Asthma Severity Classification and Preferred Clinical Therapy for Children Younger than 5 Years
of Age
CLASSIFICATION (STEPS)
Step 1: Mild intermittent
Step 2: Mild persistent
Step 3: Moderate persistent
Step 4: Severe persistent
Quick relief
Note: Adapted from National Asthma Education and Prevention Program. (2002). Expert Panel Report II: Guidelines for the diagnosis and management of asthma—
Update on selected topics 2002 (NIH Publication No. 02-5075). Bethesda, MD: NHLBI, NIH.
DESCRIPTION MEDICATIONS FOR LONG-TERM CONTROL
Brief exacerbations with symptoms no more No daily medications needed.
often than twice a week.
Nighttime symptoms no more than twice a week.
Exacerbations more than twice a week, but less Preferred treatment
than once a day. ➤ Low-dose inhaled corticosteroid (with nebulizer or MDI with hold
Nighttime symptoms more than twice a month. ing chamber with or without face mask or DPI).
Alternate treatment
➤ Cromolyn (nebulizer is preferred or MDI with holding chamber).
OR
➤ Leukotriene receptor antagonist.
Daily symptoms of coughing and wheezing. Preferred treatment
Nighttime symptoms more than once per week. ➤ Low-dose inhaled corticosteroids and long-acting
2-agonists.
OR
➤ Medium-dose inhaled corticosteroids.
Alternate treatment
➤ Low-dose inhaled corticosteroids and either leukotriene receptor
antagonist or theophylline.
If needed (particularly in children and adolescents with recurring severe
exacerbations)
Preferred treatment
➤ Medium-dose inhaled corticosteroids and long-acting inhaled
2-
agonists.
Alternative treatment
➤ Medium-dose inhaled corticosteroids and either leukotriene recep-
tor antagonist or theophylline.
Continuous daytime symptoms, limited physical Preferred treatment
activity. ➤ High-dose inhaled corticosteroids.
Frequent nighttime symptoms. Plus
➤ Long-acting inhaled
2-agonists.
And if needed,
➤ Oral corticosteroids at 2 mg/kg/day (not to exceed 60 mg per day).
Repeated efforts should be made to reduce systemic corticosteroids
and maintain control with high-dose inhaled corticosteroids.
Bronchodilator as needed for symptoms. Intensity of treatment will depend on severity of exacerbation.
➤ Preferred treatment: Short-acting inhaled 2-agonists by nebulizer, face mask, and space/holding chamber.
➤ Alternative treatment: oral 2-agonist.
With viral respiratory infection
➤ Bronchodilator every 4 to 6 hours up to 24 hours (longer with physician counsel); in general, repeat no more than once
every 6 weeks.
➤ Consider systemic corticosteroids if exacerbation is severe or patient has a history of previous severe exacerbations.
Use of short-acting 2-agonists > 2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indi-
cate the need to initiate (increase) long-term control therapy.