managing-asthma

# Managing Asthma

Structures asthma management per NAEPP guidelines with stepwise therapy and action plans.

## Why This Skill Exists

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.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the patient's age group (0-4, 5-11, ≥12 / adult)? **Default: adult (≥12)**
2. What is the current asthma severity classification or control level? **Default: assess**
3. What is the current controller medication regimen? **Default: none**
4. How often does the patient use rescue inhaler (SABA) per week? **Default: [REQUIRED]**
5. Has spirometry been performed within the past 12 months? **Default: no**
6. How many exacerbations requiring oral steroids in the past 12 months? **Default: unknown**
7. Has the patient had any ED visits or hospitalizations for asthma in the past year? **Default: no**
8. What are the patient's known triggers (allergens, exercise, occupational, GERD, medications)? **Default: unknown**

### 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)

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## Step 1: Asthma Severity Classification (Initial Assessment)

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.

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

| 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:**
- 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

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## Step 3: Inhaler Technique and Device Selection

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).

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## 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

| 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):
- 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

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## 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?

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## 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

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## 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