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 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)[3]