In 2002, the National Asthma Eduction and Prevention Program (NAEPP) updated the management guidelines:
Asthma classificationSymptom frequencyLung functionMedications required to maintain longterm control
Mild intermittentDaytime: 2 days/wk or less
Nighttime: 2 nights/month or less
PEF or FEV1: 80% or more of predicted functionNo daily medication needed
Mild persistentDaytime: More than 2 days/wk but less than 1 time/day
Nighttime: more than 2 nights/month
PEF or FEV1: 80% or more of predicted function (PEF variability 20% to 30%)Preferred: Low-dose corticosteroid (in children, may use nebulizer with or without face mask, or MDI with holding chamber, or dry powder inhaler)
Adult alternative: Cromalyn, leukotriene modifier, or nedocromil OR sustained-release theophylline to level of 5-15
Child < 5 alternative: Cromalyn (nebulizer or MDI with holding chamber), OR leukotriene modifier
Moderate persistentDaytime: daily
Nighttime: more than 1 night/wk
PEF or FEV1 60-80% of predicted function (PEF variabilty > 30%)Preferred: Low- to medium-dose inhaled corticosteroid and long-acting beta agonist (in children < 5 years old, use low-dosage inhaled steroid and LABA OR medium-dosage inhaled corticosteroid)
Adult alternative: ICS in medium dose range, OR low- to medium-dose ICS plus either leukotriene modifier or theophylline
Child < 5 alternative: low-dose ICS plus either leukotriene modifier or theophylline
Severe persistentDaytime: continual
Nighttime: frequent
PEF or FEV1 60% of less of predicted functionHigh-dosage inhaled corticosteroid and LABA

The Salmeterol Multi-Center Asthma Research Trial (SMART) studied 26,353 patients with asthma in whom a LABA or placebo was added to their existing regimen. It was stopped after 28 weeks because of concerns in a subset of patients. There were no differences between salmeterol and placebo in the primary endpoints of respiratory-related deaths and life-threatening events requiring interventions (eg intubation, ventilation). However, the number of asthma-related deaths was significantly higher in the patients who were taking salmeterol (13 patients) vs placebo (4 patients); this differnence was totally accounted for by blacks (no difference among whites); blacks were less likely to be taking inhaled steroids (38% vs 49% among whites). Patients taking inhaled steroids, however, had fewer asthma-related deaths (6/12254 with steroids vs 11/14099 without steroids) regardless of treatment with salmeterol.

The NAEPP also looked at antibiotic use in asthmatic exacerbations, and found no benefit when the clinical suspicion for bacterial infection was low. The updated guidelines note that chlamydial, mycoplasmal and other bacterial infections do NOT contribute frequently to asthma exacerbations. In fact, the data do not even support the use of antibiotics when the clinical suspicion of bacterial infection is high!

The following table was not in this article, but is pertinent (it came from JFP 53:697, 9/04). Note that pregnant patients may take inhaled steroids (they are the prefered controller agent for mild persistent asthma); budesonide is rated category B, whereas the others are rated category C. Longterm ICS in children are safe, and final height is not affected (though growth may be slowed). Lifetime use of ICS in adults may predispose to cataract formation.

DrugLow daily doseMedium daily doseHigh daily dose
Beclomethasone CFC
42 or 84 mcg/puff
Adult: 168 to 504 mcg or 4/2 to 12/6 puffs/d
Child: 84 to 336 mcg/d or 2/1 to 8/4 puffs/d
Adult: 504 to 840 mcg/d or 12/6 to 20/10 puffs/d
Child: 336 to 672 mcg/d or 8/4 to 16/8 puffs/d
Adult: > 840 mcg/d or > 20/10 puffs/d
Child: >672 mcg/d or > 16/8 puffs/d
Beclomethasone HFA
40 or 80 mcg/puff
Adult: 80 to 240 mcg/d or 2/1 to 6/3 puff/d
Child: 80 to 160 mcg/d or 2/1 to 4/2 puffs/d
Adult: 240 to 480 mcg/d or 6/3 to 12/6 puffs/d
Child: 160 to 320 mcg/d or 4/2 to 8/4 puffs/d
Adult: > 480 mcg/d or > 12/6 puffs/d
Child: >320 mcg/d or > 8/4 puffs/d
Budesonide DPI 200 mcg/inhalationAdult: 200 to 600 mcg/d or 1-3 puffs/d
Child: 200 to 400 mcg/d or 1-2 puffs/d
Adult: 600 to 1200 mcg/d or 3-6 puffs/d
Child: 400 to 800 mcg/d or 2-4 puffs/d
Adult: > 1200 mcg/d or > 6 puffs/d
Child: > 800 mcg/d or > 4 puffs/d
Budesonide inhalation suspension for nebulizaton (child dose)0.5 mg1.0 mg2.0 mg
Fluticasone MDI
44, 110 and 220 mcg/puff
Adult: 88 to 264 mcg/day
Child: 88 to 176 mcg/d
Adult: 264 to 660 mcg/d
Child: 176 to 440 mcg/d
Adult: > 660 mcg/d
Child: > 440 mcg/d
Fluticasone DPI
50, 100 or 250 mcg/inhalation
Adult: 100 to 300 mcg/d
Child: 100 to 200 mcg/d
Adult: 300 to 600 mcg/d
Child: 200 to 400 mcg/d
Adult: > 600 mcg/d
Child: > 400 mcg/d
Triamcinolone acetonide
100 mcg/puff
Adult: 400 to 1000 mcg/d
Child: 400 to 800 mcg/d
Adult: 1000 to 2000 mcg/d
Child: 800 to 1200 mcg/d
Adult: > 2000 mcg/d
Child: > 1200 mcg/d

The following table can be used to classify asthma severity by daily medication regimen and response to treatment. For example, if a patient has symptoms of mild persistent asthma when being treated with a low-dose inhaled steroid (the treatment noted above for mild persisent asthma), they are reclassified as having moderate persistent asthma.
Patient symptoms on current therapyCurrent treatment: IntermittentCurrent treatment: Mild PersistentCurrent treatment: Moderate Persistent
Mild intermittent symptomsMild intermittentMild persistentModerate persistent
Mild persistent symptomsMild persistentModerate persistentSevere persistent
Moderate persistent symptomsModerate persistentSevere persistentSevere persistent
Severe persistent symptomsServere persistentSevere persistentSevere persistent