The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.

Diagnosis and Management Goals

• Detailed medical history and physical exam to determine that symptoms of recurrent episodes of airflow obstruction are present
• Use spirometry in all patients >5 years of age to determine that airway obstruction is at least partially reversible [C].
• Consider alternative causes of airway obstruction.

Goals of therapy are to achieve control by [A]:

• Reducing impairment (prevent chronic symptoms, minimize need for rescue therapy with short-acting beta₂-agonists [SABA], maintain near-normal lung function and activity levels)
• Reducing risk (prevent exacerbations, minimize need for emergency care or hospitalization, prevent loss of lung function or prevent reduced lung growth in children, have minimal or no adverse effects of therapy)

Assessment and Monitoring

• Assess asthma severity to initiate therapy. (Use severity classification chart, assessing both domains of impairment [B] and risk [C] to determine initial treatment.)
• Assess asthma control to monitor and adjust therapy [B]. (Use asthma control chart, assessing both domains of impairment and risk to determine if therapy should be maintained or adjusted. [Step up if necessary; step down if possible.])
• Obtain lung function measures by spirometry at least every 1 to 2 years [B], more frequently for not well-controlled asthma.
• Schedule follow-up care: In general, consider scheduling patients at 2- to 6-week intervals while gaining control [D]; at 1- to 6-month intervals, depending on step of care required or duration of control, to monitor if sufficient control is maintained; at 3-month intervals if a step-down in therapy is anticipated [D].
• Assess asthma control, medication technique, written asthma action plan, patient adherence and concerns at every visit.

Education

• Provide self-management education [A]. Teach and reinforce: self-monitoring to assess control and signs of worsening asthma (either symptom or peak flow monitoring) [B]; using written asthma action plan (review differences between long-term control and quick-relief medication); taking medication correctly (inhaler technique and use of devices); avoiding environmental and occupational factors that worsen asthma.
• Tailor education to literacy level of patient; integrate education into all points of care; appreciate potential role of patient's cultural beliefs and practices in asthma management [C].
• Develop written action plan in partnership with patient [B].

Control Environmental Factors and Comorbid Conditions

• 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.

Medications

The type of evidence is provided for the most significant recommendations (See "Major Recommendations" field).

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