What are the guidelines for managing asthma based on symptom severity?

Asthma Management Guidelines Based on Symptom Severity

The management of asthma should follow a stepwise approach based on symptom severity assessment, with inhaled corticosteroids (ICS) as the cornerstone of therapy for persistent asthma and short-acting beta-agonists for quick relief. 1

Classification of Asthma Severity

Asthma severity is assessed along two domains:

1. Impairment Domain: Day-to-day symptoms and functional limitations
2. Risk Domain: Likelihood of future exacerbations

Initial Severity Classification

Classification	Symptoms	Nighttime Awakenings	Lung Function	Exacerbations
Intermittent	≤2 days/week	≤2x/month	FEV1 >80% predicted	0-1/year requiring oral steroids
Mild Persistent	>2 days/week but not daily	3-4x/month	FEV1 >80% predicted	≥2/year requiring oral steroids
Moderate Persistent	Daily	>1x/week but not nightly	FEV1 60-80% predicted	≥2/year requiring oral steroids
Severe Persistent	Throughout the day	Often 7x/week	FEV1 <60% predicted	≥2/year requiring oral steroids

Note: Patients with ≥2 exacerbations requiring oral corticosteroids in the past year should be considered to have at least mild persistent asthma, even without other persistent symptoms. 1

Stepwise Treatment Approach

Step 1: Intermittent Asthma

• Preferred: Short-acting beta-agonist (SABA) as needed
• No daily controller medication needed 1

Step 2: Mild Persistent Asthma

• Preferred: Low-dose inhaled corticosteroid (ICS)
• Alternative: Leukotriene modifier, cromolyn, or nedocromil 1

Step 3: Moderate Persistent Asthma

• Preferred: Low to medium-dose ICS plus long-acting beta-agonist (LABA)
• Alternative for children <5 years: Medium-dose ICS 1

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred: Medium to high-dose ICS plus LABA
• Consider: Adding leukotriene modifier, theophylline, or zileuton 1

Step 5: Severe Persistent Asthma

• Preferred: High-dose ICS plus LABA
• Consider: Adding oral corticosteroids 1

Step 6: Very Severe Persistent Asthma

• Preferred: High-dose ICS plus LABA plus oral corticosteroids
• Consider: Adding omalizumab for patients with allergies 1

Acute Severe Asthma Management

For life-threatening asthma exacerbations:

1. High-dose inhaled beta-agonists: Salbutamol 5 mg or terbutaline 10 mg nebulized with oxygen 1
2. High-dose systemic steroids: Prednisolone 30-60 mg or IV hydrocortisone 200 mg immediately 1
3. Add ipratropium: 0.5 mg nebulized with beta-agonist for life-threatening features 1
4. Consider IV aminophylline (250 mg over 20 minutes) or IV salbutamol/terbutaline (250 μg over 10 minutes) if not improving 1

Criteria for Hospital Admission

• Life-threatening features
• Severe attack features persisting after initial treatment
• Peak expiratory flow <33% of predicted after nebulization
• Patients seen in afternoon/evening
• Recent nocturnal symptoms or worsening symptoms
• Previous severe attacks, especially with rapid onset 1

Ongoing Monitoring and Control Assessment

After initial classification and treatment, assess asthma control at follow-up visits:

Control Level	Symptoms	Nighttime Awakenings	SABA Use	Activity Limitation
Well Controlled	≤2 days/week	≤2x/month	≤2 days/week	None
Not Well Controlled	>2 days/week	1-3x/week	>2 days/week	Some limitation
Very Poorly Controlled	Throughout the day	≥4x/week	Several times daily	Extremely limited

Adjust therapy based on control level:

• Well Controlled: Maintain current step or consider step down
• Not Well Controlled: Step up 1 step and reevaluate in 2-6 weeks
• Very Poorly Controlled: Step up 1-2 steps and consider short course of oral corticosteroids 1

Common Pitfalls and Important Considerations

1. Underuse of inhaled corticosteroids: ICS are the foundation of persistent asthma management
2. Overreliance on SABAs: Using >1 canister per month indicates inadequate control 1
3. Failure to address comorbidities: GERD, rhinosinusitis, obesity, and sleep apnea can worsen asthma control
4. Improper inhaler technique: Always check technique at follow-up visits
5. Lack of written asthma action plan: All patients should have a written plan for self-management 1

Special Populations

Children (0-4 years)

• Assess control more frequently (every 2-6 weeks initially)
• Monitor growth as ICS may cause temporary growth velocity reduction
• Consider referral to specialist if step 3 care or higher is required 1

Pregnant Women

• Most asthma medications are safe during pregnancy
• Uncontrolled asthma poses greater risk than medications 2

Referral to Asthma Specialist

Consider referral if:

• Patient required >2 bursts of oral corticosteroids in 1 year
• Exacerbation requiring hospitalization
• Step 4 care or higher is required (Step 3 for children 0-4 years)
• Immunotherapy or omalizumab is considered
• Additional testing is indicated 1

By following these guidelines based on symptom severity assessment, clinicians can effectively manage asthma to reduce impairment and risk while minimizing medication side effects.