Mild Persistent Asthma

Aka: Mild Persistent Asthma, Mild Asthma

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II. Criteria

  1. Asthma may affect activity
  2. Frequent symptoms (>2 days per week) but not daily
    1. Nighttime symptoms awaken patient 3-4 times monthly
    2. Short-acting Beta Agonist (e.g. Albuterol) more than 2 days/week (but not daily)
      1. For age 5 years and older, not more than once daily use
    3. Exacerbations
      1. Age 5 years and older
        1. Oral Corticosteroids required 2 OR more times per year
      2. Age <5 years with Asthma risk
        1. Two exacerbations in 6 months OR Wheezing >1 day for 4 episodes/year
  3. Pulmonary Function Test Criteria
    1. FEV1 or PEF > 80% predicted
    2. FEV1 to FVC Ratio normal (>85% for age 5-19, >80% for age 20-39, >75% for age 40-59, then >70%)
    3. PEF variability 20-30%

III. Management

  1. See Asthma Stepped Care
  2. Long-term control with one Anti-Inflammatory medication
    1. Inhaled Corticosteroid (Low Dose)
    2. Inhaled Cromolyn or Nedocromil
    3. Do not substitute with Long-Acting Beta Agonist
      1. Risks loss of Asthma control
      2. Steroids are key management of persistent Asthma
      3. Long-Acting Beta Agonist is in addition to steroids
      4. Lazarus (2001) JAMA 285:2583-93 [PubMed]
    4. Adult stable patients may taper steroids to half dose
      1. Hawkins (2003) BMJ 326:1115 [PubMed]
    5. Combined Inhalers with Formoterol and Corticosteroids (Symbicort, Dulera) have been studied for prn use
      1. May reduce adult severe exacerbations (esp. for those not compliant with daily Inhaled Corticosteroid)
      2. Expensive ($300 per Inhaler), risk of LABA Overdose, and only studied in adults
      3. However, compliance with Inhaled Corticosteroid daily, and prn Albuterol is still preferred strategy
      4. Beasley (2019) N Engl J Med 380(21):2020-30 +PMID: 31112386 [PubMed]
      5. O'Byrne (2018) N Engl J Med 378(20):1865-76 +PMID: 29768149 [PubMed]
  3. Short-term
    1. Rescue with beta Agonist
    2. Increased use may indicate Moderate Persistent Asthma
  4. Asthma Education
    1. Consider Group education
  5. Exacerbations
    1. See Asthma Exacerbation
    2. See Asthma Exacerbation Home Management
    3. See Emergency Management of Asthma Exacerbation
    4. See Asthma Inpatient Management
    5. See Status Asthmaticus
    6. See Asthma Exacerbation Severity Evaluation
    7. See Asthma-Related Death Risk Factors

IV. Management: As needed Inhaled Corticosteroids

  1. Indications
    1. Mild Persistent Asthma well controlled on a low-dose Corticosteroid
  2. Contraindications (and reason to return back to daily Inhaled Corticosteroids)
    1. AlbuterolInhaler use more than twice weekly
  3. Advantages
    1. May offer similar Asthma control with only one-half total Inhaled Corticosteroid dose
  4. Protocol
    1. Discontinue daily Inhaled Corticosteroid
    2. Use 2 puffs of the Inhaled Corticosteroid at the same time as the rescue Inhaler
    3. Return to daily Inhaled Corticosteroid use if rescue Inhaler used more than twice weekly
  5. References
    1. Boushey (2005) N Engl J Med 352(15):1519-28 [PubMed]
    2. Martinez (2011) Lancet 377(9766):650-7 [PubMed]
    3. Papi (2007) N Engl J Med 356(20):2040-52 [PubMed]

V. Prevention

  1. See Asthma Education
  2. Influenza Vaccine
  3. Weight loss in Obesity
  4. Exercise

VI. References

  1. Park (2017) Asthma Updates, Mayo Clinical Reviews, Rochester, MN
  2. (1997) Management of Asthma, NIH 97-4053
  3. (1995) Global Strategy for Asthma, NIH 95-3659
  4. Kalister (2001) West J Med 174:415-20 [PubMed]
  5. Kemp (2001) Am Fam Physician 63(7):1341-54 [PubMed]

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