No, according to GINA guidelines asthma should be classified in relation to control. That means use of beta-2-agonists, awakening or disturbed sleep, normal physical activity during daytime. Spirometry is of little imortance in this respect, but if you suspect reduced control a spirometry with reversibility test may be indicated to verify reduced control in the actual subject.

Absolutely yes. Although characterizing asthma in terms of control is important and the key to determine if that person's management has been followed and is successful is a top priority and guides whether or not changes in maintenance therapy is required, severity still determines if someone is a candidate for certain therapies - particularly Xolair.

No, insufficient control is sufficient indication for e.g. increased dosage on steroids or leukotrienantagonists. A normal spirometry in this situation does not change the indication for increased or supplementary medication.

Yes, it is true. The best known classification is periodically updated by GINA (Global Initiative for Asthma). It should be downloadable at internet.

I think that severity grading for asthma specialists is not useful The only questions is, intermittent or persistent? The guidelines are, however, designed for primary care physicians. In the US, severity grading may be helpful for a primary care physician in determining initial controller therapy for a controller naive patient. When I see such a patient, I'm sure that I subconsciously grade but never think about it on the conscious level. After that, control or the lack for control determines treatment intensity.

asthma classification on the basis of severity is particularly still used by general physicians who followed textbook of davidson, harrison etc. sply in India. But most of the pulmonologists prefer to follow GINA guideline which obscured severity grading. Control based classification also did cover all the parameters of severity grading of asthma. Moreover one can apply ACT, ATAQ, ACQ questionnaire very easily in the control based classification..we can have an international comparison level if we are going by control classification and overall control is the utmost outcome in the asthma treatment. So i think control classification is more validated and we should go by it

I believe it may depend on what you are trying to assess. If you are trying to spot trends you might be better off using extreme phenotypes.

My understanding was that asthma ‘severity’ in the broader sense could also be appreciated on the response to standardised therapy (eg, (inhaled)steroid resistant vs sensitive) and that these spoke to differing phenotypes.

This is a good question and all points are valid. Guidelines (GINA) are recommending to move away from "severity" as it was understood in the past (as result of one judgement) with the intention of offering a more dinamic measure which takes into account other points as response to treatment, risks or current exacerbations,... It is clear that at first visit patient has to be "graded" to select which is the preferred therapeutic approach for his/her disease and current phenotype. But I would recommend to move from this intial point to the controlled/uncontrolled classification as that helps to adapt patient status and current therapeutical options

I think GINA can be a good help

Good question. I believe that classification of asthma based on severity is valid only in the first visit where asthma is diagnosed and the patient is not taking any treatment and also in the case of a known asthmatic who is not on treatment. Then you take your treatment decisions according to the STEP. In all other cases you should be looking for the level of asthma control in order to increase or decrease treatment.

meeting criteria for control with treatment, not initial severity of symptoms. The alleged assocation between "severity" and medication selection is the antithesis of evidence based medicine.

No, there is no evidence supporting a relationship between initial assessment of severity and specifics of medication requirements to attain control. So the issue is meeting criteria for control with treatment, not initial severity of symptoms. The alleged assocation between "severity" and medication selection is the antithesis of evidence based medicine.

Absolutely, there is no question of a definite established relationship between severity and specifics of medication requirements to attain control. Probably the clearest example - but is just one of many countless published objective studies on this relationship that can easily be referenced - is the approved indication for Xolair but also the ultimate needs of meds. How often do we see patients with confirmed asthma with symptoms consistent with mild intermittent asthma and an FEV that is nearly always normal or hovering around 80% of predicted who needs more than just a rescue inhaler to ensure their asthma is controlled - nearly never. How often do we see asthma in someone who requires a rescue inhaler daily and wakes due to asthma at night nearly every night who only requires a rescue inhaler for control - again the answer is never. I could go on for pages but due to space is impossible.

Guidelines are for all physicians- specialists and primary care.

It remains important to classify asthma severity, particularly at the first encounter, so as to guide initial therapy. Thereafter, assessing control and responsiveness to therapy is the key. Regardless of baseline severity, if someone is poorly controlled on subsequent visits, one should escalate therapy, or address the reasons why someone is uncontrolled. If someone is well controlled, one can then potentially de-escalate therapy.

I think control classification works well in typical asthma patients who respond well to inhaled steroids and LABA. In Indian setting we see lot of patients with asthma having remodelled airways and relatively irreversible obstruction. In such patients I feel its difficult to achieve control based on GINA recommendations and severity classification based on spirometric values (FEV1 and IC) provides better insight. In short in patients predominantly having bronchial hyperresponsiveness, control classification would work better and in severe asthma predominantly having air-trapping and hyperinflation, spirometry + QoL classification would work better.

Thanks you all for a lively interaction.

The initial assessment is the question? GINA has kilometered away from severity and that includes all encounters with asthma patients...first contact included. Cross sectional studies have shown that respiratory physicians prescribe controller medications with scant regard to severity as it was described earlier. Are we not complicating it by assessing with one scale at the initial contact and doing away with it as we cruise along. Severity assessment is complex and consensus has it that it be dichotomized into mild (for easily controllable) and severe (high steroid dose requiring or one difficult to treat with usual medication). Beyond this it may prove too complex for routine clinical practice? Thought????

30 years ago when you are in a poor children´s hospital,asthma crisis was treatment with adrenaline SC, and Aminofiline IV with out side effects if you know the pharmacology of drugs and corticosteroid for very critical patients, if you don´t have FEV1 was very useful THE SILVERMAN ANDERSEN SCORE , the same that you use for respiratory failure in neonates, the Mexicans made many works of this use, Actually I use the same score for decide the use of rescue medication or corticosteroids adapted to Protocols of NHBLI of USA that give origin to Gina Protocols, and the step treatment. Please make a research in India using the Silverman Andersen Score and mention my reference how personal communication.

In kids, certainly. In cohort studies severity seems to be the single most important predictor of persistence.

It is important to be aware of the difference between diagnosis of asthma and follow up of the disease. In diagnosing asthma spirometry ("severity") is the main topic by assessing reversibility after SABA inhalation (12% reversibility as suggested diagnostic criteria). In follow up the patients should ideally have no reversibilty if optimally treated with inhalation steroids and LABA, meaning that spirometry has a minor role in follow up. This is the rationale behind the GINA guidelines focusing on control in the follow up visits.

It is very essential to classify Asthma on the basis of clinical features & PEFR for the physician to decide on management The classification as - Mild : more than 1 -2 attacks per week & PEFR > 80% ; Moderate : daily attacks & PEFR - 6O to 80% ; & severe : continuous attacks & PEFR < 60% - is a useful guide to determine treatment .The most important complication of asthma is acute severe asthma & this is entirely dependent on clinical features for diagnosis . The dose frequency of inhalation steroids & bronchodilators are titrated by symptoms primarily & supported by PEFR & Spirometry . Therefore , assessment based on severity is essential to manage asthma , both at home & in hospital .

The consensus emerging from the discussion seems that we must assess severity when patients are first seen and subsequently assess only control. GINA has clearly done away with the severity. A study comparing management on the basis of severity and control could very much be on...to settle the issue conclusively.

It seems reasonable and practical to grade the patients at the first visit according to severity.

At next visits, GINA recommend to stratify patients based on control of the disease (6 items, ACT, etc.)

Agree with the most recent comments of Parvaiz and Stefan (and mine also 6 days ago).

GINS guide line better works in cases of mild to moderate asthma

This is a great discussion!

I think we need both severity and control because, obviously we will treat differently two patients who are equally well controlled but one has a history of frequent and severe asthma attacks and is controlled on 1000mcgs of ICS and the other has a history of rather persistent but mild symptoms and needs 200mcgs to be kept under control. So, in asthma, the history and the level of medication are always in our mind and these are markers of severity while we base any changes in medications on the level of control.