A. Patients with Cough, Wheeze, Shortness of Breath or Dyspnea Presenting to Primary Care - Initial/recurrent symptoms consistent with asthma include cough, wheeze, dyspnea, chest tightness, chest pain, sputum production.

B. Perform Assessment - Important components of medical history are exercise tolerance, respiratory infections, respiratory irritants, allergens/triggers, occupation and hobbies, family history of asthma or allergy, and active/passive smoke exposure. Important associated conditions are rhinitis, sinusitis, eczema, and gastroesophageal reflux.

Important additional historical components are severity of symptoms, limitations in lifestyle, emergency-room visits, hospitalizations, medication use, and environmental exposure.

The physical examination for asthma focuses on the upper airway, the chest, and the skin.

The cardiorespiratory examination should be performed with emphasis on findings relevant to assessing severity of exacerbations or to identify complications.

Laboratory studies in addition to pulmonary function tests which may be helpful include evaluation of inhalant allergy with skin tests or with in vitro tests (evaluation of inhalant allergy), complete blood count including eosinophil count, chest film, total IgE, sinus CT scan and sputum examination.

C. Diagnoses Other than Asthma - Differential diagnosis of asthma includes fixed airway obstruction (e.g., upper airway obstruction, lower airway obstruction such as from neoplasm), laryngeal dysfunction, chronic obstructive pulmonary disease, emphysema, pulmonary parenchymal disorders (sarcoidosis, pulmonary fibrosis, others), bronchiectasis, cystic fibrosis, congestive heart failure, hyperventilation syndrome and pulmonary embolism.

D. Confirm Clinical Features are Consistent with Asthma - The diagnosis of asthma is based on the patient's medical history, physical examination, previous pulmonary function tests, and other laboratory test results.

E. Baseline Spirometry - All patients should undergo spirometry in the initial assessment of asthma. Spirometry detects the presence of airflow obstruction, defines the severity, and aids in the differential diagnosis of asthma. Particularly when performed before and after a bronchodilator, mild asthma is regularly detected when wheezing cannot be heard. This is especially useful when there is complaint of cough, dyspnea, or episodic wheezing. When spirometry is not available, a peak flow meter may be substituted. Peak flow meters are not interchangeable. Use the same meter if possible.

Testing should be performed in compliance with American Thoracic Society standards. Obstructive ventilatory defects can generally be determined using FEV₁, FVC and FEV₁/FVC ratio. To assess restrictive ventilatory defects, lung volumes are needed. 

H. Improvement in FEV₁ > 12 Percent and 200 ml - Failure to demonstrate a change with bronchodilator does not exclude a reversible component of obstruction.

Peak expiratory flow rate (PEF) monitoring is a simple, reproducible measure of airway obstruction that can be obtained using an inexpensive portable peak flow meter. The patient should record PEF results in a peak flow diary. Peak flow diaries include a description of asthma symptoms, actions taken, medications used, and PEF. Significant improvement in PEF with asthma treatment supports the diagnosis of asthma.

L. Episodic Obstruction Documented - Patients with mild asthma provoked primarily by exercise or environmental triggers may show normal pulmonary function when asymptomatic. Repeated measurements of FEV₁ or PEF, particularly during symptoms, may be useful in these patients. Environmental triggers include pollen, dust, mites or animals, molds, occupational exposure, respiratory infection, or respiratory irritants (e.g., smoke). Presence of wheezing may also demonstrate obstruction or indicate asthma.

This study should be done in an appropriate setting which is equipped for monitoring.

Patients at any level of severity can have mild, moderate, or severe exacerbations. Some patients with intermittent asthma may experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms.

P. Mild Intermittent Symptoms/Signs - Asymptomatic and normal PEF between exacerbations. Exacerbations are brief (from a few hours to a few days); intensity may vary. Nighttime symptoms < 2 times a month or symptoms < 2 times a week. Lung function: FEV₁ or PEF > 80 percent predicted, PEF variability < 20 percent.

See Annotation P for table of evidence.

S. Step 2 Drug Therapy - Therapy of mild persistent asthma. Long-term control with low dose inhaled corticosteroid. Other daily medication (e.g., inhaled cromolyn, nedocromil or leukotriene antagonists) may also be considered for patients >12 years of age, although their position in therapy is not fully established.

Quick relief: short-acting bronchodilator: inhaled short-acting beta2-agonist as needed for symptoms; intensity of treatment will depend on severity of exacerbation; and use of short-acting inhaled beta2-agonist on a daily basis or increasing use indicates the need for additional long-term control therapy.

See Annotation P for table of evidence.

U. Step 3 Drug Therapy - Therapy of moderate persistent asthma.

Long-term control: daily medication: either anti-inflammatory, inhaled corticosteroid (medium-dose), or inhaled corticosteroid (low-medium dose) and add a long-acting bronchodilator, especially for nighttime symptoms: either long-acting inhaled beta2-agonist, sustained-release theophylline, or long-acting beta2-agonist tablets. If needed: anti-inflammatory inhaled corticosteroids (medium-high dose) and long-acting bronchodilator, especially for nighttime symptoms, either long-acting inhaled beta2-agonist, sustained-release theophylline, or long-acting beta2-agonist tablets. See Annotation S for definitions of doses of inhaled corticosteroid.

Quick relief: Short-acting bronchodilator: inhaled beta2-agonist as needed for symptoms; intensity of treatment will depend on severity of exacerbation: use of short-acting inhaled beta2-agonist on a daily basis, or increasing use, indicates the need for additional long-term control therapy.

See Annotation P for table of evidence.

W. Step 4 Drug TherapyTherapy of severe persistent asthma.

Long-term control (daily medications). Anti-inflammatory: inhaled corticosteroid (high-dose) and long-acting bronchodilator: either long-acting inhaled beta2-agonist, sustained-release theophylline or long-acting beta2-agonist tablets and corticosteroid tablets or syrup long-term, (2mg/kg/day, generally do not exceed 60 mg per day).

Quick relief (short-acting bronchodilator). Inhaled short acting beta2-agonist as needed for symptoms; intensity of treatment will depend on severity of exacerbation; use of short-acting inhaled beta2-agonists on a daily basis, or increasing use, indicates the need for additional long-term control therapy. When respiratory failure is present or threatened, the use of intubation is regarded as appropriate therapy. See Emergency/Hospital Management of Asthma, Module C3.

Patient education is essential for successful management of asthma. Patient education should occur at the first visit for asthma and continue. Critical education elements are: (a) Proficiency demonstration of MDI technique should be reassessed at every follow-up visit. (b) An Asthma Action Plan should be developed. Providers may be able to complete asthma education in collaboration with nursing and/or health education staff when available. Additional education elements may include: understanding basic pathophysiology of asthma and therapeutic mechanism of medications; early recognition and prompt treatment of asthma exacerbations; avoidance of important triggers; indications and adverse effects of medication; and PEF monitoring.

Asthma Action Plan: patients with mild asthma who have frequent exacerbations and all patients with moderate or severe asthma should have written Asthma Action Plans. Essential components include: current medications and dosages; warning signs and symptoms of impending exacerbations; PEF measurements; instructions for use of asthma medications during exacerbations; and instructions (including telephone numbers) for when and whom to call.

Environmental Control: providers should consider allergic triggers in all patients with asthma. Referral to asthma specialist for allergy evaluation (allergy testing) should be considered if significant allergic asthma is suspected. Patients with known allergic triggers should proceed with appropriate environmental control. Patients with allergic asthma should be considered for allergy immunotherapy.

Objective Monitoring: All patients with asthma should have periodic objective monitoring of airflow obstruction. Spirometry (measurement of FEV₁) is the preferred test. Objective monitoring is also recommended at times of asthma exacerbations. Home peak flow diaries may be useful for patients with mild or moderate asthma who have frequent exacerbations. The diaries should include symptoms, actions taken, medications used, outcomes and PEF.

Identify Coexisting Conditions: gastroesophageal reflux; sinusitis/nasal polyps; medications which can aggravate asthma (e.g., aspirin, nonsteroidal anti-inflammatory agents, and beta blocking drugs including eye drops).