Summary
Definition
History and exam
Key diagnostic factors
- recent upper respiratory tract infection
- dyspnea
- cough
- expiratory wheezes
- nasal polyposis
Risk factors
- family history
- allergens/irritants
- atopic disease history
- cigarette smoking
- vaping
- respiratory viral infection early in life
- nasal polyposis
- low socioeconomic status
- obesity
- gastroesophageal reflux
- obstructive sleep apnea
Diagnostic tests
1st tests to order
- FEV₁/FVC ratio
- peak expiratory flow (PEF)
Tests to consider
- chest x-ray
- CBC
- fractional exhaled nitric oxide (FeNO)
- bronchial challenge test
- immunoassay for allergen-specific IgE
- skin prick allergy testing
- high-resolution CT (HRCT) chest
- CT sinus
Emerging tests
- sputum eosinophil count
Treatment algorithm
initial treatment step 1: asthma symptoms 1-2 days per week or less and no risk factors for exacerbations
initial treatment step 2: asthma symptoms less than 3-5 days per week and normal (or mildly reduced) lung function
initial treatment step 3: asthma symptoms most days (e.g., 4-5 days per week or more), or waking due to asthma once a week or more, low lung function, and risk factors for exacerbations
initial treatment step 4: daily asthma symptoms, waking at night once a week or more, and low lung function
ongoing treatment step 1: patients using short-acting beta agonist (SABA) alone or with newly diagnosed asthma, with normal (or mildly reduced) lung function
ongoing treatment step 2: asthma not controlled on step 1 treatment
ongoing treatment step 3: asthma not controlled on steps 1-2 treatment (track 1) or step 2 treatment (track 2), with risk factors for exacerbations
ongoing treatment step 4: asthma not controlled on step 3 treatment
ongoing treatment step 5: asthma not controlled on step 4 treatment and patient reviewed by specialist
Contributors
Authors
Lauren E. Eggert, MD
Clinical Assistant Professor
Division of Pulmonary, Allergy, and Critical Care Medicine
Department of Medicine
Stanford University School of Medicine
Stanford
CA
Disclosures
LEE has participated on advisory boards for Regeneron and AstraZeneca.
Sourav Majumdar, MD
Clinical Assistant Professor (Affiliated)
Division of Pulmonary and Critical Care Medicine
Department of Medicine
Stanford University School of Medicine
Stanford
CA
Disclosures
SM declares that he has no competing interests.
Acknowledgements
Dr Lauren E. Eggert and Dr Sourav Majumdar would like to gratefully acknowledge Dr Irwani Ibrahim, Dr Kay Choong See, Dr Francis Thien, and Dr Catherine Weiler, previous contributors to this topic.
Disclosures
II, KCS, FT, and CW declare that they have no competing interests.
Peer reviewers
Javed Sheikh, MD
Clinical Director
Division of Allergy and Inflammation
Beth Israel Deaconess Medical Center/Harvard Medical School
Boston
MA
Disclosures
JS is a consultant for Aventis, GSK, and Novartis/Genentech; is on the Speakers Bureau for Merck, Aventis, GSK, AstraZeneca, Pfizer, Novartis/Genentech, Inspire, and UCB; has had research sponsored by GSK; is an expert witness at Haemonetics; and has received publication honorarium at Emedicine.
Sheree M.S. Smith, PhD
Research Manager
Imperial College Healthcare Trust
NHLI Airways Division
Imperial College London (Honorary) Respiratory Research
Chest & Allergy
St Mary's Hospital
London
UK
Disclosures
SMSS declares that she has no competing interests.
Neil Thomson, MBChB, MD, FRCP
Professor of Respiratory Medicine
Respiratory Medicine Section
Division of Immunology, Infection & Inflammation
University of Glasgow
Glasgow
UK
Disclosures
NT declares that he has no competing interests.
References
Key articles
National Institutes of Health; National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert panel report 3: Guidelines for the diagnosis and management of asthma. August 2007 [internet publication].Full text
Global Initiative for Asthma. 2024 global strategy for asthma management and prevention. May 2024 [internet publication].Full text
Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC); Cloutier MM, Baptist AP, Blake KV, et al. 2020 focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020 Dec;146(6):1217-70.Full text Abstract
National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management. March 2021 [internet publication].Full text
British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. July 2019 [internet publication].Full text
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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