Monitoring
Asthma management should include regular assessments of clinical status (e.g., symptoms), lung function, and exacerbation prevention. Monitoring should include assessment of both symptom control and risk factors, but should not focus on exacerbation history due to the continued risk of severe exacerbations in patients with otherwise good symptom control.[1][8][266][267]
When initiating therapy, monitor at 2- to 6-week intervals to ensure adequate symptom control. Follow-up frequency should range from every 1 month to every 6 months, depending on the level of control. Review the need to step up or step down therapy at each follow-up assessment.[1][8]
Consider stepping up preventative therapy if features of poor control are present despite optimal adherence and drug delivery.
Consider stepping down treatment in children with good asthma control for 3 months or more, avoiding periods of higher risk (e.g., winter, start of school term).[1][268] In general, step-down should follow the reverse order of the step-up strategy.[268]
Symptom control
In the nonacute state, control is determined by the amount of day or night symptoms between exacerbations (wheeze, cough, or chest tightness), reliever use (excluding for the prevention of exercise-induced symptoms), the frequency of exacerbations, school absence. These parameters are monitored at follow-up, especially in children with persistent asthma.
A suggested approach for grading the level of symptom control is to assess four core questions:[1]
Are daytime symptoms present more than twice a week?
Is there night time waking due to asthma?
Is a SABA reliever used more than twice a week for symptom control (excluding pre-exercise use)?
Has there been any limitation to normal activities due to asthma?
Patients are considered well controlled if none of these are present, partly controlled if one to two are present, and uncontrolled if three to four of these are present.[1]
Spirometry (forced expiratory volume in 1 second [FEV₁] and/or peak expiratory flow [PEF]) may be used to monitor patients on an outpatient basis, with spirometry preferred from the age of 5 years where services are available and children are compliant.[1]
Guidelines differ on the use of PEF for routine self-monitoring of asthma control due to conflicting evidence of its risks and benefits: Global Initiative for Asthma (GINA) recommends routine PEF measurements as a component of self-mannagement, but British Thoracic Society, National Institute for Health and Care Excellence, and Scottish Intercollegiate Guidelines Network (BTS/NICE/SIGN) recommends against this approach.[1][8] PEF monitoring in chronic asthma is often confined to a subset of older children with poor symptom perception who show a consistent ability to perform PEF well.
BTS/NICE/SIGN also recommend the use of FeNO testing for patients with uncontrolled asthma, noting that an elevated level may indicate poor adherence to inhaled corticosteroids (ICS) therapy.[8]
A guide on how to perform and interpret spirometry, including common pitfalls.
How to use a peak flow meter to obtain a peak expiratory flow measurement.
Risk factors for exacerbation
The presence of risk factors for exacerbations, persistent airflow limitation, and medication adverse-effects should be considered at each assessment. Examples include:[1][8]
Risk of exacerbations:
Excessive SABA usage
Inadequate ICS usage (through either inadequate prescription or suboptimal adherence)
Co-morbidities (e.g., obesity, chronic rhinosinusitis)
Continued exposure to triggers (e.g., smoking/vaping, air pollution)
Psychologic or socioeconomic issues
Low FEV₁ and high bronchodilator responsiveness
Markers of type 2 inflammation (e.g., blood eosinophilia)
Past severe or life-threatening exacerbations
Risk of persistent airflow limitation:
A history of preterm birth, low birth weight
Failure to prescribe ICS treatment to patients with severe exacerbations
Continued exposure to triggers (e.g., smoking/vaping, air pollution)
Low initial FEV₁ and the presence of sputum or blood eosinophilia
Risk of adverse effects
Local or systemic effects of frequent OCS use or long-term high-dose ICS use
Questionnaires
Several tools are available for assessing asthma symptom control, including simple screening questionnaires (e.g., GINA's symptom control tool), categorical questionnaires (e.g., the UK Royal College of Physicians' "Three Questions"), and numerical questionnaires (e.g., the Asthma Control Test and Asthma Control Questionnaire, 5-item version).[1][8] GINA's symptom control tool includes questions that assess risk factors for future exacerbations.[1]
No questionnaire is ideal in the absence of a comprehensive evaluation. Strengths and limitations exist for each. For example, the Asthma Control Test has shown good internal consistency and content validity, but mixed levels of agreement with clinical measures of asthma and poor cross-cultural validity.[269][270]
Emerging monitoring tools
US guidance states that FeNO may be used as part of an ongoing monitoring and management strategy for children ages 5 years and older if assessments are frequent and the FeNO level is not used in isolation. However, it is not known what constitutes a clinically meaningful change in FeNO levels (changes <50% are unlikely to be related to asthma).[271] Monitoring by FeNO has no or modest additional benefits on clinical outcomes compared to symptom and spirometry-based monitoring.[272][273][274][275]
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