Figure 78-1 Stepwise long-term approach for managing asthma in children, 0 to 4 years of age and 5 to 11 years of age. (From National Heart Lung Blood Institute, National Asthma Education and Prevention Program: Expert panel report 3: guidelines for the diagnosis and management of asthma. Summary report 2007, NIH Publication No. 08-5846, Bethesda, MD, 2007, U.S. Department of Health and Human Services, p 42, http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf
Intermittent asthma Persistent asthma: Daily medication Consult with asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3. Step 1 Preferred:SABA PRN Step 2 Preferred:Low-dose ICS Alternative:Cromolyn, LTRA, Nedocromil, or Theophylline Step 3 Preferred:Low-dose ICS + LABA ORMedium-dose ICS Alternative:Low-dose ICS + either LTRA, Theophylline, or Zileuton Step 4 Preferred:Medium-dose ICS + LABA Alternative:Medium-dose ICS + either LTRA, Theophylline, or Zileuton Step 5 AND Preferred:High-dose ICS + LABA Consider Omalizumab for patients who have allergies Preferred:Step 6 AND High-dose ICS + LABA + oral corticosteroid Consider Omalizumab for patients who have allergies Each step: Patient education, environmental control, and management of comorbidities. Steps 2–4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see Notes). Quick-relief medication for all patients  SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up  to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corti costeroids may be needed.  Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment. AssesscontrolStep up if needed (first, check adherence, environmental control, and comorbid conditions) Step down if possible (and asthma is well controlled at least 3 months)
Figure 78-2 Stepwise approach for managing asthma in youths 12 years of age or older and adults. (From National Heart Lung Blood Institute, National Asthma Education and Prevention Program: Expert panel report 3: guidelines for the diagnosis and management of asthma. Summary report 2007, NIH Publication No. 08-5846, Bethesda, MD, 2007, U.S. Department of Health and Human Services, p 45,
Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. ICS, Inhaled corticosteroid; LABA, long-acting inhaled beta2-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta2-agonist
Notes:  The stepwise approach is meant to assist,   not replace, the clinical decision making  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.