How Do I Treat Asthma According to the NIH Guidelines?

Patient Presentation
A 7-year-old male came to clinic because the last 3 nights he has been having a cough that has been interfering with sleep.
During the day he is also having some problems running on the playground and in gym class, but no problems during rest.
He has had mild clear rhinorrhea for 4 days with no sore throat, or emesis. He has complained of feeling “warm” but his temperature was 99.0 degrees Fahrenheit.
The family is out of his albuterol metered-dose inhaler.
The past medical history reveals 1-2 asthma exacerbations a year for the last 5 years that occur with upper respiratory infections. He has never been hospitalized nor been to the emergency room. He has used oral corticosteroids for some exacerbations and in between exacerbations is well. . He had atopic dermatitis as an infant and has some dry skin in the wintertime.
He has no symptoms of allergies and there is no tobacco smoking around him.
The family history shows hayfever in both parents. His brother also had atopic dermatitis as an infant.
The review of systems is otherwise negative.
The pertinent physical exam shows an alert male in no acute distress. Respiratory rate is 26 and he is afebrile. He easily converses but coughs several times during the examination.
He has clear rhinorrhea in the nose and posterior pharynx. His lung examination shows a mildly prolonged end-expiratory phase with intermittent mild, end-expiratory wheezing.
The diagnosis of an acute exacerbation of his mild intermittent asthma is made. He is given another prescription for albuterol metered-dose inhalers with a spacer to be given 2 puffs for increased work of breathing, before bedtime, and before exercise. More than one inhaler was given so the patient would have an inhaler available at home and school.
A prescription for oral corticosteroids is given to be used if symptoms are increasing such as needing to use the albuterol more than every 4 hours. The family was again instructed on the role of the medication, how to use the medication and spacer properly, and when to call a physician or go to the emergency room for an exacerbation.
The patient’s clinical course over the next several days showed him using the inhaler ~ 4 times/day initially and then decreasing over the next 5 days. Oral corticosteroids were not begun.

Asthma is a chronic inflammatory process of the airways where episodic, reversible airway obstruction occurs and alternative diagnoses are excluded.
In children it is commonly associated with atopy. Wheezing with viral infections, a family history of allergy are strongly associated with continued asthma during childhood
Various factors can make asthma difficult to control and should be screened for in each patient. If the factors are present patient and their families should be appropriately counseled and treatment recommendations made. Examples include:

  • Allergens – indoor and outdoor
  • Irritants – including tobacco smoke or occupational or recreational exposure
  • Foods and medications – e.g. sulfites, beta-blockers, aspirin
  • Gastroesophageal reflux
  • Rhinitis and sinusitis
  • Upper respiratory tract infections

Learning Point
According to the National Institutes of Health’s Expert Panel Report entitled “Guidelines for Asthma Diagnosis and Management,” asthma is classified by severity and treatment recommendations are made based upon those classifications. More recently, studies are beginning to look at classifications based upon how well the asthma symptoms are controlled.

Overall, the goals of asthma treatment include:

  • No or minimal chronic symptoms
  • No or minimal exacerbations
  • No activities of daily living and school/work limitations
  • Maintain normal or near normal pulmonary function
  • Minimal use of short-acting inhaled beta-2 agonists
  • No or minimal medication side-effects

Review treatment and step down every 1-6 months if possible. Step up if control is not maintained.

NIH’s asthma severity and long-term control treatment recommendations include:

  • Step 1. Mild Intermittent
    • Definition
      • Symptoms < or = 2 times/week
      • Nocturnal symptoms < or = 2 times/month
      • Symptom free in-between exacerbations
    • Long-term control for patients < 5 years
      • No daily medication needed
    • Long-term control for patients > 5 years
      • No daily medication needed
  • Step 2. Mild Persistent
    • Definition
      • Symptoms > 2 times/week but < 1 time/day
      • Activities may be affected by exacerbations
      • Nocturnal symptoms > 2 times/month
    • Long-term control for patients < 5 years
      • Preferred: low-dose inhaled corticosteroid
      • Alternative: cromolyn or leukotriene receptor antagonist
    • Long-term control for patients > 5 years
      • Preferred: low-dose inhaled corticosteroid
      • Alternative: cromolyn, leukotriene modifier, nedocromil OR sustained-release theophylline
  • Step 3. Moderate Persistent
    • Definition
      • Symptoms daily
      • Nocturnal symptoms > 1 time/week
    • Long-term control for patients < 5 years
      • Preferred: low-dose inhaled corticosteroids along with a long-active inhaled beta-2 agonist, OR medium-dose inhaled corticosteroids alone
      • Alternative: low-dose inhaled corticosteroids along with either a leukotriene receptor antagonist or theophylline
      • If needed for specific patients, alternative recommendations are made by the expert group, see “To Learn More” below
    • Long-term control for patients > 5 years
      • Preferred: low-medium dose inhaled corticosteroids along with long-active inhaled beta-2 agonists
      • Alternative: increase inhaled corticosteroids within medium-dose range, OR low-medium dose inhaled corticosteroids along with either a leukotriene modifier or theophylline
  • Step 4. Severe Persistent
    • Definition
      • Symptoms continuous
      • Nocturnal symptoms frequently
    • Long-term control for patients < 5 years
      • Preferred: high-dose inhaled corticosteroids along with long-acting beta-2 agonist, AND if needed systemic corticosteroids
    • Long-term control for patients > 5 years
      • Preferred: high-dose inhaled corticosteroids along with long-acting beta-2 agonist, AND if needed systemic corticosteroids

    Short-term asthma relief includes:

    • Short-acting bronchodilators
    • Treatment intensity depends on severity of the exacerbations. Up to 3 treatments at 20-minute intervals or a single nebulizer treatment as needed.
    • Systemic corticosteroids may be needed.
    • Using short-acting beta-2 agonists > 2 times/week in intermittent asthma or daily and increasing use in persistent asthma may indicate the need to increase or initiate long-term control treatment

    Guidelines for specific medication dosing can be found in the executive summary of the guidelines listed below in To Learn More

    Questions for Further Discussion
    1. How many medication doses are there in a metered-dose inhaler?
    2. How should a peak flow meter be used?
    3. What are the potential side-effects of inhaled and systemic corticosteroid use?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Asthma in Children and
    at Pediatric Common Questions, Quick Answers for this topic: Asthma

    To view current news articles on this topic check Google News.

    Yawn BP, Brenneman SK, Allen-Ramey FC, Cabana MD, Markson LE. Assessment of asthma severity and asthma control in children.
    Pediatrics. 2006 Jul;118(1):322-9.

    National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Available from the Internet at: (rev. July 1997, cited 10/30/06).

    National Asthma Education and Prevention Program Expert Panel Report Guidelines for the Diagnosis and Management of Asthma – Update on Selected Topics 2002. Available from the Internet at: (rev. 2002, cited 10/30/06).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    November 20, 2006