Asthma Treatment

How do you treat an individual with asthma?

Medications may be delivered by several methods: inhaled (most common), oral, or via injection.  Treatment can be to establish control of asthma, which is daily treatment, or to relieve symptoms of asthma as they occur.

Control (Daily)

  • Avoidance of triggers and allergens
  • Using of controller medication, as prescribed

Controller medications may include:

  • Inhaled glucocorticosteroids
  • Leukotriene modifiers
  • Long-acting inhaled bronchodilator
  • Theophylline
  • Cromones
  • Long-acting oral beta-agonists
  • Anti-IgE
  • Systemic glucocorticosteroids
  • Oral anti-allergic compounds
  • Allergen-specific immunotherapy

Clinical control of asthma is defined as:

  • No daytime symptoms (≤ 2 times per week)
  • No limitations of daily activities, including exercise
  • No nocturnal symptoms
  • No need for reliever treatment (≤ 2 times per week)
  • Normal or near-normal lung function
  • No exacerbations


A. Assessment of current clinical control (preferably over 4 weeks)
Characteristic Controlled?(All of the following) Partly Controlled?(Any measure present) Uncontrolled
Daytime symptoms None (twice or less/week) More than twice/week Three or more features of partly controlled asthma*†
Limitation of activities None Any
Nocturnal symptoms/awakening None Any
Need for reliever/ rescue treatment None (twice or less/week) More than twice/week
Lung function (PEF or FEV1)‡ Normal <80% predicted or personal best (if known)
B. Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side-effects)
Features that are associated with increased risk of adverse events in the future include:Poor clinical control, frequent exacerbations in past year*, ever admission to critical care for asthma, low FEV1, exposure to cigarette smoke, high dose medications

Adapted from Fitzgerald, 2013. Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate. Lung function is not a reliable test for children 5 years and younger.

† By definition, an exacerbation in any week makes that an uncontrolled asthma week?

‡ Without administration of bronchodilator


To gain control of asthma, the Global Initiative for Asthma recommends a 3-pronged approach:

  • Develop a patient/medical care provider partnership
    • Education on asthma management and treatment
    • Personal written asthma action plan to help individuals respond to their asthma appropriately
  • Identify risk factors and reduce exposure to risk factors,
    • By avoidance or medication
  • Assess, treat, and monitor asthma
    • Treat to achieve control
    • Monitor to maintain control

Relief (Asthma attack)

Treatment should be administered based on the severity of the asthma attack.  Below is a table which outlines the severity of asthma based on several factors.  Some of these factors can be used in the field, however during exercise breathing and heart rates may already be increased.

  • Cessation of activity
  • Administration of relief medication via a metered-dose inhaler (MDI) ideally with a spacer
  • For mild to moderate attacks, bronchodilator use is called for
  • Bronchodilators should be used as prescribed (generally 2-4 puffs every 20 minutes for the first hour of discomfort)


Severity of Asthma Exacerbations
Mild Moderate Severe Respiratory Arrest Imminent
Breathless Walking Talking At rest
Position Can lie down Prefers sitting Hunched forward/ tripoding
Talks in Sentences Phrases Words
Alertness May be agitated Usually agitated Usually agitated Drowsy/confused
Respiratory Rate* Increased Increased > 30 breaths/min
Accessory Muscles used and Suprasternal Retractions Usually Not Usually Usually Paradoxical thoraco-abdominal motion
Wheeze Moderate, often only at the end of expiration Loud Usually Loud Absence of wheeze
Pulse (beats/min)** <100 100-120 >120 Bradycardia
PEFR after initial bronchodilator administration*** > 80% 60-80% <60%

Adapted from Fitzgerald, 2012.  Note: the presence of several parameters, but not necessarily all indicates the general classification of severity

* Respiratory rate may be elevated due to exercise, look for decreased rate with rest

**Pulse may be elevated due to exercise, look for decreased rate with rest

*** PEF % of predicted or personal best


If discomfort decreases but remains:

  • Mild attack may require 2-4 puffs every 3 to 4 hours
  • Moderate attack may require 6-10 puffs every 1 to 2 hours
  • Check pulse oxygen (O2) with a pulse oximeter
    • Administer supplemental O2 if, pulse O2 drops below 95%
  • Check and monitor PEFR after bronchodilator use
  • Activate EMS if symptoms do not improve
  • Prepare for rescue breathing and CPR after EMS is activated


Recommended List of Materials

  • Controller inhaler (for everyday use)
  • Rescue inhaler
  • Spacer if available (improvise with tape roll)
  • Peak flow meter
  • Stethoscope
  • Supplemental oxygen
  • Bag-valve mask/pocket-mask
  • Non re-breather mask
  • Pulse oximeter