Asthma – Trent Goodin, Stacy Blank


  • 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
  • Evidence of reversible airflow obstruction (i.e. improvement of obstruction post-bronchodilator) or airway hyper-reactivity (methacholine challenge)



  • Spirometry (PFT’s) with reversible obstruction
    • FEV1/FVC <0.7; # FEV1 12% and 200 mL after bronchodilator
  • “All That Wheezes Is Not Asthma” rule out alternative diagnoses:
    • Panic attacks, upper airway obstruction, foreign body, vocal cord dysfunction, CHF (cardiac asthma), COPD, ILD

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


Additional Information

  • Follow-up
    • Repeat PFTs q3-6 mosafter 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 Symbicort (budesonide-formoterol) is the formulary ICS/LABA
    • Ordering PFTs: Refer to Pulm section on PFTs for VUMC and VA specifics