Asthma Symptoms Persistent Asthma Classifications By Carol Sorgen Medically reviewed by Medically reviewed by Daniel More, MD on April 19, 2021 Daniel More, MD, is a board-certified allergist and clinical immunologist. He is an assistant clinical professor at the University of California, San Francisco School of Medicine and currently practices at Central Coast Allergy and Asthma in Salinas, California. Learn about our Medical Review Board Daniel More, MD on April 19, 2021 Print Table of Contents View All Table of Contents How Classifications Are Made Diagnostic Process Asthma Classifications Treatment Approaches Asthma is classified by the severity of symptoms in order to direct the appropriate treatment. Based on the frequency and severity of attacks, along with a review of inhaler use and pulmonary function tests, a doctor can classify the disease using criteria from "Expert Panel Report 3 (EPR-3) Guidelines for the Diagnosis and Management of Asthma." Treatment can then be staged using one or several drugs so that the disease is neither overtreated nor undertreated. Anna Koldunova / Getty Images The EPR-3 guidelines were issued in 2007 by the National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC). In December 2020, the NAEPPCC issued the EPR-4 guidelines in which the classification criteria remained the same, but six other aspects of asthma management for children 12 and over and adults were updated, among them the most effective use of inhaled corticosteroids, best ways to mitigate indoor asthma triggers, and best practices for immunotherapy. The EPR-3 guidelines are the ones most commonly used in the United States for staging of asthma treatment. There are other guidelines used internationally, including those issued by the Global Initiative on Asthma (GINA). The GINA guidelines, updated annually, are created in collaboration with the World Health Organization (WHO) and the National Heart, Lung, and Blood Institute in Bethesda, Maryland. What Type of Asthma Do You Have? How Asthma Classifications Are Made According to the EPR-3 guidelines, the assessment of asthma severity is based on five specific values, some of which are objective (with clear diagnostic measures) and others which are subjective (based on the individual's experience and perceptions). When classifying asthma severity, the following five characteristics are assessed: Symptoms, specifically the number of times per day or week an asthma attack occurs Nighttime awakenings, the number of times that symptoms awaken you on a daily, weekly, or monthly basis Rescue inhaler use, the number of times per day or week you need to use a short-acting inhaler to treat acute asthma symptoms Interference with normal activity, a subjective assessment of how your symptoms are interfering with your ability to perform everyday tasks Lung function, an evaluative measure of lung capacity and lung strength using pulmonary function tests (PFTs) Together, these values can differentiate asthma severity into one of four classifications: mild intermittent, mild persistent, moderate persistent, or severe persistent. These classifications provide the foundation from which treatment decisions are made. Ideally, asthma is classified when it's first diagnosed and before treatment begins. It can then be assessed and reclassified at any stage of the disease if treatment doesn't effectively control symptoms. Signs and Symptoms of Asthma Diagnostic Process Asthma is classified based on lung function, which is measured with a non-invasive test known as spirometry that evaluates both lung capacity and lung strength. From a classification standpoint, there are two measures in the assessment: Forced expiratory volume in one second (FEV1), the amount of air you can forcefully expel from the lungs in one second FEV1/FVC ratio, the amount of air you can forcefully exhale in one second compared to the amount of air that can be exhaled when the lungs are completely full Any value below the predicted range (based on your age, sex, and height) may indicate an obstructive lung disease like asthma. The other values (symptoms, nighttime awakening, rescue inhaler use, physical impairment) can be obtained during an interview with the patient. Also factoring into the assessment is whether oral corticosteroids (steroids) have been needed to treat severe attacks. The number of times that oral steroids are needed per year—typically in an emergency setting—can alone determine if the disease is intermittent or persistent. Monitoring Treatment Response The assessment can also be used to monitor a person's response to treatment. Once an asthma classification is made, the assessment is repeated two to six weeks later to see if the treatment is working. If asthma control is not achieved, an adjustment to the treatment plan would be needed. Given that some of the EPR-3 values are subjective, there is room for interpretation of the results. If in doubt about the findings, seek a second opinion from a qualified pulmonologist. How Asthma Is Diagnosed Asthma Classifications The purpose of the asthma classification system is to direct the appropriate treatment, neither undertreating the disease (leading to treatment failure and the premature progression of the disease) nor overtreating it (leading to early drug tolerance and an increased risk of side effects). Based on the assessment, asthma can be classified as: Mild Intermittent Asthma Asthma is considered mild intermittent if any or all of the following are true: Symptoms occur two or fewer days per week. Nighttime symptoms occur two days or fewer per month. Rescue inhalers are used two or fewer times per week (or not at all). Symptoms do not limit normal activities. Lung function is greater than 80% of the predicted value based on your age, sex, and height. Mild Persistent Asthma Asthma is considered mild persistent if any or all of the following are true: Symptoms occur more than two days a week, but not every day. Nighttime symptoms occur three to four times a month. Rescue inhalers are used more than two times weekly, but not every day, and not more than once per day. Asthma attacks mildly impair normal daily activities (enough that people may or may not notice). Lung function is greater than 80% of the predicted value based on your age, sex, and height. Moderate Persistent Asthma Asthma is considered moderate persistent if any or all of the following are true: Symptoms occur daily. Nighttime symptoms more than once weekly, but not nightly. Rescue inhalers are used daily. Asthma symptoms moderately impair normal activities (enough that people around you notice). Lung function is less than 80% of the predicted values but more than 60%. Severe Persistent Asthma Asthma is considered severe persistent if any or all of the following are true: Symptoms occur several times daily. Nighttime symptoms are frequent, often nightly. Rescue inhalers are used several times daily. Asthma symptoms severely impair your ability to function normally. Lung function is less than 60% of the predicted value. Classifying Asthma Severity in Adults and Children 12 and Over Mild Intemittent Mild Persistent Moderate Persistent Severe Persistent Acute symptoms 2 or fewer days per week More than 2 days per week, but not daily Daily Throughout the day Nighttime symptoms 2 or fewer days per month 3 to 4 times monthly More than once weekly, but not nightly Often 7 days per week Rescue inhaler use Two or fewer days per week More than 2 days per week, but not daily, and not more than once daily Daily Several times daily Interference with normal activities None Mild Moderate Severe Lung function FEV1 normal, but with exacerbations OR FEV1 over 80% — FEV1/FVC normal FEV1 over 80% — FEV1/FVC normal FEV1 under 80% but over 60% — FEV1/FVC reduced by 5% FEV1 under 60% — FEV1/FVC reduced by more than 5% Risk of severe attacks Oral steroids used 0 to 1 time per year Oral steroids used 2 or more times per year Oral steroids used 2 or more times per year Oral steroids used 2 or more times per year Classification in Younger Children In children under 12, the only variation in the classification of asthma is the FEV1/FVC ratio. While the FEV1/FVC ratio can often be normal in adults with asthma, this is less true with younger children. Asthma classification in children is defined in part by the following FEV1/FVC ratios: Mild intermittent: FEV1/FVC is over 85% of the predicted value. Mild persistent: FEV1/FVC is over 80% of the predicted value. Moderate persistent: FEV1/FVC is between 75% and 80% of the predicted value. Severe persistent: FEV1/FVC is under 75% of the predicted value. Diagnosis and Treatment of Infant Asthma Treatment Approaches The ultimate aim of asthma classification is to direct the appropriate treatment. Based on the classification, treatment can be staged according to six structured steps. With each step, the treatments become more complicated and carry a greater risk of side effects. There is not always a clear line between when a step should or should not be started. While mild intermittent asthma is almost always treated with rescue inhalers alone, persistent asthma often requires a judgment call to pick the right combination of drugs to control asthma symptoms. Once a person has been diagnosed with moderate persistent asthma, treatment decisions should be overseen by an asthma specialist rather than a general practitioner. When asthma control is achieved, a specialist is better suited to decide if or when treatments can be simplified or dosages decreased. The drugs recommended for use in treating intermittent or persistent asthma include: Short-acting beta-agonists (SABA) such as albuterol, also known as rescue inhalers Inhaled corticosteroids (ICS), typically used daily or as needed to reduce airway inflammation Long-acting beta-agonists (LABA) such as Singulair (montelukast), used daily to reduce airway hyperresponsiveness Long-acting muscarinic antagonists (LAMA), a potential alternative to adding a LABA to ICS therapy for people who cannot tolerate or aren't helped by LABAs Leukotriene receptor agonists (LTRA) like Zyflo CR (zileuton), taken orally to reduce airway inflammation Cromolyn sodium or nedocromil, known as mast cell stabilizers, useful for treating allergy-induced asthma symptoms Theophylline, an older drug sometimes used in combination therapy Xolair (omalizumab), a monoclonal antibody used to control severe allergic asthma Oral corticosteroids (OCS), typically reserved for emergencies or for people with severe persistent asthma The steps and recommended treatments vary by age. Stepwise Approach to Managing Asthma Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Ages 0-4 (preferred) SABA (as needed, for symptom relief) Low-dose ICS Medium-dose ICS Medium-dose ICS OR Singulair High-dose ICS + LABA or Singulair High-dose ICS + LABA or Singular + OCS Ages 0-4 (alternative) Cromolyn or Singulair Ages 5-11 (preferred) SABA (as needed, for symptom relief) Low-dose ICS Low-dose ICS + LABA, nedocromil, LTRA, or theophylline OR Medium-dose ICS on its own Medium-dose ICS + LABA High-dose ICS + LABA High-dose ICS + LABA + OCS Ages 5-11 (alternative) Cromolyn, LTRA, nedocromil, or theophyline Medium-dose ICS + LTRA or theophylliine High-dose ICS + theophylline or LTRA High-dose ICS + theophylline or LTRA +OCS Ages 12 and over (preferred) SABA (as needed, for symptom relief) Daily low-dose ICS + as-needed SABA OR As-needed concomitant ICS + SABA Low-dose ICS + formoterol (a specific LABA) in a single inhaler Medium-dose ICS + formoterol in a single inhaler High-dose ICS + formoterol in single inhaler OR High-dose ICS + LAMA High-dose ICS + LABA + OCS Ages 12 and over (alternative) Cromolyn, nedocromil, LTRA, or theophyline Low-dose ICS + LTRA, theophylline, or Zyflo CR Medium-dose ICS + LTRA, theophylline, or Zyflo CR Consider adding Xolair for people with allergic asthma Consider adding Xolair for people with allergic asthma How Asthma Is Treated Was this page helpful? Thanks for your feedback! Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. Sign Up You're in! Thank you, {{form.email}}, for signing up. There was an error. Please try again. What are your concerns? Other Inaccurate Hard to Understand Submit Article Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. National Heart, Lung, and Blood Institute. Clinical practice guidelines. In: Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. August 2007 Cloutier MM, Baptist AP, Blake KV, et al. 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee expert panel working group. 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