PRACTICE RECOMMENDATIONS
• Classify and treat asthma based on the patient’s worst symptom, whether or not it is the symptom that occurs most frequently. C
• Treat patients with poorly controlled asthma aggressively to gain quick control, then scale back slowly to the fewest medications and lowest doses needed to maintain control. A
• Reserve long-acting beta-agonists for use as an adjunct to inhaled corticosteroids for adults with poor baseline pulmonary function tests. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE Angela D, a 34-year-old patient, has asthma with recurrent exacerbations. She uses a low-dose inhaled corticosteroid (ICS) daily and an albuterol inhaler, as needed, for shortness of breath or wheezing. She also has allergic rhinitis, for which she uses nasal fluticasone. Yet despite this regimen, Ms. D reports she still experiences wheezing, chest tightness, and shortness of breath 3 to 4 times a week and is awak-ened by coughing at least twice a week. In the past 6 months, she has had one emergency department (ED) visit and completed 2 courses of oral steroids.
Ms. D has gained weight since her last visit 3 months ago; her body mass index has gone from 27.5 to 29 kg/m2. And, while she has always been somewhat anxious, Ms. D notes that her anxiety has gotten progressively worse, as well.
About 25 million Americans—approximately one in 12—suffer from asthma1 and, despite improvements in asthma guidelines and treatment in the last 20 years,2 many still struggle with uncontrolled symptoms.3 The consequences can be severe.
Suboptimal control of asthma is associated with a significant decrease in quality of life, a greater likelihood of absence from work or school, and an increased risk for life-threatening events, trips to the ED, hospital admissions, and death.1 A multifaceted approach, including regular assessment, aggressive medication management, and attention to comorbidities, is needed to alleviate the suffering of patients with persistent asthma. This evidence-based review can help you provide such broad-based treatment.
Diagnosis and classification go hand in hand
The cornerstones of asthma management are accurate diagnosis and assessment of disease severity, based on both qualitative and quantitative measures. Start with a patient history, eliciting information about symptoms, triggers, risk factors, and most importantly, how often symptoms occur. Classic high-pitched wheezing sounds during exhalation, a cough that often worsens at night, shortness of breath, and chest tightness should raise suspicion for an asthma diagnosis.2 But frequency (and timing) of symptoms and exacerbations, as well as changes in the patient’s ability to function normally, help to determine whether asthma is classified as mild intermittent, mild persistent, moderate persistent, or severe persistent (TABLE).2
TABLE
Classifying asthma severity2
| Findings | Mild intermittent | Mild persistent | Moderate persistent | Severe persistent |
|---|---|---|---|---|
| Frequency | ≤2/wk | >2/wk, but <1/d | Daily | Continuous |
| Exacerbations | Rare | <2/wk | ≥2/wk | Frequent |
| Activity level | Normal | May decrease with exacerbation | Frequently limited | Significantly limited |
| Nighttime symptoms | ≤2/mo | >2/mo | >1/wk | Frequent |
| FEV1 (or PEF) predicted | >80% | >80% | >60% to <80% | ≤60% |
| PEF variability | <20% | 20%-30% | >30% | >30% |
| FEV1, forced expiratory volume in one second; PEF, peak expiratory flow. | ||||
Because asthma treatment should be based on its classification, an accurate assessment of disease severity is especially important for patients like Ms. D, who have been treated for asthma but continue to have unresolved symptoms. Keep in mind that asthma classification should be based on the worst symptom a patient has, not necessarily the symptom that occurs most frequently. Thus, a patient who has daytime symptoms requiring use of a rescue inhaler 2 to 3 times a week but is awakened at night with shortness of breath 2 times a week would receive a diagnosis of moderate persistent asthma on the basis of the night-time symptoms.
In assessing asthma severity, it is also important to ask specifically about recent events, including ED visits, hospitalizations, and intubations. This information, as well as answers to questions about smoking status, mental health problems, quality of life, and treatment compliance—and whether the patient can afford to purchase the asthma medications you’ve prescribed—can be used to assess the likelihood of poor outcomes.2
Factor in spirometry findings
History and physical examination alone cannot adequately diagnose and classify asthma severity.4,5 Spirometry, a reimbursable office test that can be administered by trained staff members, can be beneficial for any patient older than 5 years for whom a diagnosis of asthma is being considered or disease severity being determined.2 Other objective measures, such as the Mini Asthma Quality of Life questionnaire (http://erj.ersjournals.com/content/14/1/32.full.pdf+html) and peak expiratory flow measurement, may be helpful, as well.2,6