Asthma Guidelines

Updated: Sep 18, 2020
  • Author: Michael J Morris, MD, FACP, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Guidelines

Guidelines Summary

The following organizations have issued guidelines for the management of asthma:

  • National Asthma Education and Prevention Program (NAEPP) [1]

  • Veteran’s Administration/Department of Defense (VA/DoD) [43]

  • Global Initiative for Asthma (GINA) [106]

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Classification Guidelines

The 2007 NAEPP guidelines [1] and the 2009 VA/DoD asthma management guidelines [43] use the severity of asthma classification below, with features of asthma severity divided into three charts to reflect classification in different age groups (0-4 y, 5-11 y, and 12 y and older). Classification includes (1) intermittent asthma, (2) mild persistent asthma, (3) moderate persistent asthma, (4) and severe persistent asthma.

Intermittent asthma is characterized as follows:

  • Symptoms of cough, wheezing, chest tightness, or difficulty breathing less than twice a week
  • Flare-ups are brief, but intensity may vary
  • Nighttime symptoms less than twice a month
  • No symptoms between flare-ups
  • Lung function test FEV 1 is 80% or more above normal values
  • Peak flow has less than 20% variability am-to-am or am-to-pm, day-to-day

Mild persistent asthma is characterized as follows:

  • Symptoms of cough, wheezing, chest tightness, or difficulty breathing 3-6 times a week
  • Flare-ups may affect activity level
  • Nighttime symptoms 3-4 times a month
  • Lung function test FEV 1 is 80% or more above normal values
  • Peak flow has less than 20-30% variability

Moderate persistent asthma is characterized as follows:

  • Symptoms of cough, wheezing, chest tightness, or difficulty breathing daily
  • Flare-ups may affect activity level
  • Nighttime symptoms 5 or more times a month
  • Lung function test FEV 1 is above 60% but below 80% of normal values
  • Peak flow has more than 30% variability

Severe persistent asthma is characterized as follows:

  • Symptoms of cough, wheezing, chest tightness, or difficulty breathing that are continual
  • Frequent nighttime symptoms
  • Lung function test FEV 1 is 60% or less of normal values
  • Peak flow has more than 30% variability

In contrast, the 2019 Global Initiative for Asthma (GINA) guidelines categorize asthma severity as mild, moderate, or severe. Severity is assessed retrospectively from the level of treatment required to control symptoms and exacerbations, as follows [106] :

  • Mild asthma: Well-controlled with as-needed reliever medication alone or with low-intensity controller treatment such as low-dose inhaled corticosteroids (ICSs), leukotriene receptor antagonists, or chromones
  • Moderate asthma: Well-controlled with low-dose ICS/long-acting beta2-agonists (LABA)
  • Severe asthma: Requires high-dose ICS/LABA to prevent it from becoming uncontrolled, or asthma that remains uncontrolled despite this treatment

The 2013 joint European Respiratory Society/American Thoracic Society (ERS/ATS) guidelines on evaluation and treatment of severe asthma reserves the definition of severe asthma for patients with refractory asthma and those in whom response to treatment of comorbidities is incomplete. [108]

The 2019 GINA guidelines stress the importance of distinguishing between severe asthma and uncontrolled asthma, as the latter is a much more common reason for persistent symptoms and exacerbations, and it may be more easily improved. The most common problems that need to be excluded before a diagnosis of severe asthma can be made are the following [106] :

  • Poor inhaler technique
  • Poor medication adherence
  • Incorrect diagnosis of asthma, with symptoms due to alternative conditions such as upper airway dysfunction, cardiac failure, or lack of fitness
  • Comorbidities and complicating conditions such as rhinosinusitis, gastroesophageal reflux, obesity, and obstructive sleep apnea
  • Ongoing exposure to sensitizing or irritant agents in the home or work environment.
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Management Guidelines

The goals for successful management of asthma outlined in the 2007 NHLBI publication "Global Strategy for Asthma Management and Prevention" (see the images below) include the following [1] :

  • Achieve and maintain control of asthma symptoms
  • Maintain normal activity levels, including exercise
  • Maintain pulmonary function as close to normal as possible
  • Prevent asthma exacerbations
  • Avoid adverse effects from asthma medications
  • Prevent asthma mortality
Asthma symptoms and severity. Recommended guidelin Asthma symptoms and severity. Recommended guidelines for determination of asthma severity based on clinical symptoms, exacerbations, and measurements of airway function. Adapted from Global Strategy for Asthma Management and Prevention: 2002 Workshop Report.
Stepwise approach to pharmacological management of Stepwise approach to pharmacological management of asthma based on asthma severity. Adapted from Global Strategy for Asthma Management and Prevention: 2002 Workshop Report.

Stepwise pharmacologic therapy

The pharmacologic treatment of asthma is based on stepwise therapy. Asthma medications should be added or deleted as the frequency and severity of the patient's symptoms change. The 2007 NAEPP guidelines offer the recommendations below. [1]

Step 1 for intermittent asthma is as follows:

  • Controller medication not indicated
  • Reliever medication is a short-acting beta-agonist (SABA) as needed for symptoms

Step 2 for mild persistent asthma is as follows:

  • Preferred controller medication is a low-dose inhaled corticosteroid
  • Alternatives include cromolyn, leukotriene receptor antagonist (LTRA), [109] or theophylline

Step 3 for moderate persistent asthma is as follows:

  • Preferred controller medication is either a low-dose inhaled corticosteroid (ICS) plus a long-acting beta-agonist (LABA) (combination medication is the preferred choice to improve compliance) [110] or an inhaled medium-dose corticosteroid
  • Alternatives include a low-dose ICS plus either an LTRA or theophylline

Step 4 for moderate-to-severe persistent asthma is as follows:

  • Preferred controller medication is an inhaled medium-dose corticosteroid plus a LABA (combination therapy)
  • Alternatives include an inhaled medium-dose corticosteroid plus either an LTRA or theophylline

Step 5 for severe persistent asthma is as follows:

  • Preferred controller medication is an inhaled high-dose corticosteroid plus LABA

Step 6 for severe persistent asthma is as follows:

  • Preferred controller medication is an inhaled high-dose corticosteroid plus LABA plus oral corticosteroid

The 2019 GINA guidelines include the stepwise recommendations below for medication and symptom control. [106]

The preferred reliever medication is specified as low-dose ICS-formoterol, which is an off-label use. Other reliever options include as-needed SABA. See the following stepwise approach:

  • Step 1: As-needed low-dose ICS-formoterol (off-label); other options are low dose ICS taken whenever SABA is taken
  • Step 2: Daily low-dose ICS, or as-needed low-dose ICS-formoterol (off-label); other options are leukotriene receptor antagonist (LTRA) or low-dose ICS taken whenever SABA is taken
  • Step 3: Low-dose ICS/LABA; other options include medium-dose ICS or low-dose ICS + LTRA
  • Step 4: Medium-dose ICS-LABA; other options are high-dose ICS, add-on tiotropium, or add-on LTRA
  • Step 5: High-dose ICS-LABA; refer for phenotypic assessment with or without add-on therapy (eg, tiotropium, anti-IgE, anti-IL5/5R, and IL4R; other options are to add low-dose OCS, but consider adverse effects

The change in GINA guidelines from SABA to ICS-formoterol as the recommended as-needed inhaler was based on the SYGMA I/II trials published in 2018. SYGMA I showed that as-needed budesonide-formoterol was superior to as-needed terbutaline but was inferior to budesonide maintenance therapy. Exacerbation rates were similar for budesonide-containing strategies, both of which were lower than terbutaline. SYGMA II concluded that as needed budesonide-formoterol was noninferior to budesonide maintenance therapy for the rate of severe exacerbations but was inferior for controlling asthma symptoms. Both trials showed a reduction in overall ICS exposure with as-needed budesonide/formoterol.

The 2013 joint European Respiratory Society/American Thoracic Society (ERS/ATS) guidelines include the following additional recommendations for treatment of severe asthma [108] :

  • For severe allergic asthma, a therapeutic trial of omalizumab
  • Do not use methotrexate or macrolide antibiotics to treat severe asthma
  • For severe asthma and recurrent exacerbations of allergic bronchopulmonary aspergillosis (ABPA), antifungal agents should be given
  • Do not use antifungal agents for severe asthma without ABPA irrespective of sensitization to fungi (ie, positive skin prick test or fungus-specific immunoglobulin E in serum)
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Exercise-Induced Asthma Guidelines

In 2013, the American Thoracic Society released clinical guidelines for the management of exercise-induced bronchoconstriction (EIB), which included the following recommendations [111] :

  • Administration of an inhaled SABA before exercise (strong recommendation); the SABA is typically administered 15 minutes before exercise
  • A controller agent is added whenever SABA therapy is used daily or more frequently
  • Interval or combination warm-up exercise before planned exercise (strong recommendation)
  • Recommend against daily use of an inhaled long-acting beta2-agonist as single therapy (strong recommendation)
  • For patients who continue to have symptoms despite using an inhaled SABA before exercise or who require an inhaled SABA daily or more frequently: (1) Daily ICS (strong recommendation), (2) Daily administration of an LTRA (strong recommendation), (3) Administration of a mast cell‒stabilizing agent before exercise (strong recommendation), and (4) Inhaled anticholinergic agent before exercise (weak recommendation)
  • For patients with EIB and allergies who continue to have symptoms despite using an inhaled SABA before exercise or who require an inhaled SABA daily or more frequently consider administration of an antihistamine (weak recommendation)
  • For exercise in cold weather, routine use of a device (eg, mask) that warms and humidifies the air during exercise (weak recommendation)
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