Asthma in adults

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 13 Jul 2024

Last updated: 01 Aug 2024

01 Aug 2024

GINA reiterates montelukast safety warning

The 2024 GINA guideline update reminds prescribers of the potential risk of neuropsychiatric adverse events in patients receiving montelukast, including:[53]

new-onset nightmares,
behavioral and mood problems (e.g., agitation, hyperactivity, irritability, nervousness, aggression), and
suicidal ideation.

Healthcare professionals should consider the benefits and risks before prescribing montelukast and have an open discussion with patients about potential adverse effects.

Healthcare professionals and patients should be alert to, and monitor for, serious behavior and mood-related changes during treatment.

See Management: approach

Original source of update

Asthma in adults presents with recurrent episodes of shortness of breath, chest tightness, wheezing, or coughing.

Examination typically demonstrates an expiratory wheeze; however, in severe asthma there is poor air entry and the chest is silent.

Treatment is stepwise, based on symptoms. Patients may need to monitor their peak expiratory flow daily and should be aware of the warning signs of a severe attack.

Some patients may develop progressive, irreversible obstructive lung disease.

Definition

Asthma is a chronic inflammatory airway disease characterized by intermittent airway obstruction and hyper-reactivity. Many cellular components are involved in the asthmatic pathway, including mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells. On insult, in susceptible people, inflammation causes increased bronchial hyper-responsiveness and recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, which are usually associated with widespread but variable airway obstruction that is reversible either spontaneously or with treatment.[1]

History and exam

Key diagnostic factors

recent upper respiratory tract infection
dyspnea
cough
expiratory wheezes
nasal polyposis

Full details

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

Full details

Diagnostic tests

1st tests to order

FEV₁/FVC ratio
peak expiratory flow (PEF)

Full details

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

Full details

Emerging tests

sputum eosinophil count

Treatment algorithm

ACUTE

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

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

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

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

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

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

Disclosures

NT declares that he has no competing interests.

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Asthma in adults

GINA reiterates montelukast safety warning

Summary

Definition

History and exam

Key diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

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

Disclosures

Sourav Majumdar, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Javed Sheikh, MD

Disclosures

Sheree M.S. Smith, PhD

Disclosures

Neil Thomson, MBChB, MD, FRCP

Disclosures

Differentials

Guidelines

Patient information

Videos

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