An overview of asthma management in children and adults

INTRODUCTION — The main goals of asthma management are to optimize control of asthma symptoms, reduce the risk of asthma exacerbations, and preserve lung function while minimizing medication adverse effects. It is expected that a person with well-controlled asthma should be able to participate in normal daily activities including sleep, work, school, play, and sports without limitation due to breathing. The four essential components of asthma management are patient education, minimizing exposure to asthma triggers, monitoring for changes in symptoms or lung function, and pharmacologic therapy. This overview topic presents the goals and components of asthma management. It is applicable to both children and adults. The recommendations are based upon major published asthma guidelines [1-4].

The diagnosis of asthma and more detailed management issues are reviewed separately. The management of asthma exacerbations is also covered separately. These topics are divided by age, care setting, and disease severity.

Asthma diagnosis and evaluation:

●(See "Asthma in children younger than 12 years: Initial evaluation and diagnosis".)

●(See "Asthma in adolescents and adults: Evaluation and diagnosis".)

●(See "Diagnosis and management of asthma in older adults".)

●(See "Evaluation of severe asthma in adolescents and adults".)

●(See "Severe asthma phenotypes".)

Detailed discussions of nonpharmacologic asthma management:

●(See "Asthma education and self-management".)

●(See "Trigger control to enhance asthma management".)

●(See "Allergen avoidance in the treatment of asthma and allergic rhinitis".)

●(See "Peak expiratory flow monitoring in asthma" and "Pulmonary function testing in asthma".)

●(See "Complementary, alternative, and integrative therapies for asthma".)

Therapeutic approaches:

●(See "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control".)

●(See "Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms".)

●(See "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies".)

●(See "Initiating asthma therapy and monitoring in adolescents and adults".)

●(See "Ongoing monitoring and titration of asthma therapies in adolescents and adults".)

●(See "Treatment of severe asthma in adolescents and adults".)

Asthma exacerbations:

●(See "Acute asthma exacerbations in children younger than 12 years: Overview of home/office management and severity assessment".)

●(See "Acute asthma exacerbations in children younger than 12 years: Emergency department management".)

●(See "Acute asthma exacerbations in children younger than 12 years: Inpatient management".)

●(See "Acute severe asthma exacerbations in children younger than 12 years: Intensive care unit management".)

●(See "Acute severe asthma exacerbations in children and adolescents: Endotracheal intubation and mechanical ventilation".)

●(See "Acute exacerbations of asthma in adults: Home and office management".)

●(See "Acute exacerbations of asthma in adults: Emergency department and inpatient management".)

●(See "Airway management in acute severe asthma for emergency medicine and critical care".)

●(See "Invasive mechanical ventilation in adults with acute exacerbations of asthma".)

GOALS OF ASTHMA TREATMENT — The goals of chronic asthma management may be divided into two domains: achieving good control of asthma-related symptoms and minimizing future risk (asthma exacerbations, suboptimal lung function, adverse effects of medication) [1,5]. The patient’s personal goals and preferences should be incorporated into a shared decision-making approach regarding asthma management.

●Optimizing control of asthma symptoms – Good control of asthma means reducing the intensity and frequency of asthma symptoms and maintaining normal or near normal activity levels. Specific goals for asthma control include:

•Freedom from frequent or troublesome symptoms of asthma (cough, chest tightness, wheezing, or shortness of breath)

•Rare to no night-time awakenings due to asthma

•Minimal need for medication for acute relief of asthma symptoms

•Optimized lung function

•Maintenance of normal daily activities, including work or school attendance and participation in athletics and exercise

•Satisfaction with asthma care on the part of patients and caregivers

●Reducing future risk – The concept of risk encompasses the various adverse outcomes associated with asthma and its treatment [1]. These include asthma exacerbations, suboptimal lung development (children), loss of lung function over time (adults) [6], and adverse effects from asthma medications. A history of ≥1 exacerbation(s) in the past year is an independent risk factor for future exacerbations, as are poor adherence to asthma medication, incorrect inhaler technique, low lung function, smoking (eg, tobacco, cannabis) or vaping, an elevated concentration of exhaled nitric oxide (fractional exhaled nitric oxide, FE_NO), and blood eosinophilia (table 1) [4].

Specific goals for reducing risk include:

•Prevention of recurrent exacerbations and need for systemic glucocorticoids and emergency department or hospital care

•Prevention of reduced lung growth in children and loss of lung function in adults (due to poor asthma control)

•Optimization of asthma pharmacotherapy with minimal or no adverse effects

PATIENT EDUCATION

Overview — A key component of optimizing asthma control is the engagement of patients as active partners in their asthma management [4]. A successful partnership depends on robust and ongoing asthma education; well-informed and motivated patients can assume a large measure of control over their asthma care.

The effectiveness of direct one-on-one education by the primary clinician, in particular, is well supported by evidence [1]. Numerous additional resources are available for asthma education, such as asthma educators, pharmacists, respiratory therapists, organized programs in the community, and online sources (eg, Asthma and Allergy Foundation, American Academy of Allergy, Asthma & Immunology, American College of Allergy, Asthma & Immunology, American Lung Association, American Thoracic Society, National Jewish Health). Patient education information from UpToDate is listed below. (See 'Information for patients' below.)

Patient education decreases asthma exacerbations and hospitalizations and improves daily function and patient satisfaction in many, but not all, studies [7-11]. Based upon limited evidence, culturally specific asthma education may improve asthma outcomes in patients with low medical literacy or nontraditional belief systems [12].

Components of asthma education and self-management — The important components of asthma education are described in detail separately and include responses to the following questions (see "Asthma education and self-management"):

●What is asthma and what are its symptoms?

●What are the asthma triggers for the individual patient and how can they be mitigated?

●Which medications should be used for quick relief of asthma symptoms, which are used for asthma control, and which can be used in both circumstances?

●What is the correct technique for each inhaler that the patient uses?

●Are there barriers that prevent the patient from taking medications regularly? If so, what methods would help improve adherence?

Inhaler technique — Education about proper inhaler technique is an essential component of asthma management. It is often helpful for patients to watch a video demonstrating use of the particular type of inhaler (eg, metered-dose inhaler with spacer, Diskus, Ellipta, Redihaler, Respimat) or nebulizer. The clinician should demonstrate correct technique, observe the patient practice the technique, and provide correction, if needed. Difficulties with actuation-inhalation coordination with metered-dose inhalers may be reduced by use of a valved holding chamber or breath-actuated device. Written instructions and/or links to instructional videos can also be helpful reminders to send with the patient. Using the fewest types of inhalers as possible may help minimize the risk of errors. (See 'Information for patients' below and "The use of inhaler devices in adults", section on 'Teaching inhaler use skills' and "The use of inhaler devices in children" and "Patient education: Inhaler techniques in adults (Beyond the Basics)" and "Patient education: Asthma inhaler techniques in children (Beyond the Basics)".)

Asthma action plan — A personalized "asthma action plan" is a written document that provides instructions for the patient to follow at home. Although supportive data are limited [1,4], many asthma specialists, including ourselves, believe that written asthma action plans are useful in engaging patients in their disease management, clarifying the medication regimen, helping patients to identify declines in asthma control, and guiding treatment adjustments in response to changes in symptoms and home measurement of peak expiratory flow (PEF) and/or forced expiratory volume in one second (FEV₁). They are also required by most schools, daycare and afterschool programs, and camps.

Symptom-based action plans are used for most patients. Home monitoring of PEF and/or FEV₁ may provide added benefit when incorporated into the asthma action plan, particularly for patients with moderate to severe asthma, patients who are poor perceivers of airflow obstruction, and during pregnancy. (See 'Home monitoring' below and "Peak expiratory flow monitoring in asthma".)

Several asthma action plan forms are available:

●National Asthma Education and Prevention Program (NAEPP) Asthma action plan (form 1)

●NAEPP Asthma action plan for children (form 2)

●Global Initiative for Asthma (GINA) action plan (inside the patient guide)

●American Academy of Allergy Asthma & Immunology – School-based asthma management program

●Asthma Society of Canada

●Asthma UK

●National Asthma Council Australia (which includes an action plan based on single-agent maintenance and reliever therapy [MART])

Instructions for the use of asthma action plans are presented separately. (See "Asthma education and self-management".)

Controlling asthma triggers — The identification and avoidance of asthma "triggers" is an important component of successful asthma management, and successful avoidance or remediation may reduce the patient's need for medication.

●Common types of triggers – Directed questions can help identify specific triggers (eg, allergens: pollen, pets, mold, cockroach, etc.; irritants: fumes, cigarette smoke exposure, etc.; respiratory viruses; physiologic: stress, hormones, exercise, etc.) to asthma and to comorbid conditions (table 2). (See "Trigger control to enhance asthma management" and "Allergen avoidance in the treatment of asthma and allergic rhinitis".)

●Work or school-associated symptoms – Adults should be questioned about symptoms not only in the home but also in the workplace, as asthma can be exacerbated by both irritant and allergen exposures in occupational settings. Approximately 20 percent of asthma in adults is thought to be work-associated. Recognized sensitizers or irritants in the workplace, similarly affected coworkers, and symptom improvements during vacation or days off are among the factors that should lead to more thorough occupational asthma evaluation [1]. Similarly, children should be questioned about symptoms that occur in school, where children may be exposed to allergens (pets, mice, cockroach) and pollutants [4]. (See "Occupational asthma: Definitions, epidemiology, causes, and risk factors".)

●Allergy testing – In addition to a clinical history, allergen-specific immunoglobulin E (IgE) blood testing or skin testing can be helpful to confirm a patient’s suspicion of allergic sensitivity or to clarify allergen sensitization when symptoms leave a patient uncertain as to the association with specific exposures. Allergen-specific immunotherapy may be an adjunct to standard pharmacologic treatment in selected patients with allergic asthma as described separately [2,4]. (See "Asthma in adolescents and adults: Evaluation and diagnosis", section on 'Tests for allergy' and "Asthma in children younger than 12 years: Initial evaluation and diagnosis", section on 'Allergy testing' and "Subcutaneous immunotherapy (SCIT) for allergic rhinoconjunctivitis and asthma: Indications and efficacy", section on 'Allergic asthma' and "Sublingual immunotherapy for allergic rhinitis and conjunctivitis: SLIT-tablets", section on 'Impact on asthma'.)

●Options for difficult-to-avoid triggers – For triggers that should not be avoided, such as physical exertion, or are difficult to avoid, such as upper respiratory tract illnesses, hormonal fluctuations, and extreme emotion, patients should be taught how to adjust their asthma management to mitigate potential exacerbation of their asthma.

Immunizations and antiviral strategies — Respiratory tract infections are common asthma triggers, and viral infections may play a role in development and worsening of asthma in children. Prevention and management strategies for upper respiratory infections are important for all patients with asthma. (See "Role of viruses in wheezing and asthma: An overview".)

●Immunizations – Providers should strongly encourage age-appropriate vaccinations against influenza, pneumococcus, pertussis, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and respiratory syncytial virus in all patients with asthma. (See "Standard immunizations for children and adolescents: Overview" and "Standard immunizations for nonpregnant adults".)

Adults aged 19 to 64 years with asthma should receive an additional pneumococcal vaccination; children aged 6 to 18 years with moderate to severe asthma may likewise benefit from an additional dose, depending on their prior vaccination status. (See "Pneumococcal vaccination in adults", section on 'Approach to healthy older adults and those with predisposing medical conditions' and "Pneumococcal vaccination in children", section on 'Immunization of high-risk children and adolescents'.)

In general, medications for asthma do not interfere with vaccine efficacy. Although there may be a small decrease in antibody levels after coronavirus disease 2019 (COVID-19) vaccination in patients receiving asthma biologics compared with healthy controls without asthma [13], there is no evidence that this is a clinically meaningful effect. Higher doses of oral glucocorticoids may mildly blunt the systemic response, so patients who have reliable follow-up on a short course of oral glucocorticoids may reasonably defer vaccination until a later visit. For most other patients, this theoretical risk does not outweigh the risk of a missed vaccination. Patients requiring ongoing use of ≥20 mg of prednisone daily should receive vaccine schedules suggested for immunocompromised individuals. (See "Immunizations in autoimmune inflammatory rheumatic disease in adults" and "Standard immunizations for children and adolescents: Overview", section on 'Other special circumstances'.)

●Antiviral therapies – Based on evidence of asthma as a risk factor for severe disease, patients with asthma may be prioritized for antiviral therapies if they develop COVID-19 or influenza infection. Note that the antiviral tablets nirmatrelvir and ritonavir interact with the long-acting beta-agonist (LABA) bronchodilators salmeterol and vilanterol, which should be held for the five days of oral antiviral therapy and three additional days thereafter. Alternative bronchodilator therapy may be needed during this time in some patients. The influenza antiviral zanamivir should not be used in patients with asthma due to risk of bronchospasm. (See "COVID-19: Management of adults with acute illness in the outpatient setting" and "Seasonal influenza in nonpregnant adults: Treatment", section on 'Patients at risk for complications or severe illness' and "Seasonal influenza in children: Management", section on 'Indications and preferred regimens'.)

The United States Centers for Disease Control and Prevention (CDC) have identified asthma as a risk factor for severe COVID-19 (SARS-CoV-2) [14]. It is uncertain, based upon observational data, whether this association is due to asthma severity itself or related to medications used to treat more symptomatic asthma. Several studies including patients with well-controlled asthma do not indicate increased risk in this population [15-25]. Other investigations, including a large meta-analysis of over 100,000 patients and a British nationwide cohort, report higher rates of various adverse outcomes, including hospitalization, intubation, prolonged mechanical ventilation, and death from COVID-19 in patients with asthma [16,23,26-28]. In the large British cohort of over 35 million adults and nearly 3 million children aged 12 to 17 years, those with mild and/or well-controlled asthma were not at increased risk of poor outcomes compared with those without asthma [23]. However, adults who required medium- to high-dose inhaled glucocorticoids carried an elevated risk of COVID-19 hospitalization and death. Similarly, adolescents who required systemic glucocorticoids for an exacerbation in the prior year were at increased risk of COVID-19 hospitalization.

●Use of asthma therapies during acute respiratory infection exposure or illness – Maintaining good asthma control helps minimize the risk of an asthma exacerbation due to respiratory infections [4]. There is a paucity of data on asthma medication use and risk of infection. We advise continued use of all regular medications necessary to maintain asthma control, including inhaled glucocorticoids, long-acting bronchodilators, leukotriene modifiers, oral glucocorticoids, and asthma biologic agents during exposure to or mild illness from respiratory infections. Increasing dose or frequency of some asthma medications according to the patient’s "asthma action plan" may also be appropriate. The usual guidelines for prompt initiation of systemic glucocorticoids for asthma exacerbations should be followed regardless of infectious exposures, as delaying therapy can increase the risk of a life-threatening exacerbation [29].

Additional information about COVID-19 is provided separately. (See "COVID-19: Clinical features" and "COVID-19: Management in hospitalized adults" and "COVID-19: Management in children" and "Patient education: COVID-19 overview (The Basics)" and "Patient education: COVID-19 vaccines (The Basics)".)

INITIAL ASSESSMENT — The initial assessment of asthma typically occurs around the time of diagnosis. (See "Asthma in children younger than 12 years: Initial evaluation and diagnosis" and "Asthma in adolescents and adults: Evaluation and diagnosis".)

Assessment of symptoms, lung function, and exacerbation risk serve as a guide to the intensity of therapy needed to bring asthma under good control. Asthma severity is influenced by multiple factors, including airway hyperresponsiveness and predisposition to allergy ("atopy"), environmental factors (such as irritant, viral, and allergen exposures), and comorbidities (such as obesity or chronic rhinosinusitis), and so it can change over time. Both the National Asthma Education and Prevention Program (NAEPP) and the Global Initiative for Asthma (GINA) practically recognize four different levels of symptoms and exacerbation risk to titrate initial therapy (table 3 and table 4 and table 5). (See 'Initiating pharmacologic treatment' below and "Initiating asthma therapy and monitoring in adolescents and adults", section on 'Assessing symptom severity and exacerbation risk' and "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control", section on 'Assessment of severity in patients not on daily therapy'.)

Besides noting the frequency of symptoms and risk factors for exacerbations, initial evaluation should include assessment (and documentation) of lung function in all persons old enough to perform testing [4]. If the patient has an exacerbation at the time of the initial evaluation, assessment of lung function should be repeated following resolution of the exacerbation. NAEPP includes spirometric or peak flow values in determining asthma severity. In contrast, GINA does not use spirometric values to guide medication selection after the diagnosis of asthma is confirmed except for a forced expiratory volume in one second (FEV₁) <60 percent of predicted, which is a risk factor for exacerbations.

Following initiation of therapy, control of asthma symptoms should be assessed and therapy adjusted accordingly (table 6 and table 7 and table 8). Good asthma control is the goal of asthma management and is achievable in the great majority of patients with asthma. (See 'Adjusting pharmacologic therapy' below and "Ongoing monitoring and titration of asthma therapies in adolescents and adults", section on 'Assessment of asthma control, exacerbation risk, and severity' and "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control", section on 'Assessment of severity in patients on daily therapy'.)

CLASSIFICATION OF ASTHMA SEVERITY — Guideline-based classification of asthma severity uses retrospective definitions that may be confusing to patients and clinicians. Categorization has minimal relevance to clinical decision-making (which is primarily guided by symptom control) except for identification of those with severe asthma, who require additional evaluation and may need advanced therapies.

●Proposed definitions of asthma severity – The Global Initiative for Asthma (GINA) and an American Thoracic Society research committee have questioned the distinction previously made between "intermittent" and "persistent" asthma as lacking in biologic basis and evidence [4,30]. This dichotomy may have provided false reassurance that patients with infrequent symptoms were at low risk of exacerbations. These issues, among others, have led to the following recommended definitions of asthma severity [4,30-32]:

•Mild asthma – Defined by minimal symptoms and minimal risk of exacerbations (table 9) in patients who are not using inhaled therapies, who are using reliever therapy alone, or who are using low-dose inhaled glucocorticoids along with reliever therapy [30]. GINA advises avoiding the term "mild asthma" altogether to avoid giving the impression that mild symptoms equates with low risk [4].

•Moderate asthma – Defined by good asthma control (table 9 and table 7 and table 8) with medium-dose inhaled glucocorticoids or low-medium-dose inhaled glucocorticoids with additional controller therapies.

•Severe asthma – Defined by asthma requiring high-dose inhaled glucocorticoids with additional controller agents to maintain good control (table 9 and table 7 and table 8) or uncontrolled asthma despite these therapies (table 10) [4,33,34].

By these retrospective definitions, asthma severity can only be assessed after achieving good control and stepping down therapy to find the minimum effective controller therapy (or unless asthma remains uncontrolled despite maximized therapy).

●Subcategories of severe asthma – The World Health Organization (WHO) has offered a definition of severe asthma that includes a useful subcategorization of patients [35]. Some patients have poor asthma control despite treatment with high-dose inhaled glucocorticoids and a long-acting beta-agonist (LABA) because of confounding and potentially remediable factors like poor medication adherence, allergen or irritant exposures in their home or work environment, or treatable comorbidities like rhinosinusitis. They are considered to have "difficult-to-treat" severe asthma. These patients may have a variety of treatment options depending on the underlying reason their asthma is difficult to treat. In contrast, other patients continue to have poor asthma control despite good medication adherence, modification of environmental exposures, and management of comorbidities. Such patients are considered to have "treatment-resistant" severe asthma and are the most likely to benefit from biologic agents. (See "Enhancing patient adherence to asthma therapy" and "Trigger control to enhance asthma management" and "Evaluation of severe asthma in adolescents and adults" and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies", section on 'Step-up therapy for severe asthma' and "Treatment of severe asthma in adolescents and adults".)

INITIATING PHARMACOLOGIC TREATMENT — Pharmacologic treatment is the mainstay of management in most patients with asthma. National and international guidelines advise initiating pharmacologic therapy based on the frequency and severity of symptoms, history of exacerbations requiring systemic glucocorticoids, and results of lung function measurement (asthma severity), and subsequently adjusting therapy up or down, as needed, according to a stepwise approach, to achieve good asthma control [1,2,4]. The approach to initial pharmacologic management of adults, adolescents, and children with asthma is discussed in greater detail separately. (See "Initiating asthma therapy and monitoring in adolescents and adults" and "Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms", section on 'Quick-relief treatment' and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies", section on 'Initiating controller therapy'.)

The initial choice of medication is based upon age of the patient (eg, ≥12 years, 5 to 11 years, 0 to 4 years), symptoms, lung function, risk factors for exacerbations, patient preference, and practical issues (eg, ability to use the medication delivery device, accessibility of medication; for adults and adolescents (table 11); for children 4 to 11 years (table 4); for infants and toddlers (table 5)).

●Inhaled bronchodilator reliever therapies – All patients with asthma should have immediate access to an inhaled bronchodilator with a rapid onset of action for prompt relief of asthma symptoms. (See "Initiating asthma therapy and monitoring in adolescents and adults", section on 'Anti-inflammatory reliever (AIR) therapy (preferred)' and "Ongoing monitoring and titration of asthma therapies in adolescents and adults", section on 'Anti-inflammatory reliever therapy (AIR) to reduce exacerbations' and "Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms", section on 'Combination inhaled glucocorticoid and beta agonist'.)

•Short-acting beta-agonist alone – The traditional choice has been a short-acting beta-agonist (SABA; eg, albuterol or levalbuterol) (table 12).

•Beta-agonist plus inhaled glucocorticoid – An alternative is the use of agents containing an inhaled glucocorticoid called "anti-inflammatory reliever therapy" (AIR), which has been promoted by national and international guidelines based on trials that demonstrate decreased exacerbation rates relative to albuterol alone as reliever across different levels of asthma severity [2,4].

A combination low-dose glucocorticoid-formoterol inhaler (eg, budesonide-formoterol 80 mcg-4.5 mcg or 160 mcg-4.5 mcg), one to two inhalations as needed for asthma symptoms (off-label), is recommended by the Global Initiative for Asthma (GINA). This recommendation is based upon the observation that formoterol has a rapid onset of action, equivalent in time course to albuterol, and therefore can be used for quick relief of symptoms. This choice can be helpful in those with risk factors for exacerbation and those who are using glucocorticoid-formoterol inhalers as part of their daily asthma regimen.

Another option for quick-relief of asthma symptoms (approved for those age ≥18 years) is a SABA combined with low-dose glucocorticoid (albuterol 90 mcg/puff with budesonide 80 mcg/puff). Dosing of these alternative agents is summarized in the table (table 13).

●Initial asthma controller therapies – While patients with infrequent symptoms and low risk of exacerbations can often be managed with as-needed therapies (with a preference towards an ICS-containing reliever), patients with more significant disease are typically managed with scheduled controller medicines (table 11 and table 4 and table 5). The most commonly used controller medications are inhaled glucocorticoids (aka, inhaled corticosteroids [ICS]) (table 14 and table 15) and inhaled long-acting beta-agonists (LABAs) used in combination with inhaled glucocorticoids (table 16 and table 17), or oral leukotriene receptor antagonists (LTRAs).

●Initiating therapy during an exacerbation – Patients who present with an acute exacerbation of asthma often require an initial, brief course of systemic glucocorticoids while long-term controller medication is initiated. Selection of the specific controller medication(s) is based upon recent symptoms and may need to be adjusted ("stepped up" or "stepped down") once the acute exacerbation has resolved. (See "Initiating asthma therapy and monitoring in adolescents and adults", section on 'Patients presenting with acute exacerbation'.)

Treatment of asthma exacerbations is reviewed separately. (See "Acute exacerbations of asthma in adults: Home and office management" and "Acute asthma exacerbations in children younger than 12 years: Overview of home/office management and severity assessment" and "Acute asthma exacerbations in children younger than 12 years: Emergency department management".)

FOLLOW-UP MONITORING

Overview — Effective asthma management requires a proactive, preventive approach, similar to the treatment of hypertension or diabetes. Routine follow-up visits for patients with active asthma are recommended, at a frequency of every one to six months, depending upon the severity of asthma and adequacy of control. Follow-up visits should be used to assess asthma control, lung function, exacerbations, inhaler technique, adherence, medication adverse effects, quality of life, and patient satisfaction with care [3].

Assessing asthma control — The assessment of asthma control focuses on the patient’s asthma symptoms and their risk for future exacerbations. Asthma symptoms are generally assessed retrospectively over the prior four weeks and should include daytime dyspnea, cough, and wheezing, nighttime awakening due to asthma symptoms, frequency of use of short-acting beta-agonists (SABAs) to relieve symptoms, and difficulty in performing normal activities and exercise (for adults and adolescents (table 9); for children 4 to 11 (table 7); for infants and toddlers (table 8)). Several quick and validated questionnaires, like the Asthma Control Test for children (figure 1) and adults (form 3), provide standardized methods for scoring asthma control and recording changes over time [4,36-46]. (See "Ongoing monitoring and titration of asthma therapies in adolescents and adults", section on 'Asthma symptom control' and "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control", section on 'Assessment of control'.)

Symptom control — Good asthma symptom control is generally defined by the following:

●Daytime asthma symptoms less than two days a week

●Rare to no nocturnal awakenings due to asthma (<1 per month)

●Use of SABA relievers less than two days a week

●No interference with normal activities

Direct questioning is important for assessment of symptom control, as many patients may not volunteer less severe symptoms without prompting. For patients on anti-inflammatory reliever (AIR) therapy containing an inhaled glucocorticoid in addition to a fast-acting beta-agonist, daytime symptoms and reliever use more than two days a week (but less than daily) may be acceptable if the disease is otherwise well controlled (ie, the patient is undertaking normal activity without nocturnal awakenings or exacerbations). Pretreatment with a SABA to prevent exercise-induced bronchoconstriction is generally not counted, although the need for daily SABA to prevent exercise-induced bronchoconstriction suggests suboptimal control that often warrants addition of controller medication [4,47]. (See "Exercise-induced bronchoconstriction", section on 'Persistent EIB symptoms despite premedication'.)

Exacerbations and lung function — In addition to reviewing symptoms, asthma control is also assessed by considering the following factors (for adults and adolescents (table 9); for children 4 to 11 years old (table 7); for infants and toddlers (table 8)) [1,4]:

●Number of exacerbations requiring oral glucocorticoids in the previous year

●Current level of lung function, if able to perform this testing (forced expiratory volume in one second [FEV₁] and FEV₁/forced vital capacity [FVC] values, or peak expiratory flow [PEF] if spirometry not available)

These factors contribute to risk of asthma exacerbation. Exacerbation risk should always be evaluated separately, even in patients who otherwise have good asthma symptom control [4,48]. Observational studies have shown that 30 to 40 percent of acute asthma episodes, 15 percent of near-fatal asthma episodes, and 15 to 30 percent of fatal asthma attacks occur in patients reporting symptoms less than weekly or only with exertion in the preceding three months [49,50]. Many common risk factors for asthma exacerbations in adults are provided in the table (table 1) and are also discussed separately. (See "Ongoing monitoring and titration of asthma therapies in adolescents and adults", section on 'Risk factors for exacerbations and adverse effects' and "Identifying patients at risk for fatal asthma".)

In those with good asthma control, PEF and spirometry should remain normal or near normal (or, when a patient’s optimal baseline lung function is abnormal, at or close to the individual’s personal best peak flow or FEV₁). Oral glucocorticoid courses and/or urgent care visits should be needed no more than once per year, and even that rate (if persistent) indicates need for improved disease control to decrease exacerbation risk and cumulative exposure to oral glucocorticosteroids [51]. (See "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control", section on 'Assessment of control' and "Ongoing monitoring and titration of asthma therapies in adolescents and adults", section on 'Patients with good daily control but frequent exacerbations' and "Major adverse effects of systemic glucocorticoids".)

Questions to assess control — The following questions are representative of those used in validated questionnaires to assess asthma control. Responses indicating evidence of impairment due to asthma or high risk of exacerbation should prompt changes in management.

●Assessment of impairment

•How often has your asthma awakened you at night or in the early morning?

•How often have you been needing to use your quick-acting relief medication for symptoms of cough, shortness of breath, or chest tightness?

•Have you needed any unscheduled care for your asthma, including calling in or messaging through the patient portal, an office or urgent care visit, an emergency department visit, or hospitalization?

•Have you been able to participate in school/work and recreational activities as desired?

•If you are measuring your peak flow, has it been lower than your personal best? Home monitoring of peak flow measurements is reviewed in detail separately. (See "Peak expiratory flow monitoring in asthma".)

●Assessment of exacerbation risk

•Have you taken oral glucocorticoids ("steroids") for your asthma in the past year?

•Have you been hospitalized for your asthma? If yes, how many times have you been hospitalized in the past year?

•Have you been admitted to the intensive care unit or been intubated because of your asthma? If yes, did this occur within the past five years?

•Do you currently vape or smoke cigarettes or does anyone in your household? If so, how many each day?

Medication adherence — Follow-up visits should also include inquiry about any adverse effects from or concerns about asthma medications. Poor adherence is very common and can be identified and managed in partnership with the patient through empathetic questioning and acknowledgement of potential barriers to optimal medication use [52]. After identifying barriers to adherence, the clinician can engage the patient collaboratively on finding solutions, which may include adopting behavioral techniques, simplifying or altering regimens, finding more affordable options through use of alternative medications or discount programs, and providing clear written instructions for medication use.

Patients should bring their inhalers to each appointment and explain how they are using them (both technique and dosing). This allows providers to ensure the inhalers are not empty or expired and patients are using correct inhaler technique. For patients having difficulty with inhaler technique, changing devices, minimizing the number of different devices, or (for appropriate metered-dose inhalers) use of a valved-holding chamber ("spacer") may optimize medication delivery to the airways and minimize deposition in the oropharynx.

Additional information on medication adherence and optimizing inhaled medication delivery can be found elsewhere. (See "Ongoing monitoring and titration of asthma therapies in adolescents and adults", section on 'Medication adherence' and "The use of inhaler devices in adults" and "The use of inhaler devices in children" and "Enhancing patient adherence to asthma therapy".)

Pulmonary function — Spirometry is the preferred method for monitoring pulmonary function in children older than approximately five years of age and adults; assessing peak expiratory flow (PEF) with a peak flow meter is an alternative strategy. Guidelines prefer use of spirometry over peak flow in medical offices, when available, due to greater accuracy of the measurement, when carefully performed by skilled technical staff [1]. Spirometry may not be performed reliably by most children younger than five years. Comparing lung function in patients experiencing poor symptom control or returning after medication adjustments to lung function obtained during periods of good control can help inform management.

Office monitoring

●Spirometry (preferred) – Spirometry, which measures FEV₁ and FVC, is a sensitive and reproducible method for assessing airflow limitation, defined as a reduced FEV₁/FVC ratio. Spirometry can detect reductions in lung function, indicating loss of asthma control and risk of a severe asthma exacerbation, particularly in patients who have few symptoms or physical findings of asthma [53,54]. We typically obtain spirometry yearly when asthma is stable and well-controlled but perform it more frequently in those with poor asthma control, patients requiring multiple controller medicines, or in those whose medications are being adjusted. Hand-held spirometers with disposable mouthpieces may allow expanded use in office settings. (See "Office spirometry" and "Pulmonary function testing in asthma" and "Overview of pulmonary function testing in children", section on 'Use of spirometry in asthma'.)

●Serial peak flow measurement – In patients with asthma in whom airway obstruction has been established by spirometry, peak flow measurement using handheld peak flow meters may be used as an alternative for longitudinal monitoring. This is generally done when office spirometry is not available. Peak flow monitoring is best used to assess changes over time and for detecting severe obstruction in a patient who may not have wheezing or complain of troublesome symptoms. Reliable PEF measurements can be made with minimal training; the costs in terms of equipment, staff, and time are minimal. Periodically, PEF values measured by peak flow meter should be correlated with peak flow measurement made via spirometry. Normal values for adults, adolescents, and children can be calculated (calculator 1 and calculator 2 and calculator 3 and calculator 4).

●Limitations of peak flow measurement – It is important to understand the limitations of PEF. A reduced peak flow is not synonymous with airway obstruction. Spirometry is needed to differentiate an obstructive from restrictive abnormality [55]. Peak flow may underestimate the severity of airflow obstruction as revealed by spirometry. Also, the accuracy of a single peak flow measurement to detect the presence of airflow obstruction is limited given the large variability of PEF among healthy individuals of the same age, height, and sex (±20 percent) [55]. The use of PEF monitoring and its limitations are presented in more detail separately. (See "Peak expiratory flow monitoring in asthma".)

Home monitoring — Home monitoring with repeated measurements of PEF or FEV₁ over time may be useful for determining relative changes or trends in asthma control in adults and adolescents with moderate to severe persistent asthma but is rarely used for children [1,4]. Home monitoring may be particularly helpful in patients who have poor perception of airflow limitation. These individuals cannot be easily identified at the outset of care, although over time they display a lack of awareness of increasing impairment and typically seek care for exacerbations only after symptoms have become severe [56,57]. (See "Identifying patients at risk for fatal asthma".)

Home monitoring may also be very useful in identifying and providing an objective measure of work or environmental triggers. (See "Occupational asthma: Clinical features, evaluation, and diagnosis", section on 'Serial peak expiratory flow measurement'.)

Peak flow meters for individual use are widely available, inexpensive, and easy to use. However, measurements are highly dependent upon the patient's technique and effort. Home spirometers are more expensive, more complicated to use, and may require patients to clean them properly for optimal function. With increased availability of video coaching and software apps to provide feedback, home spirometers are becoming a more reasonable option for technologically facile patients. For either type of device, it is important that the patient's technique be assessed in the office and any mistakes in technique corrected. Instructions for use of a PEF meter are provided separately. (See "Patient education: How to use a peak flow meter (Beyond the Basics)".)

Ideally, the patient should establish a baseline value of peak flow or FEV₁ using morning and evening measurements over the course of a week or two when feeling entirely well: the "personal best" peak flow or FEV₁ value. A chart for recording PEF values at home is available for download. The personal best value is then used to determine the normal range, which is between 80 and 100 percent of the patient's personal best. Readings below this normal range may indicate airway obstruction, a change that may occur before symptoms are perceived by the patient. (See 'Asthma action plan' above.)

Type 2 airway inflammation — Use of type 2 inflammatory markers, such as blood and sputum eosinophil counts, total serum IgE, and fractional exhaled nitric oxide (FE_NO), to adjust therapy in nonsevere asthma may be helpful in some settings. Systematic reviews have found mixed evidence regarding the use of FE_NO to guide asthma therapy [58-62], and routine monitoring is not recommended by national and international guidelines [2,4]. (See "Ongoing monitoring and titration of asthma therapies in adolescents and adults", section on 'Risk factors for exacerbations and adverse effects' and "Overview of pulmonary function testing in children", section on 'Exhaled nitric oxide'.)

However, for patients with severe asthma, characterizing the underlying type of inflammation or asthma phenotype is essential to guide selection of therapy, particularly biologics (algorithm 1). (See "Severe asthma phenotypes" and "Treatment of severe asthma in adolescents and adults", section on 'Selecting among biologic agents'.)

The potential uses of expectorated sputum eosinophilia and exhaled nitric oxide analysis in the management of asthma are discussed in more detail separately. (See "Evaluation of severe asthma in adolescents and adults", section on 'Airway inflammation' and "Exhaled nitric oxide analysis and applications".)

Comorbid conditions — Comorbid conditions can contribute to asthma symptoms and influence asthma control.

In adults, these conditions include (table 18):

●Allergic rhinitis

●Rhinosinusitis with/without nasal polyps

●Aspirin/nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (AERD)

●Chronic obstructive pulmonary disease (COPD)/emphysema overlap (ACO)

●Allergic bronchopulmonary aspergillosis

●Gastroesophageal reflux

●Obesity

●Obstructive sleep apnea

●Inducible laryngeal obstruction (also called vocal cord dysfunction)

●Depression/chronic stress

In children, the most common comorbidities include:

●Other atopic disorders (allergic rhinitis, atopic dermatitis, food allergy)

●Rhinosinusitis

●Obesity

●Deconditioning

●Gastroesophageal reflux

●Inducible laryngeal obstruction (also called vocal cord dysfunction)

●Depression/chronic stress

In addition, there is increasing awareness about the impact of the social determinants of health on the course of asthma. These include:

●Poor housing conditions

●Increased exposure to air pollution

●Lack of ready access to medications and medical care

It is reasonable to monitor and help manage these conditions as part of overall asthma care. These conditions are reviewed separately. (See "Ongoing monitoring and titration of asthma therapies in adolescents and adults", section on 'Comorbidities' and "An overview of rhinitis" and "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis" and "Aspirin-exacerbated respiratory disease" and "Chronic obstructive pulmonary disease: Diagnosis and staging" and "Clinical manifestations and diagnosis of allergic bronchopulmonary aspergillosis" and "Gastroesophageal reflux and asthma" and "Obesity and asthma" and "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Inducible laryngeal obstruction (paradoxical vocal fold motion)".)

ADJUSTING PHARMACOLOGIC THERAPY

●Stepwise titration of asthma therapy – Asthma therapy is typically adjusted in a stepwise fashion, increasing medication until asthma is controlled then decreasing medication, when possible, to minimize adverse effects.

The therapeutic tiers, or "steps," are as described in the National Asthma Education and Prevention Program (NAEPP) and Global Initiative for Asthma (GINA) guidelines (for adults and adolescents (table 6) and (table 19); for children 4 to 11 years old (table 4); for infants and toddlers (table 5)). Stepping up is based upon the degree of asthma control and risk for future exacerbations as described above (for adults and adolescents (table 9); for children 4 to 11 years old (table 7); for infants and toddlers (table 8)). (See 'Follow-up monitoring' above and "Ongoing monitoring and titration of asthma therapies in adolescents and adults" and "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control", section on 'Assessment of control' and "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control", section on 'Monitoring and dosing adjustment' and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies", section on 'Step-up therapy'.)

For patients whose asthma has been well-controlled for three to six months on a stable regimen (for adults and adolescents (table 9); for children 4 to 11 years old (table 7); for infants and toddlers (table 8)), controller medications may be reduced in a stepwise fashion. Longer periods of control are often preferred before decreasing therapy in patients with more severe asthma or ongoing exposures to potential triggers. In general, discontinuation of long-acting bronchodilators or transition off inhaled glucocorticoids to short-acting bronchodilators alone are the step changes most likely to lead to increased exacerbation risk. Stepping down therapy is discussed in greater detail elsewhere. (See "Ongoing monitoring and titration of asthma therapies in adolescents and adults", section on 'Decreasing (stepping down) therapy' and "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control", section on 'Step-down therapy'.)

Besides minimizing expense, inconvenience, and potential immediate adverse effects, the purpose of stepping down therapy in some patients is reducing long-term exposure to high doses of inhaled glucocorticoids, with their potential for systemic absorption and adverse effects on organs such as bones, eyes, hypothalamic-pituitary axis, and skin. (See "Major side effects of inhaled glucocorticoids".)

Careful monitoring as therapy is stepped down is needed to identify, and respond to, any deterioration in control. Alternatively, in follow-up of well-controlled asthma, medications can be continued unchanged, especially if history reveals serious exacerbations in the past or a high risk of future exacerbation.

●Additional options for severe asthma – In treating severe asthma, many providers add a long-acting muscarinic antagonist (LAMA; eg, tiotropium) and/or a leukotriene modifier to the combination inhaled glucocorticoid and long-acting beta-agonist (LABA). Patients with severe or difficult-to-control asthma should be referred to an asthma specialist, if available. Patients who remain poorly controlled should undergo evaluation for biologic therapies to avoid prolonged and repeated use of oral glucocorticoids. Severe asthma is reviewed in more detail separately. (See "Treatment of severe asthma in adolescents and adults" and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies", section on 'Step-up therapy for severe asthma'.)

The availability of biologic therapies (monoclonal antibodies targeting key molecules involved in airway inflammation) has revolutionized the treatment of patients with severe asthma. These treatments are reviewed briefly here and discussed in greater detail separately. Several of these agents are available for children, but age requirements differ by therapy (table 20). (See "Treatment of severe asthma in adolescents and adults", section on 'Selecting among biologic agents' and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies", section on 'Biologic agents' and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies", section on 'Step-up therapy for severe asthma'.)

•Anti-IgE therapy – For patients whose asthma is inadequately controlled on medium- to high-dose inhaled glucocorticoids and LABAs, the anti-IgE therapy omalizumab may be used when there is objective evidence of sensitivity to a perennial allergen (by allergy skin tests or in vitro measurements of allergen-specific IgE) and if the serum total IgE level is within the established target range (based on patient weight and serum total IgE level). (See "Anti-IgE therapy".)

•Anti-eosinophilic therapy – Interleukin (IL)-4, IL-5, and IL-13 promote pulmonary eosinophilia through distinct mechanisms, including selective recruitment and cellular survival pathways. IL-4 also stimulates the production of IgE by its action on B cells. Monoclonal antibodies against IL-5 (mepolizumab and reslizumab), IL-5 receptor alpha (benralizumab), and IL-4 receptor alpha subunit (dupilumab) are available for treatment of severe eosinophilic asthma that is poorly controlled with conventional therapy. Age and blood eosinophil requirements vary (table 20). (See "Treatment of severe asthma in adolescents and adults", section on 'Anti-IL-5 therapy' and "Treatment of severe asthma in adolescents and adults", section on 'Anti-lL-4 receptor alpha subunit antibody (dupilumab)'.)

•Antithymic stomal lymphopoietin therapy – Thymic stromal lymphopoietin (TSLP) promotes type 2 inflammation in asthma. Anti-TSLP is approved for adolescents and adults with severe asthma irrespective of peripheral blood eosinophil count, although patients with higher eosinophil counts tend to have a better response. (See "Treatment of severe asthma in adolescents and adults", section on 'Anti-thymic stromal lymphopoietin (tezepelumab)'.)

WHEN TO REFER — Both pulmonologists and allergists/immunologists have specialty training in asthma care. Referral for consultation or comanagement depends upon the level of experience and comfort of the primary care clinician with asthma care but is generally advisable when any of the following circumstances arise [1,4]:

●Difficulty confirming a diagnosis of asthma or questioning the diagnosis in a patient previously labeled as having asthma (signs or symptoms suggesting an alternative or exacerbating diagnosis)

●History of a life-threatening asthma exacerbation (eg, intensive care unit admission, mechanical ventilation for asthma, hypoxic seizure)

●Hospitalization for asthma, two or more courses of oral glucocorticoids in a year, or inability to discontinue oral glucocorticoids

●Need for step 5 care or higher in adults or step 4 or higher in children

●Poor asthma control after several months of active therapy and appropriate monitoring

●Anaphylaxis or confirmed food allergy in a patient with asthma

●Presence of complicating comorbidity (eg, aspirin-exacerbated respiratory disease [AERD], nasal polyposis, chronic rhinosinusitis, allergic bronchopulmonary aspergillosis [ABPA], chronic obstructive pulmonary disease [COPD], inducible laryngeal obstruction [also called vocal cord dysfunction])

●Need for additional diagnostic tests (eg, allergy skin testing, bronchoscopy, complete pulmonary function tests, fractional exhaled nitric oxide [FE_NO] testing)

●Consideration of allergen immunotherapy (see "Subcutaneous immunotherapy (SCIT) for allergic rhinoconjunctivitis and asthma: Indications and efficacy" and "Sublingual immunotherapy for allergic rhinitis and conjunctivitis: SLIT-tablets", section on 'Impact on asthma')

●Potential candidacy for therapy with biologics (benralizumab, dupilumab, mepolizumab, omalizumab, reslizumab, tezepelumab) or bronchial thermoplasty

Other possible indications for referral include [1,4]:

●Need for step 4 care in an adult

●Need for step 3 care in a child older than five years

●Need for step 2 care or higher in a child under five years

●Evaluation of potential occupational triggers

●Patients in whom psychosocial or psychiatric problems are interfering with asthma management and in whom referral to other appropriate specialists may be required

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Asthma in adolescents and adults" and "Society guideline links: Severe asthma in adolescents and adults" and "Society guideline links: Asthma in children" and "Society guideline links: Exercise-induced bronchoconstriction and exercise-induced laryngeal obstruction".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topics (see "Patient education: How to use your child's dry powder inhaler (The Basics)" and "Patient education: Asthma in children (The Basics)" and "Patient education: How to use your child's metered dose inhaler (The Basics)" and "Patient education: Asthma and pregnancy (The Basics)" and "Patient education: How to use your dry powder inhaler (adults) (The Basics)" and "Patient education: How to use your metered dose inhaler (adults) (The Basics)" and "Patient education: How to use your soft mist inhaler (adults) (The Basics)" and "Patient education: Asthma in adults (The Basics)" and "Patient education: Avoiding asthma triggers (The Basics)" and "Patient education: Medicines for asthma (The Basics)" and "Patient education: Coping with high drug prices (The Basics)" and "Patient education: Inhaled corticosteroid medicines (The Basics)")

●Beyond the Basics topics (see "Patient education: Asthma inhaler techniques in children (Beyond the Basics)" and "Patient education: Asthma treatment in children (Beyond the Basics)" and "Patient education: Asthma and pregnancy (Beyond the Basics)" and "Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)" and "Patient education: How to use a peak flow meter (Beyond the Basics)" and "Patient education: Inhaler techniques in adults (Beyond the Basics)" and "Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)" and "Patient education: Exercise-induced asthma (Beyond the Basics)" and "Patient education: Trigger avoidance in asthma (Beyond the Basics)" and "Patient education: Coping with high prescription drug prices in the United States (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Goals of treatment – The goals of asthma treatment are to reduce impairment from symptoms, attenuate the risk of adverse outcomes associated with asthma (eg, hospitalizations, loss of lung function), and minimize adverse effects from asthma medications, particularly glucocorticoids. The patient’s personal goals should also be incorporated into decision-making regarding asthma management. (See 'Goals of asthma treatment' above.)

●Patient education and action plan – Patients should learn to monitor asthma control at home, including the frequency and severity of dyspnea, cough, chest tightness, and the need for reliever medication. (See 'Components of asthma education and self-management' above and "Asthma education and self-management".)

•Inhaler technique – The technique for using each type of inhaler should be demonstrated and reviewed with the patient. It is often helpful for patients to watch a video demonstrating use of the particular type of inhaler (eg, metered dose inhaler with spacer, Diskus, Ellipta, Redihaler, Respimat) or nebulizer. (See 'Inhaler technique' above and "The use of inhaler devices in adults" and "The use of inhaler devices in children" and "Patient education: Inhaler techniques in adults (Beyond the Basics)" and "Patient education: Asthma inhaler techniques in children (Beyond the Basics)".)

•Asthma action plans – A personalized asthma action plan should be provided with detailed instructions about adjusting asthma medications based upon changes in symptoms and/or lung function (form 1 and form 2). (See 'Asthma action plan' above.)

•Identifying and controlling asthma triggers – Environmental triggers (table 2) and coexisting conditions (table 18) that interfere with good asthma control should be identified and addressed for each patient. (See 'Controlling asthma triggers' above and "Trigger control to enhance asthma management" and "Allergen avoidance in the treatment of asthma and allergic rhinitis" and "Subcutaneous immunotherapy (SCIT) for allergic rhinoconjunctivitis and asthma: Indications and efficacy".)

•Immunizations and antiviral strategies – Respiratory tract infections are common asthma triggers. Providers should strongly encourage age-appropriate vaccinations against influenza, pneumococcus, pertussis, SARS-CoV-2, and respiratory syncytial virus in all patients with asthma. (See 'Immunizations and antiviral strategies' above and "Standard immunizations for children and adolescents: Overview" and "Standard immunizations for nonpregnant adults" and "Immunizations during pregnancy".)

●Initiating pharmacologic therapy – Assessment of symptoms, lung function, and exacerbation risk serve as a guide to the intensity of therapy needed to bring asthma under good control. The initial choice of medication is also based upon age of the patient, patient or caregiver preference, and medication availability (for adults and adolescents (table 11); for children 4 to 11 years old (table 4); for infants and toddlers (table 5)). (See 'Initiating pharmacologic treatment' above.)

The approach to initial pharmacologic management of adults, adolescents, and children with asthma is discussed in greater detail separately. (See "Initiating asthma therapy and monitoring in adolescents and adults" and "Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms", section on 'Quick-relief treatment' and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies", section on 'Initiating controller therapy'.)

•Reliever therapies – All patients with asthma should have immediate access to an inhaled bronchodilator with a rapid onset of action for prompt relief of asthma symptoms. Options include short-acting beta-agonists (SABAs) or combinations of fast-acting beta-agonists with inhaled glucocorticoids (table 12 and table 13). The use of agents containing an inhaled glucocorticoid ("anti-inflammatory reliever therapy" [AIR]) has been promoted by national and international guidelines based on decreased exacerbation rates across many different levels of asthma severity.

•Controller medications – While patients with infrequent symptoms and low risk of exacerbations can often be managed with as-needed reliever therapies (AIR or SABAs alone), patients with more significant disease are typically managed with scheduled controller medicines (table 11 and table 4 and table 5). The most commonly used controller medications are inhaled glucocorticoids (table 14 and table 15), inhaled long-acting beta-agonists (LABAs; always used in combination with inhaled glucocorticoids) (table 16 and table 17), or oral leukotriene receptor antagonists.

●Follow-up monitoring – Effective asthma management requires a preventive approach, with regularly scheduled visits during which symptoms and pulmonary function are assessed, control of exposure to asthma triggers and impact of comorbid conditions reviewed, medications adjusted, and ongoing education provided. (See 'Follow-up monitoring' above.)

The evaluation of asthma control depends on the patient’s asthma symptoms and their risk for future exacerbations (for adults and adolescents (table 9); for children 4 to 11 years old (table 7); for infants and toddlers (table 8)). Risk factors for exacerbations (table 1) should be reviewed even in patients who have good symptom control. (See "Ongoing monitoring and titration of asthma therapies in adolescents and adults", section on 'Asthma symptom control' and "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control", section on 'Assessment of control'.)

●Adjusting controller medication – For patients already taking one or more controller medications, therapy is adjusted in a stepwise fashion, increasing medication until asthma is controlled then decreasing medication, when possible, to minimize adverse effects. The therapeutic tiers, or "steps," are as described in the National Asthma Education and Prevention Program (NAEPP) and Global Initiative for Asthma (GINA) guidelines (for adults and adolescents (table 6) and [simplified] (table 19); for children 4 to 11 years old (table 4); for infants and toddlers (table 5)). (See 'Follow-up monitoring' above and "Ongoing monitoring and titration of asthma therapies in adolescents and adults" and "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control", section on 'Assessment of control' and "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control", section on 'Monitoring and dosing adjustment' and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies", section on 'Step-up therapy' and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies", section on 'Step-down therapy'.)

●Specialist referral – Guidelines for specialist referral to a pulmonologist or allergist/immunologist include uncertainty about the diagnosis of asthma, poorly controlled asthma, an episode of near-fatal asthma, need for specialized diagnostic studies (eg, allergy skin testing, bronchoscopy), potential treatment with biologics, or treatment of comorbid conditions. (See 'When to refer' above.)