Outpatient / Pulmonology and Critical Care

Asthma (Outpatient)

Last Updated: 5/5/2023

# *** (Mild Intermittent, Mild/Moderate/Severe Persistent) Asthma


  • Symptoms: *** intermittent wheezing, SOB, cough; allergies, polyps, prior “GERD”
  • PFTs: *** FEV/FVC, after bronchodilator FEV increase >12%, or decreases after methacholine challenge; PEF if known (<80% personal best c/w poor control)
  • Triggers: *** exercise, cold air, infections, smoke, perfumes, allergens, ASA/NSAIDs, B blockers
  • Prior Exacerbations: ** last, h/o intubations
  • Symptoms/week (needing rescue inhaler): ***
  • Overnight Symptoms/month: ***

DDx: *** vocal cord dysfunction, ABPA, EGPA, occupational asthma, ASA-exacerbated (polyps)


-- Maintenance: *** go up ladder if >2 in either rescue inhaler use per week or nighttime awakenings per month; go down ladder if well controlled for 3 months; adjusting q6-8 weeks; ICS-LABA options - budesonide-formoterol (Symbicort), fluticasone-salmeterol (Advair), fluticasone-vilanterol (Breo Ellipta)

  • Step 1 - low dose ICS-LABA PRN with albuterol rescue PRN
  • Step 2 - low dose ICS-LABA daily with albuterol rescue PRN
  • Step 3 - medium dose ICS-LABA
  • Next Options - high dose ICS-LABA, add LTRA (Singulair - montelukast), add LAMA (Spiriva - tiotropium)
  • Refer - specialist for biologics and oral steroid consideration; or if severe exacerbation, >2 pred treatments in 1 year

-- Exercise-Induced: *** PRN albuterol or ICS-LABA 15 mins prior to exercise, add montelukast daily if needed

-- Action Plan: *** by PEF or symptoms; albuterol rescue inhaler vs 4x controller ICS PRN → pred 40mg for 5 days → hospital


-- Exacerbations: *** 

Template coming soon!

Patient Guidance and Information

Instructions for Using Different Inhalers and Sprays

ICS - take right before brushing teeth to avoid thrush

Nasal Spray - prime, point to lateral eye, use contralateral hand, head tilted down, use ipsilateral hand to open nostril on lateral side, don't sniff aggressively instead do a few snall sniffs

Metered Dose Inhaler (MDI) -  shake inhaler, prime (if haven't used recently), breath out, squeeze, slow and deep breath, hold for 5-10 seconds at max inhalation; only do one puff at a time; spacer will whistle if you go too fast

Dry Powder Inhaler (Diskus like Advair or Spiriva) - all different but in general, click to release powder, then very quick, deep breath


If You Remember Nothing Else

Asthma is by definition a disease with intermittent obstruction so they should not be chronically short of breath if they only hold a diagnosis of asthma and are controlled. Newer guidelines recommend starting with ICS-LABA (Symbicort, Advair, Breo Ellipta) PRN rather than using albuterol PRN. Go step-wise unless the patient is very poorly controlled, in which case you can jump up steps and then work your way back every 6-8 weeks. FEV1/FVC ratio may be normal in asthma, depending on whether the patient is in the midst of an exacerbation or not. Ask about how often the patient is using their rescue inhaler each week, and how often they have nighttime awakenings per month. If the answer is more than 2 for either, their asthma is poorly controlled and you need to go up a step. Make sure patients are using their inhalers correctly! Ask them to show you!

Clinical Pearls

  • FEV1/FVC <0.7 suggests an obstructive physiology - in asthma it may be normal if the patient is not poorly controlled or in the middle of an exacerbation!
  • Make sure patients are using inhalers correctly! Ask them to show you!
  • Levalbuterol supposedly causes less jitteriness and tachycardia, but probably a placebo and is not a standard medicine to give
  • LAMA should not be used alone without ICS (increased risk of severe exacerbation)
  • LABA monotherapy should not be used (increased risk of asthma-related death)

Trials and Literature

  • Novel START (2019) - PRN ICS-LABA > PRN SABA  for preventing exacerbations
  • SYGMA 2 (2018) - PRN ICS-LABA is non-inferior to maintenance ICS for preventing exacerbations
  • AZALEA (2016) - Azithromycin does not improve outcomes 
  • NEJM 2012 - Tiotropium in addition to ICS-LABA increases time to first severe exacerbation