Asthma classification

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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: Either 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
  • Preferred: Medium-dose inhaled corticosteroid + long-acting beta-agonist
  • Alternative: Medium-dose inhaled corticosteroids + either Leukotriene receptor antagonist, Theophylline, or Zileuton

STEP 5

  • Preferred: High-dose inhaled corticosteroids + long-acting beta-agonist
  • Consider adding Omalizumab for patients with allergies

STEP 6

  • Preferred: High-dose inhaled corticosteroids + long-acting beta-agonist + oral corticosteroids
  • Consider adding Omalizumab for patients with allergies
Step down if possible and asthma is controlled for at least 3 months Step-up if needed, but first check adherence, environmental control, and comorbidities
  • 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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