slideshow widget

Monday, August 13, 2012

Asthma control defined

The following was published June 27, 2011 at

What is good asthma control?

Most asthma experts will now say that thanks to modern asthma wisdom and medicine most asthmatics can gain control of their asthma.  So how do you know your asthma is controlled?  What is good asthma control?

According to the Global Initiative For Asthma Asthma Guidelines, your asthma should be classified as either controlled, partly controlled, or uncontrolled.  So what does this mean for you and me.

Let's define the above terms:

1.  Controlled:
  • No daytime symptoms (shortness of breath, chest tightness, etc.)
  • No limits on activities (you can walk, exercise, attend school, work)
  • No nighttime symptoms (no waking at night due to asthma)
  • Minimal use of rescue medicine (less than twice in two weeks)
  • Lung function (FEF or FEV1 are normal)
2.  Partly Controlled:
  • Daytime symptoms more than twice a week
  • Some limitations in activities (trouble exercising, missed days work/school)
  • Wake sometimes at night due to asthma symptoms
  • FEF and FEV1 less than 80% of predicted
  • Need rescue medicine more than twice a week
3.  Uncontrolled:  Three or more features of uncontrolled asthma.  Asthma is limiting your lifestyle, effecting your morale and general satisfaction.

The National Heart Lung and Blood Institutes (NHLBI) Asthma Guidelines define control pretty much the same as the GINA guidelines:  Control is the degree the above guidelines are met plus the degree YOUR goals of therapy are met.

Your goals may be:
  • I just want to be able to walk
  • I want to be able to exercise
  • I don't want to miss any more school or work due to my asthma
Another means to monitor control is your own personal satisfaction.  Are you satisfied with your life given your asthma severity?

I'll use myself as a for instance here.  I still use my rescue inhaler a few times per day yet I'm still able to live a normal, active life.  I never miss work due to asthma, and I can exercise and even run.

I feel my asthma rarely stops me from doing the things I want to do. Therefore, my doctor and I have decided my asthma is controlled -- or at least as controlled as it's going to be.

So essentially there's a few tools to help you and your doctor determine if your asthma is controlled:
  • Guidelines like those listed above
  • The degree to which your goals of therapy are accomplished
  • Your personal degree of satisfaction
If your asthma is controlled, GREAT!  Continue to see your doctor as often as he recommends, and no less than at least once per year. And most important, continue being a gallant asthmatic.

If your asthma is partly controlled or uncontrolled, you'll want to continue to work with your doctor.  He may continue to tweak your asthma regime until your goals are met and you're satisfied.

Remember, all asthmatics should be able to obtain asthma control.



Chad Hasselius said...

Dr Mark Millard, pulmonaologist at Baylor Asthma and Pulmonary Rehabilitation Center, developed a set of three questions to gauge asthma control, called the "Rules of 2":
1)Do you use a quick relief inhaler more than 2 times a week?
2)Do you wake up at night with asthma more than two times a month?
3)Do you refil your quick relief rescue inhaler prescription more than 2 times a year?

A person with well controlled asthma will answer "no" to all 3 questions.

Rick Frea said...

I'm going to have to say that is not true for all asthmatics, particularly your hardluck asthmatics. I know many asthmatics on all the best asthma medications -- myself included -- who would answer no to all those questions.

Rick Frea said...

I mean yes to all those questions. I know many asthmatics who would answer yes to all those questions, asthmatics who have controlled asthma. It's obviously not ideally controlled (no symptoms ever), but there's only so much that can be done in an attempt to gain such ideal control. Under Mark Millard's gauge (which is the same as noted by most asthma guidelines), at which point would you realize a person is as controlled as he's going to get?

Chad Hasselius said...

Rick, great discussion! i enjoy discussing this stuff. What we're talking about is the difference between well controlled (Millard's "Rules of 2") and partly controlled (hardluck asthmatics) asthma.

The NHLBI/NAEPP uses the classifications "well controlled", "not well controlled", and "poorly controlled." GINA uses "controlled", "partly controlled", and "not controlled".

Both the NHLBI/NAEPP and GINA guidelines use a stepwise approach to increasing or decreasing a patient's treatment regimen with the end result being well controlled asthma. If a patient has "partly controlled" or "not well controlled" asthma, their treatment regimen should be increased a step. If a patient has "poorly controlled" or "not controlled" asthma, their regimen might need to be increased 2 steps.

It all has to do with minimizing the underlying inflammation. Increasing the anti-inflammatory corticosteroid dose (low dose inhaled, moderate dose inhaled, high dose inhaled, oral) is the hallmark of increasing the steps.

Of course there are always those difficult cases where side effects or economics prevent their treatment from being stepped up, or they get to the last step and they still don't have their asthma under control.

But from what I understand, those with "intermittant", "mild persistent", and "moderate persistant" classifications of asthma (80% of the Asthma population according to an Asthma in America survey) should usually be able to get their asthma well controlled without problems. Those that can't are the ones we see in the hospital.

Rick Frea said...

You're right: great discussion. It's one topic that's been a major concern of mine, and that I've written about several times the past few years. nd you're not wrong either. In fact, for 90% of asthmatics, (or 80%), you are 100% correct. Yet there are still those among us who don't qualify under this plan. They know how to care for acute symptoms, they are still "gallant" asthmatics (do everything right, but STILL have bad days. And still may require a few extra puffs of Ventolin during the course of the day. And if I throw myself into that 10%, I haven't been to the ER in 12 years. Although I might be the exception only because I'm well educated and have a good relationship with my doctor.

Rick Frea said...

To follow the "Rules of 2" is great for most asthmatics. I recommend it all the time. But a good doctor must always understand there are those who fall outside the norm, who will require extra thought. Thankfully I have one of those doctors.

Although, there is one thing that might prove me wrong and you right. That is, if you're talking about "pure asthma" only. If you have "pure asthma," your asthma should be easier to control. Yet if you have "complicated" asthma, you have other issues to deal with on top the asthma. An example of this is allergies ,(75% of asthmatics) bronchitis, bronchiectasis. Or if you're one of those poor kids resistant to steroids. Check out this post.  

kerri said...

After a couple years getting into the swing of my asthma, my doctor moved away from using the term "control" and swapped over to using "baseline" with me [I think she figured all the control talk that I wasn't achieving easily was stressing me out]. I'd currently fall into the GINA "Partly Controlled" category because I still usually need my rescue inhaler more than two or three times a week.

Baseline for me is that I may be using my inhaler daily or multiple times a day, but 2-4 puffs of Ventolin controls those symptoms effectively and I'm able to participate in my usual activities, including exercise. I am not having multiple PEF readings a day in the yellow zone, and I am not constantly experiencing symptoms that are only dulled by the inhaler. I am able to exercise, even if I continue to have exercise induced symptoms. Like you, Rick, I have near perfect attendance at work [I have missed only one day of work in the last year and a half, but it WAS due to asthma]. AND, baseline implies that I FEEL I am at baseline and in my normal state of "control"--even if it doesn't adhere to the guidelines of control.

Chad Hasselius said...

One thing I'm reminded of from this post is that these guidelines we are grabbing these definitions from are called "guidelines" instead of "laws" for a reason. The thing about asthma is that it is unique for every individual, and so treatment plans should be individually tailored accordingly. You are a good example of that, Rick. I've learned a lot from this post.

It's a shame that in this day and age of medicine we can't get everybody to "well controlled" without the high side effects of Prednisone or high cost of Xolair.

Another thing that I find very interesting is that soon exhaled nitric oxide testing will probably supercede the subjective symptom-based approach to controlling asthma. Right now it is a new test so the reimbursement isn't good, but it sounds like biomarkers are the future of asthma control. Exhale into a device the size of a milk carton and you get your answer.

Anonymous said...

Hi. My asthma is "uncontrolled" as I am chronic severe steroid dependent. Use my nebulizer daily and can no longer work. Can no longer participate daily in activities or exercise. Hospitalized 4 times this year so far but 15 times in the last 3 years. I am on the best asthma medications and am seen by an amazing pulmonologist regularly. There is no cure and when you reach severe asthma, there is little to do but plug away every day and live life the best way you know how.

Anonymous said...

I agree with you Rick. For approximately 10% of the Asthma population, due to repeat scarring, allergy, steroid resistance, bronchiectasis, etc.medications may keep the symptoms at bay but control is not a word I could use to describe it. These guidelines can be utilize by most asthmatics but it's almost as if this 10% have a unique disease or co-morbid diseases due to repeated attacks and or medication side effects. This is where these guidelines fail and many health personal may fail to address them blaming the patient for non compliance.

danielthomas said...

Most people surrender to the idea of dealing with sneezing, shortness of breath, and other common symptoms caused by asthmatic conditions. Asthma treatment

Chad Hasselius said...

I just wanted to share these links to asthma control questionaires that I recently learned about in an AARC continuing education course: