How do you assess asthma severity and base management?

Asthma Severity Assessment and Management

Assess severity at initial presentation to initiate therapy, then monitor control at all subsequent visits to adjust treatment—this dual framework is the cornerstone of modern asthma management. 1

Initial Assessment: Classifying Severity (Treatment-Naïve Patients)

When a patient presents without current long-term controller medication, classify severity using two domains that must be evaluated separately 1:

Current Impairment Domain

Measure the following specific parameters 1, 2:

• Daytime symptoms: frequency per week
• Nighttime awakenings: frequency per week or month
• SABA use for symptom relief: days per week (excluding pre-exercise use)
• Activity limitation: interference with normal daily activities
• Pulmonary function: FEV1 or peak flow measurements

Future Risk Domain

Assess 1, 2:

• Exacerbation history: frequency requiring oral corticosteroids in past year
• Lung function trajectory: progressive decline or reduced growth in children

Severity categories based on these measures 1:

• Intermittent: Symptoms ≤2 days/week, nighttime awakenings ≤2×/month, no interference with activities
• Mild Persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3-4×/month
• Moderate Persistent: Daily symptoms, nighttime awakenings >1×/week, some activity limitation
• Severe Persistent: Symptoms throughout the day, nighttime awakenings often 7×/week, extremely limited activities

Ongoing Management: Monitoring Control

After initiating therapy, shift focus entirely from severity to control assessment—this determines whether to step up, maintain, or step down treatment 1.

Control Assessment Parameters

Use the same impairment and risk measures, but now categorize as 2, 3:

• Well-controlled: Symptoms ≤2 days/week, nighttime awakenings ≤2×/month, SABA use ≤2 days/week, no activity limitation, FEV1 >80% predicted
• Not well-controlled: Symptoms >2 days/week, nighttime awakenings 1-3×/week, SABA use >2 days/week, some activity limitation, FEV1 60-80% predicted
• Very poorly controlled: Symptoms throughout the day, nighttime awakenings ≥4×/week, SABA use several times daily, extreme activity limitation, FEV1 <60% predicted

Validated Monitoring Tools

Implement standardized questionnaires at each visit 1, 2, 3:

• Asthma Control Test (ACT): Score <20 indicates inadequate control
• Asthma Control Questionnaire (ACQ): Score ≥1.5 indicates inadequate control

Critical pitfall: Patients may have minimal day-to-day symptoms yet remain at high risk for severe exacerbations—always assess both domains independently 1.

Treatment Initiation Based on Severity

Match initial therapy to severity classification 1, 2:

• Intermittent: Step 1 (SABA as needed only)
• Mild Persistent: Step 2 (low-dose ICS)
• Moderate Persistent: Step 3-4 (medium-dose ICS or low-dose ICS/LABA combination)
• Severe Persistent: Step 5-6 (high-dose ICS/LABA, consider omalizumab for allergic asthma in patients ≥12 years) 1

Inhaled corticosteroids remain the preferred foundation for all persistent asthma across all age groups 1, 2, 3.

Treatment Adjustment Based on Control

Step-Up Criteria

If control is "not well-controlled" or "very poorly controlled" after 2-6 weeks 2, 3:

• Verify inhaler technique and adherence first
• Rule out trigger exposures and comorbidities (GERD, rhinitis, OSA, obesity) 1
• Increase to next step if technique and adherence are adequate

Step-Down Criteria

If control is "well-controlled" for at least 3 months, attempt step-down to identify the minimum effective dose 2, 3.

Monitoring Frequency and Methods

Schedule follow-up visits 2, 3:

• Every 2-6 weeks initially until control achieved
• Every 1-6 months once stable

Objective monitoring 1:

• Spirometry or peak flow at each visit
• Daily peak flow monitoring specifically for patients with moderate-severe persistent asthma, history of severe exacerbations, or poor symptom perception 1

Both symptom monitoring and peak flow monitoring are equally effective for most patients—choose based on patient preference and capability 1.

Essential Comorbidity Assessment

Identify and manage conditions that impede asthma control 1:

• Allergic rhinitis and chronic sinusitis
• GERD
• Obstructive sleep apnea
• Obesity
• Psychological stress or depression

Patient Self-Management Requirements

Every patient must receive 2, 3:

• Written asthma action plan with daily treatment instructions and exacerbation management
• Training to recognize inadequate control
• Inhaler technique verification at every visit
• Trigger identification and avoidance strategies

Common pitfall: Inadequate inhaler technique is a leading cause of poor control—assess and correct at each encounter 3.

Age-Specific Considerations

Treatment recommendations differ across three age groups 1:

• 0-4 years: Limited evidence base, ICS preferred when controller needed
• 5-11 years: ICS/LABA combination acceptable at Step 3, though increased exacerbation risk with LABA requires careful monitoring 1
• ≥12 years and adults: ICS/LABA combination equally preferred with ICS dose increase at Step 3 1