Asthma classification: Difference between revisions

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(/* Guidelines for Diagnosis and Management of Asthma Based On The National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR3) Urbano FL (2008) Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines....)
(/* Guidelines for Diagnosis and Management of Asthma Based On The National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR3) Urbano FL (2008) Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines....)
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| style="background: #DCDCDC; padding: 5px;" |'''Recommended Treatment Strategy'''
| style="background: #DCDCDC; padding: 5px;" |'''Recommended Treatment Strategy'''
| style="background: #F5F5F5; padding: 5px;" |STEP 1
| style="background: #F5F5F5; padding: 5px;" |'''STEP 1'''
Preferred: Short-acting beta-agonist PRN
Preferred: Short-acting beta-agonist PRN
| style="background: #F5F5F5; padding: 5px;" |STEP 2
| style="background: #F5F5F5; padding: 5px;" |'''STEP 2'''
Preferred: Low-dose inhaled corticosteroids
Preferred: Low-dose inhaled corticosteroids
Alternative: Cromolyn, Leukotriene receptor antagonist, Nedocromil, or Theophylline
Alternative: Cromolyn, Leukotriene receptor antagonist, Nedocromil, or Theophylline
| style="background: #F5F5F5; padding: 5px;" |STEP 3
| style="background: #F5F5F5; padding: 5px;" |'''STEP 3'''
Preferred: Low-dose inhaled corticosteroids + Long-acting beta-agonist
Preferred: Low-dose inhaled corticosteroids + Long-acting beta-agonist
OR
OR
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Alternative: Low-dose inhaled corticosteroid + either Leukotriene receptor antagonist, Theophylline, or Zileuton
Alternative: Low-dose inhaled corticosteroid + either Leukotriene receptor antagonist, Theophylline, or Zileuton
| style="background: #F5F5F5; padding: 5px;" |STEP 4
| style="background: #F5F5F5; padding: 5px;" |'''STEP 4'''





Revision as of 16:13, 24 February 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Asthma is classified into atopic and non-atopic types based on the onset of symptoms. Atopic refers to early-onset whereas non-atopic refers to late-onset. Despite the differentiation, a significant degree of overlap exists between the two types. The severity of symptoms is further classified based on the GINA severity grades into mild intermittent, mild persistent, moderate persistent and severe persistent asthma.

Classification

Based on Symptom Onset

Early-onset Asthma (Atopic, Allergic, Extrinsic)

Late-onset Asthma (Non-Atopic, Idiosyncratic, Intrinsic)

Based on GINA Severity Grade

Asthma is classified into four subgroup, namely, mild intermittent, mild persistent, moderate persistent and severe persistent based on the Global Initiative for Asthma - GINA severity grades.[1]

Mild Intermittent Asthma

Symptoms per day Symptoms per night PEF or FEV1 PEF variability
Less than once a week. Brief exacerbations. Asymptomatic and normal PEFR between exacerbations. Less than or equal to twice a month ≥ 80% of predicted normal < 20%

Step 1 Therapy:

Short-acting inhaled β2-agonists on need basis.[2][3]

Mild Persistent Asthma

Symptoms per day Symptoms per night PEF or FEV1 PEF variability
Symptoms more than twice a week but less than once a day. Exacerbations may affect activity and sleep. Greater than or equal to twice a month ≥ 80% 20-30%

Step 2 Therapy:

  • Preferred drug of choice is once a day low-dose steroid inhalation.
  • Alternative therapies include:

Moderate Persistent Asthma

Symptoms per day Symptoms per night PEF or FEV1 PEF variability
Daily symptoms. Exacerbations more than twice a week. Exacerbations may affect activity and sleep. Daily use of bronchodilators. More than once a month 60-80% ≥ 30%

Step 3 Therapy:

  • Preferred drug of choice:

Severe Persistent Asthma

Symptoms per day Symptoms per night PEF or FEV1 PEF variability
Continued symptoms. Frequent exacerbations. Limited physical activity. Frequent ≤ 60% ≥ 30%

Step 4 Therapy:

Step 5 Therapy:

Guidelines for Diagnosis and Management of Asthma Based On The National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR3) [6]

Severity Components Intermittent Persistent Asthma
Mild Moderate Severe
Symptoms Less than 1 day/week More than 2 days/week

Not daily

Daily Daily

Throughout the day

Nocturnal Symptoms Less than 2 times/month 3 to 4 times/month More than 1 time/week

Not every night

Every night
Interference w/ Activity Minimal to none Minor limitation of activity Some limitation of activity Severe limitation of activity
Short Acting Beta-Agonist Use Less than 2 days/week More than 2 days/week but not daily

Not more than once/day

Daily Several times/day
Pulmonary Function Test Normal FEV1 between exacerbations

FEV1 > 80% predicted

FEV1/FVC normal

FEV1 > 80% predicted

FEV1/FVC normal

FEV1 > 60% but < 80% predicted

FEV1/FVC reduced by 5%

FEV1 < 60% predicted

FEV1/FVC reduced by > 5%

Recommended Treatment Strategy STEP 1

Preferred: Short-acting beta-agonist PRN

STEP 2

Preferred: Low-dose inhaled corticosteroids Alternative: Cromolyn, Leukotriene receptor antagonist, Nedocromil, or Theophylline

STEP 3

Preferred: Low-dose inhaled corticosteroids + Long-acting beta-agonist OR Medium-dose inhaled corticosteroid

Alternative: Low-dose inhaled corticosteroid + either Leukotriene receptor antagonist, Theophylline, or Zileuton

STEP 4


STEP 5


STEP 6

Step down if possible and asthma is controlled for at least 3 months Step-up if needed
  • In each step, patient education, environmental control, and management of comorbidities are important.
  • In STEP 2 - 4, consider subcutaneous allergen immunotherapy for patients with allergic asthma
  • Short-acting beta agonist as needed for symptoms. Up to 3 treatments at 20 minute intervals as needed.
  • A short course of oral systemic corticosteroids may be needed. Use of a short-acting beta agonist for >2 days a week for symptom control indicates inadequate control and the need to step up therapy.


References

  1. Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M et al. (2008) Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J 31 (1):143-78. DOI:10.1183/09031936.00138707 PMID: 18166595
  2. Shim C, Williams MH (1980) Bronchial response to oral versus aerosol metaproterenol in asthma. Ann Intern Med 93 (3):428-31. PMID: 7436160
  3. Shim C, Williams MH (1981) Comparison of oral aminophylline and aerosol metaproterenol in asthma. Am J Med 71 (3):452-5. PMID: 7282733
  4. Berridge MS, Lee Z, Heald DL (2000) Pulmonary distribution and kinetics of inhaled [11Ctriamcinolone acetonide.] J Nucl Med 41 (10):1603-11. PMID: 11037987
  5. Nelson HS (2001) Advair: combination treatment with fluticasone propionate/salmeterol in the treatment of asthma. J Allergy Clin Immunol 107 (2):398-416. DOI:10.1067/mai.2001.112939 PMID: 11174215
  6. Urbano FL (2008) Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines. J Manag Care Pharm 14 (1):41-9. PMID: 18240881

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