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Assessment of asthma symptom control and risk of exacerbations

A. Level of asthma symptom control
In the past 4 weeks, has the patient had:			Well controlled	Partly controlled	Uncontrolled
Daytime symptoms more than twice/week?	Yes	No	None of these	1 to 2 of these	3 to 4 of these
Any night waking due to asthma?	Yes	No
Reliever needed more than twice/week?	Yes	No
Any activity limitation due to asthma?	Yes	No
B. Risk factors for poor asthma outcomes
Assess risk factors at diagnosis and periodically, at least every 1 to 2 years, particularly for patients experiencing exacerbations. Measure FEV₁ at start of treatment, after 3 to 6 months of controller treatment to record personal best lung function, then periodically for ongoing risk assessment.
Having uncontrolled asthma symptoms is an important risk factor for exacerbations. Additional potentially modifiable risk factors for exacerbations, even in patients with few asthma symptoms, include: Medications: ICS not prescribed; poor adherence; incorrect inhaler technique; high SABA use (with increased mortality if ≥1×200-dose canister/month)* Comorbidities: obesity; chronic rhinosinusitis; gastroesophageal reflux disease; confirmed food allergy; anxiety; depression; pregnancy Exposures: smoking^¶; allergen exposure if sensitized; air pollution Setting: major socioeconomic problems Lung function: low FEV₁, especially if <60% predicted; higher reversibility Other tests: sputum/blood eosinophilia; elevated FE_NO in allergic adults on ICS Other major independent risk factors for flare-ups (exacerbations) include: Ever being intubated or in intensive care for asthma Having 1 or more severe exacerbations in the last 12 months					Having any of these risk factors increases the patient's risk of exacerbations even if they have few asthma symptoms.
Risk factors for developing fixed airflow limitation include preterm birth, low birth weight, and greater infant weight gain; lack of ICS treatment; exposure to tobacco smoke, noxious chemicals, or occupational exposures; low FEV₁; chronic mucus hypersecretion; and sputum or blood eosinophilia
Risk factors for medication side-effects include: Systemic: frequent OCS; long-term, high dose and/or potent ICS; also taking cytochrome P450 inhibitors Local: high-dose or potent ICS; poor inhaler technique

Asthma control has two domains: symptom control and risk of future exacerbations. Assess the symptom control domain by patient's recall of previous 4 weeks; assess risk of future exacerbations by the presence of risk factors and by spirometry/or peak flow measures.

FEV₁: forced expiratory volume in one second; ICS: inhaled corticosteroids; SABA: short-acting beta-2 agonist; FE_NO: fraction of expired nitric oxide; OCS: oral corticosteroid.

* 2022 guidelines note that use of ≥3 200-dose SABA canisters/year is also associated with increased exacerbation risk.

¶ Smoking includes e-cigarette exposure.

For the most recent version of the GINA assessment of asthma control, please visit: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2022. Available at: https://ginasthma.org/gina-reports/ (Accessed on May 19, 2022). Reproduced with permission from: Global Initiative for Asthma. Asthma Management and Prevention (for Adults and Children Older than 5 Years): A Pocket Guide for Health Professionals, Updated 2019. Available at: https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/ (Accessed on July 19, 2019).

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