Mild Asthma Workup and Treatment
For patients with mild asthma, begin with spirometry to document reversible airflow obstruction (≥12% and 200mL FEV1 improvement post-bronchodilator), then initiate low-dose inhaled corticosteroids as the preferred controller medication, reserving short-acting beta-agonists for as-needed symptom relief only. 1
Initial Diagnostic Workup
Essential Objective Testing
- Spirometry is mandatory for all patients ≥5 years old to confirm diagnosis—never rely solely on symptoms as both patients and physicians frequently underestimate disease severity 2
- Document reversible airflow limitation: ≥12% and 200mL improvement in FEV1 after bronchodilator administration 3
- If spirometry is normal but symptoms suggest asthma, perform inhalation challenge testing (methacholine or exercise challenge) to confirm bronchial hyperresponsiveness 3
- Measure exhaled nitric oxide (FeNO)—elevated levels increase probability of allergic asthma 3
Clinical Assessment Components
- Symptom frequency: Document daytime symptoms, nighttime awakenings, activity limitations, and rescue inhaler use per week 1, 4
- Assess two domains: Current impairment (symptom frequency, lung function, activity restrictions) AND future risk (exacerbation likelihood, progressive decline, medication adverse effects) 2
- Identify environmental triggers and allergen exposures requiring control 1
- Screen for comorbidities: rhinitis, sinusitis, GERD, obstructive sleep apnea 5
Severity Classification for Mild Asthma
Mild intermittent asthma (Step 1): Symptoms ≤2 days/week, nighttime awakenings ≤2 times/month, no interference with normal activity, normal lung function between exacerbations 1
Mild persistent asthma (Step 2): Symptoms >2 days/week but not daily, nighttime awakenings 3-4 times/month, minor limitation of normal activity 1
Treatment Algorithm
Step 1: Mild Intermittent Asthma
- Preferred treatment: Short-acting beta-agonist (SABA) as needed only—no daily controller medication required 1
- Provide rescue inhaler (albuterol/salbutamol 2 puffs as needed for symptoms) 1
- Critical threshold: If SABA needed >2 days/week for symptom relief (excluding exercise prophylaxis), this indicates inadequate control requiring step-up to controller therapy 1, 2
Step 2: Mild Persistent Asthma
- Preferred controller: Low-dose inhaled corticosteroid (ICS) daily 1, 6
- Alternative options (if ICS not tolerated): Leukotriene receptor antagonist (montelukast 10mg daily), cromolyn, or nedocromil 1
- Continue SABA as needed for acute symptom relief 1
Important caveat: Treatment with inhaled steroids is effective and worthwhile even in early, mild asthma—symptom scores, peak flow, and inflammatory markers all improve significantly 6
Essential Patient Education and Monitoring
Written Asthma Action Plan
- All patients require a written action plan including daily medication instructions and recognition/management of worsening asthma 1, 2
- Specify when to increase treatment, when to add oral corticosteroids, and when to seek emergency care 1
Self-Monitoring Requirements
- Provide peak flow meter with instructions for home monitoring 1, 2
- Teach recognition of early warning signs: increased cough, chest tightness, increased rescue inhaler use 1
- Verify proper inhaler technique at every visit—poor technique is a major cause of treatment failure 1, 2
Follow-Up Schedule
- Initial follow-up within 2-4 weeks after starting controller therapy to assess response 1
- Once controlled, reassess every 3-6 months 1
- Before stepping up therapy, always verify: medication adherence, proper inhaler technique, and environmental control measures 2
Common Pitfalls to Avoid
Never use long-acting beta-agonists (LABAs) as monotherapy—they must always be combined with ICS due to increased risk of serious asthma-related events 2, 7
Do not dismiss normal spirometry—it is common in mild asthma patients who are asymptomatic at testing; proceed with challenge testing if clinical suspicion remains high 3
Avoid over-reliance on SABAs—using rescue inhalers >2 days/week signals need for controller therapy initiation or escalation 1, 2
Consider allergen immunotherapy for patients ≥5 years with documented allergic triggers and mild-to-moderate allergic asthma 1, 4