Improving Asthma Care

Full update November 2020

Over 3 million people in Canada and over 24 million people in the U.S. currently have asthma.6,17 In the toolbox below are practical tips and resources to improve care provided to patients with asthma.


Suggested Strategies or Resources

Prevent and treat influenza.

Vaccinate all patients six months and older, including pregnant women, yearly.1,2,12

The CDC provides current info on flu prevention, treatment, geographic activity, and links to patient education resources at

The Government of Canada has information and materials for patients and healthcare professionals about flu prevention and treatment at

Choose the right flu vaccine for the patient. The live intranasal flu vaccine (FluMist) should not be used in patients with severe asthma (on oral or high-dose ICS, active wheezing), or those with medically attended wheezing within the seven days prior to vaccination.2 For information to help you choose the right flu vaccine for your patient, get our chart, Flu Vaccines (U.S. Subscribers) (Canadian Subscribers).

Stay current on vaccinating during COVID-19 with our chart, FAQs: Immunizations During COVID-19.

Provide immunizations in your pharmacy. Technicians can learn The Basics of Immunization and Vaccines from our technician tutorial.

Understand when and how to use antivirals with our chart, Antivirals for Influenza.

Prevent pneumonia.

See our toolbox, Preventing and Treating Community-Acquired Pneumonia, for information on pneumonia vaccination and other prevention strategies, including patient education resources.

For help determining which adults need which pneumonia shot and when, get our chart, Pneumococcal Vaccination in Adults: Who Gets What and When? (U.S. Subscribers) (Canadian Subscribers).

Canadian subscribers can also get our chart, Pneumococcal Vaccination in Kids: Who Gets What and When?

Help patients quit tobacco.

Get our CE, The Pharmacist’s Role in Promoting Tobacco Cessation.

Get our chart, Smoking Cessation Drug Therapy, and our CE, Pharmacotherapy for Smoking Cessation, for help choosing smoking cessation pharmacotherapy.

For practical tips and more resources, see our toolbox, Smoking Cessation: Helping Patients Who Use Tobacco.

Get our chart, E-Cigarette and Vaping FAQs, and our Vaping Cessation Guide, to help patients stop using e-cigarettes.

Educate patients and caregivers about asthma.

The NIH’s So You Have Asthma: A Guide for Patients and Their Families (available at covers symptoms, treatments, monitoring, and more.

Canadians can get patient/caregiver information from the Canadian Lung Association at

Ensure adult patients with asthma are on the right inhalers.

Very mild asthma in adults (CTS designation):  SABA as-needed.  If higher risk of exacerbation (see footnote b), consider daily low-dose ICS plus as-needed SABA, or PRN budesonide/formoterol.10

Mild asthma in adults (e.g., GINA Step 1 or 2 [e.g., no symptoms most days]):  low-dose ICS as needed with SABA3,9 or PRN low-dose ICS/formoterol (GINA preferred).9,10  Another option is scheduled low-dose ICS plus as-needed SABA (first-line, per CTS).3,9,10 PRN low-dose ICS/formoterol is the preferred option in patients with poor adherence to daily medication and at higher risk for exacerbations (see footnote b),10 or poor perception of asthma control.3

  • Compared to PRN inhaled SABA alone, PRN low-dose budesonide/formoterol prevents a hospital visit, hospitalization, or steroid burst in about 1 in 16 adults/year [Evidence level A-1].5 Patients don’t seem to have more exacerbations using this combo PRN than with a daily low-dose ICS, with half the steroid exposure [Evidence level B-1].16
  • Refer to our chart, Comparison of Inhaled Asthma Meds (U.S.) (Canada) for dosing of PRN ICS/formoterol (e.g., Symbicort) and to identify low ICS doses for each inhaler.

Moderate asthma in adults (e.g., GINA Step 3 [e.g., symptoms most days, or nighttime symptoms ≥once/week]):  Scheduled ICS/LABA combo (preferred due to superior efficacy in patients ≥12 years of age), OR step up to a medium-dose ICS, PLUS PRN reliever.3,8,9 A non-preferred LABA alternative is LAMA.3,8

  • Guidelines recommend ICS/formoterol as controller and reliever (SMART) for convenience and adherence.3,8,9

Severe asthma in adults (e.g., GINA Step 4 or 5 [e.g., daily symptoms, or nighttime symptoms ≥once/week, and low lung function]): If needed, add a LABA (if on medium-dose ICS only) or increase to medium-dose ICS if on scheduled ICS/LABA combo (high dose not usually needed).3,8,9

  • Guidelines recommend ICS/formoterol as controller and reliever (SMART) for convenience and adherence.3,8,9
  • A LAMA (e.g., tiotropium, umeclidinium]) can be added for adults not well-controlled despite ICS/LABA (using two inhalers or a triple-therapy inhaler [e.g., Trelegy (U.S.), Enerzair Breezhaler (Canada)]).8,9,19
  • High-dose ICS does NOT offer much benefit over medium-dose ICS, as benefits plateau while adverse effects increase.20

Levalbuterol has not been proven more effective than albuterol.21

For a stepwise approach to managing asthma, get the GINA guidelines (, or NHLBI’s National Asthma Education and Prevention Program at

Get our chart, Comparison of Inhaled Asthma Meds (U.S. Subscribers) (Canadian Subscribers), for dosing and cost.

Reserve nebulizers for patients who cannot use an MDI with valved holding chamber (preferred over spacer).9

Ensure appropriate treatment, assessment, and follow-up for children with asthma.

For treatment specific to children, see our algorithm, Stepwise Pharmacotherapy of Pediatric Asthma.

Monitor growth in children using steroids.3,9

See the GINA guidelines ( for concise checklists for assessment of asthma control in children five years and younger, and for older children and adults.

Assessing control in children five years of age and younger is problematic. The GINA guidelines ( provide some direction based on expert opinion. In preschoolers, an exacerbation requiring systemic corticosteroids or hospitalization should prompt reassessment.13

In children ≥6 years of age, schedule a follow-up visit one to three months after starting treatment, or per clinical need, then every three to 12 months.9 CTS guidelines recommend follow-up every three to four months for preschoolers.13

After discharge for an exacerbation, schedule a visit within one to two days and again in one to two months for children ≤5 years of age.9

Minimize adverse effects from asthma medications.

Choose inhaled beta-2 agonists over intravenous, and oral corticosteroids over parenteral when possible.9

Spacer or valved holding chamber may reduce local side effects.22

Advise patients to rinse and spit after ICS use.9

Use the lowest ICS dose that provides control.9

  • Before escalating the dose, assess technique and ensure patients are adherent and are controlling triggers.3,8,9
  • Consider adding a LABA before increasing the ICS dose (CTS, GINA: preferred in patients 12 years and older).8,9
  • Step-down when asthma is well-controlled for at least 3 months, especially if lung function is normal, to minimize cost and side effects.9,15
    • Avoid stepping down during pregnancy, travel, or respiratory infection.9 Patients with risk factors for exacerbations (e.g., exposure to allergens or other triggers, a severe exacerbation in the past 12 months) may not be good candidates (see GINA guidelines Box 2-2B [pertains to patients ≥6 years old] or Box 6-4 [pertains to younger kids]).9
    • Ensure the patient has a written action plan (see below) and adequate meds to respond to worsening symptoms.9
    • Use clinical judgment and an approach that is basically the reverse of stepping up.9
    • Consider reducing the ICS dose by 25% to 50% every three months.9 (or as often as every three weeks in adults15). Box 3-7 in the GINA 2021 guidelines provides details on stepping down different controllers in patients ≥6 years old.9
    • In adults and adolescents with confirmed asthma, the ICS should not be completely stopped unless you are reassessing the asthma diagnosis.9 Reassess the asthma diagnosis (e.g., using spirometry) in adults who are successfully weaned from ICS.15 About one third of adults diagnosed with asthma seem to either not have asthma or go into remission within five years.15
    • If symptoms increase (e.g., rescue inhaler use or wheezing, chest tightness, shortness of breath, or cough more than twice weekly) or objective measurement of airflow obstruction worsens, resume the ICS at the lowest previously effective dose.9,15
    • If the patient is on a LABA/ICS, the first step is to continue the LABA and reduce the ICS dose by using a lower-strength formulation, or switching to once-daily dosing if already on a low ICS dose.9
    • Montelukast can be stopped without tapering.15
    • For patients on a leukotriene receptor antagonist or low-dose ICS, consider stepping down to as needed low-dose ICS/formoterol (for ages 12 and up) or as needed low-dose ICS/inhaled SABA.9

Ensure ICS users are getting adequate vitamin D and calcium.25

See our toolbox, Corticosteroids: Selection, Tapering, and More, for help tapering oral corticosteroids.

Ensure patients understand how to use their inhaler.

Ensure patients understand the difference between reliever and controller medications.

For step-by-step instructions for using different types of inhalers, links to instructional videos, information on how to obtain demo inhalers, and guidance on priming and cleaning the devices, see our chart, Correct Use of Inhalers (U.S. Subscribers) (Canadian Subscribers). Detailed information for use and care of inhalers is found in their product labeling and patient information leaflet.

Consider a spacer for patients using MDIs.

Review inhaler technique at all visits,3,8,9,14 including at the time of discharge from the hospital or emergency department.3,9 In the U.S., the CPT code 94664 can be used to bill for teaching patients correct inhaler technique.

Technicians can get our technician tutorial, Dispensing Inhaled Medications, which covers ways technicians can assist the pharmacist in helping patients get the most out of their inhaled medications, such as by identifying patients getting frequent or early refills.

Help patients stay on their medications.

See our toolbox, Medication Adherence Strategies. Includes a guide to help patients find medications they can afford, including information about discount or patient assistance programs.

Teach patients to keep track of how many doses are left in their inhaler. Some inhalers have a dose counter. See our chart, Correct Use of Inhalers (U.S. Subscribers) (Canadian Subscribers).

Encourage patients to seek refills, if needed, in advance of weekends and holidays so they don’t run out of medication.

Identify need for treatment modification.

In patients ≥6 years old, schedule a follow-up visit one to three months after starting treatment, or per clinical need, then every three to 12 months.9 After discharge for an exacerbation, schedule a visit within two to seven days (one to two days in children).9

At each visit, perform a physical exam3 and assess adherence and asthma control (see the GINA guidelines [] for concise checklists for assessment of asthma control).9 Check refill history when possible.

Examples of validated instruments for asthma assessment include the Asthma Control Questionnaire, Asthma Therapy Assessment Questionnaire (ATAQ), Asthma Control Test (ACT).9,26 An online version of the ACT is available at

To help implement the asthma guidelines in primary care practice, use the Asthma APGAR tools at

Reassess controller meds if patients have asthma symptoms or need a rescue inhaler more than twice a week, or patients wake at night with symptoms more than twice a month.11 (Canada: Asthma control criteria include ≤2 doses of rescue inhaler per week, and mild nighttime symptoms less than once per week).8

Perform spirometry in the event of progressive or prolonged loss of asthma control and at least every one to two years.24 (Spirometry cannot usually be performed in preschoolers.13) FEV1 measured after three to six months of controller treatment can be used as the patient’s “personal best” for comparison.9

Consider PEF monitoring in patients with severe asthma,9 those with poor symptom awareness,8,9 and those with a history of sudden severe exacerbations.9 Keep PEF monitoring in perspective; it is not proven more useful than symptom monitoring.23

Consider a “smart inhaler” (e.g., Hailie, Propeller, etc) with a sensor and mobile app to track the time, date, and location of inhaler use. Use the data to identify triggers, adherence problems, or need for therapy modification. See our chart, Medication Adherence Apps, for more information.

Provide alternative asthma medications when appropriate.

A leukotriene receptor antagonist (e.g., montelukast [see FDA warning about serious mental health side effects at can be considered as an:

  • alternative to scheduled ICS in mild persistent asthma.9,10
  • add-on to low-dose ICS as an alternative to adding on a LABA or increasing the ICS dose (NHLBI: in patients 5 years and older).3,8,9
  • CTS: in patients ≥12 years of age as an alternative to tiotropium as an add-on to ICS/LABA, or in children six to 11 years of age as an alternative to a LABA as an add-on to medium-dose ICS (refer younger patients).8

For patients who cannot tolerate SABAs or LABAs, consider ipratropium or tiotropium, respectively.3,7,18 Keep in mind that ipratropium has a slower onset than beta-2 agonists.9

Cromolyn (U.S.) is a non-preferred alternative to a low-dose ICS in mild asthma.3

Theophylline is a non-preferred alternative to a low-dose ICS in mild asthma in patients 5 years of age and older.3 (GINA: not for children <12 years9). It can also be added to an ICS as an alternative to adding a LABA, but requires serum concentration monitoring.3,9

Severe asthma may require long-term oral corticosteroids, but should be avoided if possible.3,9

Consider adjunctive biologic (e.g., omalizumab [Xolair]) for qualifying patients with severe asthma.3,9

If response to an alternative treatment is inadequate, try preferred treatment (if possible) before stepping up.3

Know when to consult a specialist.

In general, refer children <12 years who do not respond to a medium-dose ICS.8,9

Canada: patients who need oral corticosteroid courses frequently (≥2 courses in children) should be referred.8  Referral is also recommended for:  allergy testing; unclear diagnosis; severe asthma; asthma hospitalization; ≥2 asthma emergency department visits; or occupational asthma.8

U.S.: consult specialist if patient requires a medium-dose ICS plus LABA or any other controller medication.3

GINA: refer patients ≥12 years of age who do not respond to GINA step 4 (e.g., medium-dose ICS plus LABA).9

Manage triggers.

Identify triggers based on history, allergy testing,3 and PEF monitoring.9

  • Ask about reactions to aspirin, NSAIDs, and sulfites.4
  • Ask patients whether exposure to cold air or if changes in the weather cause symptoms.9
  • Ask adults about work history, and whether symptoms are worse at work, to identify occupational sensitizers.9

Some triggers should be avoided (e.g., smoke, occupational sensitizers, NSAIDs, aspirin [consider desensitization], confirmed food allergy), but others should not be avoided due to other benefits (e.g., exercise). Some triggers are difficult to avoid, and benefits of avoidance may not be worth the expense or trouble.9

Advise patients to avoid strong odors, and outdoor activity when pollution levels are high (although outdoor activity is usually OK if asthma is well-controlled).9 Other common triggers are dust mites, animal dander, cockroach droppings, mold, and pollen.3 Advise use of non-polluting heat sources, or vent them outdoors.9

Avoid noncardioselective beta-blockers in asthma patients. Cardioselective agents are NOT contraindicated and may be tolerated.9 Consider risk/benefit.9 Initiate under medical supervision (even intra-ocular products).9

Consider using a SABA or low-dose ICS with formoterol before exercise to prevent exercise-induced asthma.9

Identify comorbidities that may complicate asthma care.

Gastroesophageal reflux disease (GERD) is a risk factor for asthma exacerbations.9 Treat symptomatic GERD.9

Help patients lose weight.9 Asthma is more difficult to control in obese patients.9 Even weight loss of 5% to 10% can help.9 Get our chart, Weight Loss Products.

Control rhinitis and sinusitis to reduce nasal symptoms and cough.9

Manage stress when it occurs.9 Anxiety and depression are associated with worse symptoms and quality of life, and exacerbations.9 Help patients distinguish between anxiety symptoms and asthma symptoms.9

For pharmacotherapy options, see our charts, Choosing and Switching Antidepressants, Combining and Augmenting Antidepressants, and Pharmacotherapy of Anxiety: Beyond First-Line Agents.

Review the asthma guidelines.

The GINA Global Strategy for Asthma Management and Prevention is available at

Canadian asthma guidelines are available from the Canadian Thoracic Society at

Get the NHLBI’s National Asthma Education and Prevention Program at

Empower patients for self-care to prevent exacerbations (flare-ups) and hospital visits.

Teach patients to recognize symptom patterns that suggest loss of asthma control.8,9

Develop an asthma action plan for the patient to help them recognize and manage worsening asthma.3,8,9

Consider adding the colors of the inhalers when referring to them in the action plan, and/or putting red, yellow, and green stickers on the patient’s medications to correspond to the red, yellow, and green areas of the action plan.

NHLBI’s So You Have Asthma: A Guide for Patients and Their Families (at has a customizable action plan.

Another example of a customizable action plan is available at Plans are available in English, Spanish, Chinese, and Vietnamese.

Patients should be instructed when to contact their prescriber in the event of an exacerbation, even with an action plan.9

For children 5 years and younger, educate parents that flare-up warning symptoms may include coughing, reduced activity, or poor eating, as well as the more obvious signs such as increased asthma symptoms or reduced response to reliever medication.9 Urgent care is needed if the child is distressed, lethargic, or fails to respond to a SABA (e.g., more than 6 puffs are needed within the first 2 hours, or has not recovered after 24 hours), especially if the child is less than 12 months of age.9 Same-day medical help is needed if the child needs the inhaler more than three times per hour, or for more than 24 hours.9

Other patients can follow an action plan starting with 2 to 6 puffs of a SABA, repeated every 20 min. for one hour. If they do not experience rapid, sustained improvement, or symptoms worsen, they should seek medical care. The SABA can be continued every 3 to 4 hours for 24 to 48 hours.

  • In adults and adolescents, the ICS dose can be quadrupled in addition to intensifying reliever use. If using an ICS-LABA combo, mind that the max daily LABA dose is not exceeded (e.g., formoterol 72 mcg).9 This may necessitate use of a separate ICS-only inhaler.9 If PEF is <60% personal best or not improving after 48 hours, contact prescriber and add oral corticosteroid.9 See footnote a for dosing.

Treat exacerbations (flare-ups) in the outpatient setting when appropriate.

Use SABA (e.g., initially 4 to 10 MDI puffs [with spacer] for ages ≥6 years, or 2 to 6 puffs for younger children, repeated every 20 min. for the first hour).9 Give oxygen to maintain oxygen saturation 94% to 98% for children, or 93% to 95% for adults and adolescents.9

Consider oral corticosteroid (e.g., PEF <60% predicted/personal best, or not improving after 48 hours).9

  • Adults: prednisone or prednisolone 30 to 50 mg/day (CTS)8 or 40 to 50 mg/day (GINA)9 for 5 to 7 days.9 Preliminary evidence suggests that a single dose of oral dexamethasone 12 mg might work as well for mild to moderate exacerbations [Evidence level B-1].14
  • Children: there are not data to support parent-initiated oral corticosteroids in children 5 years or younger.9 However, oral corticosteroid can be started for children six years and older or for children 5 years or younger treated in the emergency department or if admitted to the hospital.9 See footnote a for dosing .

Triage patients for possible hospital admission.

For children 5 years of age and younger, hospital transfer is recommended if there is no response to SABA intensification within 1 to 2 hours; the child can’t drink or speak or has a respiratory rate >40/min, cyanosis, or silent chest; if oxygen saturation is <92% on room air; or the child comes from a resource-poor home.9

Life-threatening exacerbations in patients ≥6 years of age include drowsiness, confusion, or “silent chest.”9 Other signs/symptoms suggesting need for intensive care include speaking in words (not phrases), sitting hunched forward, respiratory rate >30/min., use of accessory muscles to breathe, pulse >120 beats per minute, oxygen saturation <90% on room air, or PEF ≤50% predicted or personal best.9

Treat exacerbations in the inpatient setting appropriately.

SABAs, administered frequently with a spacer, are the drugs of choice for acute excerbations (e.g., albuterol [salbutamol in Canada] 4 to 10 puffs every 20 minutes for the first hour [children ≥6 years and adults]).9 Nebulizers may have a role in severe or near-fatal asthma, but keep in mind that they pose a risk of spreading infection.  Whether continuous nebulization is better than intermittent dosing is unclear.9

  • Children ≤5 years of age can be given albuterol up to 6 puffs every 20 minutes for the first hour.9
  • Addition of ipratropium (e.g., 8 puffs [12 years and up]; 4 to 8 puffs ages 6 to 11 years; 1 to 2 puffs for children ≤5 years) in the ED reduces admissions.9,27,28

Within one hour of presentation, give prednisone (or equivalent) 40 to 50 mg in adults and 1 to 2 mg/kg/day in children, to a max of 20 mg for children ≤2 years, 30 mg max for children three to five years, and 40 mg max for ages six years and older.9  Usually continue for five to seven days in adolescents and adults, three to five days in children.9 Oral dexamethasone 0.6 mg/kg/day for two days is an alternative.9

Oxygen should be administered to most patients.9

Consider IV magnesium (25 to 75 mg/kg, up to 2 g27) over 20 min. in adults with FEV1 <25% to 30% at presentation, patients with severe hypoxemia despite initial treatment, or children whose FEV1 does not reach 60% predicted after one hour of therapy.9  IV magnesium may reduce the need for hospital admission.9

After first-line treatments and magnesium, IV terbutaline could be tried in children, despite limited evidence.4,27  It might hasten recovery.4  Monitor for tachyarrhythmias, hypokalemia, and (rarely) myocardial ischemia.4,27

If a child requires intubation, ketamine could be tried; it may cause bronchodilation, help maintain preload, and improve oxygenation.4

Only give antibiotics to patients who have strong evidence of a lung infection (e.g., pneumonia).9

Methylxanthines (aminophylline, theophylline) are not beneficial and increase adverse events.9

Consider establishing clinical pathways.


Prevent avoidable hospital readmissions.

See our toolbox, Reducing Hospital Readmissions.

Ensure patient is finishing any remaining oral corticosteroid or antibiotic doses at home.

Ensure controller inhaler was started/restarted at discharge, and that patient understands it is for scheduled use.

Assess understanding of treatment regimen and inhaler use.

Ensure patient has an asthma action plan.

Ensure patient’s chronic illnesses are tuned up.8,9

Get resources from the Agency for Healthcare Research and Quality such as Taking Care of Myself: A Guide for When I Leave the Hospital at This booklet is based on their Re-engineered Discharge (RED) Toolkit for helping hospitals improve the discharge process to prevent readmissions, available at

  1. Prednisone or prednisolone dosing, children: 1 to 2 mg/kg/day (max 20 mg/day <2 years 30 mg/day three to five years, or 40 mg/day ≥6 years of age; per CTS: max 50 mg/day8,13), usually for three to five days.9 Dexamethasone dosing for children: 0.6 mg/kg/day for one to two days.9
  2. Risk factors for exacerbation: history of severe asthma; poorly controlled asthma, use of >2 SABA inhalers/year; smoking.10

Abbreviations: CTS = Canadian Thoracic Society; ED = emergency department; GINA = Global Initiative for Asthma; ICS = inhaled corticosteroid; LABA = long-acting beta-2 agonist; LAMA = long acting muscarinic antagonist; MDI = metered dose inhaler; NHLBI = National Heart, Lung, and Blood Institute; PEF = peak expiratory flow; PRN = as-needed; SABA = short-acting beta-2 agonist; SMART = Single Maintenance And Reliever Therapy.


Levels of Evidence

In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.



Study Quality


Good-quality patient-oriented evidence.*

  1. High-quality RCT
  2. SR/Meta-analysis of RCTs with consistent findings
  3. All-or-none study


Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study


Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening.

*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).

RCT = randomized controlled trial; SR = systematic review [Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56.]


Prepared by the Editors of Therapeutic Research Center (361107); Last modified November 2021.


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  10. Yang, CL, Hicks EA, Mitchell P, et al. 2021 Canadian Thoracic Society guidelines-a focused update on the management of very mild and mild asthma. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine 2021. doi: 10.1080/24745332.2021.1877043.
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Cite this document as follows: Clinical Resource, Improving Asthma Care. Pharmacist’s Letter/Prescriber’s Letter. November 2020.

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