Michigan Quality Improvement Consortium Guideline
General Principles for the Diagnosis and Management of Asthma
July 2014
The following guideline recommends general principles and key clinical activities for the diagnosis and management of asthma.
Eligible Population
Key Components
Recommendation and Level of Evidence
 Detailed medical history and physical exam to determine that symptoms of recurrent episodes of airflow obstruction are present.
 Use spirometry (FEV1, FEV6, FVC, FEV1/FVC) in all patients ≥ 5 years of age to determine that airway obstruction is at least partially reversible [C].
 Wheezing
 Consider alternative causes of airway obstruction.
 History of cough
Goals of therapy are to achieve control by [A]:
(worse particularly at
 Reducing impairment: chronic symptoms, need for rescue therapy and maintain near-normal lung function and activity level.
night), recurrent
 Reducing risk: exacerbations, need for emergency care or hospitalization, loss of lung function or reduced lung growth in children, or adverse
wheeze, recurrent
effects of therapy.
difficulty in breathing,
Assessment and  Assess asthma severity to initiate therapy using severity classification chart for impairment [B] and risk [C].
recurrent chest
monitoring
tightness
 Assess asthma control to monitor and adjust therapy [B]. (Use asthma control chart, for impairment and risk. Step up if necessary; step down
 Symptoms occur or
if possible.)
worsen in the presence
 Obtain spirometry (FEV1, FEV6, FVC, FEV1/FVC) to confirm control, and at least every 1-2 years [B], more frequently for not well-controlled asthma.
of exercise, viral
 Schedule follow-up care: within 1 week, or sooner, if acute exacerbation; at 2- to 6-week intervals while gaining control [D]; monitor control at
infection, inhalant
1- to 6-month intervals, at 3-month interval if a step-down in therapy is anticipated[D].
allergens, irritants,

Assess asthma control, medication technique, written asthma action plan, patient adherence and concerns at every visit.
changes in weather,
Children and adults
with the following:
Diagnosis and
management
goals
strong emotional
Education
expression (laughing or
crying hard), stress,
menstrual cycles
 Symptoms occur or
worsen at night,
awakening the patient Control
environmental
factors and
comorbid
conditions
Medications
(See link to national
age-specific
guidelines1 for
treatment
recommendations)
Referral
1
 Develop written action plan in partnership with patient [B]. Update annually, more frequently if needed.
 Provide self-management education [A]. Teach and reinforce: self-monitoring to assess control and signs of worsening asthma (either
symptoms or peak flow monitoring) [B]; using written asthma action plan; taking medication correctly (inhaler technique and use of devices);
avoiding environmental and occupational factors that worsen asthma.
 Tailor education to literacy level of patient; appreciate potential role of patient's cultural beliefs and practices in asthma management [C].
 Recommend measures to control exposures to allergens and pollutants or irritants that make asthma worse [A].
 Consider allergen immunotherapy for patients with persistent asthma and when there is clear evidence of a relationship between symptoms
and exposure to an allergen to which the patient is sensitive [B].
 Treat comorbid conditions (e.g., allergic bronchopulmonary aspergillosis [A], gastroesophageal reflux [B], obesity [B], obstructive sleep apnea [D],
rhinitis and sinusitis [B], chronic stress or depression [D]).
 Inactivated influenza vaccine for all patients over 6 months of age [A] unless contraindicated. Intranasal influenza vaccine not for use in persons
with asthma.
 Initial treatment should be based on the severity of asthma, both impairment and risk.
 Inhaled corticosteroids (ICS) are the most effective long-term control therapy [A]. Optimize ICS use before advancing to other therapies.
 Re-evaluate in 2 - 6 weeks for control. Modify treatment based on level of control.
 Consider step down if well-controlled for 3 months.
Warning for use of Long-acting beta-agonists (LABA). See Black Box Warning:
 Do not use LABA as monotherapy. Use only with an asthma controller such as inhaled corticosteroids.
 Use for the shortest duration possible.
 Only use if not controlled on medium-dose ICS.
 Pediatric and adolescent patients who require the addition of a LABA to an inhaled corticosteroid should use a combination product containing both.
 Refer to an asthma specialist for consultation or comanagement if there are difficulties achieving or maintaining control (See national
age-specific guidelines1); immunotherapy or omalizumab is considered; additional testing is indicated; or if the patient required 2 bursts of oral
corticosteroids in the past year or a hospitalization [D].
NHLBI 2007 EPR3: Guidelines for the Diagnosis and Management of Asthma. Stepwise Approach for Managing Asthma Long Tern, Figures 13 and 16.
Levels of Evidence for the most significant recommendations: A = randomized controlled trials; B = controlled trials, no randomization; C = observational studies; D = opinion of expert panel
This guideline lists core management steps. It is based on the 2007 National Asthma Education and Prevention Program Expert Panel Report 3, Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung and Blood Institute
(www.nhlbi.nih.gov)
MQIC.ORG
Approved by MQIC Medical Directors July 2008, 2010, 2012, 2014
Adopted and Approved by Priority Health 10/2014
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FIGURE 11. CLASSIFYING ASTHMA SEVERITY AND INITIATING THERAPY IN CHILDREN
Guidelines for the Diagnosis and Management of Asthma
Key: FEV1, forced expiratory volume
in 1 second; FVC, forced vital capacity;
ICS, inhaled corticosteroids; ICU,
intensive care unit; N/A, not applicable
Notes:
■ Level of severity is determined by
both impairment and risk. Assess
impairment domain by caregiver’s
recall of previous 2–4 weeks.
Assign severity to the most severe
category in which any feature
occurs.
■ Frequency and severity of exacerbations may fluctuate over time for
patients in any severity category.
At present, there are inadequate
data to correspond frequencies
of exacerbations with different
levels of asthma severity. In general,
more frequent and severe exacerbations (e.g., requiring urgent,
unscheduled care, hospitalization,
or ICU admission) indicate greater
underlying disease severity. For
treatment purposes, patients with ≥2
exacerbations described above may
be considered the same as patients
who have persistent asthma, even in
the absence of impairment levels
consistent with persistent asthma.
FIGURE 14. CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS 12 YEARS OF AGE AND ADULTS
Assessing severity and initiating treatment for patients who are not currently taking
long-term control medications
Key: EIB, exercise-induced bronchospasm, FEV1, forced expiratory
volume in 1 second; FVC, forced vital
capacity; ICU, intensive care unit
Notes:
The stepwise approach is meant to
assist, not replace, the clinical
decisionmaking required to meet
individual patient needs.
• Level of severity is determined by
assessment of both impairment and
risk. Assess impairment domain by
patient’s/caregiver’s recall of
previous 2–4 weeks and spirometry.
Assign severity to the most severe
category in which any feature
occurs.
• At present, there are inadequate
data to correspond frequencies of
exacerbations with different levels
of asthma severity. In general, more
frequent and intense exacerbations
(e.g., requiring urgent, unscheduled
care, hospitalization, or ICU
admission) indicate greater
underlying disease severity. For
treatment purposes, patients who
had ≥2 exacerbations requiring oral
systemic corticosteroids in the past
year may be considered the same
as patients who have persistent
asthma, even in the absence of
impairment levels consistent with
persistent asthma.
•
Managing Asthma Long Term
43
FIGURE 12. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN
Key: EIB, exercise-induced bronchospasm, FEV1, forced expiratory
volume in 1 second; FVC, forced vital
capacity; ICU, intensive care unit;
N/A, not applicable
Notes:
■ The level of control is based on the
most severe impairment or risk
category. Assess impairment
domain by patient’s or caregiver’s
recall of previous 2–4 weeks.
Symptom assessment for longer
periods should reflect a global
assessment, such as whether
the patient’s asthma is better or
worse since the last visit.
■ At present, there are inadequate
data to correspond frequencies of
exacerbations with different levels of
asthma control. In general, more
frequent and intense exacerbations
(e.g., requiring urgent, unscheduled
care, hospitalization, or ICU
admission) indicate poorer
disease control.
Managing Asthma Long Term
41
44
FIGURE 15. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTHS ≥12 YEARS OF AGE AND ADULTS
Guidelines for the Diagnosis and Management of Asthma
*ACQ values of 0.76–1.4 are indeterminate regarding
well-controlled asthma.
Key: EIB, exercise-induced bronchospasm; ICU, intensive care
unit
Notes:
•
•
•
The stepwise approach is meant to assist, not replace,
the clinical decisionmaking required to meet individual
patient needs.
The level of control is based on the most severe impairment or risk category. Assess impairment domain by
patient’s recall of previous 2–4 weeks and by
spirometry/or peak flow measures. Symptom assessment
for longer periods should reflect a global assessment, such
as inquiring whether the patient’s asthma is better or
worse since the last visit.
At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma
control. In general, more frequent and intense
exacerbations (e.g., requiring urgent, unscheduled care,
hospitalization, or ICU admission) indicate poorer disease
control. For treatment purposes, patients who had ≥2
exacerbations requiring oral systemic corticosteroids in the
past year may be considered the same as patients who
have not-well-controlled asthma, even in the absence of
impairment levels consistent with not-well-controlled asthma.
ATAQ = Asthma Therapy Assessment Questionnaire©
ACQ = Asthma Control Questionnaire©
ACT = Asthma Control Test™
Minimal Important
Difference: 1.0 for the ATAQ; 0.5 for the ACQ; not
determined for the ACT.
Before step up in therapy:
— Review adherence to medication, inhaler technique,
environmental control, and comorbid conditions.
— If an alternative treatment option was used in a step,
discontinue and use the preferred treatment for that step.
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FIGURE 13. STEPWISE APPROACH FOR MANAGING ASTHMA LONG TERM IN CHILDREN, 0–4 YEARS OF AGE AND 5–11 YEARS OF AGE
Guidelines for the Diagnosis and Management of Asthma
LABA or
Montelukast
Oral corticosteriods
ICS
FIGURE 16. STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS ≥12 YEARS OF AGE AND ADULTS
Key: Alphabetical order is used when more than one
treatment option is listed within either preferred or
alternative therapy. ICS, inhaled corticosteroid; LABA, longacting inhaled beta2-agonist; LTRA, leukotriene receptor
antagonist; SABA, inhaled short-acting beta2-agonist
Notes:
•
•
•
•
•
•
Managing Asthma Long Term
•
The stepwise approach is meant to assist, not replace, the
clinical decisionmaking required to meet individual patient
needs.
If alternative treatment is used and response is inadequate,
discontinue it and use the preferred treatment before
stepping up.
Zileuton is a less desirable alternative due to limited
studies as adjunctive therapy and the need to monitor
liver function. Theophylline requires monitoring of serum
concentration levels.
In step 6, before oral corticosteroids are introduced, a trial
of high-dose ICS + LABA + either LTRA, theophylline, or
zileuton may be considered, although this approach has
not been studied in clinical trials.
Step 1, 2, and 3 preferred therapies are based on Evidence
A; step 3 alternative therapy is based on Evidence A for
LTRA, Evidence B for theophylline, and Evidence D for
zileuton. Step 4 preferred therapy is based on Evidence B,
and alternative therapy is based on Evidence B for LTRA
and theophylline and Evidence D zileuton. Step 5
preferred therapy is based on Evidence B. Step 6 preferred
therapy is based on (EPR—2 1997) and Evidence B for
omalizumab.
Immunotherapy for steps 2–4 is based on Evidence B for
house-dust mites, animal danders, and pollens; evidence is
weak or lacking for molds and cockroaches. Evidence is
strongest for immunotherapy with single allergens. The role
of allergy in asthma is greater in children than in adults.
Clinicians who administer immunotherapy or omalizumab
should be prepared and equipped to identify and treat
anaphylaxis that may occur.
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