Definition of asthma

Asthma is a chronic inflammatory disorder of the airways in which many cells and
cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes, macrophages,
neutrophils, and epithelial cells. In susceptible individuals, this inflammation causes recurrent
episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in
the early morning. These episodes are usually associated with widespread but variable airflow
obstruction that is often reversible either spontaneously or with treatment. The inflammation also
causes an associated increase in the existing bronchial hyperresponsiveness to a variety of
stimuli.
Airflow obstruction (excessive airway narrowing) in asthma is the result of contraction of
the airway smooth muscle and swelling of the airway wall due to:
smooth muscle hypertrophy and hyperplasia
inflammatory cell infiltration
oedema
goblet cell and mucous gland hyperplasia
mucus hypersecretion
protein deposition including collagen
epithelial desquamation.
This inflammatory process can cause permanent changes in the airways. Long-term
changes include increased smooth muscle, increase in bronchial blood vessels, thickening of
collagen layers and loss of normal dispensability of the airway. Potential triggers for the
inflammatory process in asthma include allergy, viral respiratory infections, gastrooesophageal
reflux disease (GORD), irritants such as tobacco smoke, air pollutants and occupational dusts,
gases and chemicals, certain drugs, and non-specific stimuli such as cold air exposure and
exercise. Education of people with asthma about the nature of the disease that it is more than
bronchospasm, and is an inflammatory disease helps them gain a greater understanding of the
need for separate types of medication for asthma management:
bronchodilator (also referred to as reliever)
medication
anti-inflammatory (also referred to as preventer)
medication
long-acting beta2 agonist (also known as symptom
controller) medication usually prescribed in
combination with an inhaled corticosteroid (ICS)
preventer.
Combination medications consist of an ICS and a symptom controller in a single inhaler
device. In addition, education about other measures to improve asthma control is important:
allergen avoidance/control
use of a written asthma action plan
smoking cessation, diet and exercise (including
specific management of exercise-induced asthma if
required).

Detection and diagnosis

There is no gold standard for the diagnosis of asthma. Recommendations regarding the
tools and techniques for asthma diagnosis are based on consensus opinion among respiratory
physicians.
The diagnosis of asthma is based on:
history
physical examination
supportive diagnostic testing, including spirometry.
History
The presence of one or more of the following characteristic symptoms is suggestive of asthma:
wheeze
chest tightness
shortness of breath
cough.
Asthma is especially likely if any of the following applies:
Symptoms are recurrent or seasonal
Symptoms are worse at night or in the early morning
Symptoms are obviously triggered by exercise,
irritants, allergies or viral infections
Symptoms are rapidly relieved by a short-acting bronchodilator.
However, the symptoms of asthma vary widely from person to person. The absence of typical
symptoms does not exclude the diagnosis of asthma. To detect possible asthma, ask about:
current symptoms
pattern of symptoms (e.g. course over day, week or year)
precipitating or aggravating factors (e.g. exercise, viral infections, ingested substances,
allergens)
relieving factors
impact on work and lifestyle
home and work environment
past history of eczema, hay fever, previous events
family history of atopy.
Examination
Examine the chest for hyperinflation and wheeze. Also look for signs of allergic rhinitis, which
commonly occurs with asthma, because its presence will affect management. Note that:
wheeze is suggestive, but not diagnostic of asthma
the absence of physical signs does not exclude a
diagnosis of asthma.
crackles on chest auscultation indicate an alternate or
concurrent diagnosis.
Diagnostic testing
Spirometry
Spirometry helps you to diagnose asthma and assess asthma control, by allowing you to:
assess change in airflow limitation

 measure the degree of airflow limitation compared with predicted normal airflow (or with
personal best in patients who have previously undergone spirometry).
Interpreting spirometry
Airflow limitation is judged to be reversible if either of the following applies:
Baseline FEV1 >1.7 L and post-bronchodilator FEV1 at least 12% higher than baseline
Baseline FEV1 1.7 L and post-bronchodilator FEV1 at least 200 mL higher than baseline.
A similar rule is used to determine reversibility based on pre-and post-bronchodilator
FVC. Results should be expressed as absolute values and also as a percentage of predicted
values, based on the patients age, height and sex.
Peak expiratory flow measurement
When diagnosing asthma, PEF is not a substitute for spirometry. (It is useful in the diagnosis of
occupational asthma where very frequent testing is required, and is it useful way to monitor
asthma control for some people.)
Single PEF measurements are not adequate for use in routine asthma management by
doctors.
A peak flow meter is used to detect and measure a persons variation in best PEF, in order to
assess variability of airflow limitation. Measurement of PEF:
is effort-dependent
varies considerably between instruments.
Isolated readings taken in the surgery or pharmacy with a meter other than the persons own must
be interpreted with caution because there is a wide normal range. Despite its limitations,
monitoring of PEF at home or work is useful when:
symptoms are intermittent
symptoms are related to occupational triggers
the diagnosis is uncertain
when monitoring treatment response.
In the absence of an acute bronchodilator FEV1 response, monitoring of PEF over several days
to weeks may be useful in making a diagnosis.
Diagnosis of asthma
A diagnosis of asthma can be made with confidence in an adult when:
the person has variable symptoms (especially cough, chest tightness, wheeze and shortness of
breath) and
spirometry shows significantly reversible airflow limitation as defined above.
Other tests
Chest X-ray
A chest X-ray is not routinely required. An X-ray should be ordered if:
the diagnosis is uncertain
there are symptoms not explained by asthma
there is a need to exclude other conditions such as pneumonia.
Allergy testing

Allergy is an important causative factor in asthma and allergy tests should be considered when
the diagnosis of asthma is made.
Classification of asthma in Adults

Intermittent asthma
Untreated asthma is classified as intermittent if all the following apply:
Daytime asthma symptoms occur less than once per week.
Night-time asthma symptoms occur less than twice per month.
Exacerbations are infrequent and brief.
FEV1 is at least 80% predicted and varies by less than 20%.
Mild persistent asthma
Untreated asthma is classified as mild persistent if one or more of the following applies (and
more severe signs and symptoms are not present):
Daytime asthma symptoms occur more than once per week but not every day.
Night-time asthma symptoms occur more than twice per month, but not every week.
Exacerbations occur occasionally and may affect activity or sleep.
FEV1 is at least 80% predicted and varies by 2030%.
Moderate persistent asthma
Untreated asthma is classified as moderate persistent if one or more of the following applies
(and more severe signs and symptoms are not present):
Daytime asthma symptoms occur every day, but do not generally restrict physical activity.
Night-time asthma symptoms occur at least once per week.
Exacerbations occur occasionally and may affect activity or sleep.
FEV1 is 6080% predicted and varies by more than 30%.
Severe persistent asthma
Untreated asthma is classified as severe persistent if one or more of the following applies:
Daytime asthma symptoms occur every day and restrict physical activity.
Night-time asthma symptoms occur every day.
Exacerbations are frequent.
FEV1 is 60% predicted or less, and varies by more than 30%.

Principles of drug treatment in adults

An important aim of drug therapy is to achieve best lung function. Drug therapy should
be commenced or amended appropriate to the level of severity and pattern of asthma symptoms
(for further details, see ongoing care section entitled Assess asthma control regularly).
All patients with symptomatic asthma should be prescribed an inhaled rapid-acting beta2 agonist
as shortterm reliever therapy.
A short-acting beta2 agonist (SABA) is recommended for most patients.
Those taking the budesonideeformoterol combination (Symbicort) according to the
maintenance and reliever regimen may use this combination as reliever and ought not
require a separate SABA.
Management of intermittent asthma
An inhaled SABA should be prescribed as short-term reliever therapy for all patients with
intermittent (symptoms once weekly or less) asthma. There is currently insufficient high quality
evidence to say whether there is any benefit of initiating preventer treatment early in adults with
mild intermittent asthma. Consistently requiring SABA more than once daily for symptom relief
indicates that a patient has poorly controlled asthma. Patients with high usage of SABA should
have their asthma management reviewed. Ensure patients understand that decreasing symptom
relief from the usual SABA dose indicates worsening asthma. If the patients usual dose provides
relief of symptoms for less than 34 hours, patients should follow their asthma action plan.
Management of persistent asthma
Most adults with asthma will require ongoing and regular daily management with
preventer therapy in addition to as-needed SABA therapy. Preventer therapy with ICS, alone or
in combination with LABA, is recommended for patients with mild, moderate or severe
persistent asthma. A leukotriene receptor antagonist (LTRA) may be considered as an alternative
to ICS where there is reason to avoid ICS or according to patient preference.
In individuals with persistent symptoms of asthma, treatment with ICS:
reduces symptoms
reduces use of rescue medication
improves lung function
decreases exacerbations
reduces hospital admissions.