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Jared Freitas


  • Typically diagnosed in childhood, but occupational asthma, aspirin-induced asthma and eosinophilic asthma are more commonly diagnosed in adults
  • Three most common symptoms: wheezing after trigger, nighttime cough, and associated dyspnea
  • COPD-asthma overlap syndromes: newer entity that typically involves intermittent symptoms
    • Obstruction is present but does not fully resolve with bronchodilator
    • Consider this diagnosis in a pt w/significant smoking history who is dx’d with asthma at age >40yo


  • Ask about triggers: cold, exercise, URIs, allergens, inhaled irritants
  • Ask about family history or personal history of atopy, eczema, allergic rhinitis
  • Exam: wheezing, prolonged expiratory phase; nasal polyps, rhinitis, eczema
  • Spirometry (PFT’s) with reversible obstruction
    • FEV1/FVC <0.7; FEV1 12% and 200 mL after bronchodilator
  • “All That Wheezes Is Not Asthma”. Must rule out alternative diagnoses:
    • Panic attacks, upper airway obstruction, foreign body, vocal cord dysfunction, CHF (cardiac asthma), COPD, ILD
  • Consider CBC w/diff to screen for significant anemia and eosinophilia (associated w/allergic asthma or eosinophilic pneumonia)
  • If concerned for allergic asthma or allergic bronchopulmonary aspergillosis, consider measuring total serum IgE levels

Classify Severity and Assess for Symptom Control with the RULE OF 2s

  • Does the patient have symptoms or require rescue inhaler ≥2 times per week?
  • Does the patient endorse nighttime symptoms ≥ 2 times per month?
  • Does the patient have to refill rescue inhaler ≥ 2 times per year?
  • Does the patient ever have to limit activity due to asthma symptoms?

Initial Assessment of Severity

  • Intermittent: No to all of the above and FEV1> 80% predicted. Start at step 1
  • Persistent: Yes to any question above. Start at Step 2
    • Mild: Less than daily symptoms, less than weekly nighttime symptoms, minor limitation to activities. FEV >80% predicted
    • Moderate: Daily symptoms, weekly nighttime symptoms, some limitation to activities. FEV 60-80% predicted
    • Severe: More severe symptoms than above, FEV1 <60% predicted
    • Consider referral to pulmonary


  • Aim to use the lowest possible step to maintain symptom control. Also consider stepping down therapy if pt has been well-controlled for >3 months
  • Prior to escalating therapy, consider:
    • Adherence to therapy (including inhaler technique), uncontrolled comorbidities (allergies, GERD, OSA, etc), and alternative diagnoses
    • Ensure patients receive MDI and spacer teaching for full effect
  • Updated Guidelines: prn ICS - LABA > prn SABA Step 1 (mild intermittent) and Step 2 (mild persistent)
    • Reduces exacerbations, easier to schedule does in future if needed
    • SYGMA Trial showed rescue/prn Budesonide-formoterol (ICS - LABA) non-inferior to daily ICS-LABA + prn SABA in preventing exacerbations
  • Follow-up
    • Repeat PFTs q3-6 mos after beginning therapy and q1-2 yrs thereafter
    • Regular follow up at least q6 mos for all patients with asthma

VA specific guidance

  • Mometasone is the formulary ICS and Wixela (fluticasone-salmeterol) is the formulary ICS/LABA
  • Ordering PFTs: Refer to Pulm section on PFTs for VUMC and VA specifics
  • Please see above text for updated guidance on using prn ICS – LABA for step 1/step 2

asthma steps

Image by National Heart, Blood, and Lung Institute. Distributed under a CC BY 2.5 license.

Last update: 2022-07-05 14:41:01