Asthma — Asthma Control Assessment — Clinical Pathway: Inpatient

Asthma Clinical Pathway — Inpatient

Asthma Control Assessment

Patient < 5 years
Is this their second asthma exacerbation requiring systemic steroids in 6 months?		 Patient ≥ 5 years
Is this their second exacerbation requiring systemic steroids in 12 months?
If yes, asthma is not well controlled, consider Step up (see Stepwise table below).

If no, assess asthma control based on symptoms/impairment prior to onset of this exacerbation. Assess control using Asthma Control Tool

Recommend Step up at discharge if not well or poorly controlled.

Stepwise Recommended Medication Escalation Treatment for Managing Asthma Long Term

Adapted from 2020 Focused Updates to the Asthma Management Guidelines: Clinician's Guide  

Age, years Step 1 Step 2 Step 3 Step 4 Step 5† Step 6†
Symptoms Intermittent Mild Persistent Moderate Persistent Severe Persistent
0-4** Preferred

SABA as needed for symptoms

And at the start of RTI add short course of daily ICS when Asthma Predictive Index (API) is positive		 Low-dose ICS and PRN SABA Medium dose ICS and PRN SABA. Daily medium-dose ICS-LABA and PRN SABA Daily high-dose ICS-LABA and PRN SABA Daily high-dose ICS-LABA + OCS and PRN SABA
5-11 Preferred SABA as needed for symptoms Daily Low-dose ICS and PRN SABA Daily and PRN combination low-dose ICS-formoterol Daily and PRN medium-dose ICS-formoterol Daily high-dose ICS-LABA and PRN SABA Daily high-dose ICS-LABA + OCS and PRN SABA
≥ 12 Preferred SABA as needed for symptoms Daily Low-Dose ICS and PRN SABA or PRN concomitant ICS and SABA Daily and PRN combination low-dose ICS-formoterol Daily and PRN combination medium-dose ICS-formoterol Daily medium or high-dose ICS-LABA + LAMA and PRN SABA Daily high-dose ICS-LABA + OCS + PRNs SABA
Quick Relief

Use SABA as needed for symptoms. The intensity of treatment depends on the severity of symptoms: up to 3 treatments at 20-minute intervals as needed.

*In steps 3 and 4, the preferred option includes the use of ICS-formoterol 1 to 2 puffs as needed up to a maximum total daily maintenance and rescue dose of 8 puffs (< 12 years) and 12 puffs (> 12 years).
*Preferred
**Adapted from 2020 NHLBI Asthma Focused Updates
Highlighted table cells are consistent with SMART

API, Preschool Age

Early frequent wheezer (≥ 3x) and 1 major or 2 minor

Major Criteria
  • Parental MD asthma
  • MD diagnosed eczema + skin/blood test to one allergen
Minor Criteria
  • Wheezing apart from colds
  • Eosinophilia
  • Allergic sensitization to milk, egg or peanuts
  • Allergic rhinitis

Inhaled Corticosteroids (ICS)

Therapeutic Substitution of Inhaled Corticosteroids

Note: Dose recommendations for each brand of product are based on data from that product’s labeling. Though equivalent doses have not been established, the following dose substitution charts for HFA Metered Dose Inhalers, a Breath-Actuated Inhaler, and Dry Powder Inhalers can be utilized for therapeutic substitution. Patient-specific responses to different products within these two categories of inhalers may vary so patients should be closely monitored for dose effectiveness.

Caution: DPI and HFA formulations are NOT interchangeable

< 12 years, Breath-Actuated and HFA inhalers

 
Breath-Actuated Metered Dose Inhaler
Beclomethasone(QVAR RediHaler) Fluticasone HFA (Flovent HFA) Mometasone HFA (Asmanex HFA)
Inhaler strength Regimen Inhaler strength Regimen Inhaler strength Regimen
LOW
Daily Dose		 40 mcg/inhalation 1 inhalation BID 44 mcg/puff 1 puff BID 100 mcg/puff 1 puff at night
40 mcg/inhalation 2 inhalations BID 44 mcg/puff 2 puffs BID 100 mcg/puff 1 puff at night
MEDIUM
Daily Dose		 80 mcg/inhalation 2 inhalations BID 110 mcg/puff 1 puff BID 100 mcg/puff 1 puff BID
HIGH
Daily Dose		 80 mcg/inhalation 3 inhalations BID 220 mcg/puff 1 puff BID 200 mcg/puff 1 puff BID
80 mcg/inhalation 4 inhalations BID 220 mcg/puff 2 puffs BID 200 mcg/puff 2 puffs BID

 

< 12 years, Dry Powder Inhalers

 
Dry Powder Inhaler (DPI)
Budesonide
(Pulmicort Flexhaler) 		Fluticasone Diskus
(Flovent Diskus)		 Mometasone DPI
(Asmanex Twisthaler)
Inhaler strength Regimen Inhaler strength Regimen Inhaler strength Regimen
LOW
Daily Dose		 90 mcg/puff 1 puff BID 50 mcg/puff 1 puff BID 110 mcg/puff 1 puff at night
90 mcg/puff 2 puffs BID 50 mcg/puff 2 puffs BID 110 mcg/puff 1 puff at night
MEDIUM
Daily Dose		 180 mcg/puff 2 puffs BID 100 mcg/puff 2 puffs BID 110 mcg/puff 1 puff BID
HIGH
Daily Dose		 180 mcg/puff 3 puffs BID 250 mcg/puff 1 puff BID 220 mcg/puff 1 puff BID
180 mcg/puff 4 puffs BID 250 mcg/puff 2 puffs BID 220 mcg/puff 2 puffs BID

 

≥ 12 years, Breath-Actuated

 
Breath-Actuated Metered Dose Inhaler
Beclomethasone
(QVAR RediHaler)		 Fluticasone HFA
(Flovent HFA)		 Mometasone HFA
(Asmanex HFA)
Inhaler strength Regimen Inhaler strength Regimen Inhaler strength Regimen
LOW
Daily Dose		 40 mcg/inhalation 1 inhalation BID 44 mcg/puff 1 puff BID 100 mcg/puff 1 puff at night
40 mcg/inhalation 2 inhalations BID 44 mcg/puff 2 puffs BID 100 mcg/puff 2 puffs at night
80 mcg/inhalation 1 inhalation BID 110 mcg/puff 1 puff BID 100 mcg/puff 1 puff BID
MEDIUM
Daily Dose		 80 mcg/inhalation 2 inhalations BID 110 mcg/puff 2 puffs BID 100 mcg/puff 2 puffs BID
80 mcg/inhalation 3 inhalations BID 220 mcg/puff 1 puff BID 200 mcg/puff 1 puff BID
HIGH
Daily Dose		 80 mcg/inhalation 4 inhalations BID 220 mcg/puff 2 puffs BID 200 mcg/puff 2 puffs BID

 

≥ 12 years, Dry Powder Inhalers

 
Dry Powder Inhaler (DPI)
Budesonide
(Pulmicort Flexhaler) 		Fluticasone Diskus
(Flovent Diskus)		 Mometasone DPI
(Asmanex Twisthaler)
Inhaler strength Regimen Inhaler strength Regimen Inhaler strength Regimen
LOW
Daily Dose		 90 mcg/puff 1 puff BID 50 mcg/puff 1 puff BID 110 mcg/puff 1 puff at night
90 mcg/puff 2 puffs BID 50 mcg/puff 2 puffs BID 110 mcg/puff 2 puffs at night
180 mcg/puff 1 puff BID 100 mcg/puff 2 puffs BID 110 mcg/puff 1 puff at night
MEDIUM
Daily Dose		 180 mcg/puff 2 puffs BID 100 mcg/puff 2 puffs BID 110 mcg/puff 1 puff BID
180 mcg/puff 3 puffs BID 250 mcg/puff 1 puff BID 220 mcg/puff 1 puff BID
HIGH
Daily Dose		 180 mcg/puff 4 puffs BID 250 mcg/puff 2 puffs BID 220 mcg/puff 2 puffs BID

 

HFA Inhalers

 
Breath-Actuated Metered Dose Inhaler
Budesonide/formoterol HFA
(Symbicort HFA)		 Mometasone/formoterol HFA
(Dulera HFA)		 Fluticasone/salmeterol HFA
(Advair HFA)
Inhaler strength Regimen Inhaler strength Regimen Inhaler strength Regimen
LOW
Daily Dose		 80 mcg/4.5 mcg per puff 2 puffs BID 100 mcg/5 mcg per puff 2 puffs daily 45 mcg/21 mcg per puff 2 puffs BID
MEDIUM
Daily Dose		 160 mcg/4.5 mcg per puff 2 puffs BID 100 mcg/5 mcg per puff 2 puffs BID 115 mcg/21 mcg per puff 2 puffs BID
HIGH
Daily Dose		 Not applicable (only low or medium dose options) 200 mcg/5 mcg per puff 2 puffs BID 230 mcg/21 mcg per puff 2 puffs BID

 

Dry Powder Inhalers

 
Dry Powder Inhaler (DPI)
Fluticasone/salmeterol
Advair Diskus AirDuo RespiClick/Generic RespiClick
Inhaler strength Regimen Inhaler strength Regimen
LOW
Daily Dose		 100 mcg/50 mcg per inhalation 1 inhalation BID 55 mcg/14 mcg per inhalation 1 inhalation BID
MEDIUM
Daily Dose		 250 mcg/50 mcg per inhalation 1 inhalation BID 113 mcg/14 mcg per inhalation 1 inhalation BID
HIGH
Daily Dose		 500 mcg/50 mcg per inhalation 1 inhalation BID 232 mcg/14 mcg per inhalation 1 inhalation BID