Managing Asthma

Documents to Request

• Spirometry with bronchodilator reversibility (baseline and post-bronchodilator FEV1)
• Peak expiratory flow (PEF) diary if available
• Current asthma action plan (if established)
• Medication list with inhaler devices and technique assessment
• Allergy testing results (skin prick or specific IgE)
• ED visit or hospitalization records for asthma
• Pharmacy refill history for rescue and controller inhalers
• Eosinophil count and total IgE (if severe or uncontrolled)

Step 1: Asthma Severity Classification (Initial Assessment)

For patients NOT currently on controller therapy, classify severity:

Classify severity by the most severe component. Any exacerbation requiring OCS places patient at minimum moderate persistent.

Step 2: Stepwise Therapy (Ages ≥12 / Adults)

NAEPP 2020 Update key changes:

• PRN ICS-formoterol (SMART) now preferred at Steps 1-4 for ages ≥12
• SABA alone (without ICS) is no longer the preferred reliever at ANY step
• Prior to stepping up, assess: adherence, inhaler technique, trigger avoidance, comorbidities

Step 3: Inhaler Technique and Device Selection

Correct technique accounts for more treatment "failure" than drug selection:

Demonstrate and observe technique at every visit. Document assessment as: correct, partially correct (specify error), or incorrect (retrain).

Step 4: Asthma Action Plan

Every patient must receive a written asthma action plan with three zones:

GREEN Zone (Doing Well):

• No cough, wheeze, chest tightness, SOB
• PEF >80% personal best
• Can do usual activities
• Continue controller medications as prescribed

YELLOW Zone (Getting Worse):

• Cough, wheeze, chest tightness, or SOB
• Waking at night due to asthma
• PEF 50-80% personal best
• Action: increase ICS-formoterol use (if on SMART) OR take 2-4 puffs SABA q20min × 3; if no improvement, start prednisone burst (40-60mg/day × 5-7 days for adults); contact provider

RED Zone (Medical Alert):

• Very short of breath, SABA not helping within 15-20 minutes
• Difficulty walking or talking due to SOB
• PEF <50% personal best
• Action: take SABA 4-6 puffs via spacer; if no improvement in 15 minutes, CALL 911; take oral prednisone if prescribed

Include: patient name, date, provider signature, medications with doses, personal best PEF, emergency contacts.

Step 5: Monitoring and Step-Down Assessment

Step-down protocol (well-controlled ≥3 months):

• Reduce one step at a time
• Step 3→2: Reduce to low-dose ICS alone or PRN ICS-formoterol
• Step 2→1: Switch to PRN ICS-formoterol only
• Never stop ICS completely without monitoring plan
• If loss of control after step-down: return to prior effective step

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is asthma severity or control level documented with supporting data (symptoms, spirometry, exacerbations)?
2. Does the therapy step match the severity/control classification?
3. Has inhaler technique been assessed and documented?
4. Does the patient have a written asthma action plan?
5. Is the next assessment date scheduled with specific step-up or step-down criteria?

Quality Audit

• Asthma severity classified (new patient) or control level assessed (established patient)
• Spirometry performed at diagnosis and within past 12 months
• Stepwise therapy matches severity/control classification
• ICS prescribed for ALL persistent asthma (not SABA-only regimens)
• SABA-only treatment reserved for truly intermittent asthma per 2020 update
• Inhaler technique assessed and documented at each visit
• Written asthma action plan provided with three zones and medication doses
• Trigger avoidance counseling documented (allergens, tobacco smoke, occupational)
• Allergy testing performed or planned for patients with allergic triggers
• ACT score documented at each visit
• Pharmacy refill history reviewed for adherence assessment
• Exacerbation history (OCS courses, ED visits, hospitalizations) documented for past 12 months
• Eosinophil count checked if considering Step 5 biologic therapy
• Step-down considered after ≥3 months of good control

Guidelines

• Never prescribe a LABA without an ICS; LABA monotherapy in asthma increases the risk of fatal and near-fatal asthma exacerbations (FDA black box warning)
• SABA overuse (≥3 canisters per year) is a marker of uncontrolled asthma and increased mortality risk; step up controller therapy
• Short-acting beta-agonist alone (without ICS) is no longer recommended as the sole treatment at ANY step per NAEPP 2020 and GINA 2023
• Montelukast (LTRA) carries an FDA black box warning for neuropsychiatric events (depression, suicidality, hallucinations); use only when ICS is not tolerated or in exercise-induced bronchospasm
• Spirometry is required for asthma diagnosis—clinical symptoms alone are insufficient; document reversibility (≥12% and ≥200mL improvement in FEV1 post-bronchodilator)
• Patients with ≥2 exacerbations requiring OCS per year should be evaluated for step-up therapy, phenotyping (eosinophilic vs. non-eosinophilic), and possible biologic eligibility
• Smoking cessation is essential; active smoking reduces ICS efficacy by approximately 50%
• All patients with asthma should receive annual influenza vaccination and age-appropriate pneumococcal vaccination