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)

• Early-age of onset
• Atopic individuals have an increased predisposition
• Environmental allergens play a strong role in the pathogenesis
• Positive personal and/or family history of atopic diseases‎ such as allergic rhinitis, urticaria and eczema
• Laboratory tests may reveal increased serum IgE levels, positive skin test to specific aero-allergens and a positive bronchoprovocation test

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

• Late-age of onset
• Non-atopic individuals have an increased predisposition
• Indoor allergens play a strong role in the pathogenesis
• Negative personal and/or family history of allergic diseases
• Laboratory tests may reveal normal serum IgE levels and a negative bronchoprovocation test

Classification 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.

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.

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:

• Use of anti-inflammatory drugs such as cromolyn or nedocromil, OR
• Theophylline, montelukast, zafirlukast along with a short-acting inhaled β2-agonists.

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:

• Moderate dose of inhaled steroid, OR
• Low dose inhaled steroid along with inhaled long-acting β2-agonists or sustained-release theophylline for nocturnal symptoms,

• Alternative strategy includes the use of low-dose of inhaled steroid along with long-acting bronchodilators (either inhaled long-acting β2-agonists or sustained-release theophylline) and/or a short-acting inhaled β2-agonists on need basis.

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 or Step 5 Therapy

Step 4 therapy:

• Preferred drug of choice: Medium-dose of inhaled steroid along with inhaled long-acting β2-agonists

• Alternative strategy includes the use of medium-dose inhaled steroids along with long-acting bronchodilators (such as inhaled β2-agonists or sustained-release theophylline used alone or in combination) and/or short-acting inhaled β2-agonists may be used on need basis.

Step 5 therapy:

• Preferred drug of choice: High-dose of inhaled steroid along with inhaled long-acting β2-agonists and omalizumab in patients who have allergies.

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