37.1 More Than Just Wheezing

Asthma is one of the most common associated comorbid conditions seen in an allergy practice. The practitioner should have a basic understanding of asthma. The author’s understanding of asthma has evolved from just a disorder of bronchoconstriction to realizing that lower airway inflammation, tissue remodeling, and airway hyperresponsiveness play a role as well. In addition, different phenotypes/endotypes of asthma, how to recognize or evaluate asthmatic patients for different phenotypes/endotypes, and what treatment each type of asthma responds best to is now being recognized and explored. It would be impossible to adequately cover asthma diagnosis, testing, and treatment in one chapter. However, even if a practitioner decides not to participate in asthma management in allergy practice, he/she should assess both their level of severity and current level of control when testing or treating asthmatic patients with immunotherapy. This chapter will focus on assessing a patient’s asthma severity and control.

37.2 How Bad It Can Get

Asthma severity is statement about the baseline quality of the patient’s asthma. It is easiest to assess in a patient newly diagnosed with asthma who’s not on long-term controller medication, but even if that patient is currently on controller medications, you can get an idea of the patient’s baseline severity level by the current medications being used to keep them in control. The National Heart, Lung, and Blood Institute (NHLBI) 2007 guidelines for the diagnosis and treatment of asthma includes recommendations on how to assess a patient’s level of asthma severity. ▶Fig. 37.1 from the NHLBI is a quick reference guide on assessing asthma severity by asking the patient about symptom frequency, nighttime awakening, use of short-acting controller medications such as albuterol, interference with normal activity, and any spirometry or pulmonary function testing results, if available.

Asthma is generally categorized as intermittent or persistent, and within the persistent category further subdivided into mild, moderate, or severe. Once categorized, the NHLBI guidelines provide recommendations for asthma therapy in a step-wise approach seen in ▶Fig. 37.2.