F I G U R E 5 - 1 .

C L A S S I F Y I N G S E V E R I T Y OF
ASTHMA E X A C E R B ATI O N S I N T H E U R G E N T O R
E M E R G E N C Y CARE S E T T I N G

Mild

Symptoms and
Signs
Dyspnea only
with activity
(assess tachypnea
in young
children)

Initial PEF (or

FEVi)
PEF >70
percent
predicted or
personal best

Moderate

Dyspnea interferes
wilh or limits usual
activity

PEF 40-69
percent
predicted or
personal best

Severe

Dyspnea at
rest; interferes
with
conversation

PEF <40
percent
predicted or
personal best

Subse
t:
Life
threat
ening

Too dyspneic to
speak: perspiring

PEF <25
percent
predicted or
personal best

Clinical Course
Usually cared for
at home
Prompt relief with
inhaled SABA
Possible short
course of oral systemic
corticosteroids
Usually requires office or
ED visit
Relief from frequent
inhaled SABA
Oral systemic
corticosteroids; some
symptoms last for 12
days
after treatment is begun
Usually requires ED
visit and likely
hospitalization
Partial relief from
frequent inhaled SABA
Oral systemic
corticosteroids; some
symptoms last for >3 days
after treatment is begun
Adjunctive therapies
are helpful
Requires
ED/hospitalization;
possible ICU
Minimal or no relief
from frequent inhaled
SABA
I ntrave nou s corti
coste raids
Adjunctive therapies
are helpful

Clinical classification of
severity
STEP 4
Severe
persistent
STEP 3
Moderate
persistent
STEP 2
Mild persistent
STEP 1
Intermittent

Symptoms

Night-time
symptoms

PEF

Continuous
Limited physical
activity
Daily
Use b2-agonist daily
Attacks affect activity
>1 time a week
but <1 time a day
<1 time a week
Asymptomatic and
normal PEF between
attacks

Frequent

<60% predicted
Variability >30%

>1 time a week

>60% - <80%
predicted
Variability >30%
>80% predicted
Variability 20-30%
>80% predicted
Variability <20%

>2 times a month

<2 times a month

Step 1
Step 1: Intermittent asthma
Controller
None required

Reliever
Inhaled b2-agonist prn
(not more than 3x a week)

 Inhaled b2-agonist or
cromone prior to exercise
or allergen exposure

Step 2: Mild persistent asthma

Controller
Daily inhaled corticosteroid
(200-500 mg), cromone,
sustained release theophylline,
or anti-leukotriene

Reliever
Inhaled b2-agonist prn
(but less than 3-4 times
per day)

If still not controlled, particularly

nocturnal symptoms, increase
inhaled steroid (500-800 mg) or add
long-actingbronchodilator

Step 3: Moderate persistent asthma

Controller
Daily inhaled corticosteroid
> 500 mg
Daily long-acting
bronchodilator
Consider anti-leukotriene

Reliever
Inhaled b2-agonist prn
(but less than 3-4 times
per day)

Step 4: Severe persistent asthma

Controller
Daily inhaled corticosteroid
800-2000 mg

Reliever
Inhaled b2-agonist prn
(but less than 3-4 times

 Daily long-acting
bronchodilator
Daily / alternate day oral
corticosteroid

per day)