What Is Severe Asthma?

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Airway inflammation and flare-ups are common to all who have asthma. But 5% to 10% of those diagnosed have severe asthma, a classification indicating that you are at greater risk for exacerbations. A number of issues can increase your chances of developing severe asthma, including underlying health conditions, genetics, and lifestyle factors.

Also known as severe persistent asthma, severe asthma is a very serious condition that can greatly reduce your quality of life and may lead to other health problems if not properly addressed. It requires the use of medium- or high-dose inhaled corticosteroids combined with longer-acting medications to manage your condition.

In some cases, severe asthma cannot be controlled even with proper use of asthma medications.

man having a hard time breathing
Geber86 / iStockphoto

Symptoms of Severe Asthma

Those with severe asthma suffer from the classic symptoms that affect all who have asthma:

These can be more intense in those with severe asthma.

Severe asthma can also cause more serious breathing problems, including:

Rapid breathing

  • The chest expands and doesn't return to a regular state even when you breathe out.
  • Breathing becomes very labored with chest retractions that cause the skin to pull in tightly against the chest and ribs (creating a clear outline of the bones).
  • Nostrils move quickly in and out.

More frequent breathing problems

  • Nighttime asthma episodes are common.
  • Breathing difficulties occur throughout the day.
  • Rescue medication is needed several times per day.

Short- and long-term complications

  • Heart rate races.
  • Face, lips, and fingernails turn blue (cyanosis) because your blood lacks oxygen.
  • Lung function is reduced.
  • Everyday activities become more difficult.

How long an attack lasts varies depending on what triggered it and how inflamed your airways are. Severe attacks last longer than mild ones, though, with breathing problems persisting for several hours and, possibly, even a few days.

In rare cases, severe asthma can be fatal. With the right treatment, however, symptoms should resolve.

Causes

Severe asthma may be caused by hypersensitivity to certain triggers such as pollen, dust mites, animal dander, mold, perfumes, and air pollution. Having exercise-induced asthma is likely to make it more difficult for you to manage asthma symptoms with an active lifestyle.

While these factors put you at risk for any degree of asthma (mild, moderate, or severe), you're more likely to suffer severe symptoms if you also fall into another high-risk category.

Age and Gender

In children, boys are more likely to suffer from severe asthma than girls. The trend switches around puberty, however. As they progress through adolescence, older girls and women are at greater risk for severe asthma.

While researchers believe sex hormones play an important role in your chances of developing severe asthma, it is not clearly understood how or why.

Obesity

Obesity also increases the likelihood that you will suffer from severe asthma. Again, the exact reason why extra weight raises the risk for severe asthma is still being researched. However, studies have found factors related to obesity that seem to play a role:

  • Pressure on the chest and abdomen from extra weight may impede breathing.
  • Fat tissue produces inflammation that affects the airways and may contribute to severe asthma.
  • People with a body mass index (BMI) over 30 respond poorly to medication used to treat asthma, including inhaled corticosteroids. This leads those with mild or moderate asthma to progressively suffer worse symptoms.

Smoking

Smoking has a negative impact on those with and without asthma. Because it causes lung tissue damage and interferes with the respiratory system's ability to keep out irritants, it's especially problematic for people with hypersensitivity.

If you have asthma and smoke, you are likely to have poorer control over your symptoms than a non-smoker with asthma. According to research, this is due to airway inflammation and less sensitivity to corticosteroid medications.

Asthma is a progressive disease. If it's not treated properly, it can develop into a more serious condition. If you do not take preventive measures, you could suffer from frequent asthma attacks, which can cause the lungs to change. This can lead to severe asthma or other lung diseases.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common sleep disorder in which your upper airway becomes blocked during sleep. It can cause snoring, choking, or gasping for air.

If you suffer from OSA, you are more likely to have severe asthma symptoms. When OSA is effectively treated, studies show that asthma may become less severe.

Chronic Sinusitis

Chronic sinus inflammation has been directly linked to asthma. This means that those with frequent sinus infections and perennial allergic rhinitis are more likely to develop some form of asthma.

In one study, about 33% of those with moderate or severe persistent rhinitis were also diagnosed with asthma. The more serious the inflammation, the greater the severity of asthma.

Gastroesophageal Reflux Disease (GERD)

GERD is a chronic disorder of the digestive system in which the esophageal doesn't completely close, allowing stomach acid to come back up the digestive tract.

GERD has been associated with uncontrolled asthma because those acids from the stomach can be inhaled into the lungs and lead to increased asthma symptoms. If your asthma symptoms are not being well managed, your doctor may recommend trying GERD medications.

Other Diseases

Less common diseases that may play a role in severe asthma include:

  • Allergic bronchopulmonary aspergillosis: This fungal infection of the lung is caused by hypersensitivity to antigens that colonize the airways.
  • Churg-Strauss syndrome: A rare autoimmune condition, Churg-Strauss syndrome causes inflammation of the blood vessels and primarily affects the lungs.
  • Primary immunodeficiencies: These deficiencies of the immune system include a wide range of disorders. In adults with asthma, the disorders frequently exacerbate asthma symptoms.

Diagnosis

Severe asthma is not the same as uncontrolled asthma, and the two designations can be distinguished by some key factors.

Severe Asthma
  • Symptoms cannot be controlled with typical medication dosages

  • Adjustments in treatment not successful in controlling symptoms

Uncontrolled Asthma
  • Mild or moderate asthma in which symptoms are not well-managed with your current medication plan

  • Should improve with treatment changes

When presenting with symptoms of severe asthma, your doctor will likely adjust your current asthma treatment plan to see if you improve. If they don't, that very fact helps inform a diagnosis of severe asthma.

Your doctor will check your overall pulmonary function since severe asthma often reduces lung function. Poor lung function can be determined by spirometry or another pulmonary function test (PFT). These breathing tests generally focus on your forced expiratory volume (FEV), or how much air you can exhale into a spirometer in one second.

Differential Diagnoses

Sometimes, asthma symptoms aren't caused by asthma at all, which is why asthma medications don’t work. For instance, vocal cord dysfunction (VCD) is a medical condition that mimics asthma but is caused by the vocal cords closing over the airway, leading to shortness of breath and wheezing-like sounds.

Your doctor should consider a VCD diagnosis if you are suffering from uncontrollable asthma symptoms. This diagnosis is best made using nasal endoscopy.

In other instances, you may have asthma and may begin to show signs of severe asthma. These symptoms are not always due to asthma progression; they may be caused by another condition. Upper respiratory tract infections and rhinosinusitis are the most common illnesses that can produce symptoms that mimic severe asthma in people who already have mild or moderate asthma.

Treatment

To be properly treated for severe asthma, you may need to consult with several specialists, including a pulmonologist, otolaryngologist (ear, nose, throat doctor), and an allergist.

A combination of treatments is often used to manage severe asthma. These may include:

  • Corticosteroids: Inhaled corticosteroids (ICS) are a first-line treatment to reduce inflammation and symptoms. Severe asthma often requires courses of stronger oral corticosteroids.
  • Beta-2 (β2) agonists: Both short-acting beta-agonists (SABAs) and long-acting beta-agonists (LABAs) may be used to help relieve bronchial muscle spasms. LABAs are more likely used in conjunction with an ICS to control more severe symptoms.
  • Anticholinergics: These medications relax the airway muscles to counter bronchoconstriction and enable you to breathe more easily .
  • Biologics: These are medications made from living organisms. To treat severe asthma, they target specific cells or chemical messengers to reduce inflammation and the overactive immune system responses that trigger asthma.
  • Immunotherapy: Allergy shots can reduce sensitivity to allergens, which can then reduce severe asthma symptoms in many people.

Sometimes severe asthma does not improve with treatment. This causes a condition that doctors previously labeled status asthmaticus—what's now more commonly referred to as acute severe asthma. Characterized by low oxygen and elevated carbon dioxide levels in the blood, acute severe asthma can lead to respiratory failure and requires emergency medical attention.

If asthma symptoms do not improve after the use of a rescue inhaler, you should seek immediate treatment in an emergency room.

Coping

Severe asthma can significantly impact your quality of life. Chronic breathing issues may make it hard to work and enjoy leisure activities. Those with severe asthma are at greater risk of hospitalization compared to those with mild or moderate asthma.

It's important, therefore, to work closely with your doctor to ensure you are appropriately following the treatment plan so you can maximize your tolerance for activity safely and effectively.

You should also consider consulting with a therapist to avoid depression, which is a common issue that people with severe asthma face.

A Word From Verywell

Severe persistent asthma is more than having an occasional bad asthma attack or intermittent episodes of uncontrolled symptoms. The condition can be dangerous and possibly fatal.

Ensure that all the specialists you see are aware of the medications you are taking and the advice you are following. Consider maintaining your own medical file so you can share information with your doctors in case they don't receive updated records electronically. This can help you develop an asthma plan and allow you to better manage your symptoms.

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