Understanding the Different Stages of Asthma

Asthma, like many diseases, is classified into different levels, or stages. This helps healthcare professionals develop the right plan of care for each person who has asthma.

But what does it mean, exactly, when the doctor tells you that you have "intermittent" asthma versus "moderate persistent" asthma? How does that affect you and what to expect from asthma?

This post will help bring you to a better understanding of the various stages of asthma. These classifications are drawn directly from our national asthma guidelines, developed by a task force of healthcare professionals. The guidelines were written by the National Asthma Education and Prevention Program (or NAEPP for short).¹

The 4 stages

There are 4 different stages of asthma:

• Intermittent
• Mild persistent
• Moderate persistent
• Severe persistent

And, as a reminder, the hallmark symptoms of asthma include:

• Wheezing
• Cough
• Chest tightness
• Difficulty breathing

Each of these stages, sometimes called steps, is defined by symptom frequency, both during the day and at night. Each stage is also defined by clinical measurements of lung function. It's possible for people with asthma, especially children, to move up and down these stages over time. Let's take a closer look at each stage.

First stage: intermittent asthma

At this stage, asthma is likely more of on occasional bothersome occurrence, rather than a disease that interferes significantly with day to day quality of life. I speak from experience -- my asthma has been at this stage for some years, although when I was younger and living in a different climate, it was more severe.

Symptoms. With intermittent asthma, daytime symptoms (see above) generally occur less than twice a week. Nighttime symptoms that interfere with sleep occur less than twice a month. Although symptoms might intensify into a flare-up at times, severity varies and the flare is brief. In between flare-ups, there are no active symptoms.

Lung function tests. To aid with diagnosis and treatment, the doctor may order a lung function test that measures your ability to breathe effectively. The test is expressed in terms of FEV, or Forced Expiratory Volume, and the resultant FEV1 will be 80% or more above normal values. If a peak flow meter is used, the readings show less than 20% variability am-to-am or am-to-pm, day-to-day.

Treatment. In terms of treatment for intermittent asthma, a daily controller medicine is usually not needed. However, a quick-relief, or rescue, inhaler will be prescribed to be used when symptoms do arise or flare-up.

Second stage: mild persistent asthma

Although this stage is still relatively mild, asthma is beginning to become more noticeable and starting to interfere with your quality of life.

Symptoms. In mild persistent asthma, daytime symptoms are occurring 3 to 6 times a week. Nighttime symptoms interfere with sleep nearly every week, or 3 to 4 times a month. Flare-ups are more severe and may affect activity levels.

Lung function tests. As with intermittent asthma, the FEV1 is 80% or more above normal values. Peak flow readings show less than 20-30% variability.

Treatment. A low dose inhaled steroid will be used as a controller medication to prevent and control symptoms. Less common alternatives might include cromolyn, a leukotriene receptor antagonist (LTRA), or theophylline. The doctor will also prescribe a quick-relief inhaler for flare-ups.

Third stage: moderate persistent asthma

At this stage, asthma is beginning to significantly affect quality of life on a daily basis, unless treated. It becomes difficult to ignore.

Symptoms. In moderate persistent asthma, daytime symptoms occur every day. Nighttime symptoms are also more common, becoming noticeable 5 or more times a month. Flare-ups are more frequent and likely affect the activity level.

Lung function tests. At this stage, the FEV1 has deteriorated, measuring above 60% but below 80% of normal values. Peak flow readings are showing more than 30% variability.

Treatment. For this level of asthma, the preferred controller medication is a low-dose inhaled corticosteroid, plus a long-acting beta-agonist. These are usually packaged in the form of a combination inhaler. Another option is an inhaled medium-dose steroid. And, of course, a quick-relief inhaler will be prescribed as needed to deal with flare-ups.

Fourth stage: severe persistent asthma

This is the most severe level of asthma, where control is basically non-existent. Quality of life is greatly affected and missed school and work days are frequent.

Symptoms. Daytime symptoms are continual and nighttime symptoms are frequent. Basically, the person in this stage will feel as though they are in a continuous flare-up.

Lung function tests. In this stage of asthma, the FEV 1 is 60% or less of normal values. Peak flow readings have more than 30% variability.

Treatment. The preferred controller medication is an inhaled medium-dose steroid plus a long-acting beta agonist (combination therapy). Alternatives include an inhaled medium-dose steroid, plus either a leukotriene receptor antagonist or theophylline. If neither of those medication regimes result in asthma control, then an inhaled high-dose steroid plus a long-acting beta agonist combination will be tried. And if that does not produce control, then an inhaled high-dose steroid/long-acting beta agonist combination will be prescribed, plus an oral steroid, such as prednisone. Other treatment options for uncontrolled asthma might include:

• tiotropium mist inhaler for patients with a history of exacerbations
• omalizumab for severe allergic asthma
• mepolizumab for severe eosinophilic asthma

In summary

Keep in mind that the main goals in asthma treatment are to prevent asthma attacks and to control the disease. How that is done will depend on your doctor's assessment of which stage of asthma you are currently at. It will also depend on you. You have a couple of responsibilities:

• Be open with your doctor about how you're feeling, when your symptoms occur and how often. Also be sure to share how you respond to any prescribed medications. Do they help? How do they make you feel? Are you having any side effects?
• Follow your Asthma Action Plan. Every asthma patient should have a written action plan that spells out the exact plan of care and how to respond when things go awry. Asthma control is dependent on how well you are able or willing to follow the treatment plan and work to avoid contact with any triggers or irritants.

It's also important to understand that your asthma stage will likely change over time. It might get milder, as mine did. Or, it might become more severe. Whatever happens, if you work closely with your health care team, you will hopefully find the right solution for you.