Evaluation and Management of Asthma

Initial Diagnosis

• The American Academy of Allergy, Asthma, and Immunology recommends establishing the diagnosis using spirometry in all patients ≥5 years old to demonstrate reversible airflow obstruction, then classify severity to initiate treatment and subsequently monitor control to adjust therapy using a stepwise approach 1
• Document recurrent episodes of airflow obstruction including wheezing, breathlessness, chest tightness, and cough (particularly at night or early morning) 1
• Obtain detailed history focusing on symptom frequency (daytime and nighttime) 2
• Obtain detailed history focusing on activity limitations and school/work attendance 2
• Obtain detailed history focusing on frequency of short-acting β-agonist (SABA) use 1
• Obtain detailed history focusing on trigger exposures (allergens, irritants, exercise, infections, medications) 1
• Perform spirometry at initial assessment in all patients ≥5 years old 2
• Demonstrate reversibility: FEV₁ improvement ≥12% and ≥200 mL after bronchodilator administration 1
• Consider bronchoprovocation testing (methacholine, histamine, exercise) when spirometry is normal but asthma is suspected—a negative test helps rule out asthma 3
• Measure peak expiratory flow in children and when spirometry unavailable 4
• Critical differential diagnoses to rule out include COPD, congestive heart failure, vocal cord dysfunction, pulmonary embolism, ACE inhibitor-induced cough in adults 3
• Critical differential diagnoses to rule out include foreign body aspiration, cystic fibrosis, vascular rings, recurrent aspiration in children 3
• Critical differential diagnoses to rule out include vocal cord dysfunction (look for inspiratory flow-volume loop flattening on spirometry) in all ages 3

Severity Classification (Treatment-Naïve Patients)

• Classify severity before initiating therapy using both impairment and risk domains 1
• Classify as intermittent: Symptoms ≤2 days/week, nighttime awakenings ≤2×/month, SABA use ≤2 days/week, no interference with activities, FEV₁ >80% predicted 2
• Classify as mild persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3-4×/month 2
• Classify as moderate persistent: Daily symptoms, nighttime awakenings >1×/week, some activity limitation, FEV₁ 60-80% predicted 2
• Classify as severe persistent: Symptoms throughout the day, nighttime awakenings often 7×/week, extreme activity limitation, FEV₁ <60% predicted 2
• Assess exacerbation history: ≥2 exacerbations requiring oral corticosteroids in past year indicates higher risk 5

Stepwise Pharmacotherapy

• Use SABA as needed for symptom relief: up to 3 treatments at 20-minute intervals 5
• Use SABA >2 days/week (excluding exercise prophylaxis) indicates inadequate control requiring step-up 5
• Step 1 (Intermittent): SABA as needed only 5
• Step 2 (Mild Persistent): Low-dose inhaled corticosteroid (ICS) 5
• Step 3 (Moderate Persistent): Low-dose ICS + long-acting β-agonist (LABA), OR medium-dose ICS 5
• Step 4: Medium-dose ICS + LABA 5
• Step 5 (Severe Persistent): High-dose ICS + LABA 5
• Consider omalizumab for allergic asthma 5
• Step 6: High-dose ICS + LABA + oral corticosteroids 5
• Consider omalizumab for IgE-mediated disease 5

Ongoing Monitoring and Control Assessment

• Visit every 2-6 weeks when initiating therapy or stepping up 2
• Visit every 1-6 months once control achieved 2
• Visit every 3 months when considering step-down 2
• Control assessment (≥12 Years Old): Well-Controlled, Not Well-Controlled, Very Poorly Controlled 8
• Perform spirometry at least every 1-2 years, more frequently if poorly controlled 2
• Consider daily peak flow monitoring for moderate-severe persistent asthma, history of severe exacerbations, or poor symptom perception 2

Adjusting Therapy

• Before stepping up, verify medication adherence, correct inhaler technique, environmental trigger control, and treatment of comorbidities (rhinitis, sinusitis, GERD, OSA, obesity) 5
• Step up 1-2 steps if not well-controlled or very poorly controlled 6
• Consider step-down after ≥3 months of well-controlled asthma 5
• Monitor closely at 3-month intervals during step-down 2

Patient Education and Self-Management

• Develop written asthma action plan with instructions for daily management and managing worsening symptoms 1
• Teach proper inhaler technique and verify at every visit 1
• Train self-monitoring using either symptoms or peak flow (benefits are similar) 7
• Identify and avoid triggers: allergens, tobacco smoke, irritants, infections 1
• Distinguish long-term control from quick-relief medications 1
• Multifaceted allergen avoidance for sensitized patients with persistent asthma (single interventions generally ineffective) 1
• All patients must avoid tobacco smoke exposure 1
• Consider allergen immunotherapy when clear relationship between symptoms and specific allergen exposure 1

Specialist Referral Indications

• Refer for consultation or co-management when difficulty achieving or maintaining control, ≥2 oral corticosteroid bursts in past year, any hospitalization for asthma, Step 4+ care required, immunotherapy or omalizumab considered, additional diagnostic testing needed 5