Criteria

Your Organizational Guidance

ebpracticenet urges you to prioritize the following organizational guidance:

Astma bij volwassenen: diagnose en monitoring in de eerste lijnPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2020Asthme chez l’adulte : diagnostic et surveillance en soins de santé primairesPublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2020

In an urgent care setting or where a patient presents with an acute exacerbation, please refer to guidance for diagnosing Acute asthma exacerbation in adults.

Global Initiative for Asthma (GINA)[52]

According to international guidelines from the Global Initiative for Asthma (GINA), asthma is defined by a history of respiratory symptoms, such as wheeze, shortness of breath, chest tightness, and cough, that vary over time and in intensity, together with confirmed variable expiratory airflow limitation. People with asthma generally have more than one type of respiratory symptom. In adults, an isolated cough is unlikely to be asthma. Descriptions may vary between cultures and by age.

Variable respiratory symptoms

  • Symptoms vary over time and in intensity

  • Symptoms are often worse at night, or on waking

  • Symptoms may be triggered by exercise, laughter, allergens, or cold air

  • Symptoms may appear or worsen with viral infections

Confirmed variable expiratory airflow limitation

  • Consists of documented excessive variability in lung function and documented expiratory airflow limitation.

  • Peak expiratory flow (PEF) measurement can be used as an alternative to spirometry where spirometry services are not available. Although the PEF is less reliable than spirometry, its use is preferred where diagnosis would otherwise rely on symptoms only. Use the highest of three readings and the same meter at each measurement over time.

  • At a time when forced expiratory volume at 1 second (FEV₁) is reduced, a reduced FEV₁/forced vital capacity (FVC) ratio from spirometry indicates airflow limitation. Adults without airflow limitation normally have an FEV₁/FVC ratio of >0.75 to 0.80.

  • One or more of the following tests confirms excessive variability in lung function. The greater the variations, or the more occasions that excess variation is seen, then the more likely is the diagnosis of asthma. Tests can be repeated during symptoms or early in the morning if initially negative:

    • A positive bronchodilator responsiveness (reversibility) test; more likely to be positive if bronchodilator medication is withheld before test: short-acting beta agonist (SABA) ≥4 hours, twice-daily long-acting beta agonist (LABA) 24 hours, once-daily LABA 36 hours. In adults, an increase in FEV₁ of >12% and >200 mL from baseline (or PEF of ≥20%), 10-15 minutes after 200-400 micrograms of albuterol or equivalent, is a positive test; there is greater diagnostic confidence if the increase is >15% and >400 mL

    • Excessive variability in twice-daily peak expiratory flow (PEF) over 2 weeks (subtract each day’s highest from each day’s lowest value and divide by the mean). In adults, an average daily diurnal variability in PEF of >10% is considered excessive

    • A significant increase in lung function after 4 weeks of anti-inflammatory treatment. In adults, an increase in FEV₁ by >12% and >200 mL (or PEF by ≥20%) from baseline after 4 weeks of treatment, outside respiratory infections, indicates excessive variability

    • A positive exercise challenge test. In adults, a fall in FEV₁ of >10% and >200 mL from baseline is a positive test

    • A positive bronchial challenge test. A fall in FEV₁ from baseline of ≥20% with standard doses of methacholine, or ≥15% with standardized hyperventilation, hypertonic saline, or mannitol challenge

    • Excessive variation in lung function between visits: good specificity but poor sensitivity. In adults, a variation in FEV₁ of >12% and >200 mL between visits (or PEF of ≥20%), outside of respiratory infections, indicates excessive variability.

Assessment of asthma severity (after initiation of treatment)[52]

International guidelines from the GINA state that asthma severity is assessed retrospectively, once the patient has been on controller treatment for several months and, if appropriate, a step-down in treatment has been attempted. Asthma severity may change over time.

  • Mild asthma: asthma that is well controlled with step 1 or step 2 treatment, i.e., as-needed inhaled corticosteroid (ICS)-formoterol, or with low-dose ICS plus as-needed short-acting beta-agonist (SABA).

    • GINA does not distinguish between so-called "intermittent" and "mild persistent asthma."

    • GINA recommends generally avoiding use of the term "mild asthma" as it conflates it with being low risk. If "mild asthma" needs to be used, it should be qualified with a reminder that infrequent or mild symptoms can still have severe or fatal exacerbations.

    • Debate around the definition of mild asthma is ongoing and pending further stakeholder discussion.[72]

  • Moderate asthma: asthma that is well controlled on step 3 or step 4 treatment, such as low- or medium-dose ICS plus long-acting beta agonist (ICS-LABA).

  • Severe asthma: asthma that remains uncontrolled despite optimized treatment with high-dose ICS-LABA, or that requires high-dose ICS-LABA to stop it from becoming uncontrolled.

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