Summary
Definition
History and exam
Key diagnostic factors
- recent upper respiratory tract infection
- dyspnea
- cough
- expiratory wheezes
- nasal polyposis
Risk factors
- family history
- allergens
- atopic history
- cigarette smoking or vaping
- respiratory viral infection early in life
- low socioeconomic status
- nasal polyposis
- obesity
- gastroesophageal reflux disease (GERD)
- obstructive sleep apnea
Diagnostic investigations
1st investigations to order
- FEV₁/FVC ratio
- peak expiratory flow rate (PEFR)
- CXR
- CBC
- fractional exhaled nitric oxide (FeNO)
Investigations to consider
- bronchial challenge test
- immunoassay for allergen-specific IgE
- skin prick allergy testing
Emerging tests
- sputum eosinophil count
Treatment algorithm
initial treatment: infrequent asthma symptoms (e.g., less than twice a month) and no risk factors for exacerbations
initial treatment: asthma symptoms or need for a reliever twice a month or more (but less than 4-5 days per week)
initial treatment: troublesome asthma symptoms most days, or waking due to asthma once a week or more, especially if any risk factors exist
initial treatment: severely uncontrolled asthma or acute exacerbation
ongoing treatment: step 1 (symptoms less than twice a month and no exacerbation risk factors)
ongoing treatment: step 2 (asthma not controlled on step 1 treatment)
ongoing treatment: step 3 (asthma not controlled on step 2 treatment)
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.
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