Asthma – PocketRounds

Asthma Control Test

Score 5-25. Higher score = better control.

1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done?

2. During the past 4 weeks, how often have you had shortness of breath?

3. During the past 4 weeks, how often did your asthma symptoms wake you up at night?

4. During the past 4 weeks, how often have you used your rescue inhaler?

5. How would you rate your asthma control during the past 4 weeks?

Symptoms/ Diagnosis

Variable wheeze, cough, chest tightness, dyspnea
Triggers: dust, pollen, smoke, wildfires, exercise, viral illness
Ask about childhood asthma, family history, premature birth
Spirometry with bronchodilator reversibility is standard
FEV1 ↑ ≥12% and ≥200 mL supports asthma
If spirometry normal → methacholine challenge
PEF can assist if spirometry unavailable

PFT's

Test	Findings in Asthma	Notes
FEV1/FVC Ratio	↓ (Reduced) (<0.75-0.80)	Hallmark of obstructive lung disease
FEV1 (Post-Bronchodilator)	↑ by ≥12% and ≥200 mL improvement	Confirms reversible airway obstruction
FEF 25-75%	↓ (Reduced)	Suggests early small airway involvement
TLC (Total Lung Capacity)	Normal or ↑	Hyperinflation may occur in severe cases
RV (Residual Volume)	↑ (Increased)	Air trapping due to airway obstruction
DLCO (Diffusion Capacity)	Normal	Differentiates from COPD (which may have ↓ DLCO)
Methacholine Challenge	FEV1 ↓ by ≥20% at low doses	Indicates airway hyperreactivity when spirometry is normal

Control

Asthma control is assessed using the Asthma Control Test (ACT)

ACT ≥20 = well controlled
ACT ≤19 = not well controlled

Treatment: Formoterol + ICS (Symbicort)

Mild: PRN Symbicort. 2 puffs prior to trigger
More symptoms: Symbicort BID with additional doses PRN for symptom relief
- Formoterol preferred over salmeterol due to rapid onset (5-10 min vs 2 hours)
If no ICS-formoterol: use ICS whenever SABA used
Montelukast for allergic/exercise/ASA-sensitive asthma
Always check inhaler technique

Treatment Options

	Qualifying criteria	Step 1Intermittent / very mild	Step 2Mild persistent	Step 3Moderate symptoms	Step 4More severe / frequent symptoms
	Who fits this step	Symptoms ≤2 days/week Night symptoms ≤2/month Normal FEV₁ Exacerbations ≤1/year	Symptoms 3 to 6 days/week Night symptoms 2 to 4/month Minimal activity limitation ≥2 steroid-requiring exacerbations/year	Daily symptoms Night symptoms >1/week Some activity limitation Airflow obstruction between flares	Frequent activity limitation Night awakenings More severe obstruction
Option 1	ICS-formoterol regimen	Low-dose ICS-formoterol as needed	Low-dose ICS-formoterol as needed	Low-dose ICS-formoterol maintenance + reliever	Medium-dose ICS-formoterol maintenance + reliever
Option 2	Alternative maintenance	No daily controller	Anti-inflammatory reliever only or Low-dose ICS daily	Low-dose ICS-LABA or Low-dose ICS + LAMA or LTRA	Medium-dose ICS-LABA or Medium-dose ICS + LAMA or LTRA
	and	and	and	and	and
	Alternative reliever	ICS-SABA as needed or ICS + SABA as needed or SABA as needed	ICS-SABA as needed or ICS + SABA as needed or SABA as needed	ICS-SABA as needed or ICS + SABA as needed or SABA as needed	ICS-SABA as needed or ICS + SABA as needed or SABA as needed

Inpatient Management

Assess severity: WOB, speech, accessory use, AMS, O2 need; red flags = silent chest, fatigue, rising CO2
O2 to SpO2 >92%
Bronchodilators: albuterol ± ipratropium (q2–4h or continuous if severe)
Steroids early: IV or PO, do not delay
Mg sulfate IV if severe or poor response
Reassess frequently: WOB, air movement, SpO2
VBG/ABG if worsening or c/f hypercapnia
CXR only if atypical or c/f PNA/PTX
Escalate: continuous nebs, consider NIV briefly, early ICU
Intubate if AMS, exhaustion, rising CO2, refractory hypoxemia
Avoid: sedatives, routine abx, stopping controller therapy
Discharge: stable on spaced nebs, off O2, steroids completed/prescribed, on ICS regimen, inhaler teaching + follow-up

Assess asthma exacerbation severity

↓

Signs of impending respiratory failure?

↓

Severe exacerbation?
(PEF ≤50% predicted or personal best)

Yes

↓

Admit, ICU/Anesthesia consult

• SABA + ipratropium neb
• O2 target SpO2 93 to 95%
• IV methylprednisolone 40 to 60 mg
• IV magnesium sulfate 2 g over 20 min
• Assess alternate dx/comorbidities

Severe exacerbation

↓

• Nebulized SABA or SABA/ipratropium q20 min x1 hr or continuous
• O2 target SpO2 93 to 95%
• IV methylprednisolone 40 to 60 mg
• Or prednisone 60 mg PO

Mild to moderate exacerbation

↓

• SABA by neb or MDI q20 min x1 hr, then PRN
• O2 target SpO2 >92%
• Prednisone 40 mg PO

Worsening
symptoms, PEF, SpO2

↓

Admit, ICU/Anesthesia consult

• SABA/ipratropium nebs
• O2 target SpO2 93 to 95%
• IV methylprednisolone 40 to 60 mg if not already given
• Assess alternate dx/comorbidities

Good response
Symptoms resolved, PEF >80%

↓

Discharge home

• Reliever q4 to 6h PRN
• Prednisone 40 to 60 mg/day x 5 days
• Inhaler teaching + action plan
• PCP follow-up
• Resume/initiate ICS if needed

Incomplete response
Persistent dyspnea/wheeze or PEF 60 to 80%

↓

Continue observed treatment for another 1 to 3 hours and reassess

Good response
Symptoms resolved, PEF >80%

↓

Discharge home

• Reliever q4 to 6h PRN
• Prednisone 40 to 60 mg/day x 5 days
• Inhaler teaching + action plan
• PCP follow-up
• Resume/initiate ICS if needed

Incomplete response after reassessment
Persistent symptoms/wheeze or PEF 60 to 80%

↓

Worsening
symptoms, PEF, SpO2

↓

Admit, ICU/Anesthesia consult

• SABA/ipratropium nebs
• O2 target SpO2 93 to 95%
• IV methylprednisolone 40 to 60 mg if not already given
• Assess alternate dx/comorbidities

Still incomplete
PEF 60 to 80%, prior severe exacerbations, or poor adherence

↓

Admit to hospital
Continued treatment and monitoring

Substantial improvement
PEF 60 to 80%, good understanding/follow-up

↓

Discharge home

• Reliever q4 to 6h PRN
• Prednisone 40 to 60 mg/day x 5 days
• Inhaler teaching + action plan
• PCP follow-up
• Resume/initiate ICS if needed

Outpatient Exacerbations

Use personal best PEF
- Green ≥80% → continue usual meds
- Yellow 50–79% → step up meds, monitor closely
- Red <50% → send to ED
Send to ED regardless of PEF if patient has: severe dyspnea, speaking only short phrases, accessory muscle use, no improvement after rescue therapy

Asthma Phenotypes

High T2 Inflammation: Allergic asthma, high eosinophils, responds to ICS and biologics
Low T2 Asthma: Poor response to biologics, limited treatment options
Cough-variant Asthma: Montelukast may help
Obesity-associated Asthma: Unique pathophysiology, often harder to control