To get rid of asthma symptoms, doctors select therapy regimens to achieve control over pathological processes. One of the approaches is the stepwise treatment of bronchial asthma. 

Thanks to such tactics, it is possible to alleviate the condition of the asthmatic and control the disease in the future. 

What is step therapy

Stepwise treatment of asthma is a process in which the amount and dosage of drugs is increased if it is not possible to reduce the intensity of the manifestations of the disease and control the disease.

Initially, the doctor determines the severity of the pathology. A mild degree corresponds to the first stage of therapy; in severe pathological processes, treatment begins with the 3rd or 4th stage.

Thanks to an individual approach, it is possible to control the course of the disease using the minimum amount of drugs.

In the process of taking medications, their effectiveness is continuously assessed and, according to indications, prescriptions are adjusted. If the chosen tactics does not bring the desired results and the patient’s condition worsens, the dosage is increased (go to a step higher). This is done until the asthmatics stabilize or improve.

Goals of Step Therapy

Components of the asthma treatment process:

  1. Assessment of disease control.
  2. A therapy that aims to achieve control.
  3. Patient monitoring.

In bronchial asthma, the goals of stepwise therapy are:

  • reduction of bronchial obstruction;
  • reducing the need for bronchodilator drugs;
  • increasing patient activity and improving their quality of life;
  • improvement of indicators of external respiration;
  • prevention of seizures;
  • elimination of factors provoking an exacerbation of the disease.

The condition of patients is assessed before the course of therapy in order to determine the dosage and the regimen of drug intake. This is necessary to prevent asthma attacks.

If it is possible to achieve effective control of bronchial asthma for at least three months from the beginning of the course, the dosage is reduced.

Principles of stepwise treatment of bronchial asthma 

In a stepwise approach to treatment, the doctor takes into account the patient’s condition, the frequency of attacks, and then prescribes medications. If prescriptions control asthma, gradually reduce the amount or dosage of the prescribed drugs.

With partial control of pathology, the issue of increasing doses of drugs or adding other drugs is considered.

For patients with progressive asthma who have not previously received adequate treatment, the course begins with the second stage. If attacks of bronchospasm occur daily, asthmatics are indicated for treatment immediately from the third stage.

At each stage of therapy, patients use emergency medications, depending on their needs, to quickly stop the symptoms of suffocation.

The effectiveness of the treatment increases from 1 step. The doctor chooses tactics depending on the severity of bronchial asthma:

  1. Light intermittent , or episodic. Not more than two bouts of bronchospasm are observed per month only after exposure to provoking factors. During periods of remission, a person’s health is satisfactory. The patient does not need long-term treatment. Medication is prescribed only to prevent seizures.
  2. Light persistent . Attacks more often than 1 time per week. An asthmatic person has bronchospasm at night (no more than 2 times a month). During exacerbations, physical activity decreases and sleep is disturbed.
  3. Moderate persistent . Patients have daily attacks day and night (no more than 1 time per week). The activity of asthmatics is reduced. Constant monitoring of pathology is required.
  4. Persistent, severe. Daily attacks during the day and at night (more than 1 time per week) with a deterioration in the quality of life. Exacerbations develop weekly.

Five steps of asthma therapy

Treatment of bronchial asthma step by step allows you to eliminate the symptoms of the disease and increase the interictal periods.

The tactics are selected depending on the severity of the disease.

Stage 1

Assumes taking only emergency drugs. The policy is chosen for those patients who are not receiving supportive care and who periodically experience asthma symptoms during the day.

Usually, an exacerbation occurs no more than twice a month. Medicines for the relief of asthma are aerosol β2-agonists with a rapid action. After 3 minutes, the remedies stop the symptoms by expanding the bronchi.

Possible alternative drugs are oral β2-agonists or short-acting theophyllines, inhaled anticholinergic drugs. But the effect of these funds comes more slowly.

If an attack of suffocation occurs against the background of physical activity, short-acting or fast-acting inhalers are prescribed as a prophylaxis.

You can also use these medications after exercise if signs of asthma develop. Alternative drugs are cromones – drugs for allergies.

Patients are also advised to extend the duration of the warm-up before exercise to reduce the risk of bronchospasm. In the intermittent form, medication is not prescribed for long-term treatment. However, if the frequency of attacks increases, the doctor moves to the second stage.

Stage 2

The tactics are selected for people with a mild persistent form of the disease. Asthmatics have to take daily medications to prevent bronchospasm and control pathology.

First of all, the doctor prescribes anti-inflammatory corticosteroid drugs in low dosages for taking once a day. To eliminate bronchospasm, fast-acting medicines are used.

Alternatively, if the patient refuses hormones, antileukotriene drugs may be prescribed to reduce inflammation.

Such medicines are also indicated for allergic reactions (rhinitis) and the occurrence of undesirable effects from taking glucocorticoids. If choking occurs at night, one of the long-acting bronchodilators is prescribed .

Perhaps the appointment of other drugs – theophyllines and cromones . However, their action is insufficient for maintenance therapy. In addition, medications have side effects that worsen the patient’s condition. If therapy is ineffective, they move on to the next step.

Stage 3

In case of a moderate illness, drugs are prescribed to eliminate the attack and one or two drugs to control the course of the pathology. Usually the doctor prescribes the following combination:

  1. inhaled glucocorticoids in small doses;
  2. β2-agonist with prolonged action.

With this combination, the patient receives hormonal drugs in lower dosages, and the effect of therapy does not decrease. If control over the disease has not been achieved within three months of treatment, the dose of aerosol hormonal agents is increased.

An attack of bronchospasm is recommended to be stopped with prolonged β2-agonists with a quick effect, for example. Preparations containing formoterol . To enhance the therapeutic effect, this substance is combined with budesonide .

As an alternative treatment, patients are offered the following combination of medicines:

  1. inhaled glucocorticoids in low doses;
  2. antileukotriene drugs or small doses of theophyllines.

Patients are advised to use inhalers with spacers to help distribute the medication evenly.

If additional treatment with oral corticosteroids is required, and symptoms worsen, proceed to the next step of therapy.

Stage 4

At 4 steps, emergency medications and several medications for supportive therapy are required. The choice of medication depends on the treatment in the previous steps. Doctors prefer the following combination:

  1. inhaled glucocorticoids in medium to high doses;
  2. long-acting inhaled β2-agonists;
  3. one of the drugs, if necessary: ​​delayed- release theophylline, antileukotriene drugs, oral β2-agonist, oral corticosteroid.

Increasing the dosage of hormonal drugs is necessary as a temporary treatment. If after six months there is no effect, the dose is reduced due to the risk of developing undesirable actions.

The following combinations increase the effectiveness of treatment:

  1. antileukotriene drugs with hormones in medium and low doses;
  2. long-acting beta2-agonists with hormones in low doses with the addition of sustained-release theophyllines.

Increasing the frequency of budesonide medications also increases the chances of achieving disease control. If there are side effects of beta2-agonists, an anticholinergic agent containing ipratropium bromide is prescribed .

Stage 5

The tactic is chosen for severe asthma. More often, therapy is carried out in a hospital setting. Patients are prescribed the following drugs:

  1. inhaled drugs for emergency treatment;
  2. high-dose inhaled glucocorticoids;
  3. long-acting β2 agonist;
  4. antibodies to immunoglobulin E;
  5. oral glucocorticoids (for uncontrolled asthma and frequent exacerbations);  
  6. theophylline.

For all 5 stages of bronchial asthma treatment, it is imperative to maintain control over the disease for three months.

Then the doctor decides to reduce the number of drugs taken or reduce their dosage in order to establish a minimum amount of therapy.

Features of stepwise treatment of asthma in children

Stepwise therapy of bronchial asthma of any form in adolescents and children practically does not differ from the treatment of adults. Therapy begins with establishing the severity of the disease.

The doctor pays a special role in prescribing drugs to their side effects. The differences in treatment in children are:

  1. With a persistent form without growth retardation, long-term anti-inflammatory therapy is carried out.
  2. In the mild stage of the disease, inhaled glucocorticoids are prescribed in doses that do not cause side effects in the child. Alternatively, preparations containing ipratropium bromide are offered in a form that is appropriate for age.
  3. The second line drugs are cromones (antiallergic drugs).
  4. With a pathology of moderate severity, metered-dose inhaled glucocorticoids are prescribed. Spacers are recommended . Another therapy option is a combination of hormones with long-acting inhaled β2-agonists (allowed for children from 4 years of age).
  5. For the prevention of seizures, a child under 4 years of age is prescribed an oral β2-agonist in the evening.

In a severe form of the disease, when the symptoms bother the child regularly, the quality of sleep is disturbed and emphysema develops, treatment with inhaled hormones is prescribed.

The complex of therapy includes inhalation with the use of β2-sympathomimetics of prolonged action (1-2 times) and oral hormones. A combination of budesonide and formoterol can be used as emergency drugs .

Inhalation therapy in newborns has features:

  1. Using a jet nebulizer with a compressor. During an attack, drugs containing fenoterol, salbutamol are used , for long-term therapy – drugs with budesonide , cromoglycic acid.
  2. Use of metered aerosols with a spacer and mask.
  3. With the development of hypoxia, an oxygen mask is indicated.
  4. In emergencies, β2-sympathomimetics are administered intravenously. With an increase in symptoms, adrenaline is injected subcutaneously and the baby is transferred to artificial ventilation.

Drug treatment for children is complemented by immunotherapy. Potential sources of allergens are also eliminated.

Inhalation systems must meet the requirements of children. Children from 7 years old can be transferred to a metered-dose aerosol.

Evaluation of the effectiveness of treatment

The criteria for effective therapy of bronchial asthma are:

  1. Reducing the severity of symptoms.
  2. Elimination of attacks at night.
  3. Reducing the frequency of exacerbations of the disease.
  4. Reducing the dosage of β2-agonists.
  5. Increased patient activity.
  6. Complete control over the disease.
  7. Lack of unwanted effects from drugs.

The physician monitors the patient after the appointment and assesses the body’s response to the prescribed dose of medication. Adjust the dosage if necessary.

The stepwise approach to treatment is based on the determination of the minimum maintenance dose of drugs.

A good response to the use of β2-agonists during an attack is that they act for 4 hours.

With an incomplete response to the action of the drug, the complex of therapy includes oral hormones and inhalation of anticholinergic agents. If the answer is poor, a doctor is called. The patient is taken to the intensive care unit.

Step down a step

To make the transition to a lower level, the effectiveness of therapy is reviewed every six months or 3 months. If the pathology remains under control, prescriptions may be gradually reduced.

This reduces the risk of side effects of the drugs in patients and improves the susceptibility to further therapy.

They move on to the next step in this way: reduce the dosage of the main drug or cancel drugs for maintenance therapy. In the course of changing treatment tactics, patients are monitored.

If there is no worsening of the condition, monotherapy is prescribed – they go to stage 2. In the future, a transition to the first stage is possible.


The treatment that is offered for bronchial asthma at every stage is not common to all patients.

To achieve control over the disease, it is necessary to draw up an individual plan for each, taking into account the age, characteristics of the disease, and comorbidities.

Thus, you can significantly reduce the risk of exacerbations, prolong periods of remission, eliminate or alleviate symptoms.

A clear therapy scheme and specific recommendations of doctors allow the patient to become a physically active person and lead a fulfilling life.