control difficult are allergens, patient behaviors, reflux disease and obesity. The preferred treatments in step one for all age groups start with a short-acting inhaled beta-adrenergic agonist. Step two adds a low dose inhaled corticosteroid. Step three for ages 12 to adult, a long-acting beta agonist is added to the treatment. For ages 5 to 11 a long-acting beta agonist, a leukotriene, or theophylline can be added. In ages up to four, the preferred method is to increase the inhaled corticosteroid to a medium dose. Step four, ages five to adult recommends increasing to a medium dose inhaled corticosteroid and taking with a long-acting beta agonist. In ages up to four adding a long-acting beta agonist or montelukast to the medium dose inhaled corticosteroid is recommended. Step five for ages five to adult, recommendation is to increase inhaled corticosteroids to a high dose and take with a long-acting beta agonist. In ages, up to four, the

5 inhaled corticosteroid should also be increased to a high dose and continue with a long-acting beta agonist or montelukast. Step six the last step, recommendations for all ages is to add an oral corticosteroid. In the stepwise approach, medications can also be stepped down to a less intensive treatment if symptoms have been controlled for at three months. Oral corticosteroids are initially discontinued, if they are on inhaled corticosteroids, they may be reduced by 50%. The next step down would be reducing long-acting bronchodilators. If symptom-free for 6 to 12 months long- term therapy may be stopped (Arcangelo et al., 2017). Because asthma is a chronic disorder, therapy is based on long-term efforts to prevent exacerbations and suppress inflammation. The stepwise approach is meant to assist decision- making when increasing or decreasing medications. This approach helps in gaining control of asthma by helping clinicians in individualizing and tailoring the best medicine with the least amount of side effects and exacerbations. Summary Asthma is a chronic disease characterized by inflammation and obstruction of the airways. Exacerbations are common, and attacks can often be scary. Symptoms include dyspnea, wheezing, chest pain, and hypoxia. Attacks can be life-threatening and need to be dealt with immediately with quick-acting bronchodilators. Long-term medications are dosed depending on the severity of symptoms. Short-term medications are used in an exacerbation event. Asthma medications are typically tailored to an individual. Not everyone with asthma will take the same