Structures asthma management per NAEPP guidelines with stepwise therapy and action plans. Use when managing asthma, adjusting controller medications, or creating asthma action plans.
Structures asthma management per NAEPP guidelines with stepwise therapy and action plans.
Asthma affects approximately 25 million Americans, including 5 million children, and accounts for 1.6 million ED visits and 3,500 deaths annually. The NAEPP Expert Panel Report 3 (EPR-3) and the 2020 Focused Updates from NHLBI provide the stepwise approach to therapy, with significant updates including the recommendation for PRN ICS-formoterol as both reliever and controller therapy (single maintenance and reliever therapy, or SMART). Despite effective treatments, approximately 60% of asthma patients remain uncontrolled, primarily due to poor adherence, incorrect inhaler technique, and under-treatment.
This skill enforces the NAEPP stepwise approach to asthma classification, therapy selection, action plan creation, and monitoring. Proper implementation reduces exacerbations, ED visits, hospitalizations, and oral corticosteroid courses while improving patient quality of life and lung function.
For patients NOT currently on controller therapy, classify severity:
| Component | Intermittent | Mild Persistent | Moderate Persistent | Severe Persistent |
|---|---|---|---|---|
| Symptoms | ≤2 days/week | >2 days/week, not daily | Daily | Throughout the day |
| Nighttime awakenings | ≤2x/month | 3-4x/month | >1x/week, not nightly | Often 7x/week |
| SABA use for rescue | ≤2 days/week | >2 days/week, not daily | Daily | Several times/day |
| Activity limitation | None | Minor | Some | Extremely limited |
| FEV1 (% predicted) | >80% | >80% | 60-80% | <60% |
| FEV1/FVC | Normal | Normal | Reduced 5% | Reduced >5% |
| Exacerbations requiring OCS | 0-1/year | ≥2/year | ≥2/year | ≥2/year |
Classify severity by the most severe component. Any exacerbation requiring OCS places patient at minimum moderate persistent.
| Step | Preferred Controller | Alternative Controller | SABA Use |
|---|---|---|---|
| Step 1 (Intermittent) | PRN low-dose ICS-formoterol (SMART) | PRN SABA + PRN ICS with each SABA use | As needed |
| Step 2 (Mild Persistent) | Low-dose ICS daily OR PRN ICS-formoterol | LTRA (montelukast); less effective than ICS | PRN |
| Step 3 (Moderate Persistent) | Low-dose ICS-LABA (e.g., fluticasone-salmeterol 100/50 or budesonide-formoterol 80/4.5) | Medium-dose ICS alone | PRN ICS-formoterol preferred |
| Step 4 | Medium-dose ICS-LABA | Medium-dose ICS + LTRA or medium-dose ICS + LAMA (tiotropium) | PRN ICS-formoterol |
| Step 5 | High-dose ICS-LABA + LAMA (tiotropium) | Consider biologic add-on per phenotype | PRN ICS-formoterol |
| Step 6 | High-dose ICS-LABA + biologic (omalizumab, mepolizumab, dupilumab, tezepelumab) | Oral corticosteroids (lowest dose, shortest duration) | PRN |
NAEPP 2020 Update key changes:
Correct technique accounts for more treatment "failure" than drug selection:
| Device Type | Inspiratory Flow Required | Common Errors | Best For |
|---|---|---|---|
| MDI (metered-dose inhaler) | Slow, deep inhalation | Poor coordination, no spacer, fast inhalation | With spacer for all ages |
| MDI + spacer/VHC | Slow inhalation or tidal breathing | Not priming, not cleaning spacer | Children, elderly, poor coordination |
| DPI (dry powder inhaler) | Fast, forceful inhalation (>60 L/min) | Exhaling into device, insufficient inspiratory force | Age ≥5 with good inspiratory effort |
| SMI (soft mist inhaler, Respimat) | Slow, deep inhalation | Same as MDI without coordination issue | Elderly, COPD overlap |
| Nebulizer | Tidal breathing | Long treatment time, poor cleaning | Severe exacerbations, young children, elderly |
Demonstrate and observe technique at every visit. Document assessment as: correct, partially correct (specify error), or incorrect (retrain).
Every patient must receive a written asthma action plan with three zones:
GREEN Zone (Doing Well):
YELLOW Zone (Getting Worse):
RED Zone (Medical Alert):
Include: patient name, date, provider signature, medications with doses, personal best PEF, emergency contacts.
| Assessment | Frequency | Tool |
|---|---|---|
| Symptom control | Every visit | ACT (Asthma Control Test) score ≥20 = well-controlled |
| Spirometry | At diagnosis, after treatment initiation, every 1-2 years | FEV1 % predicted |
| Inhaler technique | Every visit | Observation and correction |
| Adherence | Every visit | Pharmacy refill data + patient report |
| Exacerbation frequency | Every visit | OCS courses, ED visits, hospitalizations |
| Step-down readiness | After 3+ months of good control | Reduce by one step; monitor for 3 months |
Step-down protocol (well-controlled ≥3 months):