青少年和成人间歇性和轻度持续性哮喘的治疗 - UpToDate

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青少年和成人间歇性和轻度持续性哮喘的治疗
AUTHOR: Christopher H Fanta, MD
SECTION EDITOR: Bruce S Bochner, MD
DEPUTY E D I T O R : Paul Dieffenbach, MD
翻译: 王筝扬, 副主任医师
我们的所有专题都会依据新发表的证据和同行评议过程而更新。
文献评审有效期至： 2023-07.
专题最后更新日期： 2023-06-12.
There is a newer version of this topic available in English. 该主题有一个新的英文版

本。
引言
对于任何严重程度的哮喘，治疗目标都是尽量减轻哮喘症状，尽量改善肺功能，并防止哮喘发作。哮喘
治疗的基本原则是治疗强度应个体化，与症状发作频率和严重程度及发作风险相匹配。对于所有哮喘患
者，无论轻重，实现长期成功控制的关键都是有效沟通、持续进行患者教育和定期评估控制情况。
本专题将讨论成人和青少年间歇性和持续性轻度哮喘的治疗，重点讨论药物治疗。本专题中的推荐基于
以下指南：美国国家哮喘教育和预防项目(National Asthma Education and Prevention Program,
NAEPP)指南，包括2020年哮喘管理指南重点更新；全球哮喘防治创议(Global Initiative for Asthma,
GINA)指南[1-3]。哮喘治疗的概述，以及其他严重程度哮喘的治疗，详见其他专题。(参见 “哮喘管理
概述”和 “青少年和成人中度持续性哮喘的治疗”和 “青少年及成人重症哮喘的治疗”)
哮喘分类
轻度哮喘可分为间歇性或轻度持续性。哮喘的类别一般通过评估当前功能受损情况及将来发作风险确
定，前者基于患者自诉症状和肺功能测量结果，后者基于过去1年内严重发作的次数[1]：
new.migangpro.com/contents/zh-Hans/treatment-of-intermittent-and-mild-persistent-asthma-in-adolescents-and-adults/print?search=哮喘&source=se… 1/55
● 患者自诉的过去2-4周内日间和夜间症状及运动受限情况
● 目前的呼气峰流速(peak expiratory flow, PEF)，或第1秒用力呼气容积(forced expiratory
volume in one second, FEV1)及FEV1与用力肺活量(forced vital capacity, FVC)的比值(参见
“哮喘患者呼气峰流速监测”和 “诊室肺量计检查”)
● 过去1年内需要口服糖皮质激素治疗的发作次数
GINA与NAEPP描述哮喘严重程度所用的指标组合及阈值略有不同，总结见附表( 表 1)[2,3]。务必牢
记，尽管间歇性或轻度持续性哮喘患者的症状一般为轻度且发作频率较低，但仍可能会有重度甚至危及
生命的发作。
● 间歇性哮喘–间歇性哮喘具有下列特征( 表 1)[1]：
• 每周日间哮喘症状发作≤2日
• 每月夜间憋醒≤2次
• 每周使用短效β受体激动剂(short-acting beta-agonist, SABA)缓解症状的时间≤2日
• 发作间期的正常活动不受影响
• 无症状时，PEF或FEV1测量值一直维持在正常范围内(即>80%预测正常值)
• 无症状时，FEV1/FVC比值正常(以年龄校正值为标准)
• 过去1年中需要口服糖皮质激素治疗的发作≤1次
如果任一方面的病情重于上文所述，则应归为比间歇性哮喘更为严重的类别。然而，对于运动前
预防性使用吸入性支气管扩张剂来避免运动性支气管收缩的患者，即使其每周运动时间>2日，也
可能为间歇性哮喘。(参见 “运动诱发的支气管收缩”)
仅在少有的特定情况下(例如，与猫接触或病毒性呼吸道感染期间)才出现哮喘症状加重的其他患
者，即使症状较严重，如果每年需要口服糖皮质激素治疗的次数不超过1次，则也可考虑为间歇性
哮喘( 表 1)[1]。
● 轻度持续性哮喘–轻度持续性哮喘的特征为PEF或FEV1测量值在正常范围内(≥80%预测正常值)、
FEV1/FVC比值正常或接近正常，同时存在下列任意1项( 表 1)：
• 每周出现症状的时间>2日，但并非每日出现
• 每月因哮喘而在夜间憋醒3-4次，但≤每周1次
• 每周使用快速缓解支气管扩张剂来治疗症状的时间>2日，但并非每日使用
• 正常活动受到轻度影响
• 每年需口服糖皮质激素治疗的发作≥2次
纳入“过去1年需糖皮质激素治疗的哮喘发作≥2次”这一标准是因为观察到这类患者将来哮喘发
作的风险增加，而抗炎治疗可降低该风险。因此，哮喘专家建议，即使不存在哮喘症状频繁发
作、夜间憋醒或正常活动水平受损，也采用药物策略来降低发作风险。(参见下文‘轻度持续性哮
喘的药物治疗’)
这些哮喘严重程度判断标准适用于评估时未规律应用药物控制哮喘的患者，而不适用于已在规律
使用控制药物治疗的哮喘患者。对于已在规律使用控制治疗的患者，哮喘评估最好是针对哮喘的
控制情况，而不是哮喘严重程度。(参见 “哮喘管理概述”，关于‘调整控制药物’一节)
尚无明确的生物学基础或可检测的生物标志物来区分间歇性哮喘与轻度持续性哮喘。产生这种概
念是为了帮助指导药物选择，以便维持良好的哮喘控制。由于各种内源性和外源性因素，包括对
特定或可能未知的环境暴露的反应，患者全年的哮喘严重程度可能在间歇性与轻度持续性之间变
化。
● 中度持续性哮喘–存在下列任何表现均提示为中等严重程度的哮喘( 表 1)：
• 哮喘症状每日发作。
• 每周夜间憋醒>1次。
• 每日均需使用速效支气管扩张剂来缓解症状。
• 有超过轻度的正常活动受限。
• FEV1为60%-80%预测值，FEV1/FVC比值低于正常范围的可信区间下限。计算机生成的肺量计检
查结果中通常会提供基于年龄的FEV1/FVC比值正常范围，以及平均值和95%可信区间。
中度持续性哮喘患者所需药物治疗超过推荐用于轻度哮喘治疗的范畴[1,3]。(参见 “青少年和成
人中度持续性哮喘的治疗”)
患者教育
对于间歇性及轻度持续性哮喘患者，非药物治疗必不可少，包括避免诱发因素和患者教育。
避免诱发因素 — 消除或避免已知的诱发因素有助于控制病情。病史采集对于确定家庭、学校和/或
工作场所的环境变应原和刺激物暴露十分重要。相关内容详见其他专题。(参见 “控制诱发因素以加强
哮喘管理”和 “哮喘和变态反应性鼻炎治疗中的变应原回避”和 “职业性哮喘：定义、流行病学、病
因和危险因素”)
哮喘行动计划 — 患者教育是一个持续过程，旨在使患者和医护人员之间建立合作关系，以实现并
维持哮喘控制。除了患者教育材料，还应为每名哮喘患者提供个体化哮喘行动计划，其中详细说明基线
时及发作时如何自行给药( 表格 1)。轻度哮喘患者须明白，与病情更严重的哮喘患者一样，其也有
可能发生可危及生命的重度哮喘发作。(参见 “哮喘教育和自我管理”)
输送吸入性药物 — 哮喘药物主要通过吸入装置输送，但其效果依赖于特定装置的最佳使用。(参见
“成人吸入器的用法”)
SABA有定量吸入器(metered dose inhaler, MDI)、干粉吸入器(dry powder inhaler, DPI)和雾化吸入

溶液剂型( 表 2)。目前所有MDI都使用氢氟烷(hydrofluoroalkane, HFA)作为抛射剂，而不是氯氟
烃，后者到2010年时已被淘汰。
所有吸入性药物都必须到胸腔内气道才能发挥作用。许多患者难以掌握恰当的吸入技巧，特别是使用
MDI时。每次开始使用新的吸入装置时，都要详细了解操作技巧。正确的吸入器使用技巧见附表
( 表 3和表 4和表 5)。应向患者展示吸入器的剂量计数器(大多数吸入器都有)，以便患者了
解药物何时用尽。MDI在首次使用前应预喷，如果数日至数周未使用(具体取决于MDI产品)，再次使用时
也应预喷。由于最初的喷雾中药物含量可能不足，使用前需向周围空气预喷至少1次。
除了指导正确使用方法和反复强化，使用单向阀储雾罐或储雾器也有助于优化MDI的药物输送，从而提
高效果( 表 4)。目前可使用的储雾器包括Aerochamber、Optichamber、Ellipse、Vortex等。(参见
“成人吸入器的用法”，关于‘吸入器使用方法教学’一节)
美国和其他一些国家有沙丁胺醇干粉制剂(如ProAir RespiClick)。对于部分患者而言，使用DPI装置可
能更容易掌握吸入技术，因为该装置仅在吸气时释放药物，患者无需根据药物的释放来配合吸气
( 表 5)。DPI装置不需要预喷，且不应与单向阀储雾罐(储雾器)一同使用。沙丁胺醇干粉制剂还有带
电子记录系统和配套智能设备应用程序的产品(即Digihaler)，能够在使用者喷入药物时测量吸气气
流，并形成使用频率和时间的电子记录。
各种吸入器装置的使用和清洁详见其他专题。(参见 “成人吸入器的用法”)
药物治疗的目标
治疗的主要目标是缓解症状，预防哮喘急性发作，并提高生存质量。部分哮喘患者存在肺功能进行性下
降的风险，目前没有证据表明治疗能改变此自然病程。
● 不可逆性气流阻塞–哮喘与慢性气道炎症有关，即便患者不吸烟，炎症也可逐步进展，造成永久
性的气道壁结构改变，进而导致不可逆性气流阻塞。但是，部分患者的气道炎症可持续到较大年
龄而不伴肺功能永久性改变。不可逆性气道梗阻似乎最常发生于长期重度疾病患者，或有重度哮
喘反复发作病史的患者[1,4]。在一些有儿童期哮喘病史的患者中，不可逆性气道梗阻也可能是儿
童期肺生长受损所致[5]。(参见 “哮喘的自然病程”)
若能识别出必定进展为永久性肺损害的患者，并行早期干预以阻止其进展为不可逆性气流阻塞，
则明显更为妥当。不过，目前尚无法预测轻度哮喘是否会如此进展。目前尚未在大型成人轻度哮
喘患者队列中开展流行病学研究，以进行生理学(肺功能)和组织学的长期随访[6,7]。
一项有关成人的小型临床试验发现，相比初步诊断为哮喘后很快开始治疗，延迟启用(2年后)抗炎
治疗(即吸入性糖皮质激素)的好处更少[8,9]。该结果提示，吸入性糖皮质激素(常称为吸入性皮
质类固醇或简称吸入性类固醇)可能有助于预防部分患者逐渐发生肺功能改变。然而，一些后续研
究发现，吸入性糖皮质激素并不能预防疾病进展或肺功能异常[10-12]。因此，鉴于目前没有证据
表明长期治疗可以防止部分哮喘患者发生不可逆性气流阻塞，治疗的主要目标仍是改善症状和预
防哮喘发作。
● 小气道功能障碍–外周气道炎症和狭窄在所有严重程度的哮喘中均存在，并且当哮喘无症状，由
FEV1和PEF衡量的呼气流量也正常时，其仍可能存在。有人提出，若肺活量的中间部分出现呼气流
量减少(呼出肺活量25%-75%时的用力呼气流量，即FEF25-75，以往称为最大呼气中段流量)，则反
映小气道功能障碍，即使FEV1或PEF正常，其也可检测出持续性外周阻塞。但需强调以下几点：
• FEF25-75下降伴FEV1正常，对小气道阻塞没有特异性，可见于健康人。
• 使FEF25-75恢复正常并不是哮喘治疗的推荐目标，可能导致过度治疗。
• 专门针对外周气道的治疗与传统治疗相比，均没有改善哮喘结局。(参见 “诊室肺量计检
查”，关于‘其他流量指标’一节)
● 慢性气道炎症在间歇性和轻度持续性哮喘中的作用–与其他所有的哮喘患者一样，间歇性和轻
度持续性哮喘患者有气道高反应性，表现为气道平滑肌明显比正常情况容易收缩，且收缩程度太
大；这些患者的慢性气道炎症常以嗜酸性粒细胞浸润为主。慢性气道炎症可促进气道高反应性。
抑制哮喘患者的慢性气道炎症，例如给予吸入性糖皮质激素，可以减轻支气管高反应性，但不能
完全消除。正如我们对患者讲的那样，使用控制药物可以减轻呼吸道的痉挛。
过去几十年的做法一直是以间歇性哮喘和轻度持续性哮喘之间的区别为分界线，区分哪些患者可
以仅按需使用支气管扩张剂(间歇性哮喘)，哪些患者的哮喘负担严重到还应当用控制(抗炎)药物
治疗其慢性气道炎症(持续性哮喘)。设立间歇性哮喘这一类别的原因是：一些患者每年只有几次
哮喘发作，从未发生过严重发作；每日应用抗炎治疗(如吸入性糖皮质激素)的推荐会带来经济负
担，还可能带来心理负担，同时存在药物副作用风险。因此，人们认为若症状轻微而极少发生，
肺功能基本正常，且哮喘发作不频繁(即间歇性哮喘)，持续性气道炎症可不治疗。
最近，制定GINA指南的国际哮喘研究和管理专家对这种方法提出了质疑，这在GINA 2019和后续指
南中有所阐述[3]。这些专家指出，某些间歇性哮喘患者会发生严重到导致住院、呼吸衰竭甚至死
亡、但原本可预防的哮喘发作。专家发现，使用SABA的间歇性哮喘患者若无医护人员干预，自我
给药频率很容易从“每周用药≤2日”大幅增加；他们还为间歇性哮喘患者提供了能够处理慢性气
道炎症、而无需每日使用吸入性糖皮质激的治疗选择。
间歇性哮喘和轻度持续性哮喘的传统治疗方法[1]，以及GINA和NAEPP指南提出的新策略，均见下
文[2,3]。
间歇性哮喘的药物治疗
应确保所有哮喘患者有条件立即使用速效吸入性支气管扩张剂，以迅速缓解哮喘症状，这类药物包括沙
丁胺醇、左沙丁胺醇、福莫特罗-小剂量糖皮质激素复方制剂、SABA-小剂量糖皮质激素复方制剂。下文
将介绍选择药物的基本原则( 表 6)。
我们认为，按需使用布地奈德-福莫特罗复方吸入器治疗间歇性哮喘的优势是这种方法已得到证实可减
少哮喘发作，包括导致急诊科就诊和住院的重度哮喘发作。其缺点是：依赖单一品牌的吸入器，许多患
者可能因费用和健康保险政策而无法获得药物；一些患者不愿使用含有糖皮质激素的药物；可能发生糖
皮质激素相关副作用，包括口腔假丝酵母菌病和发音障碍。对于所有含糖皮质激素的MDI，我们建议使
用储雾器并在每次用完后漱口，但如果携带布地奈德-福莫特罗MDI是为了在需要时缓解症状，遵守此建
议的难度会加大，因为携带储雾器很麻烦，也不一定有方便漱口的场所。
短效β受体激动剂用于快速缓解症状 — 数十年来，间歇性哮喘的传统治疗策略是按需使用SABA，
以缓解咳嗽、胸闷、呼吸急促或喘息等症状( 表 6)[1,2]。虽然有时称其为“紧急吸入器”，但应明
确，患者无需等到发生医疗急症才使用速效支气管扩张剂吸入器。也可在暴露于已知的哮喘诱发因素之
前5-20分钟预防性使用SABA，如在冷空气中锻炼或进行体力活动前。这仍然是我们的首选策略，也是
NAEPP指南2020年重点更新中所偏好的策略[2]。
吸入性SABA起效快(5分钟内)、作用持续时间中等(4-6小时)，且具有相对的β-2受体选择性，例如沙丁
胺醇和左沙丁胺醇(在美国称为albuterol和levalbuterol，在其他国家称为salbutamol和
levosalbutamol，但分别是完全相同的药物)( 表 2)。
副作用一般较轻，为拟交感神经刺激作用，包括兴奋感、紧张和心动过速。若患者对这些副作用特别敏
感，我们建议使用常规剂量的一半(只吸1次而不是2次)，用药后漱口以尽量减少经口的全身性吸收，偶
尔可使用短效毒蕈碱受体拮抗剂(异丙托铵)而不是SABA。
左沙丁胺醇是沙丁胺醇的R-对映异构体，是从组成沙丁胺醇的R-和S-对映异构体外消旋混合物中纯化而
来，有雾化吸入用液体，也有MDI。MDI每喷含有45μg左沙丁胺醇(90μg沙丁胺醇)。左沙丁胺醇的起效
速度、作用持续时间和副作用与沙丁胺醇相当。过去曾希望左沙丁胺醇的刺激性副作用比沙丁胺醇小，
但这种差异还没有得到明确证实。
按需联合使用小剂量糖皮质激素-福莫特罗 — GINA首选的间歇性哮喘治疗方案是采用小剂量糖皮
质激素-福莫特罗复方吸入器来按需缓解哮喘症状(在美国属于超适应证应用)( 表 6)[3]。福莫特罗
作用时间长(支气管扩张作用持续最长达12小时)，且与沙丁胺醇同样快速起效(3-5分钟内)。虽然传统
上用于哮喘的维持治疗(与吸入性糖皮质激素一起使用)，但其起效快，适合快速缓解症状。福莫特罗联
合吸入性糖皮质激素可治疗气道平滑肌收缩和气道炎症；患者症状越严重，复方吸入器的使用越频率，
输送到气道抑制炎症的糖皮质激素剂量就越大。这种策略称为“抗炎补救(antiinflammatory
rescue)”。
● 用法用量–若用于快速缓解哮喘症状，布地奈德-福莫特罗的剂量为1吸(HFA吸入器为80μg-
4.5μg/吸或160μg-4.5μg/吸；DPI为100μg-6μg/吸或200μg-6μg/吸，但美国没有)，需要缓
解症状时使用(在美国属于超适应证应用)[13]。对于严重症状发作，可每20分钟给予2吸，总剂量
不超过6吸。MDI制剂的最大推荐日剂量为12吸(福莫特罗54μg)。
● 效果–支持此方法的证据来自随机试验，这些试验同时纳入间歇性和轻度持续性哮喘患者，比较
了按需应用小剂量布地奈德+福莫特罗与按需使用沙丁胺醇。联合治疗组的哮喘发作和重度发作次
数均更少，而不良事件没有增加，详见下文。因此，这种方法对已经或可能出现反复或重度发作
的间歇性哮喘患者尤其有益。(参见下文‘有效性’)
● 其他复方吸入器–倍氯米松-福莫特罗(美国没有)和莫米松-福莫特罗可能与布地奈德-福莫特罗
效果可能相当，但证据不太可靠。
按需联用短效β受体激动剂和吸入性糖皮质激素 — 间歇性哮喘的潜在替代疗法是按需使用小剂
量糖皮质激素-SABA(如沙丁胺醇)复方吸入器[2,3]。这种“基于症状”的方法根据患者感知的补救性支
气管扩张剂需求来确定吸入性糖皮质激素给药频率，研究证实，对于中至重度哮喘患者，此法比按需单
用沙丁胺醇可更有效减少哮喘发作和改善哮喘生存质量[14]。与糖皮质激素-福莫特罗复方吸入器相
比，这种方法用于间歇性哮喘和轻度持续性哮喘的数据更少，而且全球很多地区尚未普遍提供糖皮质激
素-沙丁胺醇复方吸入器。2023年1月，美国批准了一种沙丁胺醇-布地奈德复方吸入器，详见下文。(参
见下文‘按需联用吸入性糖皮质激素与短效β受体激动剂’)
按需使用糖皮质激素-SABA复方制剂可称为“抗炎补救”。尽管2020年NAEPP指南重点更新未评估该方案
治疗间歇性哮喘的情况，但其可能也适用于某些严重发作风险增加、单用SABA疗效不足的间歇性哮喘患
者，比如患者有危及生命发作既往史、未定期接受医疗随访以评估哮喘严重程度变化，或有可预测的哮
喘控制恶化情况(如间歇性高强度变应原暴露期间)。在推荐这种疗法广泛用于间歇性哮喘之前，还需获
得更多的临床试验数据和真实世界经验。
轻度持续性哮喘的药物治疗
目前认为，轻度持续性哮喘患者(参见上文‘哮喘分类’)的疾病活动负担和哮喘发作风险通过单纯按需
使用支气管扩张剂不能得到充分处理[1,2,13]。加用定期或恰当的间歇性抗炎治疗后，症状发作频率通
常减少，气道高反应性减轻，肺功能改善，哮喘发作风险也降低。吸入性糖皮质激素针对的是哮喘的基
础气道炎症，包含在所有严重程度持续性哮喘的一线治疗中，用于轻度哮喘时以小剂量开始应用。
对于轻度持续性哮喘，每日使用小剂量吸入性糖皮质激素的推荐已持续了约30年(传统策略)[1]。这种
方法的主要缺点是患者依从性较差，只有不到50%的患者会定期进行吸入性糖皮质激素续方。阻碍规律
使用的因素包括费用、患者对药物依赖和长期副作用的恐惧、常见不良反应(包括鹅口疮和发音障碍)，
以及不能在每次用药后立即改善症状。已评估过其他方案，包括2019年以来GINA首选推荐方案[3]，建
议根据症状(按需)使用小剂量糖皮质激素与速效长效β受体激动剂(long-acting beta agonist, LABA)

的复方吸入器。此策略和其他新疗法见下文。
方法 — 美国国家指南和国际指南均建议首选吸入性糖皮质激素来治疗轻度持续性哮喘，但具体的
药物选择和用药方案不同( 表 6)[1,2,13]。方法差异与当地监管机构审批和药物上市情况部分相
关。
● NAEPP指南首选方案–定期(每日)使用单独的小剂量吸入性糖皮质激素，并在需要时用SABA缓解
症状[2]。在美国，这仍然是最常用的轻度持续性哮喘治疗方法。(参见下文‘每日使用小剂量吸
入性糖皮质激素’)
● GINA首选方案–按需使用含有小剂量糖皮质激素和速效LABA福莫特罗的复方吸入器(在美国属于
超适应证使用)[3]。这与GINA推荐的间歇性哮喘第1级治疗相同。(参见下文‘按需应用吸入性糖
皮质激素+福莫特罗’和‘按需联合使用小剂量糖皮质激素-福莫特罗’)
● NAEPP和GINA的替代方案–按需使用小剂量吸入性糖皮质激素和SABA缓解症状，可单独使用或使
用复方吸入器[2,3]。(参见下文‘按需联用吸入性糖皮质激素与短效β受体激动剂’)
对于轻度持续性哮喘，也可规律使用口服白三烯受体拮抗剂(leukotriene receptor antagonist,

LTRA)，同时按需使用SABA。这种方法控制症状和预防哮喘发作的效果不如每日使用小剂量吸入性糖皮
质激素。(参见下文‘替代方案：白三烯调节剂’)
历来使用的小剂量糖皮质激素替代方案还有长效口服支气管扩张剂茶碱和吸入性色甘酸盐(色甘酸钠和
奈多罗米)，但由于副作用发生率高且出现严重不良后果的风险增加(茶碱)，或者在美国不易获得(色甘
酸盐)，其应用受限；这两种药物均未获得推荐[1-3]。(参见下文‘避免或很少使用的药物’)
每日使用小剂量吸入性糖皮质激素 — 根据美国国家指南和国际指南，推荐对所有严重程度的持续
性哮喘都使用吸入性糖皮质激素( 表 6)[1-3]。对于轻度持续性哮喘，NAEPP指南2020年重点更新的
首选治疗推荐仍是每日使用吸入性糖皮质激素，并在需要时用SABA快速缓解症状[2]；GINA指南将其用
作替代方案[3]。(参见 “哮喘管理概述”)
● 患者教育–若采用每日使用吸入性糖皮质激素并单独用SABA缓解症状的方案，患者教育非常重
要，可使患者理解这两种吸入药物的不同作用：前者要每日使用，但没有立即缓解症状的作用；
后者可立即缓解症状，应随时携带，但只在症状发作时(或运动前)按需使用。(参见上文‘哮喘行
动计划’)
● 吸入器使用技巧–开具吸入性糖皮质激素时，还应指导正确的吸入器使用方法，告知患者长期使
用小剂量糖皮质激素是安全的，说明使用后应漱口以尽量降低发生口腔假丝酵母菌病的风险，以
及若通过MDI给药则最好使用单向阀储雾罐(储雾器)。通过MDI使用吸入性糖皮质激素时采用单向
阀储雾罐的重要优势是可减少药物沉积在口咽，从而既能减少全身性吸收，又能降低发生口咽假
丝酵母菌病和发音障碍的风险。加用吸入性糖皮质激素后，可能需要长达2周才能观察到疗效，有
些患者可能需要几个月才达到最大获益。(参见上文‘输送吸入性药物’)
初始用法用量 — 使用吸入性糖皮质激素治疗轻度持续性哮喘时，最初应采用小剂量[1,2]。吸入
性糖皮质激素的常用起始剂量和不同类型见附表中的小剂量栏( 表 7)。
小剂量吸入性糖皮质激素中，莫米松的批准用法是一日1次。传统上，其他吸入性糖皮质激素是一日给
药2次，但许多轻度哮喘患者可能也可一日用药1次，这可能会改善依从性[15,16]。
与其他吸入性糖皮质激素相比，更多证据支持布地奈德在妊娠期使用的安全性。(参见 “妊娠期哮喘的
处理”)
吸入性糖皮质激素有MDI、呼吸驱动式MDI、DPI和雾化吸入用溶液(布地奈德)( 表 7)。若采用糖皮质
激素MDI，推荐使用单向阀储雾罐(储雾器)，以尽量多地将药物输送到支气管，并尽量减少药物在口咽
沉积；储雾器不与DPI或呼吸驱动式MDI一起使用。(参见上文‘输送吸入性药物’和 “成人吸入器的用
法”)
不良反应 — 使用小剂量吸入性糖皮质激素的患者可能出现口腔假丝酵母菌病和发音障碍(声音嘶
哑)，但长期不良反应罕见。吸入性糖皮质激素的局部和全身性副作用，以及尽量减少这些副作用的策
略，详见其他专题。(参见 “吸入性糖皮质激素的主要副作用”和 “糖皮质激素性骨质疏松的临床表
现和评估”)
有效性 — 规律使用吸入性糖皮质激素治疗可减少症状发作频率和吸入性支气管扩张剂的使用需
求、改善总体生存质量，并降低严重发作的风险[17-24]。此外，该治疗可能通过减轻气道炎症而降低
支气管高反应性，从而减弱气道对哮喘诱发因素的过度敏感性[17]。下列代表性研究证实了吸入性糖皮
质激素的有效性[17-23,25]：
● 一项多中心双盲试验纳入7000多例轻度持续性哮喘患者，随机分组给予小剂量吸入性布地奈德(一
次400μg，一日1次)或安慰剂，治疗3年[18]。与安慰剂相比，早期启用布地奈德与研究期间重度
哮喘发作的风险较低有关(3.2% vs 5.5%，HR 0.56，95%CI 0.45-0.71)。布地奈德组的肺功能更
好，出现症状的天数更少[18,26]。
● 另一项试验纳入103例近期发作轻度哮喘患者，随机分配至大剂量布地奈德组(一次600μg，一日2
次)或特布他林组(一次375μg，一日2次)[19]。随访1年和2年时，与特布他林组相比，布地奈德
组的早晨PEF增加更多(32.8L/分 vs 4.8L/分)、哮喘症状更少，并且对SABA附加治疗的需求更
少。
吸入性糖皮质激素对部分哮喘患者无效。研究表明，在哮喘控制、FEV1或支气管反应性方面，多达
35%-40%的患者可能没有改善[27-29]。一项随机、交叉设计试验纳入295例有轻度持续性哮喘的青少年
和成人，评估了气道嗜酸性粒细胞性炎症的程度是否可能影响吸入性糖皮质激素的疗效[29]。对于痰液
嗜酸性粒细胞<2%的患者(73%)，该试验根据症状日志、哮喘控制测试结果(Asthma Control Test)和
FEV1综合评估了哮喘控制改善情况，发现吸入性莫米松治疗12周组相比长效毒蕈碱受体拮抗剂噻托溴铵
治疗12周组，获得哮喘控制改善的患者比例基本相近(57% vs 60%)，仅略高于安慰剂组(40%-43%)。值
得注意的是，疗效差异主要是由于FEV1的变化，该变化会使结果向支持应用噻托溴铵等支气管扩张剂的
方向偏倚。对于痰液嗜酸性粒细胞比例高(≥2%)的患者，莫米松效果显著优于安慰剂(治疗有效率74%
vs 26%)，但噻托溴铵效果并不优于安慰剂。在开展更多长期试验来证实这些发现之前，尚不能推荐改
变临床实践。
一些研究显示，小剂量吸入性糖皮质激素对吸烟的轻度哮喘患者的疗效相对较差，但并非所有研究都能
证实这一点[30-33]。对于一直吸烟的哮喘患者，尚未确定最佳的药物治疗选择。
按需应用吸入性糖皮质激素+福莫特罗 — 按需联合使用吸入性糖皮质激素与福莫特罗(在美国属
超适应证应用)的推荐是依据一些随机试验，这些试验发现，此方法能比每日使用吸入性糖皮质激素+按
需使用SABA更有效预防需全身性类固醇治疗的重度哮喘发作，同时减少了吸入性糖皮质激素的年剂量。
(参见下文‘有效性’)
此方法的优点还包括不需要每日用药，以及可以使用1个吸入器而非2个单独的装置。另一方面，这些研
究显示，相比按需联合使用布地奈德-福莫特罗，每日使用吸入性糖皮质激素预防哮喘发作(包括非重度
发作)的效果相当，且改善患者自诉症状的效果略好。
相比每日使用吸入性糖皮质激素，糖皮质激素-福莫特罗联合用药的不良反应率未增加。
用法用量和装置 — 关于按需使用吸入性糖皮质激素+速效LABA的已发表文献主要限于布地奈德-福
莫特罗DPI(200μg-6μg/吸，按需使用1吸)，美国没有该制剂。布地奈德-福莫特罗联合给药MDI的用法
用量相似：160μg-4.5μg/吸，按需使用1吸；或80μg-4.5μg/吸，按需使用2吸。虽然是超适应证使
用，但这种用法得到了国际指南和临床试验的支持[3]。(参见下文‘有效性’)
目前也有另一种吸入性糖皮质激素(莫米松)与福莫特罗的复方吸入器(莫米松-福莫特罗MDI：50μg-
5μg、100μg-5μg和200μg-5μg)。莫米松比布地奈德更强效。虽然尚无研究评估基于症状使用莫米
松-福莫特罗治疗轻度持续性哮喘，但我们预计按需使用1-2吸的疗效与布地奈德-福莫特罗相当。
类似地，在欧洲和美国以外的其他国家有一种用于维持治疗的小剂量倍氯米松-福莫特罗(100μg-6μg)
复方吸入器。这是按需使用小剂量布地奈德-福莫特罗的替代疗法，但相比布地奈德-福莫特罗，按需应
用倍氯米松-福莫特罗的相关临床试验数据不太可靠[3,34]。与布地奈德-福莫特罗的用法用量相匹配的
用法为按需使用1吸(超适应证使用)。
安全性和不良反应 — 2017年年底，美国FDA在审查了4项大型临床安全性试验后，取消了以前对
LABA-糖皮质激素复方吸入器的黑框警示，这4项试验在共40,000余例研究对象中检验了LABA-糖皮质激
素复方吸入器相对于单用吸入性糖皮质激素的安全性和有效性[35]。FDA的结论是，与吸入性糖皮质激
素联用时，LABA不会显著增加发生哮喘相关严重副作用的风险。值得注意的是，这些安全性数据来自
有关规律使用LABA-糖皮质激素复方吸入器的研究。不应单用LABA治疗哮喘。(参见下文‘避免或很少使
new.migangpro.com/contents/zh-Hans/treatment-of-intermittent-and-mild-persistent-asthma-in-adolescents-and-adults/print?search=哮喘&source=s… 10/55
用的药物’和 “β受体激动剂用于哮喘的急性给药及预防性应用”，关于‘LABA用于长期维持治
疗’一节)
LABA的潜在副作用通常较轻微，包括头痛、肌肉痛性痉挛和拟交感神经刺激作用(包括引起快速性心律
失常的低风险)。
吸入性糖皮质激素的不良反应详见其他专题。(参见 “吸入性糖皮质激素的主要副作用”)
有效性 — 一些试验和系统评价探讨了轻度持续性哮喘患者是否可能采用按需给予糖皮质激素-速
效LABA复方吸入器来缓解症状的治疗方案，而非每日使用吸入性糖皮质激素+用SABA进行“补救性”治
疗[36-44]。
● 开放性试验Novel START纳入668例间歇性或轻度持续性哮喘成人患者，随机分为以下3组：按需使
用沙丁胺醇组；布地奈德(200μg/吸，一次1吸，一日2次)+按需使用沙丁胺醇组(即布地奈德
组)；按需使用布地奈德-福莫特罗联合治疗组(200μg-6μg/吸，一次1吸)[42]。52周后，布地奈
德-福莫特罗组的年发作率低于沙丁胺醇组(19% vs 40%，RR 0.49，95%CI 0.33-0.72)，与布地奈
德组相当(RR 1.12，95%CI 0.70-1.79)。按需使用布地奈德-福莫特罗组的重度发作比其他任何一
组都少。然而，在控制哮喘症状方面，规律使用布地奈德优于按需使用布地奈德-福莫特罗。一日
2次使用布地奈德的平均依从率为56%。
● 随机试验SYGMA1纳入3836例年龄≥12岁的轻度哮喘患者，随机分为3组：特布他林组，给予安慰剂
(一日2次)+按需使用吸入性特布他林；布地奈德-福莫特罗组，给予安慰剂(一日2次)+按需使用布
地奈德-福莫特罗(200μg布地奈德、6μg福莫特罗)；布地奈德维持治疗组，给予布地奈德(一次
200μg，一日2次)+按需使用特布他林[40]。52周后，布地奈德-福莫特罗组中，每例患者哮喘得
到良好控制的周数的平均百分比低于布地奈德维持治疗组(OR 0.64，95%CI 0.57-0.73)，但高于
特布他林组。2个布地奈德治疗组中重度发作(需要全身性糖皮质激素治疗)的年发生率相近(布地
奈德-福莫特罗组为6%，单用布地奈德组为6.9%；RR 0.83，95%CI 0.59-1.16)。布地奈德-福莫特
罗组中，吸入性糖皮质激素中位日剂量是一日2次布地奈德组的17%。
● 单独的SYGMA 2试验纳入4176例≥12岁的轻度哮喘患者，比较了按需使用布地奈德-福莫特罗
(200μg-6μg)与一日2次布地奈德(200μg)维持治疗[41]。52周后，在重度发作的预防方面，布
地奈德-福莫特罗的效果不弱于布地奈德每日给药(10.4% vs 10.6%；年化RR 0.97，95%置信上限
为1.16)。两组首次发作时间也相似，但根据哮喘控制问卷5(Asthma Control Questionnaire-
5)，布地奈德维持治疗更有利于控制症状。
按需联用吸入性糖皮质激素与短效β受体激动剂 — 这种方法类似于上文介绍的按需使用吸入性
糖皮质激素+LABA(福莫特罗)的方案，但用更传统的SABA(如沙丁胺醇)代替长效福莫特罗[36,45-47]。
NAEPP指南2020年重点更新纳入了按需使用吸入性糖皮质激素与SABA治疗轻度持续性哮喘[2]，但这种疗
法的实际应用受限，糖皮质激素-SABA复方吸入器至今仍未普及。一种沙丁胺醇-布地奈德复方吸入器已
获美国FDA批准在该国使用[48]。没有复方吸入器时，要使用这种疗法就需要随时携带2个单独的吸入
器，以便在症状发作时相继使用。这种方法对患者依从性的影响很大。
可获取情况 — 美国FDA已批准了一种沙丁胺醇-布地奈德MDI(每喷90μg-80μg)，但预计到2024年
初才会普及[48]。其他地区已采用其他糖皮质激素-SABA复方吸入器(如倍氯米松-沙丁胺醇)来控制轻度
持续性哮喘。患者可通过SABA获得快速缓解，同时也会得到吸入性糖皮质激素的抗炎治疗。患者越常发
生需要快速缓解的症状，接受的抗炎治疗就越多[45]。
有效性 — 虽然相关数据较少，但按需使用吸入性糖皮质激素+沙丁胺醇来缓解症状的方案，与每
日使用吸入性糖皮质激素＋按需间歇性使用沙丁胺醇可能效果相近。为期44周的TREXA试验将843例儿童
和青少年患者随机分为以下4组：联合治疗组，方案为倍氯米松维持治疗(一次40μg，一日2次)，联合
倍氯米松＋沙丁胺醇补救性治疗(每使用1吸沙丁胺醇，就应用40μg倍氯米松)；倍氯米松维持治疗组，
方案为倍氯米松一次40μg、一日2次，并采用沙丁胺醇补救性治疗；倍氯米松缓解治疗组，方案为每日
应用安慰剂，并采用倍氯米松＋沙丁胺醇补救性治疗；安慰剂组，方案为每日应用安慰剂，并采用沙丁
胺醇补救性治疗[46]。相比仅使用沙丁胺醇补救性治疗，倍氯米松维持治疗或缓解治疗组的发作率都较
低。
替代方案：白三烯调节剂 — LTRA是轻度持续性哮喘的替代治疗方案( 表 6和表 8)[1,3]。虽
然这些药物使用方便(口服，一日1次或2次)，但根据美国国家指南和国际指南，吸入性糖皮质激素仍是
对轻度持续性哮喘患者启动长期控制治疗时的首选，因为其效果更好、更稳定[1-3]。(参见 “抗白三
烯药物在哮喘治疗中的应用”)
患者选择 — 通过尝试性治疗能最可靠地区分抗白三烯药物治疗有效和无效的患者。治疗约1个月
后症状未改善则视为无疗效。尚无证据表明LTRA对特应性哮喘(即有明确变应原敏感性的哮喘)的疗效优
于非特应性哮喘。(参见下文‘有效性’和 “抗白三烯药物在哮喘治疗中的应用”)
以下特定情况中，抗白三烯药物可能有效：
● 对于轻度持续性哮喘合并变应性鼻炎的患者，使用LTRA可以同时治疗这两种疾病。LTRA能有效治
疗季节性和常年性变应性鼻炎，效果与第2代抗组胺药相当，但远不如鼻内糖皮质激素给药。(参
见 “变应性鼻炎的药物治疗”，关于‘需谨慎使用的疗法’一节)
● 若运动性支气管痉挛为显著特征，可采用LTRA预防运动引起的症状。长期使用LTRA预防运动性支
气管收缩不会出现支气管保护效应逐渐消失(快速耐受)，而这种现象可见于LABA[49]。(参见
“运动诱发的支气管收缩”，关于‘长时间或频繁运动’一节)
● 对于有阿司匹林加重性呼吸系统疾病的哮喘患者，基线时及摄入阿司匹林或任何非甾体类抗炎药
(nonsteroidal antiinflammatory drug, NSAID)时，会过量产生白三烯。这种情况下使用白三烯
调节剂有生物学意义，有可能改善哮喘的整体控制情况。这并不能使这些患者摄入阿司匹林或
NSAID变得安全。(参见 “阿司匹林加重性呼吸系统疾病”)
可用的药物和用法用量 — 美国使用的LTRA是扎鲁司特和孟鲁司特( 表 8)。
● 扎鲁司特(安可来)–青少年和成人的剂量为一次20mg，一日2次。空腹服用的吸收效果最佳。该药
在肝脏中通过CYP2C9代谢。唯一与其有显著相互作用的药物是华法林，两者合用会导致凝血酶原
时间增加。
● 孟鲁司特(顺尔宁)–青少年和成人的剂量为一次10mg，一日1次[50]。美国FDA发布了针对孟鲁司
特的黑框警示，警告此药可能引起行为和心境相关改变，因此用于有精神健康问题的患者时应尤
其谨慎，尤其是已有抑郁症的患者。尚无显著药物相互作用的报道。大多数临床试验中，孟鲁司
特是在晚上使用；但尚无临床证据表明晚上给药优于早晨给药。如果患者吞咽药片存在困难，可
使用咀嚼片。
齐留通抑制5-脂加氧酶，从而抑制白三烯B4、C4、D4和E4的产生，由于不良反应发生率较高而一般仅用
于较严重哮喘。(参见 “青少年及成人重症哮喘的治疗”，关于‘抗白三烯药物’一节)
LTRA的用法用量和不良反应详见其他专题。(参见 “抗白三烯药物在哮喘治疗中的应用”，关于‘不良
反应’一节)
有效性 — 有关轻至中度哮喘患者的临床试验表明，扎鲁司特和孟鲁司特可诱导持续性支气管扩
张，并改善症状[51,52]。此外，这些药物可以减少SABA吸入器的补救性使用需求，并且一些研究显
示，这些药物还可防止发生需要口服糖皮质激素治疗的急性哮喘发作。相对于吸入性药物，一日仅使用
1次或2次的口服药物依从性较高[53]。
但白三烯调节剂的效果通常不如吸入性糖皮质激素[28,54,55]。例如，一项纳入451例患者的随机试验
发现，与接受扎鲁司特治疗的患者相比，接受小剂量吸入性氟替卡松治疗的患者中，肺功能和无症状天
数的改善明显更好，且补救性药物的使用更少[54]。另一方面，权衡吸入性糖皮质激素的更好疗效与口
服药物的更好依从性时，发现这两类药物在“现实”实践中达到的结局相似[56]。
部分哮喘患者对白三烯阻断药的反应良好，而其他患者不然。这种差别可能与不同患者中白三烯过度表
达对哮喘发生机制的相对促进作用差异有关。临床上尚无可识别出白三烯“过度表达”患者的检测，但
阿司匹林加重性呼吸系统疾病患者(即摄入阿司匹林或NSAID会使哮喘急剧恶化的患者)通常会产生过量
的白三烯，因而可能获益于LTRA。抗白三烯治疗在阿司匹林加重性呼吸系统疾病中的作用详见其他专
题。(参见 “阿司匹林加重性呼吸系统疾病”)
变应原免疫治疗 — 2020年哮喘管理指南重点更新建议考虑将皮下免疫治疗(subcutaneous
immunotherapy, SCIT)作为持续性过敏性哮喘患者的辅助治疗[2]。其强调应仔细选择患者，包括要有
由过敏性暴露诱发哮喘的病史，以及通过血液或皮肤试验证实变应原致敏。SCIT是在最佳药物治疗后给
予，优点可能包括改善哮喘控制、能减少哮喘治疗药物用量以及可能逐渐改变哮喘的基础严重程度(免
疫调节作用)。其风险包括经皮下给予的变应原引起变态反应，甚至引起可能危及生命的全身性过敏反
应。(参见 “变应性鼻-结膜炎和哮喘的皮下免疫治疗：适应证与疗效”)
其他策略 — 一些其他策略经证实对轻度持续性哮喘有效，但尚无充分证据支持其广泛应用，各哮
喘管理指南也未推荐这些方法。包括以下2种方法：
间歇性使用大剂量吸入性糖皮质激素 — 对于轻度持续性哮喘患者，根据定义，其症状负担较
轻，可能不愿全年每日使用吸入性糖皮质激素。在哮喘症状发作或预计可能发生哮喘症状时(例如，上
呼吸道感染初期)，规律(即每日)使用吸入性糖皮质激素治疗持续10-14日，预防哮喘发作的效果可能与
全年每日用药相当。一项随机试验评估了这种策略，其纳入225例轻度持续性哮喘患者，给予短疗程大
剂量布地奈德治疗(症状发作频率增加时使用，一次800μg，一日2次，连用10日)，并在必要时给予短
疗程口服糖皮质激素来控制发作，同时每日给予以下3种治疗之一：吸入性布地奈德，一次200μg，一
日2次；口服扎鲁司特(一种LTRA)，一次20mg，一日2次；安慰剂(这组患者仅采用了间歇性大剂量吸入
性糖皮质激素治疗)。所有患者均按需使用沙丁胺醇[36]。1年后，各组的重度发作率、口服糖皮质激素
需求、生存质量和肺功能没有差异，这表明吸入性糖皮质激素间歇性给药可能足以治疗特定的轻度哮喘
患者，但每日应用布地奈德组的无症状天数更多。间歇性使用的吸入性类固醇的剂量相当于布地奈德
DPI 180μg/喷、一次4喷、一日2次。
一日1次给予吸入性糖皮质激素+长效β受体激动剂 — 对于轻度哮喘，一日1次使用吸入性糖皮
质激素+LABA可能足以实现良好控制。例如，一项随机试验纳入500例轻度持续性哮喘患者，结果显示，
一日1次小剂量氟替卡松(100μg/d)+沙美特罗治疗的效果与一日2次吸入性丙酸氟替卡松(200μg/d)相
当，且优于LTRA孟鲁司特，试验治疗期为16周[57]。这些研究中，按需使用SABA吸入器来快速缓解症
状。长效支气管扩张剂联合吸入性糖皮质激素的潜在优势在于，通常每次用药都会改善症状(与单用吸
入性糖皮质激素不同)，这可能有利于改善长期依从性。现有一种DPI含吸入性糖皮质激素糠酸氟替卡松
+超长效β受体激动剂维兰特罗，一日用药1次，但其中的糖皮质激素为中效(100μg)或高效(200μg)，
仅用于中度或重度持续性哮喘。
避免或很少使用的药物
避免使用的药物：
● 长效β受体激动剂单药治疗—美国国家指南、国际指南和美国FDA推荐不要单用LABA治疗哮喘，
尽管其被归为长期控制药物[1,3,35]。(参见 “β受体激动剂用于哮喘的急性给药及预防性应
用”，关于‘反对LABA单药治疗的证据’一节)
没有联用抗炎治疗时，LABA与发生呼吸衰竭和死于哮喘的风险增加有关[58]。研究还显示，LABA
单药治疗不如吸入性糖皮质激素单药治疗。哮喘临床研究网络的沙美特罗或吸入性皮质类固醇试
验中，在中等剂量吸入性糖皮质激素治疗下哮喘控制良好的患者被随机分配至继续使用吸入性糖
皮质激素或改为采用一日2次的沙美特罗治疗[59]。虽然两组患者达到的峰流速值相近，但单用沙
美特罗组中治疗失败(主要为需要加强治疗的哮喘发作)的发生率显著更高。
● 消旋肾上腺素—美国FDA已批准短效支气管扩张剂吸入性消旋肾上腺素作为非处方药销售。我们与
许多专业协会一样不鼓励使用该药，如美国胸科学会及美国过敏、哮喘与免疫学会。我们发现短
效选择性β-2受体激动剂更有效、作用时间更长，且更安全。
● 口服β受体激动剂–口服β受体激动剂，如沙丁胺醇液体或片剂、特布他林片剂，一般不是治疗
轻度哮喘的恰当替代性支气管扩张剂。相比相同药物的吸入性制剂，上述剂型起效更慢、支气管
扩张作用较弱，并且副作用更多[60,61]。
很少使用的药物：
● 异丙托铵–吸入性异丙托铵是一种毒蕈碱受体拮抗剂；与吸入性SABA相比，该药对哮喘的起效较
慢(15-20分钟)、支气管扩张作用明显较弱。因此不推荐使用该药，除非情况非常特殊，例如使用
吸入性β受体激动剂或同时使用单胺氧化酶抑制剂引起快速性心律失常时。一篇系统评价发现，
对于成人哮喘患者，除了急性重度哮喘发作的情况之外，异丙托铵+SABA并不优于单用SABA[62]。
● 茶碱–缓释茶碱是一种长效支气管扩张剂，在过去广泛用作持续性哮喘的控制药物。因为抗炎作
用很弱，常致副作用，使用时必须监测血药水平以避免毒性，加上如今有了效果更好的长效支气
管扩张剂，该药现已很少使用。
由于可能发生危及生命的严重毒性，且有其他长效吸入性支气管扩张剂可以使用，茶碱的应用大
大减少。茶碱在哮喘治疗中的用法用量详见其他专题。(参见 “茶碱在哮喘中的应用”)
● 色甘酸盐–色甘酸钠和奈多罗米是替代性药物，可用于预防运动性支气管收缩或预防可预见性过
敏暴露(例如，拜访有猫的家庭)所致哮喘症状，但不易获得( 表 9)。在美国和加拿大，没有色
甘酸钠和奈多罗米MDI。在美国，这类药物治疗哮喘的剂型只有色甘酸钠雾化液。在许多其他国
家，有基于HFA和DPI的色甘酸钠和奈多罗米剂型。
这类药物通过稳定肥大细胞和其他特性来预防支气管痉挛，但不能快速扩张支气管。它们用作长
期控制药物的缺点是需要一日给药3-4次。
安慰剂对照盲法研究发现，在运动或其他诱发因素暴露前10-20分钟，使用2吸色甘酸钠或奈多罗
米可有效预防运动性支气管收缩[63,64]。在运动前将这类药物与吸入性β受体激动剂联用可产生
叠加的保护作用[65]。
长期管理
应在患者每次就诊时评估哮喘控制水平[1,3]。评估应基于：上次就诊后的临床病史，可采用经验证的
问卷，如哮喘控制测试(Asthma Control Test)和哮喘控制问卷(Asthma Control Questionnaire)；当
前肺功能；患者未来哮喘发作的风险水平。哮喘管理的目标是实现良好哮喘控制，其定义标准同间歇性
哮喘：每周日间哮喘症状发作≤2日；每月夜间憋醒≤2次；每周使用SABA缓解症状≤2日；发作间期的
正常活动不受影响；无症状时不存在气流阻塞；过去1年中需要口服糖皮质激素治疗的发作≤1次。哮喘
控制的概念总结见附表，并详见其他专题( 表 10)。(参见 “哮喘管理概述”，关于‘调整控制药
物’一节)
升级治疗 — 如果初始治疗未充分控制哮喘，应详细评估用药技巧、依从性及诱发因素回避情况。
处理合并的医学问题也可能改善哮喘控制，如慢性鼻-鼻窦炎、胃食管反流、肥胖和吸烟。如果采取这
些干预措施后哮喘控制仍然较差，则治疗应“升级”到下一个水平( 表 6)[1,3]。应在调整治疗方案
后2-6周重新评估患者。
降级治疗 — 一般而言，哮喘降级治疗对中度和重度持续性哮喘患者最为重要，应尽可能减少中等
剂量和高剂量的吸入性糖皮质激素。对于间歇性和轻度持续性哮喘患者，降级治疗不那么重要，但仍然
可能有益于减少终生药物总暴露量。部分患者的哮喘在1年中的某些时候最适合归类为间歇性，而在其
他时候适合归类为持续性。这类患者可交替使用第1级治疗和第2级治疗( 表 6)[1,3]。对于轻度哮喘
患者，这可能意味着只在哮喘症状加重期间才规律使用吸入性糖皮质激素，或尝试按需使用小剂量糖皮
质激素-福莫特罗吸入器(超适应证应用)。
学会指南链接
部分国家及地区的学会指南和政府指南的链接参见其他专题。(参见 “学会指南链接：青少年和成人哮
喘”)
患者教育
UpToDate提供两种类型的患者教育资料：“基础篇”和“高级篇”。基础篇通俗易懂，相当于5-6年级
阅读水平(美国)，可以解答关于某种疾病患者可能想了解的4-5个关键问题；基础篇更适合想了解疾病
概况且喜欢阅读简短易读资料的患者。高级篇篇幅较长，内容更深入详尽；相当于10-12年级阅读水平
(美国)，适合想深入了解并且能接受一些医学术语的患者。
以下是与此专题相关的患者教育资料。我们建议您以打印或电子邮件的方式给予患者。(您也可以通过
检索“患者教育”和关键词找到更多相关专题内容。)
● 基础篇(参见 “患者教育：哮喘治疗药物(基础篇)”和 “患者教育：吸入性皮质类固醇药物(基

础篇)”)
● 高级篇(参见 “Patient education: Asthma treatment in adolescents and adults (Beyond

the Basics)”和 “Patient education: Trigger avoidance in asthma (Beyond the
Basics)”和 “Patient education: How to use a peak flow meter (Beyond the Basics)”和
“Patient education: Inhaler techniques in adults (Beyond the Basics)”)
总结与推荐
● 分类–轻度哮喘可分为间歇性哮喘或轻度持续性哮喘，其界定标准在以下方面存在差异：日间和
夜间哮喘症状发作的频率、需要使用补救性支气管扩张剂的频率以及哮喘所致活动受限的程度。
( 表 1)。两种情况均存在发作间期肺功能正常或接近正常的特征。(参见上文‘哮喘分类’)
● 治疗目标–哮喘治疗的基本原则是治疗应个体化，与症状的发作频率、严重程度及未来发作风险
相匹配。务必牢记，尽管间歇性或轻度持续性哮喘患者的症状一般呈轻度，且发作频率较低，但
仍可能发生重度甚至危及生命的哮喘发作。(参见上文‘引言’和‘哮喘分类’)
个体患者中慢性轻度哮喘的病程无法预测。少数轻度哮喘患者的病情可能逐渐加重并发生不可逆
性气道梗阻，但大多数患者不会。发生该结局的易感因素不明，抗炎治疗也未明确显示出保护作
用。因此，哮喘治疗的主要目标是缓解症状和预防急性发作，而非长期保留肺功能。(参见上
文‘药物治疗的目标’)
● 哮喘诱发因素–哮喘管理的一个重要内容是识别并回避诱发因素(运动除外)。病史采集对于确定
家庭和/或工作场所环境变应原和刺激物暴露十分重要。随后可进行皮肤过敏试验或针对血液中抗
原特异性IgE的免疫测定，以识别患者对常见气源性致敏原的敏感性，作为对病史信息的补充。
(参见上文‘避免诱发因素’和 “控制诱发因素以加强哮喘管理”和 “哮喘和变态反应性鼻炎治
疗中的变应原回避”)
● 应能立刻使用吸入性支气管扩张剂–所有哮喘患者都应能立刻使用速效吸入性支气管扩张剂
( 表 6)。(参见上文‘间歇性哮喘的药物治疗’)
● 支气管扩张剂吸入器治疗间歇性哮喘–在选择间歇性哮喘患者的速效支气管扩张剂时，根据美
国国家哮喘教育和预防项目(NAEPP)指南2020年重点更新的推荐，我们建议按需使用短效β受体激
动剂(SABA)来治疗症状，如沙丁胺醇或左沙丁胺醇( 表 2)(Grade 2C)。对于大多数间歇性哮
喘患者，我们首选按需使用SABA，依据是该药应用历史较久、普及度高且费用较低，并能避免吸
入糖皮质激素的潜在不良反应。合理替代方案包括：小剂量糖皮质激素-福莫特罗复方吸入器，如
布地奈德-福莫特罗160μg-4.5μg，按需使用1吸，以缓解哮喘症状(超适应证使用)；小剂量糖皮
质激素-沙丁胺醇复方制剂，如沙丁胺醇-布地奈德90μg-80μg，按需使用2吸，以缓解哮喘症状
( 表 6)。按需联用糖皮质激素和速效β受体激动剂(“抗炎补救”)可降低重度哮喘发作的风
险，建议用于有严重发作风险的间歇性哮喘患者，比如患者有危及生命发作既往史、可能暴露于
加重哮喘的过敏性或刺激性诱发因素，或未定期接受医疗随访以发现需要升级治疗的哮喘控制恶
化。出现需要急诊治疗的急性发作后，我们也鼓励使用糖皮质激素-长效β受体激动剂(LABA)或糖
皮质激素-SABA复方吸入器。(参见上文‘间歇性哮喘的药物治疗’)
● 用于治疗轻度持续性哮喘的控制药物–对于轻度持续性哮喘患者，我们推荐使用含小剂量吸入
性糖皮质激素的方案( 表 6)(Grade 1B)。就吸入性糖皮质激素的使用频率而言，我们建议定
期(每日)小剂量用药(单用或联合LABA)，而不是仅按需用药(联合速效β受体激动剂)( 表 7和
表 11)(Grade 2B)。虽然后一种方案似乎能同样有效地降低哮喘发作频率和严重程度，但总
体症状控制效果略差(参见上文‘轻度持续性哮喘的药物治疗’)。我们发现，患者对每日吸入性
糖皮质激素这种推荐方案的总体依从性较低，某些患者更适合基于症状的间歇性治疗。此类患者
可按需使用糖皮质激素-福莫特罗复方吸入器或糖皮质激素-沙丁胺醇复方吸入器，以缓解症状。
这种治疗方案根据症状发作频率来调整给药频率，对于全年哮喘严重程度在间歇性与轻度持续性
之间变化的患者可能尤其有效。
对于轻度持续性哮喘，替代疗法可采用每日口服白三烯受体拮抗剂(LTRA)，同时按需使用SABA缓
解症状( 表 8)。若使用白三烯调节剂治疗后无改善，应更换为吸入性糖皮质激素治疗方案。
(参见上文‘替代方案：白三烯调节剂’)
● 监测哮喘并调整治疗–每次因哮喘相关原因就诊时，都应重新评估哮喘控制情况( 表 10)。复
诊时也应持续进行患者/家庭教育。(参见上文‘长期管理’)
哮喘控制不佳时应升级治疗方案；已很好地控制症状数月时，治疗应降级( 表 6)。对于轻度持
续性哮喘，降级治疗可能意味着：找到可维持良好哮喘控制的最低吸入性糖皮质激素剂量，在症
状加重期间间歇性使用吸入性糖皮质激素，或更换为按需使用布地奈德-沙丁胺醇或布地奈德-福
莫特罗复方吸入器(超适应证使用)。调整治疗方案后2-6周，应重新评估患者。(参见上文‘长期
管理’)
使用UpToDate临床顾问须遵循使用条款.
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专题 527 版本 36.0.zh-Hans.1.0
图表
Approaches to asthma controller therapy in adolescents and adults
National Asthma Education and

Prevention Program: Expert Panel Global Initiative for Asthma (GINA)
Working Group (NAEPP 2020)
Asthma
symptoms/lung Therapy* Asthma symptoms Therapy
function
Intermittent asthma/step 1 Step 1
Daytime symptoms SABA, as needed Infrequent asthma Low-dose ICS with

≤2 days/week symptoms (eg, <2 rapid onset LABA
Nocturnal times/week) (eg, budesonide-
awakenings formoterol
≤2/month combination MDI
Normal FEV1 160 mcg-4.5
mcg/inhalation or
Exacerbations
DPI 200 mcg-6
≤1/year
mcg/inhalation) 1
inhalation, as
needed (preferred)
or
Low-dose ICS
whenever SABA
used or as-needed
low-dose ICS-SABA
Mild persistent asthma/step 2 Step 2
Daytime symptoms Low-dose ICS daily Asthma symptoms Low-dose ICS-

>2 but <7 and SABA as or need for reliever formoterol as
days/week needed inhaler ≥2 needed (preferred)
Nocturnal or times/week or
awakenings 3 to 4 Low-dose ICS-SABA Low-dose ICS daily
nights/month or ICS plus SABA, and SABA as
Minor interference concomitantly needed
with activities administered, as
Other options
FEV1 within the needed
Low-dose ICS-
normal range Alternative option(s) SABA or ICS plus
Exacerbations Daily LTRA and SABA,
≥2/year SABA as needed concomitantly
administered, as
needed
or (less
preferred)
LTRA daily and
SABA as needed
Moderate persistent asthma/step 3 Step 3
Daily symptoms Combination low- Troublesome Low-dose ICS-

Nocturnal dose ICS-formoterol asthma symptoms formoterol as
awakenings daily and 1 to 2 most days, maintenance and
>1/week inhalations as nocturnal reliever therapy (ie,
Daily need for SABA needed up to 12 awakening due to budesonide-
inhalations/day asthma ≥1 formoterol)
Some activity
(preferred option) time/month, risk (preferred)
limitation
factors for or
FEV1 60 to 80% Alternative option(s)
exacerbations ¶ Low-dose ICS-LABA
predicted Medium-dose ICS
daily and SABA as combination daily
Exacerbations
needed and SABA as
≥2/year
needed
or
Low-dose ICS- Other options
LABA Medium-dose ICS
combination daily daily and SABA as
or low-dose ICS needed
plus LAMA daily or
or low-dose ICS Low-dose ICS plus
plus LTRA daily LTRA daily and
and SABA as SABA as needed
needed
or
Low-dose ICS
daily plus zileuton
and SABA as
needed
Severe persistent asthma/steps 4 to 6 Steps 4 to 5
Symptoms all day Step 4: Severely Step 4:

Nocturnal Combination uncontrolled Medium-dose
awakenings nightly medium dose asthma with ≥3 of ICS-formoterol as
Need for SABA ICS-formoterol the following: maintenance and
several times/day daily and 1 to 2 daytime asthma reliever therapy
inhalations as symptoms >2 (preferred)
Extreme limitation
needed to 12 times/week; or
in activity
inhalations/day nocturnal
(preferred option) awakening due to
FEV1 <60% Alternative option(s) asthma; reliever Medium dose

predicted Medium-dose needed for ICS-LABA daily
Exacerbations ICS-LABA daily or symptoms >2 and SABA as
≥2/year medium-dose ICS times/week, or needed
plus LAMA daily activity limitation
Other options
and SABA as due to asthma
Possible add-on
needed or
LAMA or switch to
or An acute ICS-LAMA-LABA
Medium-dose ICS exacerbation
Possible add-on
daily plus LTRA or LTRA
zileuton and
High-dose ICS-
SABA as needed*
LABA trial (3 to 6
months) if other
add-ons
insufficient – May
need short course
of oral
glucocorticoids
Step 5: Step 5:
Medium to high- Medium-dose
dose ICS-LABA ICS-formoterol as
plus LAMA daily maintenance and
and SABA as reliever therapy
needed plus LAMA daily
(preferred) (preferred)
Alternative option(s) or
Medium-high Medium-dose
dose ICS-LABA ICS-LABA plus
daily or high-dose LAMA daily and
ICS + LTRA* daily SABA as needed
and SABA as Assess asthma
needed phenotype and
Possible addition evaluate for
of asthma possible addition
biologics Δ of asthma
biologics Δ
Other options
High-dose ICS-
LABA trial (3 to 6
months)
Possible add-on
LTRA or
azithromycin
Oral
glucocorticoids
titrated to
optimize asthma
control and
minimize adverse
effects
Step 6:
High-dose ICS-
LABA daily;
consider LAMA as
substitute for
LABA or as add-
on therapy if not
done previously ◊
Oral
glucocorticoids,
titrated to
optimize asthma
control and
minimize adverse
effects
Possible addition
of asthma
biologics Δ
Initial therapies are noted above. A higher level of initial therapy, sometimes with concurrent use of
oral glucocorticoids, may be chosen if the patient presents with an acute exacerbation. Treatment
may be stepped down if asthma is well controlled for at least three months, or stepped up 1 or 2
steps if asthma is not well controlled or is very poorly controlled. At follow-up visits, check
adherence, inhaler technique, environmental factors, and comorbid conditions. Subcutaneous
immunotherapy is suggested as an adjunct to standard pharmacotherapy in individuals who have
demonstrated allergy to the included allergens and whose asthma is well-controlled whenever
immunotherapy is administered. Consult with asthma specialist if step 4 or higher is required.
FEV1: forced expiratory volume in one second; SABA: short-acting beta-agonist; ICS: inhaled
corticosteroid (glucocorticoid); LABA: long-acting beta-agonist; MDI: metered dose inhaler; DPI: dry
powder inhaler; LTRA: leukotriene receptor antagonist; IgE: immunoglobulin E; IL: interleukin; LAMA:
long-acting muscarinic antagonist.
* Theophylline and cromolyn are not included in the table even though they were included in
NAEPP-EPR 3 (2007) and theophylline is included in NAEPP (2020). These agents are rarely used now,
due to availability of more effective options.
¶ Risk factors for exacerbations include: smoking, allergen exposure if sensitized, previous
intubation or intensive care unit stay for asthma, low FEV1 (especially <60% predicted), obesity, food
allergy, chronic rhinosinusitis, and poor adherence/inhaler technique.
Δ Asthma biologics include anti-immunoglobulin E, anti-interleukin (IL)-5, anti-IL-5R, anti-IL-4R (anti-

IL-4/IL-13), and anti-thymic stromal lymphopoietin (anti-TSLP). Refer to UpToDate graphic on our
approach to selection of biologic agents for add-on therapy for severe asthma in adolescents and
adults.
◊ The NAEPP 2020 Focused Updates included LAMA therapy in step 5 but not step 6; however, a trial
of add-on LAMA therapy is reasonable, if not previously assessed.
References:
1. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and
management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-
4051). https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma.
2. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and
Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol 2020;146:1217-70.
https://www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-updates.
3. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA). www.ginasthma.org.
Graphic 127798 Version 7.0
Asthma action plan
Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the
Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.
Usual doses of short-acting bronchodilators for asthma in adolescents and

adults*
Drug name(s) Preparation(s) ¶ Dose
Albuterol MDI Δ MDI: 90 Usual dose: 2 inhalations every 4 to 6 hours as

mcg/inhalation (United needed
States) Acute exacerbation at home: 2 to 4
MDI: 100 inhalations, can be repeated every 20 minutes
mcg/inhalation for a total of 3 doses, then as directed ◊
(Canada) Acute care setting: 4 to 8 inhalations every 20
minutes for 3 doses § , then taper depending
on response to therapy
Albuterol DPI DPI Δ : 90 Usual dose: 2 inhalations every 4 to 6 hours,

mcg/actuation (United as needed
States) Acute exacerbation at home: 2 to 4
inhalations, can be repeated every 20 minutes
for a total of 3 doses, then as directed ◊
Acute care setting: 4 to 8 inhalations every 20
minutes for 3 doses § , then taper depending
on response to therapy
Albuterol DPI (Canada) DPI: 200 mcg/actuation Usual dose: 1 inhalation every 4 to 6 hours, as
(Canada) needed
Exercise-induced bronchoconstriction: 1
inhalation 15 minutes prior to exercise
Albuterol solution for Nebulizer solutions: Usual dose: 2.5 mg every 4 to 6 hours, as
nebulization 0.083% (2.5 mg/3 needed
mL) Acute exacerbation at home: Administer 2.5
0.5% (2.5 mg/0.5 mg, can repeat every 20 minutes for total of 3
mL) concentrate; doses, then decrease frequency to every 1 to 4
must be diluted hours, as tolerated ¥
in 2.5 mL saline Acute care setting: Administer 2.5 to 5 mg,
can repeat every 20 minutes for total of 3
doses, then decrease frequency to every 1 to 4
hours, as tolerated
Acute care setting (critically ill): Continuous
nebulizer treatment: Use a large volume
nebulizer, 10 to 15 mg/hour in monitored
setting
Albuterol-budesonide MDI: Albuterol 90 mcg Usual dose: 2 inhalations every 4 to 6 hours as

MDI and budesonide 80 needed
mcg/actuation (United Acute exacerbation at home: 2 inhalations,

States) can be repeated every 20 minutes for a total
of 3 doses, then as directed ¥
Levalbuterol MDI Δ 45 mcg/inhalation Usual dose: 2 inhalations every 4 to 6 hours,

(United States) as needed
Acute exacerbation at home: 2 to 4
inhalations; can be repeated every 20 minutes
for a total of 3 doses, then as directed ◊
Acute care setting: 4 to 8 inhalations every 20
minutes for 3 doses, then taper depending on
response to therapy §
Levalbuterol solution Nebulizer solution: Usual dose: Administer 0.63 to 1.25 mg

for nebulization 0.63 mg/3 mL (equivalent to 1.25 to 2.5 mg albuterol) every
1.25 mg/3 mL 6 to 8 hours, as needed (up to 3 doses per 24
1.25 mg/0.5 mL hours)
concentrate; Acute exacerbation at home: Administer 1.25
must be diluted mg; can be repeated every 20 minutes for a
in 2.5 mL saline total of 3 doses, then decrease frequency to
every 1 to 4 hours, as tolerated ¥
Acute care setting: Administer 1.25 mg to 2.5
mg (equivalent to 2.5 to 5 mg of albuterol);
can repeat every 20 minutes for total of 3
doses, then decrease frequency to every 1 to 4
hours, as tolerated
Terbutaline DPI DPI: 0.5 mg/actuation Usual dose: 1 inhalation every 4 hours, as
(Canada) needed
If no effect after 5 minutes, can repeat dose
Ipratropium-albuterol SMI: Ipratropium 20 Usual dose (off-label): 2 inhalations every 6

SMI mcg and albuterol 100 hours, as needed
mcg/inhalation (United Acute exacerbation (off-label): 4 to 8
States) inhalations every 20 minutes for 3 doses, and
then as needed for up to 3 hours
Ipratropium-albuterol Nebulizer solution: Usual dose (off-label): Administer 1 vial (3 mL)

solution for Ipratropium 0.5 mg every 4 to 6 hours, as needed
nebulization and albuterol 2.5 mg Acute exacerbation (off-label): Administer 1
per 3 mL/vial ‡ vial (3 mL), every 20 minutes for 3 doses, and
then as needed for up to 3 hours ¥
MDI: metered-dose inhaler; DPI: dry-powder inhaler; SMI: soft mist inhaler.
* Oral formulations of albuterol and terbutaline are less effective than inhaled formulations and are
not recommended in asthma. Inhaled epinephrine (MDI or nebulized) is not recommended for
routine use.
¶ Doses shown and strengths (ie, mcg per puff or inhalation) are based upon product descriptions
approved in the United States and Canada as noted, which may differ from how strengths are
described for products available in other countries. Consult local product information before use.
Δ Agent can also be used to prevent exercise-induced bronchoconstriction, 2 inhalations 5 to 20

minutes prior to exercise.
◊ Typically, two puffs are used for mild-to-moderate symptoms and four puffs for more severe
symptoms; over the course of the first hour, the patient can determine (based on action plan or
clinician guidance) whether to continue self-care at home or seek additional medical attention.
§ The number of inhalations is based on the severity of respiratory impairment, number of

inhalations the patient has already used, and availability of monitoring. When administering an
albuterol MDI for acute asthma exacerbation in an office or acute care setting, use of a valved
holding chamber and careful attention to technique are recommended.
¥ Over the course of the first hour, the patient can determine (based on action plan or clinician
guidance) whether to continue self-care at home or seek additional medical attention.
‡ Nebulizer solution in Canada is ipratropium 0.5 mg and albuterol 2.5 mg per 2.5 mL.
Technique for use of a pressurized metered dose inhaler (MDI) without a sp
acer or chamber
Remove the cover of the mouthpiece.
Prime your inhaler if this is the first time you are using it, if you have not used it for several days, or if
you have dropped it. Priming an MDI usually involves shaking it and spraying it into the air (away
from your face) a total of up to 4 times. See the information that came with your inhaler for exact
instructions.
Shake MDI canister vigorously for 5 seconds.
Hold the MDI upright with your index finger on the top of the medication canister and your thumb
supporting the bottom of the inhaler.
Breathe out normally.
Put the mouthpiece between your teeth and close your lips around mouthpiece or position
mouthpiece approximately 4 cm (approximately width of 2 fingers) from your mouth.
Keep your tongue away from the opening of the mouthpiece.
Press down the top of the canister with the index finger to release the medication.
At the same time as the canister is pressed, breathe in deeply and slowly through your mouth until
your lungs are completely filled; this should take 4 to 6 seconds.
Hold the medication in your lungs for as long as comfortable (approximately 5 to 10 seconds) before
breathing out.
If you need a second puff, wait approximately 15 to 30 seconds between puffs. Shake canister again
before the next puff.
When finished, recap mouthpiece.
If your inhaler contains a steroid medicine (sometimes called glucocorticoid or corticosteroid), rinse
your mouth and gargle with water after you use it. Then spit out the water. Do not swallow it.
These instructions do not apply to dry powder or soft mist inhalers. Cleaning instructions are
provided separately.
More detailed information about individual medication formulations can be found at

http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm.
Technique for use of a pressurized metered dose inhaler (MDI) with a spacer
or chamber*
Uncap mouthpiece and check for loose objects in the device.
Prime your inhaler if this is the first time you are using it, if you have not used it for several days, or if
you have dropped it. Priming an MDI usually involves shaking it and spraying it into the air (away
from your face) a total of up to 4 times. See the information that came with your inhaler for exact
instructions.
Insert MDI into spacer.
Shake canister vigorously for approximately 5 seconds.
Hold the MDI upright with your index finger on the top of the medication canister and your thumb
supporting the bottom of the inhaler. You may need to use the other hand to hold the spacer.
Breathe out normally through your mouth.
Put the mouthpiece between your teeth and close your lips tightly around mouthpiece of spacer. (If
using a mask attached to the chamber, place the mask completely over your nose and mouth.)
Make sure your tongue does not block the opening of the mouthpiece of the spacer.
Press down the top of the canister with your index finger to release the medicine.
At the same time, breathe in deeply and slowly through your mouth until your lungs are completely
filled; this should take 3 to 5 seconds.
Hold the medicine in your lungs for approximately 5 to 10 seconds. If you did not get a full breath or
cannot hold your breath long enough, you can inhale a second time to fully empty the chamber and
hold your breath again for approximately 5 seconds. For infants and young children, or if unable to
cooperate with a deep breath or breath-holding, 5 to 6 normal breaths will allow complete emptying
of the chamber.
If you need more than one puff, wait approximately 15 to 30 seconds between puffs. Shake canister
again before the next puff. Do not load both puffs into the chamber and then empty the chamber
with a single inhalation.
When finished, recap mouthpiece.
If your inhaler contains a steroid medicine (sometimes called glucocorticoid or corticosteroid), rinse
your mouth and gargle with water after you use it. Then spit out the water. Do not swallow it.
You can use your spacer for more than 1 medication. Just remove the first MDI and insert the other
one.
These instructions do not apply to dry powder or soft mist inhalers. Cleaning instructions are
provided separately.
* We prefer to use a "valved holding chamber" for the spacer (eg, AeroChamber, Easivent,
Optichamber, Vortex). The valve holds the medicine in the chamber until you take your deep breath
in. This helps get the medicine into your lungs. Also, when you breathe out into the mouthpiece, the
valve prevents your breath from going into the chamber. If your spacer does not have this valve, you
should breathe out through your nose or remove the spacer from your mouth before breathing out.
Technique for use of various dry powder inhalers*
Load a dose of medicine
For single-dose inhalers, load a dose by taking a pill out of its packaging and putting the pill into
the inhaler. Then push 1 or more buttons on the inhaler to poke holes in the pill.
For multiple-dose inhalers, load a dose by sliding a lever or twisting part of the inhaler. Loading
a dose should decrease the counter on the device by one. This means a dose is ready to be
inhaled.
Once the dose is loaded, maintain your inhaler in the correct position - some inhalers need to be
held upright, but others need to be horizontal. The dose may be lost or spilled if the inhaler is
tipped over after loading.
Medication delivery
Open the device or take off the cap to expose the mouthpiece, if necessary.
While holding the inhaler away from your mouth, breathe out (exhale) fully. Do not exhale into
the mouthpiece.
Put the mouthpiece between your lips. Breathe in quickly and steadily through your mouth, as
deeply as possible. Do not breathe in through your nose. You might not taste or feel the
medicine, even when you are using the inhaler correctly. If your device has air vent holes, do not
cover those holes while inhaling through the device.
Remove the device from your mouth and hold your breath for about 10 seconds (or as long as
you comfortably can).
Breathe out slowly (away from the mouthpiece).
If you are supposed to take 2 puffs of your inhaler, load/activate another dose and breathe it in.
Rinse your mouth out with water, gargle, and spit out the water.
Device maintenance and storage
After use, close your inhaler or replace the cover or cap. Make sure the device is fully closed
before storing.
For single dose inhalers, you often need to dispose of the used dose. Please refer to the package
insert.
Pay attention to the number of doses you have remaining. For multi-dose devices, observe the
counter to determine when you need a refill on the device. For single dose devices, monitor the
number of individual doses remaining.
Store your inhaler in a cool, dry place.
Dry powder inhalers generally do not require internal cleaning. The mouthpiece may be wiped
off with a dry cloth. Please refer to the package insert for additional device-specific instructions.
* Each dry powder inhaler comes with its own directions. Although the general technique is similar,
various devices are loaded and activated differently. Some devices load each dose separately, while
others contain a month's worth of medication and do not require loading. Refer to the package
insert of each device or to the manufacturer website for additional instructions.
Simplified approach to initial asthma therapy for adolescents and adults
Asthma symptoms Initial therapy
Intermittent asthma (step 1)
Infrequent asthma symptoms (eg, <2 SABA as needed (preferred)

times/week) or
Low-dose ICS plus fast-acting beta agonist
(eg, budesonide-formoterol or albuterol-
budesonide MDI) as needed
Mild persistent asthma (step 2)
Asthma symptoms or need for reliever Low-dose ICS daily and separate SABA as
inhaler ≥2 times/week but <4-5 days/week reliever (preferred)
or
Low-dose ICS plus fast-acting beta agonist
(eg, budesonide-formoterol or albuterol-
budesonide MDI) as needed
or
LTRA daily with SABA as needed
Moderate persistent asthma (step 3)
Troublesome asthma symptoms most days Preferred options ¶

Nocturnal awakening due to asthma ≥1 Low-dose ICS-formoterol combination
time/week inhaler as maintenance and reliever therapy
Risk factors for exacerbations* or
Low-dose ICS-LABA combination inhaler
daily and separate SABA as reliever
Severe persistent asthma (step 4)
Daily asthma symptoms (≥1/week) Preferred options Δ

Nocturnal awakening due to asthma ≥1 Medium-dose ICS-formoterol combination
time/week inhaler as maintenance and reliever therapy
Low lung function or
Medium-dose ICS-LABA combination inhaler
daily and separate SABA as reliever
Evaluate for add-on therapies ◊
Severe persistent asthma (steps 5-6)
Ongoing asthma symptoms and waking Medium- to high-dose ICS-LABA combination

with asthma despite step 4 therapy inhaler daily plus LAMA daily and separate
SABA as reliever
Evaluate for add-on therapies ◊
Initial therapy for asthma is based on the frequency and severity of asthma symptoms. Patients who
present with an acute exacerbation may need oral glucocorticoids in addition. The response to
therapy should be assessed in 2 to 12 weeks depending on clinical urgency. Treatment may be
stepped down if asthma is well controlled for at least three months, or stepped up 1 or 2 steps if
asthma is not well controlled or is very poorly controlled. At follow-up visits, check adherence,
inhaler technique, environmental factors, and comorbid conditions. Subcutaneous immunotherapy
is suggested as an adjunct to standard pharmacotherapy in individuals who have demonstrated
allergy to the included allergens and whose asthma is well controlled whenever immunotherapy is
administered. Consult with an asthma specialist if step 4 or higher is required.
DPI: dry powder inhaler; FEV1: forced expiratory volume in one second; ICS: inhaled corticosteroid
(glucocorticoid); LABA: long acting beta-agonist; LMA: leukotriene modifying agent (eg, zileuton);
LTRA: leukotriene receptor antagonist (eg, montelukast, zafirlukast); MDI: metered dose inhaler;
SABA: short-acting beta-agonist; LAMA: long-acting muscarinic antagonist.
* Risk factors for exacerbations include the following: smoking, allergen exposure if sensitized,
previous intubation or intensive care unit stay for asthma, low FEV1 (especially <60% predicted),
obesity, food allergy, chronic rhinosinusitis, and poor adherence/inhaler technique.
¶ Other options for moderate persistent asthma (step 3): Medium-dose ICS daily, with SABA as
reliever; or Low-dose ICS-LABA plus LTRA daily, with SABA as reliever.
Δ Other options for severe persistent asthma (step 4): High-dose ICS with SABA as reliever;
medium-dose ICS and substitute tiotropium (or other LAMA depending on availability and
regulatory approval) for LABA; or High-dose ICS daily with SABA as reliever.
◊ Add-on therapies may include:

Tiotropium (or other LAMA depending on availability and regulatory approval) may be
substituted for LABA or added on (step 4).
LTRA/LMA are more commonly added on for concomitant nasal polyposis or aspirin-
exacerbated respiratory disease. The US Food and Drug Administration issued a boxed
warning for montelukast in March 2020.
Asthma biologics include anti-immunoglobulin E, anti-interleukin (IL)-5, anti-IL-5R, anti-IL-4R
(anti-IL-4/IL-13), and anti-thymic stromal lymphopoietin (anti-TSLP). Refer to UpToDate graphic
on approach to selection of biologic agents for add-on therapy.
Theophylline, cromolyn, and nedocromil are additional options that are not included in the
table as they are rarely used, due to more effective options with fewer adverse effects
(theophylline) or limited availability (cromolyn, nedocromil).
References:
1. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and
management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007 (NIH publication no. 08-
4051). https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma.
2. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and
Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol 2020; 146:1217.
https://www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-updates.
3. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA). www.ginasthma.org.
Estimated comparative daily doses for inhaled glucocorticoids in

adolescents ≥12 years and adults
Low dose Medium dose High dose

Drug (total daily (total daily (total daily
dose) dose) dose)*
Beclomethasone HFA 80 to 160 mcg >160 to 320 mcg >320 to 640 mcg
(Qvar RediHaler product available in
United States)
Administer as 2 divided doses
40 mcg per actuation 2 or 4 inhalations ¶ ¶
80 mcg per actuation 2 inhalations 4 inhalations 6 or 8 inhalations
Beclomethasone HFA Δ 100 to 200 mcg >200 to 400 mcg >400 to 800 mcg
(Qvar product available in Canada,
Europe, and elsewhere)
50 mcg per actuation 2 to 4 inhalations ¶ ¶
Budesonide DPI 180 to 360 mcg >360 to 720 mcg >720 to 1440 mcg
(Pulmicort Flexhaler product available
in United States)
90 mcg per actuation 2 or 4 inhalations ¶ ¶
Budesonide DPI Δ 200 to 400 mcg >400 to 800 mcg >800 to 2400 mcg
(Pulmicort Turbuhaler or Turbohaler
product available in Canada, Europe,
and elsewhere)
Administer low doses (ie, ≤400

mcg/day) once daily; administer higher
doses (ie, >400 mcg/day) as 2 to 4
divided doses
200 mcg per actuation 1 to 2 inhalations 3 to 4 inhalations ¶
400 mcg per actuation 1 inhalation 2 inhalations 3 to 6 inhalations
Ciclesonide HFA 160 mcg 320 mcg 640 mcg

(Alvesco product available in United
States, Europe, and elsewhere)
United States: Administer as 2 divided

doses
Australia, Europe, and elsewhere:

Administer lower doses (ie, 160 to 320
mcg/day) once daily; administer 640
mcg dose as 2 divided doses
80 mcg per actuation 2 inhalations 4 inhalations ¶
160 mcg per actuation ◊ 2 inhalations 4 inhalations
Ciclesonide HFA Δ 100 to 200 mcg >200 to 400 mcg >400 to 800 mcg
(Alvesco product available in Canada)
Administer lower doses (eg, 100 to 400

mcg) once daily; administer 800 mcg
dose as 2 divided doses
100 mcg per actuation 1 to 2 inhalations 3 to 4 inhalations ¶
200 mcg per actuation 1 inhalation 2 inhalations 3 to 4 inhalations
Fluticasone propionate HFA 176 to 220 mcg >220 to 440 mcg >440 to 1760 mcg
(Flovent HFA product available in
United States)
44 mcg per actuation 4 inhalations ¶ ¶
220 mcg per actuation ◊ 2 inhalations 4 to 8 inhalations
Fluticasone propionate HFA Δ 100 to 250 mcg >250 to 500 mcg >500 to 2000 mcg
(Flovent HFA product available in
Canada; Flixotide Evohaler product
available in Europe and elsewhere)
Fluticasone propionate DPI 100 to 250 mcg >250 to 500 mcg >500 to 2000 mcg
(Flovent Diskus product available in
United States and Canada; Flixotide
Accuhaler product available in Europe

and elsewhere)
500 mcg per actuation (strength not ◊ ◊ 2 or 4 inhalations

available in United States)
Fluticasone propionate DPI 110 mcg 226 mcg 464 mcg

(Armonair Digihaler product available
in United States; Aermony Respiclick
product available in Canada)
113 mcg per actuation ◊ 2 inhalations ¶
232 mcg per actuation ◊ ◊ 2 inhalations
Fluticasone furoate DPI 50 mcg (by use of 100 mcg 200 mcg
(Arnuity Ellipta product available in pediatric DPI,
United States, Canada, Australia, and which is off-label
elsewhere, but not available in Europe in adolescents
or UK) and adults)
Administer once daily
NOTE: Inhaled fluticasone furoate has

a greater anti-inflammatory potency
per microgram than fluticasone
propionate inhalers. Thus, fluticasone
furoate is administered at a lower daily
dose and used only once daily.
50 mcg per actuation 1 inhalation ¶ ¶
100 mcg per actuation ◊ 1 inhalation 2 inhalations
200 mcg per actuation ◊ ◊ 1 inhalation
Mometasone DPI 220 mcg >220 to 440 mcg >440 to 880 mcg
(Asmanex Twisthaler product available
in United States)
May administer lower doses (ie, 220 to

440 mcg/day) once daily; administer
880 mcg dose as 2 divided doses
220 mcg per actuation 1 inhalation 2 inhalations 4 inhalations
Mometasone HFA 200 mcg >200 to 400 mcg >400 to 800 mcg
(Asmanex HFA product available in
United States)
200 mcg per actuation ◊ 2 inhalations 4 inhalations
Mometasone DPI Δ 200 mcg >200 to 400 mcg >400 to 800 mcg
(Asmanex Twisthaler product available
in Canada, Europe, and elsewhere)
May administer lower doses (ie, 200 to

400 mcg/day) once daily; administer
800 mcg dose as 2 divided doses
200 mcg per actuation 1 inhalation 2 inhalations ¶
400 mcg per actuation ◊ 1 inhalation 2 inhalations
The most important determinant of appropriate dosing is the clinician's judgment of the
patient's response to therapy. The clinician must monitor the patient's response on several
clinical parameters and adjust the dose accordingly. The stepwise approach to therapy
emphasizes that once control of asthma is achieved, the dose of medication should be carefully
titrated to the minimum dose required to maintain control, thus reducing the potential for
adverse effects.
Suggested total daily doses for low, medium, and high dose inhaled glucocorticoid regimens are
based on daily doses recommended by Global Initiative for Asthma (GINA), National Asthma
Education and Prevention Program (NAEPP), and/or product labeling [1-5] . This is not a table of
equivalence.
Depending on the specific product, total daily doses are administered once or divided and given
twice daily. Refer to local product information or a clinical drug reference (eg, Lexicomp).
Some doses are outside the approved product information recommendations.
DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant metered dose inhaler.
* Evidence for additional improvement with dose increases >1000 mcg/day is limited.
¶ Select alternate preparation with higher mcg/actuation to improve convenience.
Δ Products shaded in light gray color are not available in the United States but are available widely
elsewhere.
◊ Select preparation with fewer mcg/actuation.
Data from:
1. Global Initiative for Asthma (GINA); Global Strategy for Asthma Management and Prevention; 2021. Available at
www.ginasthma.org.
2. National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and
Management of Asthma; 2007. NIH Publication 08-4051 available at http://www.nhlbi.nih.gov/health-
pro/guidelines/current/asthma-guidelines/full-report and pro.
3. US Food & Drug Administration (FDA) approved product information. US National Library of Medicine. (Available
online at www.dailymed.nlm.nih.gov/dailymed/index.cfm.)
4. Health Canada-approved product monograph. Health Canada. (Available online at https://health-
products.canada.ca/dpd-bdpp/index-eng.jsp.)
5. European Medicines Agency (EMA) summary of product characteristics. European Medicines Agency. (Available online
at www.ema.europa.eu/en/medicines.)
Usual doses of antileukotriene agents in the management of persistent

asthma
Infant and Adolescent

Medication Preparations Pediatric
small child and adult
Montelukast Granules: 4 mg 12 months* to 5 6 to 14 years: 5 ≥15 years and

per packet years: 4 mg mg chewable adult: 10 mg
granules or tablet once daily tablet once daily
Chewable tablets:
chewable tablet in evening in evening
4 mg, 5 mg
once daily in
Tablet: 10 mg evening
Zafirlukast ¶ Tablets: 10 mg, 20 (Not studied) 5 to 11 years: 10 ≥12 years and

mg mg twice per day adult: 20 mg
twice per day
Zileuton ¶ Immediate- (Not studied) (Not studied) ≥12 years and

release tablet: adult:
600 mg Immediate
Extended-release release: 600
tablet: 600 mg mg four
times per
day
Extended
release:
1200 mg
twice per
day
Pranlukast Δ Capsules: 112.5 24 months to 5 6 to 11 years: 7 to ≥12 years and

mg, 225 mg years: 7 to 10 10 mg/kg per day adult: 225 mg
mg/kg granules granules in two twice per day
Granules: 50 mg,
per day in two divided doses
70 mg, 100 mg
divided doses (maximum 225
per packet
mg twice per day)
* Approved for use in infants ≥6 months in some countries other than United States.
¶ Elevated transaminases and severe hepatoxicity have been reported.
Δ Not available in United States. Available in Japan, Mexico, Venezuela, Turkey, and Korea.
Data from:
1. US Food & Drug Administration approved prescribing information. Available

at https://dailymed.nlm.nih.gov/dailymed/ (Accessed September 20, 2020).
2. Bisgaard H, et al. Pediatric Pulmonol 2009; 44:568.
3. Keam SJ, et al. Drugs 2003; 63:991.
Initial dosing* of chromones (cromoglycates) in asthma
Trade
Medication Dose form Availability Age 0 to 4 Age 5 to 11
(brand) name
Cromolyn Nebulizer United States Various >2 years: 2 mL (20 2 mL (20 mg)
sodium solution: 10 generics mg) nebulization 4 nebulization 4
Canada
(sodium mg per mL in times per day times per
cromoglycate) 2 mL sterile European day

ampules Union (some
countries)
Other
countries
Metered- European Intal CFC free Not studied Two puffs 4

dose inhaler; Union (some times per day
1 mg per countries)
puff (CFC
Australia
free)
Other
countries
Not available
in US or
Canada
Metered- European Intal Forte CFC Not studied Two puffs 2

dose inhaler; Union (some free to 4
5 mg per countries) times per day
puff (CFC
Australia
free)
Other
countries
Not available
in US or
Canada
Powder for European Intal Spincaps Not studied One

inhalation Union (some Spinhaler inhalation (20
capsules with countries) mg) 4 times
spinhaler per day
Australia
device; 20
mg per Other
capsule countries
Not available
in US or
Canada
Nedocromil Metered- European Tilade CFC free >2 years: Two Two puffs 4

sodium dose inhaler; Union (some puffs 4 times per times per
2 mg per countries) day ¶ day ¶
puff (CFC
Australia
free)
Other
countries
Not available
in US or
Canada
CFC: chlorofluorocarbons.
* Usual doses for initiating treatment for asthma symptom prophylaxis are shown in the table. Dose
may be adjusted up or downward based upon symptom control and allergen exposure. An
additional dose may be given before anticipated trigger exposure. Dose recommendations vary by
country; consult local licensed product information before use.
¶ Not licensed for use in children age <6 years in many countries where it is available.
Assessment of asthma symptom control and risk of exacerbations
A. Level of asthma symptom control

In the past 4 weeks, has the patient had: Well Partly Uncontrolled
controlled controlled
Daytime symptoms more than None of 1 to 2 of 3 to 4 of

twice/week? Yes No these these these
Any night waking due to
asthma? Yes No
SABA reliever* needed more
than twice/week? Yes No
Any activity limitation due to
asthma? Yes No
B. Risk factors for poor asthma outcomes

Assess risk factors at diagnosis and periodically, at least every 1 to 2 years, particularly for patients
experiencing exacerbations.
Measure FEV1 at start of treatment, after 3 to 6 months of controller treatment to record personal
best lung function, then periodically for ongoing risk assessment.
Having uncontrolled asthma symptoms is an important risk factor for Having any of
exacerbations. these risk
factors
Additional potentially modifiable risk factors for exacerbations, even in patients
increases the
with few asthma symptoms, include:
patient's risk
Medications: ICS not prescribed; poor adherence; incorrect inhaler
of
technique; high SABA use (with increased mortality if
exacerbations
≥1×200-dose canister/month) ¶
even if they
Comorbidities: obesity; chronic rhinosinusitis; gastroesophageal reflux
have few
disease; confirmed food allergy; anxiety; depression; pregnancy
asthma
Exposures: smoking Δ ; allergen exposure if sensitized; air pollution symptoms.
Setting: major socioeconomic problems
Lung function: low FEV1, especially if <60% predicted; higher reversibility
Other tests: sputum/blood eosinophilia; elevated FENO in allergic adults on
ICS
Other major independent risk factors for flare-ups (exacerbations) include:

Ever being intubated or in intensive care for asthma
Having 1 or more severe exacerbations in the last 12 months
Risk factors for developing fixed airflow limitation include preterm birth, low birth weight, and
greater infant weight gain; lack of ICS treatment; exposure to tobacco smoke, noxious chemicals,
or occupational exposures; low FEV1; chronic mucus hypersecretion; and sputum or blood
eosinophilia
Risk factors for medication side-effects include:

Systemic: frequent OCS; long-term, high dose and/or potent ICS; also taking cytochrome
P450 inhibitors
Local: high-dose or potent ICS; poor inhaler technique
Asthma control has two domains: symptom control and risk of future exacerbations. Assess the
symptom control domain by patient's recall of previous 4 weeks; assess risk of future exacerbations
by the presence of risk factors and by spirometry/or peak flow measures.
FEV1: forced expiratory volume in one second; ICS: inhaled corticosteroids; SABA: short-acting beta-2
agonist; FENO: fraction of expired nitric oxide; OCS: oral corticosteroid.
* The threshold of two uses per week as a measure of poor control is only appropriate for SABA
relievers. Use of anti-inflammatory relievers (eg low-dose ICS-formoterol or ICS-SABA) provides
additional ICS therapy and leads to lower risk of subsequent exacerbation than increased SABA
alone. However, average weekly use of anti-inflammatory reliever should still be assessed when
reviewing need for or dosing of maintenance ICS.
¶ Current guidelines note that use of ≥3 200-dose SABA canisters/year is also associated with
increased exacerbation risk.
Δ Smoking includes e-cigarette exposure.
For the most recent version of the GINA assessment of asthma control, please visit: Global Initiative for Asthma. Global
Strategy for Asthma Management and Prevention, 2023. Available at: https://ginasthma.org/2023-gina-main-report/
(Accessed on May 19, 2023). Reproduced with permission from: Global Initiative for Asthma. Asthma Management and
Prevention (for Adults and Children Older than 5 Years): A Pocket Guide for Health Professionals, Updated 2019. Available at:
https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/ (Accessed on July 19, 2019).
Usual doses of combined inhaled glucocorticoids and bronchodilators
Medication Low dose Medium dose High dose
ICS-SABA combination
Budesonide-albuterol HFA (Brand name: Airsupra)*
NOTE: Not used for maintenance therapy.
Acute symptom relief: Budesonide-albuterol (80 mcg/90 mcg) 2 inhalations as needed (usual
maximum: 12 inhalations/day).
ICS-LABA combinations
Beclomethasone [beclometasone]-formoterol DPI or HFA (Not available in United States or

Canada, but available elsewhere [sample brand names: Formodual, Fostair, Foster]) ¶ Δ
100 mcg/6 mcg 1 inhalation twice a 2 inhalations twice a

day day
200 mcg/6 mcg 2 inhalations twice a

day
Budesonide-formoterol HFA (Brand name: Symbicort) ¶
80 mcg/4.5 mcg 2 inhalations twice a

day
160 mcg/4.5 mcg 2 inhalations twice a

day
Fluticasone furoate-vilanterol DPI (Brand name: Breo Ellipta) Δ
NOTE: Inhaled fluticasone furoate has a greater anti-inflammatory potency per microgram than
fluticasone propionate inhalers. Thus, fluticasone furoate is administered at a lower daily dose and
used only once daily.
50 mcg/25 mcg ◊ 1 inhalation once daily
100 mcg/25 mcg 1 inhalation once daily
200 mcg/25 mcg 1 inhalation once daily
Fluticasone propionate-formoterol MDI (Not available in United States or Canada, but

available elsewhere [sample brand name: Flutiform])
50 mcg/5 mcg 2 inhalations twice

daily

daily

daily
Fluticasone propionate-salmeterol DPI (Brand names: Advair Diskus, Wixela Inhub) Δ
100 mcg/50 mcg 1 inhalation twice a

day

day

day
Fluticasone propionate-salmeterol HFA (Brand name: Advair HFA)

day

day

day
Fluticasone propionate-salmeterol DPI (Brand names: AirDuo RespiClick, AirDuo Digihaler) Δ §

day
113 mcg/14 mcg 1 inhalation twice a 1 inhalation twice a

day day

day
Mometasone-formoterol HFA (Brand name: Dulera)

day

day
Mometasone-indacaterol DPI (Brand name: Atectura Breezhaler; available in Canada) Δ
80 mcg/150 mcg 1 inhalation (capsule)

once a day
160 mcg/150 1 inhalation (capsule)

mcg once a day

mcg once a day
ICS-LAMA-LABA combinations ¥
Fluticasone furoate-umeclidinium-vilanterol DPI (Brand name: Trelegy Ellipta) Δ
100 mcg/62.5 1 inhalation once daily

mcg/25 mcg
200 mcg/62.5 1 inhalation once daily

mcg/25 mcg
Mometasone-glycopyrrolate (glycopyrronium)-indacaterol DPI (Brand name: Enerzair

Breezhaler; available in Canada)* Δ

mcg/150 mcg once a day
Do not exceed the maximum number of inhalations/puffs per day listed in the table due to the risk
of toxicity from an excess dose of long-acting beta-agonist (ie, salmeterol, formoterol, or vilanterol).
Brand names and dose per puff or per inhalation of commercially available fixed dose combinations
are according to United States prescribing information, unless otherwise noted. Consult local
product information before use.
ICS: inhaled glucocorticoid (inhaled corticosteroid); SABA: short-acting beta-agonist; LABA: long-
acting beta-agonist; LAMA: long-acting muscarinic antagonist; HFA: metered dose inhaler with
hydrofluoroalkane propellant; DPI: dry powder inhaler; SMI: soft mist inhaler.
* Not approved for use in patients <18 years old.
¶ When using ICS-formoterol as reliever, use one to two inhalations as needed. Maximum daily dose
of maintenance and rescue is 12 inhalations.
Δ DPI contains lactose which may have small amounts of milk protein.
◊ Fluticasone furoate-vilanterol 50 mcg/25 mcg DPI is approved for use in patients 5 to 11 years old;
use in adolescents and adults is off-label.
§ In AirDuo inhalers, the daily dose of salmeterol is approximately one-fourth of the dose in Advair,
and the daily dose of fluticasone is approximately one-half that of the comparable low-, medium-,
and high-dose strengths of Advair.
¥ Alternatively, tiotropium SMI (Brand name: Spiriva Respimat) can be used with an ICS or ICS-LABA
inhaler. The dose in asthma is two inhalations (1.25 mcg/inhalation) once daily.
Reference: Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention.
https://ginasthma.org/wp-content/uploads/2023/05/GINA-2023-Full-Report-2023-WMS.pdf. Updated 2023 (Accessed on June
13, 2023).
Contributor Disclosures
Christopher H Fanta, MD Grant/Research/Clinical Trial Support: Samsung Research of America [Asthma,
COPD]. All of the relevant financial relationships listed have been mitigated. Bruce S Bochner, MD Equity
Ownership/Stock Options: Allakos [Eosinophil and mast cell-related diseases]. Patent Holder: anti-Siglec-8
antibodies [Lirentelimab/AK002, eosinophil and mast cell-associated disease]. Grant/Research/Clinical Trial
Support: NIAID [Siglec-6, Siglec-8, asthma, anaphylaxis, food allergy, Bruton's tyrosine kinase,
mastocytosis, nanoparticle targeting]. Consultant/Advisory Boards: Acelyrin, Inc [Eosinophil and mast cell-
related diseases]; Allakos [Eosinophil and mast cell-related diseases]; Blueprint Medicines [Eosinophil and
mast cell-related diseases]; Lupagen, Inc [Eosinophil and mast cell-related diseases]; Regeneron
[Eosinophil and mast cell-related diseases]; Sanofi [Eosinophil and mast cell-related diseases]; StealthBio
Therapeutics [Eosinophil and mast cell-related diseases]; Third Harmonic Bio [Eosinophil and mast cell-
related diseases]. Other Financial Interest: Elsevier [Publication royalties]; Johns Hopkins University School
of Medicine [Royalties related to licensing of intellectual property to Allakos, Inc]. All of the relevant
financial relationships listed have been mitigated. Paul Dieffenbach, MD No relevant financial
relationship(s) with ineligible companies to disclose.
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青少年和成人间歇性和轻度持续性哮喘的治疗 - UpToDate

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8/2/23, 6:38 PM 青少年和成人间歇性和轻度持续性哮喘的治疗 - UpToDate

Official reprint from UpToDate®

翻译: 王筝扬, 副主任医师

There is a newer version of this topic available in English. 该主题有一个新的英文版

SABA有定量吸入器(metered dose inhaler, MDI)、干粉吸入器(dry powder inhaler, DPI)和雾化吸入

议根据症状(按需)使用小剂量糖皮质激素与速效长效β受体激动剂(long-acting beta agonist, LABA)

对于轻度持续性哮喘，也可规律使用口服白三烯受体拮抗剂(leukotriene receptor antagonist,

● 基础篇(参见 “患者教育：哮喘治疗药物(基础篇)”和 “患者教育：吸入性皮质类固醇药物(基

● 高级篇(参见 “Patient education: Asthma treatment in adolescents and adults (Beyond

8. Haahtela T, Järvinen M, Kava T, et al. Effects of reducing or discontinuing inhaled

19. Haahtela T, Järvinen M, Kava T, et al. Comparison of a beta 2-agonist, terbutaline,

44. Hardy J, Baggott C, Fingleton J, et al. Budesonide-formoterol reliever therapy versus

51. Suissa S, Dennis R, Ernst P, et al. Effectiveness of the leukotriene receptor

56. Price D, Musgrave SD, Shepstone L, et al. Leukotriene antagonists as first-line or

Approaches to asthma controller therapy in adolescents and adults

National Asthma Education and

Intermittent asthma/step 1 Step 1

Daytime symptoms SABA, as needed Infrequent asthma Low-dose ICS with

Mild persistent asthma/step 2 Step 2

Daytime symptoms Low-dose ICS daily Asthma symptoms Low-dose ICS-

Moderate persistent asthma/step 3 Step 3

Daily symptoms Combination low- Troublesome Low-dose ICS-

Severe persistent asthma/steps 4 to 6 Steps 4 to 5

Symptoms all day Step 4: Severely Step 4:

FEV1 <60% Alternative option(s) asthma; reliever Medium dose

allergy, chronic rhinosinusitis, and poor adherence/inhaler technique.

Δ Asthma biologics include anti-immunoglobulin E, anti-interleukin (IL)-5, anti-IL-5R, anti-IL-4R (anti-

Graphic 127798 Version 7.0

Asthma action plan

Graphic 55900 Version 4.0

Usual doses of short-acting bronchodilators for asthma in adolescents and

Drug name(s) Preparation(s) ¶ Dose

Albuterol MDI Δ MDI: 90 Usual dose: 2 inhalations every 4 to 6 hours as

Albuterol DPI DPI Δ : 90 Usual dose: 2 inhalations every 4 to 6 hours,

Albuterol-budesonide MDI: Albuterol 90 mcg Usual dose: 2 inhalations every 4 to 6 hours as

mcg/actuation (United Acute exacerbation at home: 2 inhalations,

Levalbuterol MDI Δ 45 mcg/inhalation Usual dose: 2 inhalations every 4 to 6 hours,

Levalbuterol solution Nebulizer solution: Usual dose: Administer 0.63 to 1.25 mg

Ipratropium-albuterol SMI: Ipratropium 20 Usual dose (off-label): 2 inhalations every 6

Ipratropium-albuterol Nebulizer solution: Usual dose (off-label): Administer 1 vial (3 mL)

Δ Agent can also be used to prevent exercise-induced bronchoconstriction, 2 inhalations 5 to 20

§ The number of inhalations is based on the severity of respiratory impairment, number of

Graphic 72467 Version 27.0

Remove the cover of the mouthpiece.

Shake MDI canister vigorously for 5 seconds.

Breathe out normally.

Keep your tongue away from the opening of the mouthpiece.

When finished, recap mouthpiece.

More detailed information about individual medication formulations can be found at

Graphic 103302 Version 7.0

Uncap mouthpiece and check for loose objects in the device.

Insert MDI into spacer.

Shake canister vigorously for approximately 5 seconds.

Breathe out normally through your mouth.

When finished, recap mouthpiece.

Graphic 103303 Version 9.0

Technique for use of various dry powder inhalers*

Load a dose of medicine

Breathe out slowly (away from the mouthpiece).

Device maintenance and storage

Store your inhaler in a cool, dry place.

Graphic 51020 Version 13.0

Simplified approach to initial asthma therapy for adolescents and adults

Asthma symptoms Initial therapy