t ≤2d /
≤ 2 days/week
k >2d /
> 2 days/week but not daily
k b t t d il D il
Daily Th
Throughout the day  
h t th d

> 1x/week 
Nighttime awakenings ≤ 2x/month 3‐4x/month Often 7x/week
but not nightly

Impairment Short‐acting beta2‐agonist 
use for symptom control
use for symptom control  ≤ 2 days/week
≤ 2 days/week > 2 days/week but not daily
> 2 days/week but not daily  Daily Several times per day
Several times per day
(not prevention of EIB)

Interference with normal 
None Minor limitation Some limitation Extremely limited
activity

• Normal FEV1 between 
• FEV1 = 60‐80%     • FEV1< 60% predicted
exacerbations • FEV1 = >80% predicted
predicted • FEV1/FVC
/FVC <75%
<75%
Lung function • FEV1 > 80% predicted • FEV1/FVC >80%
• FEV1/FVC =75‐80%
• FEV1/FVC >85%

0‐1/year ≥ 2/year
Exacerbations requiring 
Risk oral systemic  Consider severity and interval since last exacerbation
corticosteroids Frequency and severity may fluctuate over time for patients in any severity category
q y y y p y y g y
Relative annual risk of exacerbations may be related to FEV1
Step 3, medium‐dose  Step 3, medium‐dose 
ICS option ICS option, or Step 4
Step 1 Step 2 and consider short course of oral systemic 
Recommended Step for Initiating Treatment corticosteroids

In 2‐6
In 2 6 weeks, evaluate level of asthma control that is achieved, and adjust therapy accordingly
weeks evaluate level of asthma control that is achieved and adjust therapy accordingly

FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity; ICS = inhaled corticosteroids
National Asthma Education and Prevention Program. Publication No. 07‐4051. Available 
from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
FDA‐Approved Agents in Children
ICS Age indications
Mometasone 110 mcg ages 4 to 11, 220 mcg down to age 12
110 mcg ages 4 to 11, 220 mcg down to age 12
Budesonide MDI down to age 6, respules down to age 12 
months to 8 years
Fl ti
Fluticasone MDI d Diskus
MDI and Di k down
d t
to age 4
4
Beclomethasone Down to age 5
Ciclesonide Down to age 12
ICS + LABA Age Indication
Fluticasone/salmeterol MDI down to age 12 years, Diskus down to age 4 
years
Budesonide/formoterol MDI down to age 12 years
g y
Mometasone/formoterol MDI down to age 12 years
LABA = long‐acting beta‐agonist; MDI = meter dose inhaler
National Asthma Education and Prevention Program. Publication No. 07-4051.
Available from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
FDA‐Approved LTRA Agents in Adults

Leukotriene Receptor Antagonists  Doses
Zafirlukast 10 mg twice daily ages 5‐11 

Montelukast 4 mg oral granules ages 6‐23 

months, 4 mg oral granules or oral 
tablet ages 2‐5, 5 mg chewable 
tablet ages 6‐14

LTRA = Leukotriene
LTRA L k ti R
Receptor Antagonists 
t A t it
National Asthma Education and Prevention Program. Publication No.
07-4051. Available from:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
 Stepwise Approach for Managing Asthma in 
Children 0‐4 Years of Age
Intermittent  Persistent Asthma: Daily Medication
Consult with asthma specialist if step 3 care or higher is required.
Asthma Consider consultation at step 2. Step up if 
needed
Step 6
(first, check 
(first check
Step 5 Preferred: adherence, 
inhaler 
Preferred: High‐dose             
Step 4 technique, and 
High‐dose ICS  ICS + environmental 
Step 3 Preferred:
+ control))
either LABA
either LABA   
Medium‐
Step 2 Preferred: either LABA  or  Assess 
dose ICS +
or  Montelukast control
Preferred: Medium‐
Step 1 dose ICS either LABA  Montelukast
Preferred: Low‐dose ICS or  Step down if 
short‐acting
short acting  Montelukast Oral systemic
Oral systemic      possible
beta2‐agonist Alternative: Corticosteroids
(and asthma is 
(SABA) Cromolyn or  well controlled 
As needed Montelukast at least 3 
months)
Patient Education and Environmental Control at Each Step
• Quick‐Relief Medication for All Patients
• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms.
• With viral respiratory infection: SABA q 4‐6 hours up to 24 hours (longer with physician consult). Consider short 
course of oral systemic corticosteroids if exacerbation is severe or patient has history of previous severe 
exacerbations.
• Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations on 
Caution: Frequent use of SABA may indicate the need to step up treatment See text for recommendations on
initiating daily long‐term‐control therapy.
Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy.
National Asthma Education and Prevention Program. Publication No. 07-4051. Available
from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
 Stepwise Approach for Managing Asthma in 
Children 5‐11 Years of Age
Intermittent 
Intermittent Persistent Asthma: Daily Medication
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Asthma
Consider consultation at step 3.
Step up if 
Step 6 needed
Step 5 Preferred: (first, check 
(first, check
Step 4 Preferred: High‐dose              adherence, 
inhaler 
High‐dose ICS  ICS + LABA + 
Preferred: technique, and 
Step 3 + LABA oral systemic  environmental 
Preferred: Medium‐dose 
Step2 Alternative: corticosteroid control, and 
EITHER: ICS + LABA
Alternative: comorbid
Preferred:    Low‐dose ICS  Alternative: High‐dose ICS 
Step 1 conditions)
Low‐dose ICS + either  + either LTRA  High‐dose ICS 
Medium‐dose 
Preferred: Alternative: LABA,  LTRA,  or  + either LTRA  Assess 
ICS+ either
SABA  Cromolyn,  or  Theophylline or  control
LTRA, , Theohylline LTRA or 
As needed
As needed Theophylline + +
OR medium  Theophylline Step down if 
Nedocromil, or  oral systemic 
Theophylline dose ICS corticosteroid possible
Each step: Patient education, environmental control, and management of comorbidities. (and asthma is 
Steps 2‐4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma*  well controlled 
at least 3 
• Quick‐Relief Medication for All Patients
f f
months)
• 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.

Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy.
National Asthma Education and Prevention Program. Publication No. 07‐4051. Available 
from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
 Assessing Asthma Control and Adjusting 
Therapy in Children 0‐4
Therapy in Children 0 4 Years of Age
Years of Age
Components of Control
Symptoms
Nighttime awakenings
Interference with normal 
Impairment activity
Short‐acting beta2‐agonist use 
for symptom control (not  ≤ 2 days/week
prevention of EIB)
Exacerbations requiring oral 
systemic corticosteroids
Risk
Treatment‐related adverse 
effects
Recommended Action for Treatment
National Asthma Education and Prevention Program. Publication No. 07‐4051. Available
from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
Classification of Asthma Control (0‐4 years of age)
Not Well 
Well Controlled Very Poorly Controlled
Controlled
≤ 2 days/week  > 2 days/week Throughout the day  
≤ 1x/month > 1x/month >1x/week
None Some limitation Extremely limited 
> 2 days/week Several times per day
0‐1/year 2‐3/year > 3/year
Medication side effects can very 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.
• Step up (1 step) and • Consider short course of oral 
• Reevaluate in 2‐6 weeks
R l t i 26 k t i corticosteroids
systemic ti t id
• Maintain current treatment
• If no clear benefit in 4‐6  • Step up (1‐2 steps), and
• Regular follow‐up every 1‐6 
weeks, consider  • Reevaluate in 2 weeks
months
• Consider step down if well 
alternative diagnoses or  • If no clear benefit in 4‐6 
adjusting therapy weeks, consider alternative 
controlled for at least 3 
• For side effects, consider  diagnoses or adjusting therapy
months
aalternative treatment 
te at e t eat e t • For side effects, consider 
o s de e ects, co s de
options alternative treatment options
 
 Assessing Asthma Control and Adjusting 
Therapy in Children 5‐11 Years of Age
Classification of Asthma Control (5‐11 years of age)
Components of Control
Well Controlled Not Well Controlled Very Poorly Controlled
≤ 2 days/week but not more than  > 2 days/week or multiple 
Symptoms Throughout the day  
once on each day times on ≤ 2 days/month

Nighttime awakenings ≤ 1x/month ≥ 2x/month > 2x/week

Interference with normal 
None Some limitation Extremely limited 
activity
Impairment
Short‐acting beta2‐agonist use 
for symptom control (not 
y p ( ≤ 2 days/week
y ≥ 2 days/week
y Several times per day
p y
prevention of EIB)
Lung function • 60‐80% 
• > 80% predicted/personal best • < 60% predicted/personal best
• FEV1 or peak flow predicted/personal best
• > 80% • < 75%
• FEV1/FVC • 75‐80%

EExacerbations requiring oral 
b ti ii l 0‐1/year
0 1/year ≥ 2/year
≥ 2/year
systemic corticosteroids Consider severity and interval since last exacerbation

Risk Reduction in lung growth Evaluation requires long‐term follow‐up

Medication side effects can vary in intensity from none to very troublesome and worrisome. The level 
Treatment‐related adverse 
of intensity does not correlate to specific levels of control but should be considered in the overall 
eeffects
ects
assessment of risk
f ik

• Maintain current step • Step up at least 1 step  • Consider short course of oral 

• Regular follow‐up every 1‐6  and systemic corticosteroids
months • Reevaluate in 2‐6 weeks • Step up 1‐2 steps, and
Recommended Action for Treatment
• Consider step down if well  • For side effects, consider  • Reevaluate in 2 weeks
controlled for at least 3
controlled for at least 3  alternative treatment
alternative treatment  • For side effects, consider 
For side effects, consider
months options alternative treatment options

National Asthma Education and Prevention Program. Publication No. 07‐4051. 
Available from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
 Classifying Asthma Severity and Initiating 
Treatment in Persons ≥ 12 Years of Age
Treatment in Persons ≥ 12 Years of Age
Classification of Asthma Severity (≥ 12 years of age)
Components of Severity Persistent
Intermittent Mild Moderate Severe
> 2 days/week 
Symptoms ≤ 2 days/week Daily Throughout the day  
but not daily
Impairment > 1x/week but not 
Nighttime awakenings ≤ 2x/month 3‐4x/month Often 7x/week
nightly
Normal  Short‐acting beta
g 2‐agonist use 
g > 2 days/week 
≤ 2 days/week
≤ 2 days/week
FEV1/FVC: for symptom control (not  but not daily, and not  Daily Several times per day
8‐19 yr: 85% prevention of EIB) more than 1x on any day

20‐39 yr: 80% Interference with normal activity None Minor limitation Some limitation Extremely limited

40‐59 yr: 75% • Normal FEV1 between  • FEV1 > 60% but         
60‐80
60 80 yr: 70%
yr: 70% exacerbations • FEV1 > 80% predicted
p < 80% predicted
p • FEV1 < 60% predicted
p
L
Lung function
f i
• FEV1 > 80% predicted • FEV1/FVC normal • FEV1/FVC reduced  • FEV1/FVC reduced > 5%
• FEV1/FVC normal 5%

0 – 1/year  ≥ 2/year

Exacerbations requiring oral  Consider severity and interval since last exacerbation
Risk systemic corticosteroids
y Frequency and severity may fluctuate over time for patients in any severity category
Frequency and severity may fluctuate over time for patients in any severity category
Relative annual risk of exacerbations may be related to FEV1

Step 3 Step 4 or 5
Recommended Step  Step 1 Step 2
and consider short course of oral systemic 
for Initiating Treatment
for Initiating Treatment corticosteroids
In 2‐6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly

National Asthma Education and Prevention Program. Publication No. 07‐4051. Available 
at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
 Stepwise Approach for Managing Asthma in 
Youths ≥ 12 Years of Age and Adults
Youths ≥ 12 Years of Age and Adults
Intermittent  Persistent Asthma: Daily Medication                                                                          
Consult with asthma specialist if step 4 care or higher is required.                         
Asthma Consider consultation at step 3.

Step 6
Step 5 Step up if 
Step 4 Preferred:
needed
Preferred: Preferred:
Step 3 Medium‐dose 
High‐dose             
(first, check 
Preferred:           High‐dose ICS 
ICS + LABA
ICS + LABA ICS + LABA + 
ICS + LABA + adherence
adherence, 
St 2
Step2 Low dose  
Alternative:
+ LABA
environmental 
ICS + LABA oral  
Preferred:    OR medium‐ Medium‐ AND corticosteroid control, and 
Step 1 Low‐dose ICS dose ICS dose  AND comorbid
Alternative:
Consider 
Alternative: ICS+either Consider  conditions)
Preferred: low‐dose Omalizumab
Cromolyn, 
y LTRA,  Omalizumab
SABA
SABA  ICS + either
ICS + either  Theophylline,  for patients
for patients  Assess 
A
LTRA,  LTRA,  who have  for patients 
As needed or Zileuton control
Nedocromil, or  Theophylline, or  allergies  who have 
Theophylline  Zileuton allergies Step down if 
possible
Each step: Patient education, environmental control, and management of comorbidities.
Steps 2‐4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma ((and asthma is 
d th i
well controlled 
• Quick‐Relief Medication for All Patients                                                                                         at least 3 
months)
• 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.

National Asthma Education and Prevention Program. Publication No. 07‐4051. Available 
from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
 Assessing Asthma Control and Adjusting 
Therapy in Youth ≥ 12 Years of Age and Adults
Classification of Asthma Control ( ≥ 12 years of age)
Classification of Asthma Control ( ≥ 12 years of age)
Components of Control Well Controlled Not Well Controlled Very Poorly Controlled
Symptoms ≤ 2 days/week >2 days/week Throughout the day
Nighttime awakenings ≤ 2x/month 1‐3x/week ≥ 4x/week
Interference ith normal acti it
Interference with normal activity None Some limitation
Some limitation E tremel limited
Extremely limited
Short‐acting beta2‐agonist use for 
symptom control (not prevention of  ≤ 2 days/week >2 days/week Several times per day
EIB)
> 80% predicted/  60‐80% predicted/ 
FEV1 or peak flow < 60% predicted/ personal best
personal best
personal best personal best
personal best
Impairment Validated Questionnaires
ATAQ 0 1‐2 3‐4
ACQ ≤ 0.75* ≥ 1.5 N/A
ACT ≥ 20 16‐19 ≤ 15

Exacerbations requiring oral systemic  0‐1/year
/ ≥ 2/year
/
corticosteroids Consider severity and interval since last exacerbation
Progressive loss of lung function Evaluation requires long‐term follow‐up care

Risk Medication side effects can vary in intensity from none to very troublesome and worrisome.  The 
Treatment‐related adverse effects level of intensity does not correlate to specific levels of control but should be considered in the 
y p
overall assessment of risk
• Maintain current step • Consider short course of oral systemic 
• Step up 1 step and
• Regular follow ups  corticosteroids,
• Reevaluate in 2‐6 
every 1‐6 months to  • Step up 1‐2 steps, and
weeks
maintain control
Recommended Action for Treatment
Recommended Action for Treatment • For side effects, 
For side effects, • Reevaluate in 2 weeks
• Consider step down if 
d d f
consider alternative  • For side effects, consider alternative 
well controlled for at 
treatment options treatment options
least 3 months
National Asthma Education and Prevention Program. Publication No. 07‐4051. 
Available from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
 FDA‐Approved ICS and Combination 
Agents in Adults
Agents in Adults
ICS Doses
Mometasone Twisthaler® ‐ 110 mcg or 220 mcg
Budesonide Flexhaler® – 90 mcg or  180 mcg
Respules® – 0.25 & 0.5 mg or 1mg/2mL
Fl ti
Fluticasone Diskus® ‐
Di k ® 50 mcg, 100 mcg or 250 mcg
50 100 250
MDI – 110 mcg or 220 mcg
Beclomethasone MDI ‐ 40 mcg or 80 mcg
Ciclesonide MDI – 80 mcg or 160 mcg

ICS + LABA Doses
Fluticasone/salmeterol MDI – 45/21, 115/21, 230/21
Diskus® 100/50, 250/50 or 500/50
Budesonide/formoterol MDI – 80/4.5 or 160/4.5
Mometasone/formoterol MDI – 100/5 or 200/5
National Asthma Education and Prevention Program. Publication No. 07‐4051. 
Available from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
 FDA‐Approved LTRA Agents in Adults

Leukotriene Receptor Antagonists  Doses
Zafirlukast 20 mg tablets

Montelukast 10 mg tablets

National Asthma Education and Prevention Program. Publication No. 07‐4051. 
Available from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.