What is the recommended approach to evaluate and manage a patient with uncontrolled asthma, including assessment of diagnosis, triggers, inhaler technique, adherence, and stepwise pharmacologic escalation?

Management of Uncontrolled Asthma

Before escalating pharmacologic therapy in uncontrolled asthma, you must systematically verify inhaler technique, assess medication adherence, identify environmental triggers, and rule out comorbidities—only then should you step up treatment according to the stepwise approach. 1

Initial Systematic Assessment

When a patient presents with uncontrolled asthma, the first priority is identifying correctable factors rather than immediately escalating medications. This structured approach prevents unnecessary treatment intensification and addresses the root causes of poor control.

Confirm the Diagnosis

• Verify asthma diagnosis with spirometry demonstrating bronchodilator reversibility (≥12% and ≥200 mL improvement in FEV1) 2
• Exclude alternative diagnoses including COPD, vocal cord dysfunction, and other airway diseases that may masquerade as poorly controlled asthma 3
• Repeat spirometry if not performed recently, as objective lung function assessment is essential 2

Assess Current Control Status

Classify control into three categories based on the most severe impairment or risk factor 1:

Well Controlled:

• Symptoms ≤2 days/week 1
• Nighttime awakenings ≤2 times/month 1
• No interference with normal activity 1
• SABA use ≤2 days/week 1
• FEV1 or peak flow >80% predicted 1
• 0-1 exacerbations requiring oral corticosteroids per year 1

Not Well Controlled:

• Symptoms >2 days/week 1
• Nighttime awakenings 1-3 times/week 1
• Some activity limitation 1
• SABA use >2 days/week 1
• FEV1 or peak flow 60-80% predicted 1
• ≥2 exacerbations requiring oral corticosteroids per year 1

Very Poorly Controlled:

• Symptoms throughout the day 1
• Nighttime awakenings ≥4 times/week 1
• Extremely limited activity 1
• SABA use several times daily 1
• FEV1 or peak flow <60% predicted 1

Use validated questionnaires (ACT ≥20 = well controlled, 16-19 = not well controlled, ≤15 = very poorly controlled) to objectively measure control 1, 4

Critical Pre-Escalation Checklist

This step is mandatory before any medication adjustment. Failure to address these factors is the most common pitfall in asthma management.

Verify Inhaler Technique

• Directly observe the patient using their inhaler at every visit 5, 2
• Inadequate inhaler technique is a leading cause of apparent treatment failure 2
• Add a spacer device to metered-dose inhalers if technique is suboptimal 1, 5

Assess Medication Adherence

• High adherence (>75% of prescribed doses) is required to prevent exacerbations 6
• Nonadherence accounts for approximately 24% of asthma exacerbations 6
• Review prescription fill patterns and directly ask about missed doses 6
• Address barriers to adherence including cost, side effect concerns, and complexity of regimen 1

Identify and Address Environmental Triggers

• Perform allergy testing (skin or specific IgE) for perennial indoor allergens in all patients with persistent asthma requiring daily medications 2
• Specifically assess exposure to: tobacco smoke, house dust mite, cockroach, cat/dog dander, and mold 2
• Implement targeted environmental control measures based on identified sensitivities 2
• Reducing allergen exposure can substantially decrease inflammation, symptoms, and medication requirements 2

Evaluate and Treat Comorbidities

Address conditions that worsen asthma control 2:

• Allergic rhinitis and chronic rhinosinusitis - treat aggressively as upper airway disease directly impacts lower airway control 2
• Gastroesophageal reflux disease - consider trial of proton pump inhibitor therapy 2, 3
• Obesity - weight loss improves asthma outcomes 2
• Anxiety and depression - psychological factors may contribute to poor control 2, 3
• Vocal cord dysfunction - can mimic or coexist with asthma 3

Stepwise Pharmacologic Escalation

Only after completing the above assessment should you escalate therapy. The approach depends on current treatment level and degree of poor control.

For Not Well Controlled Asthma

Step up one step and reassess in 2-6 weeks 1:

• If on SABA alone (Step 1): Initiate daily low-dose ICS 5, 2
• If on low-dose ICS (Step 2): Add LABA or increase to medium-dose ICS 5, 2
• If on low-dose ICS/LABA (Step 3): Increase to medium-dose ICS/LABA 5, 2
• If on medium-dose ICS/LABA (Step 3): Increase to high-dose ICS/LABA (Step 4) 4

For Very Poorly Controlled Asthma

Consider short course of oral corticosteroids (prednisolone 30-60 mg daily for 5-7 days), step up 1-2 steps, and reassess in 2 weeks 1, 5:

• More aggressive escalation is warranted given the severity of impairment 1
• Oral corticosteroids provide rapid symptom relief while initiating or intensifying controller therapy 5

Preferred Treatment at Each Step

• Step 1: SABA as needed 5
• Step 2: Low-dose ICS (most effective single controller medication) 5, 2
• Step 3: Low-to-medium dose ICS/LABA combination 5, 2
• Step 4: High-dose ICS/LABA combination 4
• Step 5: High-dose ICS/LABA plus additional controller (LAMA, leukotriene modifier) 4
• Step 6: High-dose ICS/LABA plus oral corticosteroids or biologic therapy 1, 4

Important: Adding LABA to ICS is more effective than doubling the ICS dose 2. Do not increase ICS beyond high-dose levels, as this provides minimal benefit with substantially increased risk of systemic adverse effects 4.

Specialist Referral Criteria

Refer to an asthma specialist when 1, 4:

• Difficulty achieving or maintaining control despite appropriate therapy 1
• ≥2 bursts of oral corticosteroids in the past year 1, 4
• Any hospitalization for asthma 1
• Step 4 or higher therapy required 1
• Consideration of biologic therapy (anti-IgE, anti-IL5/IL5R, anti-IL4R) for severe persistent asthma with type 2 inflammation 4
• Need for additional diagnostic testing 1

Patient Education and Self-Management

Written Asthma Action Plan

Provide all patients with a written action plan that includes 2:

• Daily management instructions specifying controller and rescue medication use 2
• How to recognize worsening asthma (increased symptoms, SABA use, or peak flow <75% personal best) 2
• Specific instructions for medication adjustments when control deteriorates 2
• When to seek urgent medical care 2

Ongoing Monitoring

• Schedule follow-up 2-6 weeks after any treatment change 1, 4
• Use validated questionnaires (ACT, ACQ) at each visit to objectively track control 1, 4
• Track exacerbation frequency—more than 2 requiring oral corticosteroids per year indicates poor control regardless of symptom scores 4
• Provide annual influenza vaccination 2

Common Pitfalls to Avoid

• Never escalate therapy without first verifying technique, adherence, and trigger control 1
• Do not prescribe antibiotics for exacerbations unless bacterial infection is confirmed—they are overused without evidence of benefit 2
• Never use sedation during acute exacerbations—it is contraindicated and dangerous 2
• Avoid simply doubling ICS when LABA addition is more effective 2
• Do not continue ineffective alternative therapies—switch to preferred treatment before stepping up 1
• Recognize that approximately 40% of patients with uncontrolled asthma are not using controller therapy at all—this represents a fundamental management failure 7