Classifying Asthma Severity and Initiating Treatment in children 5 to 11 years of age

PULMONARY & CRITICAL CARE

Assessing severity and initiating therapy in children who are not currently taking long-term control medication.
Level of severity is determined by both impairment and risk.

Components of severity Classification of asthma severity (5 to 11 years of age)
Intermittent Persistent
Mild Moderate Severe
Impairment Symptoms ≤2 days/week >2 days/week but not daily Daily Throughout the day
Nighttime awakenings ≤2 times/month 3 to 4 times/month >1 time/week but not nightly Often 7 times/week
Short-acting beta2 agonist use for symptom control (not prevention of EIB) ≤2 days/week >2 days/week but not daily Daily Several times per day
Interference with normal activity None Minor limitation Some (moderate) limitation Extremely limited
Lung function
  • Normal FEV1 between exacerbations
  • FEV1 >80 percent predicted
  • FEV1/FVC >85 percent
  • FEV1 ≥80 percent predicted
  • FEV1/FVC >80 percent
  • FEV1 = 60 to 80 percent predicted
  • FEV1/FVC = 75 to 80 percent
  • FEV1 <60 percent predicted
  • FEV1/FVC <75 percent
Risk Exacerbations requiring oral systemic glucocorticoids 0 to 1/year (see footnote) ≥2/year (see footnote)
Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time for patients in any severity category
Relative annual risk of exacerbations may be related to FEV1
Recommended step for initiating treatment Step 1 Step 2 Step 3, medium dose-inhaled glucocorticoids option Step 3, medium dose-inhaled glucocorticoids option, or Step 4
And consider a short course of oral systemic glucocorticoids
In 2 to 6 weeks, evaluate the level of asthma control that is achieved and adjust therapy accordingly
Image of the above table from NIH.gov
  •  Assess impairment domain by the patient’s/caregiver’s recall of the previous 2 to 4 weeks and spirometry.
  • Assign severity to the most severe category in which any feature occurs.
  • At present, data are inadequate to correlate frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic glucocorticoids 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.
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