Stepwise Approach
The stepwise approach gradually increases (“step-up”) or decreases (“step down”) treatment to achieve or maintain asthma control. It uses a continuous cycle to assess, adjust, and review response to treatment. The GINA 2022 Main Report1 and the NAEPP 2020 guidelines2 recommend using a stepwise approach to treatment.
For the initial diagnosis and treatment of asthma:

Confirm the diagnosis of asthma (using key indicators and spirometry).

Classify asthma severity: intermittent, mild persistent, moderate persistent, or severe persistent.

Use the age-appropriate treatment steps presented in the stepwise approach for initial controller treatment options. See:
-  GINA 2022, Initial treatment choices by age¹:

• Box 3-4-A, 3-4Bi, and 3-4-Bii for presenting symptoms and initial treatment options for adults and adolescents
• Box 3-4C and 3-4Di and 3-4 Dii for presenting symptoms and initial treatment options in children ages 6-11 years
• Box 6-5, Personalized management of asthma in children 5 years and younger (stepwise treatment steps)

NAEPP 2020, Stepwise Approach for Management of Asthma in Individuals by age 0-4, 5-11, and ≥12: Figures 1.b, 1.c and 1.d LINKS respectively2

Use a shared decision-making approach with the patient/family to select an appropriate treatment. Factors to consider may include:

• Treatment agent preferred
• Practical issues (cost, likeliness of adherence with treatment, inhaler technique)
• Patient views
• Patient characteristics or phenotype

Provide patients/families with the education and skills needed to adhere to and use medications effectively (i.e. Asthma action plan, teaching for inhaler devices).

Schedule follow up within 1–3 months for step-up and step-down management after starting treatment and thereafter every 3–12 months for maintenance depending on concerns and severity of disease.

For asthma management:

1. Assess asthma control: “well controlled”, “not well controlled” or “very poorly controlled.”
2. Identify reason(s) for lack of control (ie, exposure to allergens, irritants (tobacco smoke, pollutants), nonadherence to medication regimen, improper medication technique, recent viral infection, etc).
3. Use the age-appropriate GINA 2022 and NAEPP 2020 stepwise tables and a shared decision-making approach with the patient/family to maintain or adjust therapy based on the level of asthma control). See: 
   
   -  GINA 2022 guidelines, Main treatment figures1:
   1. Box 3-5A, Personalized management for adults and adolescents to control symptoms and minimize future risk
   2. Box 3-5B, Personalized management for children ages 6-11 years to control symptoms and minimize future risk
   3. Box 6-5, Personalized management of asthma in children 5 years and younger (stepwise treatment steps) 
      
      NAEPP 2020, Stepwise Approach for Management of Asthma in Individuals by age 0-4, 5-11, and ≥12: Figures 1.b, 1.c and 1.d LINKS respectively²
4. Update/maintain the asthma action plan and support with educational messages and skills needed to adhere to and use medications effectively.
5. Schedule follow up for maintenance ie, within 1–3 months for step-up and step-down management after starting treatment and thereafter every 3–12 months. depending on concerns and severity of disease.

References:
¹Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2022. Available from: www.ginasthma.org.
²NAEPP 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group