| Classification | Symptoms | Long-Term Control | Quick Relief |
| Step 4. Severe persistent. | Continual symptoms, limited physical activity, frequent exacerbations, nighttime symptoms common, FEV1 or PEF <60% predicted, PEF variability >30% |
Daily: Anti-inflammatory medication: (high-dose inhaled corticosteroid) and long-acting bronchodilator and corticosteroid tablets or syrup. Children
>5 years old give daily anti-inflammatory medicine. High-dose corticosteroid with spacer and face mask. If needed add systemic corticosteroids. |
Short-acting bronchodilator (inhaled beta2-agonists prn symptoms). Use on a daily basis or use indicates need for additional long-term control therapy. Children <5 years old give a bronchodilator prn for symptoms up to 3 times/day. |
| Step 3. Moderate persistent. | Daily symptoms and daily use of inhaled short-acting beta2-agonist, exacerbations affect activity and occur 2 times/week, nighttime symptoms >1/week, FEV1 or PEF >60% 80% predicted, PEF variability>30% | Anti-inflammatory: inhaled corticosteroid (medium dose) or inhaled corticosteroid (low-med dose) and long-acting bronchodilator daily.If needed: Anti-inflammatory: inhaledcorticosteroid (med-high dose)and long-acting bronchodilator.Children 5 years old give daily anti-inflammatory medication.Either medium-dose corticosteroidwith spacer and face mask or medium-dose inhaled corticosteroidand nedocromil or medium-dose corticosteroid and long-acting bronchodilator (theophylline). | Short-acting bronchodilator: beta2-agonist prn symptoms. Use on a daily basis or use indicates needfor additional long-term controltherapy. Children 5 years old give bronchodilator up to 3 times/day. |
| Step 2. Mild persistent. | Symptoms >2 times/ week, but <1 time/day, exacerbations may affect activity, nighttime symptoms >2 times/month, FEV1 or PEF 80% predicted, PEF variability 20%30% |
Daily: Anti-inflammatory: either inhaled corticosteroid (low doses) or cromolyn or nedocromil (usually children begin with a trial). Sustained-release theophylline orzafirlukast or
zileuton,montelukast.
Children 5 years old give daily anti-inflammatory medication. Cromolyn (nebulizer or MDI) or nedocromil (MDI only) tid-qid or low-dose inhaled corticosteroid with spacer and face mask. |
Short-acting inhaled beta2-agonists prn symptoms. Use on a daily basis or use indicates need for additional long-term control therapy.
Children 5 years old, give bronchodilator prn symptoms. |
| Step 1. Mild intermittent. | Symptoms < 2 times/week, asymptomatic and normal PEF between exacerbations, exacerbations brief, nighttime symptoms <2 times/month, FEV1 or PEF >80% of predicted, PEF variability <20%. |
No daily medication needed. Children < 5 years old, no daily medication needed |
Short-acting inhaled beta2-agonists prn for symptoms. Use of short-acting inhaled beta2-agonists >2 times/week may indicate the need to initiate long-term control therapy. Children <5 years old: bronchodilator prn symptoms <2 times/week (either inhaled short-acting beta2-agonist by nebulizer or face mask and spacer or oral beta2-agonist for symptoms). With viral respiratory infection:bronchodilator q46h up to 24 hours, repeat no more than once every 6 weeks, or consider systemic corticosteroid. |