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{{Asthma}}
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==Overview==
==Overview==
Asthma is classified into '''atopic and non-atopic''' types based on the onset of symptoms. Atopic refers to early-onset whereas non-atopic refers to late-onset. Despite the differentiation, a significant degree of overlap exists between the two types. The severity of symptoms is further classified based on the '''GINA severity grades''' into mild intermittent, mild persistent, moderate persistent and severe persistent asthma.
Asthma is classified into [[atopic]] and non-atopic types based on the onset of [[symptoms]]. Atopic refers to early-onset whereas non-atopic refers to late-onset. Despite the differentiation, a significant degree of overlap exists between the two types. The severity of symptoms is further classified based on the GINA severity grades into mild intermittent, mild persistent, moderate persistent and severe persistent asthma.


==Classification Based on Symptom Onset==
==Classification==
===Based on Symptom Onset===
====Early-onset Asthma (Atopic, Allergic, Extrinsic)====
====Early-onset Asthma (Atopic, Allergic, Extrinsic)====
*Early-age of onset
*Early-age of onset
*[[Atopy|Atopic individuals]] have an increased predisposition  
*[[Atopy|Atopic individuals]] have an increased predisposition  
*[[Asthma triggers|Environmental allergens]] play a strong role in the pathogenesis
*[[Asthma triggers|Environmental allergens]] play a strong role in the pathogenesis
*Positive personal and/or family history of [[atopic diseases‎]] such as [[allergic rhinitis]], [[urticaria]] and [[eczema]]
*Positive personal and/or family history of [[atopic diseases]] such as [[allergic rhinitis]], [[urticaria]] and [[eczema]]
*[[Asthma laboratory tests|Laboratory tests]] may reveal increased [[Asthma laboratory tests#Serum and Sputum Examination|serum IgE levels]], positive [[Asthma laboratory tests#Allergy Testing|skin test]] to specific aero-allergens and a positive [[Asthma bronchial challenge test#Bronchoprovocation Test|bronchoprovocation test]]
*[[Asthma laboratory tests|Laboratory tests]] may reveal increased [[Asthma laboratory tests#Serum and Sputum Examination|serum IgE levels]], positive [[Asthma laboratory tests#Allergy Testing|skin test]] to specific aero-allergens and a positive [[Asthma bronchial challenge test#Bronchoprovocation Test|bronchoprovocation test]]


====Late-onset Asthma (Non-Atopic, Idiosyncratic, Intrinsic)====
====Late-onset Asthma (Non-Atopic, Idiosyncratic, Intrinsic)====
*Late-age of onset
*Late-age of onset
*Non-atopic individuals have an increased predisposition  
*Non- atopic individuals have an increased predisposition  
*[[Asthma triggers|Indoor allergens]] play a strong role in the pathogenesis
*[[Asthma triggers|Indoor allergens]] play a strong role in the pathogenesis
*Negative personal and/or family history of [[atopic diseases‎|allergic diseases]]
*Negative personal and/or family history of [[atopic diseases‎|allergic diseases]]
*[[Asthma laboratory tests|Laboratory tests]] may reveal normal [[Asthma laboratory tests#Serum and Sputum Examination|serum IgE levels]] and a negative [[Asthma bronchial challenge test#Bronchoprovocation Test|bronchoprovocation test]]     
*[[Asthma laboratory tests|Laboratory tests]] may reveal normal [[Asthma laboratory tests#Serum and Sputum Examination|serum IgE levels]] and a negative [[Asthma bronchial challenge test#Bronchoprovocation Test|bronchoprovocation test]]     


==Classification Based on GINA Severity Grade==
===Based on GINA Severity Grade===
Asthma is classified into four subgroup, namely, mild intermittent, mild persistent, moderate persistent and severe persistent based on the '''Global Initiative for Asthma - GINA severity grades'''.<ref name="pmid18166595">Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18166595 Global strategy for asthma management and prevention: GINA executive summary.] ''Eur Respir J'' 31 (1):143-78. [http://dx.doi.org/10.1183/09031936.00138707 DOI:10.1183/09031936.00138707] PMID: [http://pubmed.gov/18166595 18166595]</ref>
Asthma is classified into four subgroups: mild intermittent, mild persistent, moderate persistent and severe persistent based on the ''Global Initiative for Asthma - GINA severity grades''.<ref name="pmid18166595">Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18166595 Global strategy for asthma management and prevention: GINA executive summary.] ''Eur Respir J'' 31 (1):143-78. [http://dx.doi.org/10.1183/09031936.00138707 DOI:10.1183/09031936.00138707] PMID: [http://pubmed.gov/18166595 18166595]</ref>


==Mild Intermittent Asthma==
====Mild Intermittent Asthma====
 
{| align="center" style="border: 0px; font-size: 90%; margin: 3px; width:70%;"
{| border="1" align="center" style="background:lightskyblue"  
|-
|-
| bgcolor="CornFlowerBlue"  style="text-align:center" |'''Symptoms per day'''
| style="width: 55%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''Symptoms per night'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms at night'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''PEF or FEV1'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''PEF variability'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
|-
|-
| style="text-align:center" | Less than once a week. Brief exacerbations. Asymptomatic and normal PEFR between exacerbations.
| style="background: #DCDCDC; padding: 5px; text-align: left;" |
| style="text-align:center" | Less than or equal to twice a month
*Less than once a week  
| style="text-align:center" | ≥ 80% of predicted normal
*Brief exacerbations
| style="text-align:center" | < 20%
*Asymptomatic and normal PEFR between exacerbations
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Less than or equal to twice a month
| style="background: #DCDCDC; padding: 5px; text-align: center;" | ≥ 80% of predicted normal
| style="background: #DCDCDC; padding: 5px; text-align: center;" | < 20%
|}
|}


====Step 1 therapy:====
====Mild Persistent Asthma====
Short-acting inhaled [[Bronchodilator#Short-acting β2-agonists|β2-agonists]] on need basis.<ref name="pmid7436160">Shim C, Williams MH (1980) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7436160 Bronchial response to oral versus aerosol metaproterenol in asthma.] ''Ann Intern Med'' 93 (3):428-31. PMID: [http://pubmed.gov/7436160 7436160]</ref><ref name="pmid7282733">Shim C, Williams MH (1981) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7282733 Comparison of oral aminophylline and aerosol metaproterenol in asthma.] ''Am J Med'' 71 (3):452-5. PMID: [http://pubmed.gov/7282733 7282733]</ref>
{| align="center" style="border: 0px; font-size: 90%; margin: 3px; width:70%;"
 
==Mild Persistent Asthma==
 
{| border="1" align="center" style="background:lightskyblue"  
|-
|-
| bgcolor="CornFlowerBlue"  style="text-align:center" |'''Symptoms per day'''
| style="width: 55%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''Symptoms per night'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms at night'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''PEF or FEV1'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''PEF variability'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
|-
|-
| style="text-align:center" | Symptoms more than twice a week but less than once a day. Exacerbations may affect activity and sleep.  
| style="background: #DCDCDC; padding: 5px; text-align: left;" |  
| style="text-align:center" | greater than or equal to twice a month
*Symptoms more than twice a week but less than once a day
| style="text-align:center" | ≥ 80%
*Exacerbations may affect activity and sleep.  
| style="text-align:center" | 20-30%
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Greater than or equal to twice a month
| style="background: #DCDCDC; padding: 5px; text-align: center;" | ≥ 80%
| style="background: #DCDCDC; padding: 5px; text-align: center;" | 20-30%
|}
|}


====Step 2 therapy:====
====Moderate Persistent Asthma====
*Preferred drug of choice is once a day [[steroid|low-dose steroid]] inhalation.
{| align="center" style="border: 0px; font-size: 90%; margin: 3px; width:70%;"  
*Alternative therapies include:
:*Use of anti-inflammatory drugs such as [[cromolyn]] or [[nedocromil]], ''OR''
:*[[Theophylline]], [[montelukast]], [[zafirlukast]] along with a short-acting inhaled [[Bronchodilator#Short-acting β2-agonists|β2-agonists]].<ref name="pmid11037987">Berridge MS, Lee Z, Heald DL (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11037987 Pulmonary distribution and kinetics of inhaled [11C]triamcinolone acetonide.] ''J Nucl Med'' 41 (10):1603-11. PMID: [http://pubmed.gov/11037987 11037987]</ref>
 
==Moderate Persistent Asthma==
 
{| border="1" align="center" style="background:lightskyblue"  
|-
|-
| bgcolor="CornFlowerBlue"  style="text-align:center" |'''Symptoms per day'''
| style="width: 55%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''Symptoms per night'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms at night'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''PEF or FEV1'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''PEF variability'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
|-
|-
| style="text-align:center" | Daily symptoms. Exacerbations more than twice a week. Exacerbations may affect activity and sleep. Daily use of [[Bronchodilators#Short-acting β2-agonists|bronchodilators]].    
| style="background: #DCDCDC; padding: 5px; text-align: left;" |  
| style="text-align:center" | more than once a month
*Daily symptoms
| style="text-align:center" | 60-80%
*Exacerbations more than twice a week
| style="text-align:center" | ≥ 30%
*Exacerbations may affect activity and sleep
*Daily use of [[Bronchodilators#Short-acting β2-agonists|bronchodilators]]   
| style="background: #DCDCDC; padding: 5px; text-align: center;" | More than once a month
| style="background: #DCDCDC; padding: 5px; text-align: center;" | 60-80%
| style="background: #DCDCDC; padding: 5px; text-align: center;" | ≥ 30%
|}
|}


====Step 3 therapy:====
====Severe Persistent Asthma====
*Preferred drug of choice:
{| align="center" style="border: 0px; font-size: 90%; margin: 3px; width:70%;"  
:*Moderate dose of inhaled [[steroid]], ''OR''
:*Low dose inhaled [[steroid]] along with inhaled [[Bronchodilators#Long-acting β2-agonists|long-acting β2-agonists]] <ref name="pmid11174215">Nelson HS (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11174215 Advair: combination treatment with fluticasone propionate/salmeterol in the treatment of asthma.] ''J Allergy Clin Immunol'' 107 (2):398-416. [http://dx.doi.org/10.1067/mai.2001.112939 DOI:10.1067/mai.2001.112939] PMID: [http://pubmed.gov/11174215 11174215]</ref> or [[Bronchodilators#Theophylline|sustained-release theophylline]] for nocturnal symptoms,
 
*Alternative strategy includes the use of low-dose of inhaled [[steroid]] along with long-acting bronchodilators (either [[Bronchodilators#Long-acting β2-agonists|inhaled long-acting β2-agonists]] or [[Bronchodilators#Theophylline|sustained-release theophylline]]) and/or a short-acting inhaled [[Bronchodilator#Short-acting β2-agonists|β2-agonists]] on need basis.
 
==Severe Persistent Asthma==
 
{| border="1" align="center" style="background:lightskyblue"  
|-
|-
| bgcolor="CornFlowerBlue"  style="text-align:center" |'''Symptoms per day'''
| style="width: 55%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms per day'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''Symptoms per night'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''Symptoms at night'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''PEF or FEV1'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF or FEV1'''}}
| bgcolor="CornFlowerBlue" style="text-align:center" |'''PEF variability'''
| style="width: 15%; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|'''PEF variability'''}}
|-
|-
| style="text-align:center" | Continued symptoms. Frequent exacerbations. Limited physical activity.  
| style="background: #DCDCDC; padding: 5px; text-align: left;" |  
| style="text-align:center" | Frequent
*Continued symptoms
| style="text-align:center" | ≤ 60%
*Frequent exacerbations
| style="text-align:center" | ≥ 30%
*Limited physical activity   
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Frequent
| style="background: #DCDCDC; padding: 5px; text-align: center;" | ≤ 60%
| style="background: #DCDCDC; padding: 5px; text-align: center;" | ≥ 30%
|}
|}


====Step 4 or Step 5 Therapy====
==Guidelines for Diagnosis and Management of Asthma Based On The National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR3) <ref name="pmid18240881">Urbano FL (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18240881 Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines.] ''J Manag Care Pharm'' 14 (1):41-9. PMID: [http://pubmed.gov/18240881 18240881]</ref>==
'''Step 4 therapy:'''
*Preferred drug of choice: Medium-dose of inhaled [[steroid]] along with  [[Bronchodilators#Long-acting β2-agonists|inhaled long-acting β2-agonists]]


*Alternative strategy includes the use of medium-dose inhaled [[steroids]] along with long-acting [[bronchodilators]] (such as [[Bronchodilators#Long-acting β2-agonists|inhaled β2-agonists]] or [[Bronchodilators#Theophylline|sustained-release theophylline]] used alone or in combination) and/or short-acting inhaled [[Bronchodilator#Short-acting β2-agonists|β2-agonists]] may be used on need basis.
{| style="border: 0px; font-size: 90%; margin: 3px;"
! rowspan="2" style="text-align: center; background: #4479BA; text-align: center; width: 12%;" | {{fontcolor|#FFF|Severity Components}}
! rowspan="2" style="text-align: center; background: #4479BA; text-align: center; width: 22%;" | {{fontcolor|#FFF|Intermittent}}
! colspan="3" style="text-align: center; background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Persistent Asthma}}
|-
| style="text-align: center; background: #7d7d7d; text-align: center; width: 22%;" | {{fontcolor|#FFF|'''Mild'''}}
| style="text-align: center; background: #7d7d7d; text-align: center; width: 22%;" | {{fontcolor|#FFF|'''Moderate'''}}
| style="text-align: center; background: #7d7d7d; text-align: center; width: 22%;" | {{fontcolor|#FFF|'''Severe'''}}
|-
| style="background: #DCDCDC; padding: 5px;" |'''Symptoms'''
| style="background: #F5F5F5; padding: 5px;" |
* Less than 1 day/week
| style="background: #F5F5F5; padding: 5px;" |
* More than 2 days/week
* Not daily
| style="background: #F5F5F5; padding: 5px;" |
* Daily
| style="background: #F5F5F5; padding: 5px;" |
* Daily
* Throughout the day
|-
| style="background: #DCDCDC; padding: 5px;" |'''Nocturnal Symptoms'''
| style="background: #F5F5F5; padding: 5px;" |
* Less than 2 times/month
| style="background: #F5F5F5; padding: 5px;" |
* 3 to 4 times/month
| style="background: #F5F5F5; padding: 5px;" |
* More than 1 time/week
* Not every night
| style="background: #F5F5F5; padding: 5px;" |
* Every night
|-
| style="background: #DCDCDC; padding: 5px;" |'''Interference w/ Activity'''
| style="background: #F5F5F5; padding: 5px;" |
* Minimal to none
| style="background: #F5F5F5; padding: 5px;" |
* Minor limitation of activity
| style="background: #F5F5F5; padding: 5px;" |
* Some limitation of activity
| style="background: #F5F5F5; padding: 5px;" |
* Severe limitation of activity
|-
| style="background: #DCDCDC; padding: 5px;" |'''Short-Acting Beta-Agonist Use'''
| style="background: #F5F5F5; padding: 5px;" |
* Less than 2 days/week
| style="background: #F5F5F5; padding: 5px;" |
* More than 2 days/week but not daily
* Not more than once/day
| style="background: #F5F5F5; padding: 5px;" |
* Daily
| style="background: #F5F5F5; padding: 5px;" |
* Several times/day
|-
| style="background: #DCDCDC; padding: 5px;" |'''Pulmonary Function Test'''
| style="background: #F5F5F5; padding: 5px;" |
* Normal FEV<sub>1</sub> between exacerbations
* FEV<sub>1</sub> > 80% predicted
* FEV<sub>1</sub>/FVC normal
| style="background: #F5F5F5; padding: 5px;" |
* FEV<sub>1</sub> > 80% predicted
* FEV<sub>1</sub>/FVC normal
| style="background: #F5F5F5; padding: 5px;" |
* FEV<sub>1</sub> > 60% but < 80% predicted
* FEV<sub>1</sub>/FVC reduced by 5%
| style="background: #F5F5F5; padding: 5px;" |
* FEV<sub>1</sub> < 60% predicted
* FEV<sub>1</sub>/FVC reduced by > 5%
|-
| style="background: #DCDCDC; padding: 5px;" |'''Recommended Treatment Strategy'''
| style="background: #F5F5F5; padding: 5px; vertical-align:top;" |'''STEP 1'''
* ''Preferred:'' Short-acting beta-agonist PRN
| style="background: #F5F5F5; padding: 5px; vertical-align:top;" |'''STEP 2'''
* ''Preferred:'' Low-dose inhaled corticosteroids
* ''Alternative:'' Cromolyn, Leukotriene receptor antagonist, Nedocromil, or Theophylline
| style="background: #F5F5F5; padding: 5px; vertical-align:top;" |'''STEP 3'''
* ''Preferred:'' '''Either''' low-dose inhaled corticosteroids + long-acting beta-agonist '''OR''' Medium-dose inhaled corticosteroid


'''Step 5 therapy:'''
* ''Alternative:'' Low-dose inhaled corticosteroid + either Leukotriene receptor antagonist, Theophylline, or Zileuton
*Preferred drug of choice: High-dose of inhaled [[steroid]] along with  [[Bronchodilators#Long-acting β2-agonists|inhaled long-acting β2-agonists]] and [[omalizumab]] in patients who have allergies.
| style="background: #F5F5F5; padding: 5px;" |'''STEP 4'''
* ''Preferred:'' Medium-dose inhaled corticosteroid + long-acting beta-agonist
* ''Alternative:'' Medium-dose inhaled corticosteroids + either Leukotriene receptor antagonist, Theophylline, or Zileuton


==Guidelines for Diagnosis and Management of Asthma Based On The National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR3) <ref name="pmid18240881">Urbano FL (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18240881 Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines.] ''J Manag Care Pharm'' 14 (1):41-9. PMID: [http://pubmed.gov/18240881 18240881]</ref>==
'''STEP 5'''
* ''Preferred:'' High-dose inhaled corticosteroids + long-acting beta-agonist
* Consider adding Omalizumab for patients with allergies


[[File:Asthma Severity Classification.JPG|center|900px]]
'''STEP 6'''
 
* ''Preferred:'' High-dose inhaled corticosteroids + long-acting beta-agonist + oral corticosteroids
<br clear="left"/>
* Consider adding Omalizumab for patients with allergies
|-
| colspan="5" style="text-align: center; background: #4479BA; padding: 5px;" | {{fontcolor|#FFF|'''Step down if possible and asthma is controlled for at least 3 months'''}} [[File:Dualarrow.png|200px]] {{fontcolor|#FFF|'''Step-up if needed, but first check adherence, environmental control, and comorbidities'''}}
|-
| colspan="5" style="background: #F5F5F5; padding: 5px;" |
* In each step, patient education, environmental control, and management of comorbidities are important.
* In STEP 2 - 4, consider subcutaneous allergen immunotherapy for patients with allergic asthma
|-
| colspan="5" style="background: #F5F5F5; padding: 5px;" |
* Short-acting beta-agonist as needed for symptoms. Up to 3 treatments at 20 minute intervals as needed.
* A short course of oral systemic corticosteroids may be needed. Use of a short-acting beta agonist for >2 days a week for symptom control indicates inadequate control and the need to step up therapy.
|}


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}


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[[Category:Up-To-Date]]
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{{WH}}
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Latest revision as of 20:30, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Asthma is classified into atopic and non-atopic types based on the onset of symptoms. Atopic refers to early-onset whereas non-atopic refers to late-onset. Despite the differentiation, a significant degree of overlap exists between the two types. The severity of symptoms is further classified based on the GINA severity grades into mild intermittent, mild persistent, moderate persistent and severe persistent asthma.

Classification

Based on Symptom Onset

Early-onset Asthma (Atopic, Allergic, Extrinsic)

Late-onset Asthma (Non-Atopic, Idiosyncratic, Intrinsic)

Based on GINA Severity Grade

Asthma is classified into four subgroups: mild intermittent, mild persistent, moderate persistent and severe persistent based on the Global Initiative for Asthma - GINA severity grades.[1]

Mild Intermittent Asthma

Symptoms per day Symptoms at night PEF or FEV1 PEF variability
  • Less than once a week
  • Brief exacerbations
  • Asymptomatic and normal PEFR between exacerbations
 Less than or equal to twice a month ≥ 80% of predicted normal < 20%

Mild Persistent Asthma

Symptoms per day Symptoms at night PEF or FEV1 PEF variability
  • Symptoms more than twice a week but less than once a day
  • Exacerbations may affect activity and sleep.
 Greater than or equal to twice a month ≥ 80% 20-30%

Moderate Persistent Asthma

Symptoms per day Symptoms at night PEF or FEV1 PEF variability
  • Daily symptoms
  • Exacerbations more than twice a week
  • Exacerbations may affect activity and sleep
  • Daily use of bronchodilators
 More than once a month 60-80% ≥ 30%

Severe Persistent Asthma

Symptoms per day Symptoms at night PEF or FEV1 PEF variability
  • Continued symptoms
  • Frequent exacerbations
  • Limited physical activity
 Frequent ≤ 60% ≥ 30%

Guidelines for Diagnosis and Management of Asthma Based On The National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR3) [2]

Severity Components Intermittent Persistent Asthma
Mild Moderate Severe
Symptoms
  • Less than 1 day/week
  • More than 2 days/week
  • Not daily
  • Daily
  • Daily
  • Throughout the day
Nocturnal Symptoms
  • Less than 2 times/month
  • 3 to 4 times/month
  • More than 1 time/week
  • Not every night
  • Every night
Interference w/ Activity
  • Minimal to none
  • Minor limitation of activity
  • Some limitation of activity
  • Severe limitation of activity
Short-Acting Beta-Agonist Use
  • Less than 2 days/week
  • More than 2 days/week but not daily
  • Not more than once/day
  • Daily
  • Several times/day
Pulmonary Function Test
  • Normal FEV1 between exacerbations
  • FEV1 > 80% predicted
  • FEV1/FVC normal
  • FEV1 > 80% predicted
  • FEV1/FVC normal
  • FEV1 > 60% but < 80% predicted
  • FEV1/FVC reduced by 5%
  • FEV1 < 60% predicted
  • FEV1/FVC reduced by > 5%
Recommended Treatment Strategy STEP 1
  • Preferred: Short-acting beta-agonist PRN
 STEP 2
  • Preferred: Low-dose inhaled corticosteroids
  • Alternative: Cromolyn, Leukotriene receptor antagonist, Nedocromil, or Theophylline
 STEP 3
  • Preferred: Either low-dose inhaled corticosteroids + long-acting beta-agonist OR Medium-dose inhaled corticosteroid
  • Alternative: Low-dose inhaled corticosteroid + either Leukotriene receptor antagonist, Theophylline, or Zileuton
 STEP 4
  • Preferred: Medium-dose inhaled corticosteroid + long-acting beta-agonist
  • Alternative: Medium-dose inhaled corticosteroids + either Leukotriene receptor antagonist, Theophylline, or Zileuton

STEP 5

  • Preferred: High-dose inhaled corticosteroids + long-acting beta-agonist
  • Consider adding Omalizumab for patients with allergies

STEP 6

  • Preferred: High-dose inhaled corticosteroids + long-acting beta-agonist + oral corticosteroids
  • Consider adding Omalizumab for patients with allergies
Step down if possible and asthma is controlled for at least 3 months Step-up if needed, but first check adherence, environmental control, and comorbidities
  • In each step, patient education, environmental control, and management of comorbidities are important.
  • In STEP 2 - 4, consider subcutaneous allergen immunotherapy for patients with allergic asthma
  • Short-acting beta-agonist as needed for symptoms. Up to 3 treatments at 20 minute intervals as needed.
  • A short course of oral systemic corticosteroids may be needed. Use of a short-acting beta agonist for >2 days a week for symptom control indicates inadequate control and the need to step up therapy.

References

  1. ↑ Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M et al. (2008) Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J 31 (1):143-78. DOI:10.1183/09031936.00138707 PMID: 18166595
  2. ↑ Urbano FL (2008) Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines. J Manag Care Pharm 14 (1):41-9. PMID: 18240881

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