Mild Asthma

Elisabeth H. Bel, M.D., Ph.D.

N Engl J Med 2013; 369:549-557August 8, 2013DOI: 10.1056/NEJMcp1214826

Comments open through August 14, 2013

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See Key Clinical Points

Video

Mild Asthma.

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.

A 20-year-old college student with a history of asthma and allergic rhinitis, which were diagnosed in childhood, presents with cough and tightness of the chest that interfere with his sleep three or four times per month. He requires albuterol two or three times per week. He enjoys playing tennis but generally wheezes after a match. Last year, during the pollen season, he sought treatment in an emergency department for acute asthma but was not admitted to the hospital. His forced expiratory volume in 1 second (FEV₁) is 93% of the predicted value. How should this case be evaluated and managed?

The Clinical Problem

Asthma is a chronic inflammatory disease of the airways that is characterized by variable narrowing of the airways and symptoms of intermittent dyspnea, wheezing, and nighttime or early-morning coughing. Asthma is a major health problem throughout the world, affecting an estimated 315 million persons of all ages.1 The prevalence of asthma varies widely among countries, ranging from 2% in Vietnam to 27% in Australia.1 Asthma occurs more frequently in adults than in children and more frequently in boys than in girls; however, after the teenage years, asthma occurs more frequently in women than in men. 2 Asthma is clinically heterogeneous, and its pathophysiology is complex.3 Airway eosinophilic inflammation is typical, but many patients with mild asthma have persistently noneosinophilic disease.4 Airway hyperresponsiveness is a consistent feature; irreversible airflow obstruction develops in some patients, presumably as a consequence of remodeling of the airway wall.3 Short periods of loss of asthma control may occur as a result of exposure to nonspecific “triggers,” such as fumes, strong smells, or exercise. Moderate or severe exacerbations are usually due to exposure to allergens or viruses, particularly human rhinovirus.5 The development of asthma in children is influenced by genetic predisposition as well as by environmental factors, including viral infection and sensitization to aeroallergens (e.g., house dust mites or animal dander).6 Altered repair responses of the airway epithelium to these insults lead to inflamed airways, altered smooth-muscle function, and increased production of mucus.3 Persons who are born and raised on a farm have a reduced risk of allergy and asthma, probably because they have been exposed to a wide variety of microorganisms. 7 Risk factors for the development of asthma in middle-aged and older adults are diverse and include work-related exposures (e.g., isocyanates or cleaning products) and lifestyle factors (e.g., smoking or obesity).8,9

Key Clinical Points

Control of Asthma

Most patients with asthma have mild, persistent disease, which tends to be underdiagnosed, undertreated, and inadequately controlled.
The diagnosis of asthma is based on the presence of symptoms of dyspnea, cough, and wheezing and objective confirmation of variable airflow limitation that is at least partially reversible.
For mild, persistent asthma, regular controller treatment with low-dose inhaled glucocorticoids and rescue treatment with short-acting beta₂-agonists, as needed, is recommended as the initial treatment.
If asthma control is not achieved within 3 to 4 months, maintenance treatment should be stepped up with the addition of a second controller medication (long-acting beta₂-agonist or leukotriene modifier) or with an increase in the dose of inhaled glucocorticoids.
Ongoing patient education, written action plans, and regular follow-up visits to reassess asthma control and adjust therapy are integral to successful management.