What Is Severe Asthma?

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Severe asthma is asthma characterized by symptoms that are difficult to prevent and control with medication. It represents asthma that has progressed to the most serious stage of the disease. People with severe persistent asthma tend to experience near-constant symptoms such as difficulty breathing, a need to use a rescue inhaler multiple times a day, and frequent night awakenings. These symptoms, along with other criteria, are used to diagnose severe asthma. At this stage, asthma can interfere with daily activity and must be treated aggressively. In addition to standard asthma medications, including inhaled corticosteroids (ICSs) and short- and long-acting beta agonists (SABAs and LABAs, respectively), leukotriene receptor antagonists (LTRAs) such as montelukast and zafirlukast, as well as biologic medications, may be prescribed.

Once known as status asthmaticus, the term "severe persistent asthma" was established and defined in 2007 in guidelines issued by the National Asthma Education and Prevention Program Expert Panel Report 3. It is the most serious of four classifications, the others being intermittent, mild persistent, and moderate persistent asthma. These designations were maintained in a 2020 update of the guidelines.

Young woman treating asthma with inhaler
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Severe Asthma Symptoms

People with severe persistent asthma experience the classic symptoms of the disease—wheezing, cough, chest tightness, and shortness of breath—but more frequently than those in other groups and in spite of medication. What's more, the symptoms can be fatal. The criteria used to diagnose severe asthma are broken down according to age group.

 Age Group  0 to 4 5 to 11 12 and over
Symptoms Throughout day Throughout day Throughout day
Night Awakenings  More than once per week Often seven times per week Often seven times per week
Need for Rescue Inhaler  Several times per day  Several times per day  Several times per day
 Interference with Activity  Extremely limited  Extremely limited  Extremely limited
 Lung Function  N/A FEV1: < 60%
FEV1/FVC: < 75%
FEV1: <60%
Reducted >5%

Coping with the effects of these symptoms is difficult. If you have severe asthma, you are more likely to be unable to hold down a job and are also more likely to spend time in the hospital. The high cost of treatment and loss of work can cause a strain on financial resources. Depression and feelings of frustration are also very common.

Causes

Asthma has many triggers, but those with severe asthma can be more sensitive to them. Environmental allergens, such as pollen, dust, animal dander, mold, pollutants, perfumes, and microbes, are the most common culprits. In some cases, physical activity can trigger an asthma attack (exercise-induced asthma).

Other health issues can raise the risk of severe asthma or exacerbate asthma you already have. You may be more at risk for severe asthma if:

  • You have other health problems in addition to your asthma, such as diabetes and obesity.
  • You exhibit psychological symptoms, such as anxiety, that may contribute to breathing problems.
  • You are a smoker.
  • You are not compliant with your asthma treatment.

An estimated 5% to 10% of all individuals who have asthma meet the criteria for severe asthma.

People with asthma may experience more severe symptoms with age. One study found that, as they get older, people with severe asthma skewed female, had greater airflow limitation, were likely obese, and had a higher number of blood eosinophils (a type of white blood cell).

Diagnosis

You may be diagnosed with severe asthma if your symptoms are not controlled by generally-prescribed asthma medications.

Pulmonary function also plays a role in diagnosing this condition. Patients with severe asthma often demonstrate significant reduction of their lung function when tested by spirometry or a 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.

Treatment

Severe asthma is best treated by a doctor who specializes in this condition. Multiple types of doctors may be necessary for treating all aspects of this complex illness. Your team may include a pulmonologist, otolaryngologist (ear, nose, throat doctor), and an immunologist/allergist.

Asthma is traditionally treated with the following medications (sometimes in combination):

  • Corticosteroids: Inhaled corticosteroids (ICS) are a first-line treatment to reduce inflammation and symptoms. However, severe asthma often requires courses of stronger oral corticosteroids.
  • Beta-2 (β2) agonists: Both short-acting (SABAs) and long-acting (LABAs) β2 agonists may be used to help relieve bronchial muscle spasms. LABAs are more likely used in conjunction with an ICS to control more severe symptoms.
  • Leukotriene receptor antagonists (LTRAs): These drugs help dilate airways and reduce airway inflammation. The most commonly used LTRAs for asthma treatment are montelukast and zafirlukast.

If those medications fail to control symptoms, your doctor may prescribe biologics— medications derived from living organisms that target inflammatory processes and pathways in the body that produce symptoms. The following medications may be prescribed for severe asthma:

  • Monoclonal antibodies: These medications target the underlying inflammatory condition of severe asthma. One commonly used medication is Xolair (omalizumab), which slows airway responses to inhaled allergens.
  • Interleukin inhibitors: These drugs target cytokines, a molecule that helps trigger the inflammatory response in an asthma attack. Drugs approved by the U.S. Food and Drug Administration (FDA) include Nucala (mepolizumab), Cinqair (reslizumab), and Fasenra (benralizumab); Dupixent (dupilumab), another approved interleukin inhibitor, attacks a different inflammatory pathway.

In one study, patients who took dupilumab with corticosteroids were able to reduce their steroid use significantly; 25% of participants no longer needed steroids to control symptoms. Also, their rate of severe exacerbations fell while forced expiratory volume rose.

If you have severe asthma, it's essential that you adhere to your treatment regimen by taking all of your medications on time and as directed. You should also work with your doctor to develop a written treatment plan that helps you to recognize if your health is deteriorating or if you need immediate medical attention.

Other Treatments

Conditions such as allergies, nasal polyps, or sinus problems may also contribute to your asthma symptoms. If you have severe asthma, you should be evaluated and appropriately treated for these conditions.

Allergies, in particular, can greatly exacerbate asthma symptoms and should be managed appropriately. Immunotherapy (allergy shots) may be recommended.

Triggers such as exercise or allergies must be identified and avoided. Also, obesity can make asthma worse, so weight management may be an appropriate part of your treatment plan.

Non-medical treatment such as physiotherapy may be beneficial in conjunction with the above. A physiotherapist may teach you different ways of breathing, how to change your breathing patterns, relaxation techniques, or help you to modify your exercise routine so that you can still participate in physical activity despite your breathing problems. 

Individuals with significant community and family support tend to have better treatment outcomes than those who lack these important resources. Seeking therapy and other support groups, like those online, can make a big difference in your mood and day-to-day ability to cope.

A Word From Verywell

If you experience acute and severe asthma symptoms that persist and don't respond to medication, seek emergency care immediately. Resources exist to help people cope with this condition. The Asthma and Allergy Foundation of America offers a free online course for practitioners and patients on living with severe persistent asthma.

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