All patients should have a strategy for treatment that they have discussed and agreed to after consulting with their physician. It is best that these instructions be in writing for easy reference and that close communication (aided by peak flow measurements) be maintained with the physician. Often the details of a "strategy" will be revised. No treatment plan should ever be regarded as final, since there are frequent variations in asthma as well as new medications that become available. Treatment is best given in a "step-by-step" fashion, avoiding simultaneous administration of several new agents, so the physician and patient can more accurately determine what treatment is most effective.

Treatment Goals

Treatment goals for bronchial asthma are maintaining a normal lifestyle including vigorous exercise; reversing bronchial narrowing, inflammation and irritability, thereby sustaining "normal" lung function; and avoiding adverse medication effects. Symptoms such as shortness of breath, wheezing, and coughing should be minimal. Whenever medication side effects such as those encountered with long-term oral corticosteroids outweigh benefits, the medication program must be revised.

Treatment Strategy: Mild Asthma

Mild intermittent asthma can often be treated with infrequent use of a B2-adrenergic agonist delivered by MDI. The B-agonist would be used "as needed," not regularly. Short-acting agents are preferred because of their more rapid onset. Patients with mild persistent asthma require the addition of an anti-inflammatory agent which is used on a regular basis. The preferred agents are inhaled corticosteroids (low doses) or cromolyn or nedocromil. Children usually begin with a trial of cromolyn or nedocromil. Cromolyn and nedocromil may be particularly helpful in cough asthma where blockage of bronchial nerve reflexes often reduces symptoms. Cromolyn is also preferred during pregnancy. The antileukotrienes may also be considered as an alternative. Montelukast has been approved for childre, aged six and older.

Treatment Strategy: Moderate Asthma

Patients with moderate persistent asthma require higher doses of topical corticosteroids and the addition of a long-acting inhaled B2-adrenergic agonist (salmeterol or formoterol). This medication is administered every twelve hours on a regular basis. These patients continue to use a short-acting B2-agonist spray when symptoms break through. This has been appropriately termed "rescue" medication. Adding a long-acting B2-agonist, however, frequently results in a reduction in the use of the shortacting agent. In view of the detrimental effects of overuse of B-agonists, this reduction is highly beneficial. Due to the slow onset of action, it must be emphasized that the long-acting B-agonist must not be used for relief of acute asthmatic attacks.

Alternative agents for these patients include theophylline, sustained-release B2-agonist tablets, and the anti-leukotrienes.