To set asthma goals, you need a baseline. A challenge for any provider in treating a patient is tailoring a treatment plan to fit his level of asthma. Is it intermittent, mild persistent, moderate persistent, or severe persistent? To do this, your health care provider needs to ask specific questions regarding your child's medical history: Does your family have a history of asthma; how often does he wheeze; how does he react to certain asthma triggers; how is he sleeping; is he having problems breathing while in school; how often does he use a quick-relief medication; how does he react to exercise?

Then there are the objective measures of how is he really breathing. A child generally above the age of four or five will be asked during a physician visit to breathe into the hose of a spirometer, a machine that measures the speed and volume of air flowing in and out of his lungs. For younger children, signs and symptoms will be evaluated.

Assessing Severity

From these questions and testing, the severity of the child's underlying asthma can be determined, which will aid in the creation of an asthma action plan that provides medical directions. This level of severity looks at risk (i.e., reports of a flare-up requiring oral corticosteroids) and impairment (i.e., specific symptoms in the past two weeks or nighttime awakenings). Under the 2007 NIH guidelines, the classifications of asthma severity are separated into three age categories: 0 to 4 years, 5 to 11 years, and 12 years to adult. The severity classifications are:

• Intermittent — Asthma symptoms are mild and do not last for long, and quick-relief medications are needed infrequently. Generally, these children do not need hospital or emergency room care. However, severe flare-ups still could occur that might require additional medication.

• Mild Persistent — Brief but recurrent episodes may occur that are usually treated with quick-relief medications. Everyday medications, though, might be suggested. Symptoms such as coughing or wheezing may occur no more than twice a week.

• Moderate Persistent — Asthma symptoms appear daily, and quick-relief medications usually are needed daily. Daily inhaled corticosteroids probably will be needed. Risk for flare-ups exist that may point to a need for hospitalization or an emergency room visit.

• Severe Persistent — Symptoms appear daily, and quick-relief medications are quickly used up. Stronger inhaled corticosteroids are needed. Asthma specialists may be needed in providing treatment.

Determining the level of severity usually depends on the frequency and intensity of asthma flare-ups, according to the guidelines. (See Appendix C.) Also, children who are determined to have intermittent symptoms still could encounter severe flare-ups.

Assessing Control

The current NIH asthma guidelines also encourage health care providers to assess how well a child's asthma is being controlled with treatment. The assessments, which review daily impairment and flare-up risks, are divided into three age categories: 0–4 years, 5–11 years, and 12 years to adult. The levels of control are:

• Well Controlled — Symptoms appear less than twice a week and no interference is reported with daily activities.

• Not Well Controlled — Symptoms appear more than twice a week and some limitation is reported with daily activities.

• Very Poorly Controlled — Symptoms occur throughout the day and normal activities are extremely limited.

A child receiving treatment who has no asthma flare-ups — or only one asthma flare-up that requires an oral corticosteroid — during a one-year period may be considered to have her condition well-controlled. A child with flare-ups more than three times a year that require oral corticosteroids may be considered to have very poorly controlled asthma. However, the guidelines note that not only the frequency but the intensity of the flare-ups needs to be taken into consideration as well when considering the level of asthma control. In the long run, the goal is to develop a treatment plan and strategies that are targeted just for your child's asthma (Also see Chapters 3 and 6). And, it should be a plan that she is comfortable following every day — whether it's at home, school, a friend's house, an athletic field, or a nearby shopping mall.