Asthma
The INESSS tool does not cover severe asthma, which needs specialist care.
Diagnose
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Suspect | Wheeze, breathlessness out of proportion, chest tightness, cough or sputum.Symptoms vary over time and are worse at night or on waking. Triggers: exercise, cold air, irritants, allergens, viral infection. |
| Confirm, age 6 and older | Compatible symptoms plus pre-bronchodilator FEV1/FVC below the LLN.No LLN on the report: below 0.80 at age 6–17, below 0.75 in adults. Confirm objectively in anyone able to do lung function tests. |
| Reversibility | Post-bronchodilator FEV1 up ≥12%Adults also need ≥200 mL. PEF up ≥20% is an alternative in adults. |
| If spirometry is not conclusive | Bronchial challenge test. PEF variability (adults). Same FEV1 or PEF response after ≥4 weeks of anti-inflammatory maintenance. |
| Severity | Graded by the treatment needed for control, not by symptoms. |
| Severe asthma: refer | Any of: Uncontrolled on high-dose ICS + LABA; Worse when high-dose inhaled therapy is reduced; Oral corticosteroids for more than half of the past year. |
Treat
- INESSS Institut national d'excellence en santé et services sociaux
- CTS Canadian Thoracic Society
| Decision | Guideline |
|---|---|
| Everyone | Everyone with asthma has a reliever.Never LABA without ICS. |
| Age 12 and older | No SABA alone.Start a regimen that contains ICS from the first prescription. CTS 2021 allows PRN SABA alone in well-controlled patients at lower exacerbation risk.Québec leads: follow INESSS. |
| High risk of severe exacerbation | In the past 12 months, a severe exacerbation or any one of: Uncontrolled asthma; More than 2 SABA inhalers a year; FEV1 <60% of personal best or predicted (age 12 and older); Active or passive smoking or vaping; Irritant or allergen exposure when sensitized; Blood eosinophils ≥0.3 × 10⁹/L. |
| Start step, age 6 and older | Step 1: symptoms <2 times a month and no risk factor for severe exacerbation. Step 2: symptoms ≥2 times a month, or ≥1 risk factor. Step 3: symptoms most days, or waking from asthma ≥1 time a week. Start higher with poor lung function, near-daily symptoms, or a first visit during a severe exacerbation. |
| Option A: Formoterol/budesonide | Prefer it when poor ICS adherence is expected.Health Canada approves only this ICS/LABA as a reliever, with or without maintenance, from age 12. When it is the maintenance, it is also the reliever. |
| Option B: ICS with a SABA reliever | Prefer it with good ICS adherence, or when a non-dry-powder inhaler is wanted.Step 1: ICS with each SABA use (not Health Canada-approved), or daily low-dose ICS. Step 2: daily low-dose ICS. Step 3: daily low-dose ICS + LABA. Step 4: daily medium-dose ICS + LABA. Reliever: SABA PRN. ICS dose categories are in the INESSS tool, appendix 1. |
| Step 5 | Add a LAMA and refer for assessment of high-dose ICS or a biologic. |
| Next step | Step up, refer, or both if uncontrolled after ≥3 months of adherent use with correct technique. |
| Drug | Maintenance | Reliever |
|---|---|---|
| Steps 1–2 | ||
| Formoterol/budesonide (Symbicort Turbuhaler 200) | None | 1–2 inhalations PRN |
| Step 3 | ||
| Formoterol/budesonide (Symbicort Turbuhaler 200) | 1 inhalation BID | 1 inhalation PRN |
| Step 4 | ||
| Formoterol/budesonide (Symbicort Turbuhaler 200) | 2 inhalations BID | 1 inhalation PRN |
Loss of control (action plan yellow zone)
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Any flare | Treatment has failed.Reassess the person and the treatment. |
| Age 12 and older, on SABA PRN | Switch the reliever to Formoterol/budesonide PRNOr start ICS maintenance. |
| Age 12 and older, on Formoterol/budesonide | PRN only: use it more often, at most 6 inhalations at a time and 8 a day. Maintenance and reliever: add PRN doses or raise maintenance, at most 8 a day, for 7–14 days. |
| Age 12 and older, on ICS or another ICS/LABA | Age 16 and older: quadruple the ICS dose for 7–14 days. Age 12–15: do not raise the ICS dose. |
| Oral steroid, age 12 and older | Prednisone 30–50 mg PO DIE, morning, for 5–7 daysOn a maintenance regimen, consider it instead of stepping up. |
| When to give an oral steroid | Any of: Symptoms persist after 2–3 days of stepped-up treatment; Fast worsening; PEF or FEV1 <60% of predicted or personal best. |
| Under 12 | On SABA PRN: consider ICS maintenance. On Formoterol/budesonide maintenance and reliever (age 6 and older): add PRN doses, at most 8 a day including maintenance. On ICS, LTRA or another ICS/LABA: do not raise the ICS dose. |
| Oral steroid, under 12 | Prednisone or prednisolone 1–2 mg/kg PO DIE, morning, for 3–5 daysOnly exceptionally: a flare in the past year and a poor or short-lived SABA response. Caregivers seek care promptly if it is used. |
Follow-up
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Visits | 1–3 months after a start or changeEvery 3–12 months once stable. |
| After hospitalization | Within 4 weeks after a severe exacerbation that needed hospital care. |
| Spirometry | 3–6 months after the start, when possibleThen at least yearly. |
| Reliever use | More than 2 SABA inhalers a year raises exacerbation risk. |
| Reliever use, mortality | More than 1 SABA inhaler a month raises mortality risk. |
| Formoterol/budesonide reliever | No inhaler-count cutoff applies.Overuse still signals poor control. |
| Stepping down | Not during: A respiratory infection; Pregnancy; The time just before or during travel. |
| Action plan | Everyone has a written action plan.Review it:
After a major treatment change;
After loss of control;
At least yearly in adults, every 6–12 months in children. INESSS tool, p. 9 opens in a new tabMSSS action plan opens in a new tabFrench version opens in a new tab |
Pregnancy and breastfeeding
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Drugs | SABA, ICS, LABA and oral corticosteroids (when a flare needs them) are safe in pregnancy and breastfeeding. |
| Before or early in pregnancy | Review the written action plan and inhaler technique. |
| Visits | Every 4–6 weeks while pregnant.Do not step down. |
Children under 12
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Age 11 and under | SABA alone is allowed as the reliever at step 1. |
| Age 6–11, preferred steps | Step 2: daily low-dose ICS. Step 3: daily medium-dose ICS. Step 4: daily medium-dose ICS + LABA. Step 5: refer. Reliever: SABA PRN. |
| Formoterol/budesonide under 12 | Health Canada approves it from age 12. Not for PRN-only use under 12. INESSS lists it as maintenance and reliever from step 3 at age 6–11, as an alternative. The 100/6 mcg doses are in the INESSS tool. |
| Age 5 and under, steps | Step 2: daily low-dose ICS. Step 3: daily medium-dose ICS. Step 4: refer. Reliever: SABA PRN. |
| Age 5 and under, diagnosis | Spirometry is usually not possible.Diagnose on both: Compatible symptoms, seen by a clinician (preferred) or clearly reported by a caregiver; A clear response to a treatment trial. |
| Trial, not in exacerbation | Daily medium-dose ICS + SABA PRN for ≥3 months.ICS dose categories are in the INESSS tool, appendix 1. |
| Trial, in exacerbation | SABA, with or without a systemic corticosteroid. |
Reviewed 17 October 2026 against the official sources below.
Sources
Blue square: Québec · red round: Canada. The code names the body; each section's key gives its full name.