Guidelines Summary
The following organizations have issued guidelines for the management of asthma:
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:
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Symptoms of cough, wheezing, chest tightness, or difficulty breathing less than twice a week
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Flare-ups are brief, but intensity may vary
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Nighttime symptoms less than twice a month
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No symptoms between flare-ups
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Lung function test FEV 1 is 80% or more above normal values
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Peak flow has less than 20% variability am-to-am or am-to-pm, day-to-day
Mild persistent asthma is characterized as follows:
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Symptoms of cough, wheezing, chest tightness, or difficulty breathing 3-6 times a week
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Flare-ups may affect activity level
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Nighttime symptoms 3-4 times a month
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Lung function test FEV 1 is 80% or more above normal values
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Peak flow has less than 20-30% variability
Moderate persistent asthma is characterized as follows:
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Symptoms of cough, wheezing, chest tightness, or difficulty breathing daily
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Flare-ups may affect activity level
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Nighttime symptoms 5 or more times a month
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Lung function test FEV 1 is above 60% but below 80% of normal values
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Peak flow has more than 30% variability
Severe persistent asthma is characterized as follows:
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Symptoms of cough, wheezing, chest tightness, or difficulty breathing that are continual
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Frequent nighttime symptoms
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Lung function test FEV 1 is 60% or less of normal values
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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] :
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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
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Moderate asthma: Well-controlled with low-dose ICS/long-acting beta2-agonists (LABA)
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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. [109]
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] :
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Poor inhaler technique
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Poor medication adherence
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Incorrect diagnosis of asthma, with symptoms due to alternative conditions such as upper airway dysfunction, cardiac failure, or lack of fitness
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Comorbidities and complicating conditions such as rhinosinusitis, gastroesophageal reflux, obesity, and obstructive sleep apnea
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Ongoing exposure to sensitizing or irritant agents in the home or work environment.
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] :
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Achieve and maintain control of asthma symptoms
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Maintain normal activity levels, including exercise
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Maintain pulmonary function as close to normal as possible
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Prevent asthma exacerbations
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Avoid adverse effects from asthma medications
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Prevent asthma mortality
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 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:
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Controller medication not indicated
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Reliever medication is a short-acting beta-agonist (SABA) as needed for symptoms
Step 2 for mild persistent asthma is as follows:
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Preferred controller medication is a low-dose inhaled corticosteroid
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Alternatives include cromolyn, leukotriene receptor antagonist (LTRA), [110] or theophylline
Step 3 for moderate persistent asthma is as follows:
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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) [111] or an inhaled medium-dose corticosteroid
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Alternatives include a low-dose ICS plus either an LTRA or theophylline
Step 4 for moderate-to-severe persistent asthma is as follows:
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Preferred controller medication is an inhaled medium-dose corticosteroid plus a LABA (combination therapy)
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Alternatives include an inhaled medium-dose corticosteroid plus either an LTRA or theophylline
Step 5 for severe persistent asthma is as follows:
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Preferred controller medication is an inhaled high-dose corticosteroid plus LABA
Step 6 for severe persistent asthma is as follows:
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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:
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Step 1: As-needed low-dose ICS-formoterol (off-label); other options are low dose ICS taken whenever SABA is taken
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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
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Step 3: Low-dose ICS/LABA; other options include medium-dose ICS or low-dose ICS + LTRA
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Step 4: Medium-dose ICS-LABA; other options are high-dose ICS, add-on tiotropium, or add-on LTRA
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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 [109] :
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For severe allergic asthma, a therapeutic trial of omalizumab
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Do not use methotrexate or macrolide antibiotics to treat severe asthma
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For severe asthma and recurrent exacerbations of allergic bronchopulmonary aspergillosis (ABPA), antifungal agents should be given
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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)
Japanese Society of Allergology
Guidelines for adult asthma were published in October 2020 by the Japanese Society of Allergology (JSA). [108]
Diagnosis
The JSA recommends spirometry for assessing the extent of airflow limitation or airway reversibility.
The JSA recommends daily measurement of peak expiratory flow for unstable asthma and patients lacking obvious dyspnea during attack.
Although useful for diagnosing asthma, the JSA does not recommend assessing bronchial hyperresponsiveness in patients with low FEV1 (≤1 L) or low %FEV1 (≤50%) since excess airway narrowing may occur due to irritant inhalation.
Treatment of long-term adult asthma
The JSA recommends using a jet nebulizer for budesonide (BUD) inhalation suspension.
The JSA recommends adding one or more agents other than inhaled corticosteroids (ICSs), as opposed to increasing the dose of an ICS, to control asthma.
The JSA recommends long-acting β2-agonists (LABAs), leukotriene receptor antagonists (LTRAs), sustained-release theophylline, and long-acting muscarinic antagonists as add-on drugs.
The JSA recommends that anti-immunoglobulin E antibodies and other biologics as well as oral steroids be reserved for very severe and persistent asthma related to allergic reactions.
The JSA recommends inhaled β2-agonists, aminophylline, corticosteroids, adrenaline, oxygen therapy, and other approaches be used as needed during acute exacerbations.
Treatment during pregnancy
The JSA recommends ICSs as first-line treatment for long-term management of pregnant women with asthma.
The JSA recommends a short-acting beta-agonist (SABA) as needed for pregnant women with mild intermittent asthma.
The JSA recommends low-dose ICS; LTRA, controlled-release theophylline, and/or disodium cromoglycate (DSCG) as needed in pregnant women with mild persistent asthma.
The JSA recommends low-dose ICS and LABA or moderate-dose ICS and LABA in combination with LTRA or controlled-release theophylline as needed in pregnant women with moderate persistent asthma.
The JSA recommends high-dose ICS and LABA; oral steroids as needed for pregnant women with severe persistent asthma.
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 [112] :
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Administration of an inhaled SABA before exercise (strong recommendation); the SABA is typically administered 15 minutes before exercise
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A controller agent is added whenever SABA therapy is used daily or more frequently
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Interval or combination warm-up exercise before planned exercise (strong recommendation)
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Recommend against daily use of an inhaled long-acting beta2-agonist as single therapy (strong recommendation)
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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)
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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)
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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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Pathogenesis of asthma. Antigen presentation by the dendritic cell with the lymphocyte and cytokine response leading to airway inflammation and asthma symptoms.
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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.
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Stepwise approach to pharmacological management of asthma based on asthma severity. Adapted from Global Strategy for Asthma Management and Prevention: 2002 Workshop Report.
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Asthma. High-resolution CT scan of the thorax obtained during inspiration in a patient with recurrent left lower lobe pneumonia shows a bronchial mucoepidermoid carcinoma (arrow).
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Asthma. High-resolution CT scan of the thorax obtained during expiration in a patient with recurrent left lower lobe pneumonia shows a bronchial mucoepidermoid carcinoma. Note the normal increase in right lung attenuation during expiration (right arrow). The left lung remains lucent, especially the upper lobe, secondary to bronchial obstruction with airtrapping (left upper arrow). The vasculature on the left is diminutive, secondary to reflex vasoconstriction. Left pleural thickening and abnormal linear opacities are noted in the left lower lobe; these are the result of prior episodes of postobstructive pneumonia (left lower arrow).
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High-resolution CT scan of the thorax obtained during inspiration demonstrates airtrapping in a patient with asthma. Inspiratory findings are normal.
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High-resolution CT scan of the thorax obtained during expiration demonstrates a mosaic pattern of lung attenuation in a patient with asthma. Lucent areas (arrows) represent areas of airtrapping (same patient as in the previous image).
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Posteroanterior chest radiograph demonstrates a pneumomediastinum in bronchial asthma. Mediastinal air is noted adjacent to the anteroposterior window and airtrapping extends to the neck, especially on the right side.
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Lateral chest radiograph demonstrates a pneumomediastinum in bronchial asthma. Air is noted anterior to the trachea (same patient as in the previous image).
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Asthma. High-resolution CT scan of the thorax obtained during inspiration in a patient with recurrent left lower lobe pneumonia shows a bronchial mucoepidermoid carcinoma (arrow).
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Asthma. High-resolution CT scan of the thorax obtained during expiration in a patient with recurrent left lower lobe pneumonia shows a bronchial mucoepidermoid carcinoma (same patient as in the previous image). Note the normal increase in right lung attenuation during expiration (right arrow). The left lung remains lucent, especially the upper lobe, secondary to bronchial obstruction with airtrapping (left upper arrow). The vasculature on the left is diminutive, secondary to reflex vasoconstriction. Left pleural thickening and abnormal linear opacities are noted in the left lower lobe; these are the result of prior episodes of postobstructive pneumonia (left lower arrow).
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Asthma. High-resolution CT scan of the thorax demonstrates mild bronchial thickening and dilatation in a patient with bilateral lung transplants and bronchial asthma.
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Asthma. High-resolution CT scan of the thorax demonstrates central bronchiectasis, a hallmark of allergic bronchopulmonary aspergillosis (right arrow), and the peripheral tree-in-bud appearance of centrilobular opacities (left arrow), which represent mucoid impaction of the small bronchioles.
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Asthma is characterized by chronic inflammation and asthma exacerbations, where an environmental trigger initiates inflammation, which makes it difficult to breathe. This video covers the pathophysiology of asthma, signs and symptoms, types, and treatment.
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- Overview
- Presentation
- DDx
- Workup
- Approach Considerations
- Blood and Sputum Eosinophils
- Serum Immunoglobulin E
- Arterial Blood Gas
- Periostin
- Pulse Oximetry Assessment
- Chest Radiography
- Chest CT Scanning
- Electrocardiography
- MRI
- Nuclear Imaging
- Allergy Skin Testing
- Pulmonary Function Testing
- Bronchoprovocation
- Peak Flow Monitoring
- Impulse Oscillometry
- Exhaled Nitric Oxide
- Sinus CT Scanning
- 24-Hour pH Monitoring
- Histologic Findings
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- Treatment
- Approach Considerations
- Environmental Control
- Allergen Immunotherapy
- Monoclonal Antibody Therapy
- Bronchial Thermoplasty
- Acute Exacerbation
- Asthma in Pregnancy
- Gastroesophageal Reflux Disease
- Sinusitis
- Nocturnal Asthma
- Long-Term Monitoring
- Functional Assessment of Airway Obstruction
- Perioperative Considerations
- Approach to Level of Activity
- Dietary Considerations
- Consultations
- Deterrence
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- Guidelines
- Medication
- Medication Summary
- Beta2-adrenergic agonist agents
- Anticholinergic Agents
- Anticholinergic agent combinations
- Corticosteroid, oral
- Long-acting beta2 agonists
- Beta2-Agonist/Corticosteroid Combinations
- Nonselective Phosphodiesterase Enzyme Inhibitors
- Mast cell stabilizers
- Corticosteroid, Inhalant
- Leukotriene Receptor Antagonist
- Monoclonal Antibodies, Anti-asthmatics
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- Questions & Answers
- Media Gallery
- References
