What is the recommended approach to diagnose asthma, assess its severity, and implement stepwise treatment including rescue and controller medications?

Approach to Asthma

Confirm asthma with spirometry showing airflow obstruction (FEV₁/FVC below age-specific thresholds) that improves by ≥12% and ≥200 mL after bronchodilator, then initiate daily low-dose inhaled corticosteroid (ICS) for all patients with persistent symptoms, reserving short-acting beta-agonists (SABA) strictly for rescue use. 1, 2

Diagnosis

Establish the Diagnosis with Objective Testing

• Spirometry is mandatory in all patients ≥5 years old to document reversible airflow obstruction; do not rely on symptoms alone 1
• Baseline obstruction is defined by FEV₁/FVC ratios below age-specific cutoffs: <85% (ages 8-19), <80% (ages 20-39), <75% (ages 40-59), <70% (ages 60-80) 2
• Bronchodilator reversibility test: administer 4 puffs of albuterol and repeat spirometry after 15 minutes; a positive test shows FEV₁ increase ≥12% AND ≥200 mL from baseline 1, 2
• When spirometry is normal but clinical suspicion remains high, perform methacholine or exercise challenge testing to demonstrate bronchial hyperresponsiveness 2
• Alternatively, a 4-week trial of ICS therapy that produces FEV₁ improvement >12% and >200 mL supports the diagnosis 2

Key Clinical Features to Document

• Symptom pattern: recurrent episodes of wheezing, dyspnea, chest tightness, or cough that worsen at night or early morning 1, 3
• Frequency of daytime symptoms per week 1, 2
• Nighttime awakenings per month due to asthma 1, 2
• Activity limitation and days of restricted physical activity 2
• SABA rescue use (puffs per day or days per week) 1, 2

Exclude Alternative Diagnoses

• COPD: fixed obstruction with minimal reversibility, typically in smokers with >10 pack-year history 2
• Vocal cord dysfunction: inspiratory stridor, flattened inspiratory loop on spirometry, no response to bronchodilators 1, 2
• Cardiac disease/heart failure: evaluate with chest imaging and BNP if suspected 2
• GERD: consider in patients with nighttime symptoms or poor control despite therapy 1

Severity Classification

Assess Both Impairment and Risk Domains

Assign the patient to the most severe category present in any single feature 2

Impairment Domain (past 2-4 weeks):

Severity	Daytime Symptoms	Night Awakenings	SABA Use	Activity Limitation	FEV₁ (% predicted)
Intermittent	≤2 days/week	≤2×/month	≤2 days/week	None	>80%
Mild Persistent	>2 days/week but not daily	3-4×/month	>2 days/week but not daily	Minor	>80%
Moderate Persistent	Daily	>1×/week but not nightly	Daily	Some	60-80%
Severe Persistent	Throughout day	≥4×/week	Several times/day	Extreme	<60%

1, 2

Risk Domain:

• ≥2 exacerbations requiring oral corticosteroids in the past year automatically upgrades the patient to higher severity regardless of impairment measures 1, 2

Stepwise Pharmacologic Treatment

Mild Persistent Asthma (Step 2)

• Initiate daily low-dose ICS (budesonide 180-400 µg/day or fluticasone 88-264 µg/day) plus as-needed SABA 1, 2
• ICS improves asthma control more effectively than any other single long-term controller medication 1, 2
• If ICS is not tolerated, use leukotriene receptor antagonist as alternative (less effective) 1, 2

Moderate Persistent Asthma (Step 3)

• Preferred: low-to-medium dose ICS + LABA combination (e.g., fluticasone-salmeterol 100-250/50 µg BID or budesonide-formoterol 80-160/4.5 µg BID) 1, 2
• This combination provides synergistic efficacy equal to or better than doubling ICS dose alone 1, 2
• Never prescribe LABA without concurrent ICS due to increased mortality risk with monotherapy 2

Severe Persistent Asthma (Steps 4-6)

• Step 4: Medium-dose ICS-LABA; refer to pulmonology/allergy specialist 1, 2
• Step 5: High-dose ICS-LABA; add omalizumab if allergic asthma is documented (positive skin testing or specific IgE to perennial allergens) 1, 2
• Step 6: High-dose ICS-LABA plus maintenance oral corticosteroid (prednisone 5-10 mg daily, lowest effective dose) 1, 2
• Specialist referral is recommended at Step 4 or higher 2

Essential Non-Pharmacologic Components

Allergy Testing and Environmental Control

• Perform skin testing or specific IgE for perennial indoor allergens (dust mite, cockroach, cat, dog, mold) in all patients requiring daily medication 1, 2
• Implement multi-component allergen reduction for identified sensitivities; single interventions are ineffective 1, 2
• Complete tobacco smoke avoidance is mandatory; counsel cessation at every visit 1, 2

Patient Education and Self-Management

• Provide written asthma action plan to every patient, specifying: (1) daily controller regimen, (2) when to increase therapy (symptoms worsening or peak flow <80% personal best), (3) when to start oral corticosteroids (peak flow <60% personal best), (4) when to seek emergency care (peak flow <50% after treatment) 1, 2
• Verify inhaler technique at every visit; start with metered-dose inhaler (MDI) with spacer and demonstrate proper use 1, 2
• Teach patients to distinguish between long-term controller medications (taken daily) and quick-relief medications (used as needed) 1

Comorbidity Management

• Allergic rhinitis/sinusitis: treat with intranasal corticosteroids and antihistamines 1, 2
• GERD: avoid heavy meals, fried foods, caffeine, alcohol within 3 hours of bedtime; elevate head of bed 6-8 inches; use proton pump inhibitor 1, 2
• Obesity: weight loss may improve asthma control 1, 2
• Obstructive sleep apnea: evaluate in overweight/obese patients with poor control 1, 2
• Depression/stress: address with additional self-management education and coping skills 1, 2

Ongoing Assessment and Monitoring

Define Well-Controlled Asthma (All Criteria Must Be Met)

• Daytime symptoms ≤2 days/week 1, 2
• No nighttime awakenings 1, 2
• SABA use ≤2 days/week 1, 2
• No activity limitation 1, 2
• FEV₁ or peak flow ≥80% predicted or personal best 1, 2
• No exacerbations requiring oral corticosteroids 2

Follow-Up Schedule

• Initial follow-up: 2-4 weeks after starting therapy to assess lung function, symptom control (using Asthma Control Test [ACT] or Asthma Control Questionnaire [ACQ]), and inhaler technique 1, 2
• While gaining control: every 1-6 weeks 1
• Once controlled: every 1-6 months depending on step of care 1
• Spirometry: at least every 1-2 years, more frequently if not well controlled 1, 2

Treatment Adjustment Algorithm

Before Stepping Up Therapy:

1. Confirm medication adherence by directly asking about missed doses 2
2. Verify inhaler technique by having patient demonstrate use 1, 2
3. Assess environmental trigger control and allergen/irritant exposures 1, 2
4. Manage comorbid conditions (GERD, rhinitis, obesity, sleep apnea) 1, 2

When to Step Up:

• Any deviation from well-controlled criteria warrants treatment escalation 2
• Increase therapy by 1 step and reassess in 2-4 weeks 2
• For very poorly controlled asthma (peak flow <60% predicted), prescribe oral prednisone 30-40 mg daily for 7-21 days and increase therapy by 1-2 steps 2

When to Step Down:

• Consider only after ≥3 months of sustained control 1, 2
• Reduce ICS dose by 25-50% every 3 months while monitoring for loss of control 2

Common Pitfalls to Avoid

• Do not diagnose asthma on symptoms alone; objective spirometry is essential 1, 2
• Do not use peak flow meters for diagnosis; they are monitoring tools only 2
• Do not prescribe LABA without concurrent ICS; monotherapy increases mortality 2
• Do not accept frequent SABA use (>2 days/week) as normal; this indicates need for controller therapy 1, 2
• Do not step up therapy without first confirming adherence, proper technique, environmental control, and comorbidity management 2
• Do not use antibiotics for exacerbations unless bacterial infection is confirmed 2
• Never use sedation during acute exacerbations; it is contraindicated and dangerous 2