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Your doctor may use different terms when discussing your asthma. This is because asthma care will vary from person to person based upon the frequency of symptoms and how severe the symptoms are. The terms come from two sets of guidelines used to classify asthma severity:

  • Global Initiative for Asthma (GINA)
  • National Asthma Education and Prevention Program (NAEPP) EPR-4

The two guidelines use different methodologies with varying and overlapping terms. This is due in part to GINA reflecting data up to 2020, while NAEPP EPR-4 is based on data prior to 2016. Some doctors who follow GINA may use different terms to describe types of asthma and level of severity than doctors who follow NAEPP, and vice versa.

Asthma care according to these guidelines is referred to as “guidelines-based asthma care.”  The guidelines can be used together when developing a treatment plan. The following is an overview of GINA and NAEPP EPR-4 guidelines and the terms your doctor may use when discussing your asthma.

What are the most recent Global Initiative for Asthma (GINA) guidelines for asthma management and treatment?

GINA guidelines are updated every year. In 2021, the GINA released an update to its asthma management and prevention guidelines to simplify asthma severity into mild, moderate or severe categories. With GINA guidelines, asthma severity is assessed after treatment is underway.

Medications and dosages are placed into five steps of treatment. What steps to start patients at for treatment is determined by the frequency and severity of symptoms. Based on the steps to manage symptoms, asthma severity is assessed.

Source: ginaasthma.org

What are the National Institutes of Health guidelines used in asthma management and treatment?

The National Institutes of Health’s NAEPP expert panel issued comprehensive national asthma guidelines in 2007. These guidelines are referred to as the EPR-3 guidelines. EPR stands for “Expert Panel Report.” The guidelines assessed the severity of asthma through symptom frequency, impact on activity and breathing tests. These guidelines are still commonly used by many doctors in the United States today.

In December 2020, the NAEPP expert panel announced a focused update to six areas of its national asthma guidelines. These guidelines are referred to as the EPR-4 guidelines.

NAEPP guidelines define asthma as intermittent or persistent. Persistent asthma is then broken down into mild, moderate and severe categories.

Photo of Asthma Severity Chart for ages0-4Source: NAEPP Asthma Guidelines, 2018

Photo of Asthma Severity Chart for ages 5-11Source: NAEPP Asthma Guidelines, 2018

Photo of Asthma Severity Chart for ages 12 and upSource: NAEPP Asthma Guidelines, 2018

What is mild asthma?

People with mild asthma have symptoms that are well controlled by either Step 1 or 2 medications.

  • Step 1: This step is for patients with mild asthma who experience symptoms less than twice per month and no risk of exacerbations. They may be prescribed an as-needed, low-dose inhaled corticosteroid (ICS)-formoterol. It is no longer recommended that patients with mild asthma use a short-acting beta2-agonist (SABA) alone to treat asthma.
  • Step 2: This step is for patients who experience symptoms twice a month or more, but not daily. They may be prescribed a daily low-dose ICS or an as-needed, low-dose ICS-formoterol, with an as-needed SABA.

What is moderate asthma?

People with moderate asthma have symptoms that are well controlled with Step 3 or 4 medications.

  • Step 3: This step is for patients who experience symptoms most days, or wake up with asthma symptoms once a week or more. Treatment involves a low-dose ICS and a long-acting beta2-agonist (LABA), with an as-needed SABA or a low-dose ICS-formoterol for both maintenance and quick-relief therapy.
  • Step 4: This step is for patients who experience symptoms most days, wake with asthma once a week or more, or have low lung function. Treatment involves a medium-dose ICS-LABA, with an as-needed SABA.

What is severe asthma?

People with severe asthma require treatment with Step 5 to control symptoms. They have uncontrolled asthma despite following their treatment plan and using proper inhaler technique.

  • Step 5: This step is for patients who are considered to have severe or difficult-to-treat asthma. They should be referred to a pulmonologist. Treatment involves a high-dose ICS-LABA or short-course oral corticosteroids. Doctors may recommend a phenotype assessment to determine add-on therapy such as long-acting muscarinic antagonists (LAMA) and biologics.

What is intermittent asthma?

People with intermittent asthma have symptoms that come and go. They experience symptoms less than twice a week and flare-ups are short. They have symptoms at night no more than twice a month.

People with intermittent asthma have a forced expiratory volume of 80% or more. FEV1 measures how much air a person can exhale during a forced breath. Their peak flow rate varies by less than 20%.

With intermittent asthma, symptoms don’t affect your daily activities.

What is persistent asthma?

People with persistent asthma have symptoms more than twice a week. They may impact daily activities. Persistent asthma is divided further as mild, moderate, or severe.

What is mild persistent asthma?

Characteristics of mild persistent asthma include:

  • asthma symptoms (cough, wheezing, chest tightness, difficulty breathing) 3-6 times weekly
  • level of activity may be affected by flare-ups
  • symptoms at night occur 3-4 times a month
  • FEV1 is 80% or greater
  • peak flow varies by less than 20%

What is moderate persistent asthma? 

Characteristics of moderate persistent asthma include:

  • asthma symptoms daily
  • level of activity is somewhat affected by flare-ups and symptoms
  • symptoms at night occur 5 or more times a month
  • FEV1 is 60-80%
  • peak flow varies by more than 30%

What is severe persistent asthma?

Characteristics of moderate persistent asthma include:

  • asthma symptoms throughout the day
  • level of activity is very limited by flare-ups and symptoms
  • symptoms at night occur frequently
  • FEV1 is 60% or less
  • peak flow varies by more than 30%

How should I discuss my asthma severity with my doctor?

Doctors follow asthma guidelines to help patients find the best treatment for your asthma. It is important to not only take your medications as prescribed, but also keep track of your symptoms.

Some tips to make the most out of your doctor appointments:

  • Make sure you have an Asthma Action Plan.
  • Keep a diary of your asthma symptoms and frequency.
  • Keep track of how frequently you use your medications.
  • Be honest about your compliance with medications.
  • Make a list of questions or concerns you want addressed.

As you can see, there are a number of different terms your doctor may use to describe your asthma. Ask your doctor to explain if you don’t understand what terms they are using and what they mean. Remember: anyone can have a severe, or even fatal, asthma flare-up. For this reason, it is critical to work together with your doctor to understand your asthma and to develop a management and treatment plan that is right for you.

 


References:

Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007 

EPR4 update 

Global Initiative for Asthma

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