Severe Asthma ToolkitSevere Asthma Toolkit
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  • What is Severe Asthma?
    • Overview
    • Definition
    • Prevalence & Burden
    • Pathophysiology
    • Symptoms
    • Severe Asthma Attacks / Exacerbations / Flare-ups
    • Asthma Phenotypes
  • Diagnosis & Assessment
    • Overview
    • Diagnosis Overview
    • Assessment Overview
    • Lung Function Assessments
    • Questionnaires
    • Allergy Assessments
    • Phenotyping
    • Bronchoscopy
    • Imaging
    • Occupational Asthma
  • Management
    • Overview
    • Asthma Education
      • About Severe Asthma
      • Asthma Pathophysiology
      • Medications Education
      • Self-Monitoring
      • Triggers
      • Review
    • Written Action Plans
    • Adherence
    • Inhaler Technique
    • Physical Activity & Exercise
    • Interdisciplinary Approach & Multidimensional Assessment
    • Referral
  • Medications
    • Overview
    • Relievers
    • Preventers / Controllers
    • Add-on Therapies
    • Monoclonal Antibodies
    • Bronchial Thermoplasty
  • Co-Morbidities
    • Overview
    • Pulmonary & Upper Airways
      • Allergic & Non-Allergic Rhinitis
      • Chronic Rhinosinusitis
      • Dysfunctional Breathing
      • Vocal Cord Dysfunction
      • Chronic Obstructive Pulmonary Disease
      • Bronchiectasis
      • Obstructive Sleep Apnoea
    • Extra-Pulmonary
      • Obesity
      • Anxiety & Depression
      • Gastro-oesophageal Reflux Disease (GORD)
      • Osteoporosis
      • Cardiovascular Disease & Metabolic Disease
  • Living with Severe Asthma
    • Overview
    • Daily Symptom Burden
    • Mental & Emotional Health
    • Intimacy & Relationships
    • Self-Management Support
    • Medication Use & Costs
    • Experience of Care
    • Experience of Asthma Attacks
    • Prognosis
  • Establishing a Clinic
    • Overview
    • Set-up
    • Staffing & Multidisciplinary Team Approach
    • Facilities
    • Delivery Approach
    • Tailored Referrals
    • Evaluation
    • Opportunities for Training & Research
    • Barriers & Hurdles
  • Paediatrics
    • Overview
    • Management in Paediatrics
    • Assessment in Paediatrics
    • Alternative Diagnosis & Co-Morbidities in Paediatrics
    • Psychosocial Issues in Paediatrics
    • Medications in Paediatrics
    • Asthma in the Adolescent Population
  • Resources
    • Overview
    • Clinic Recommendations
    • Infographics
    • Asthma Assessment Resources
    • Systematic & Multidimensional Assessment Resources
      • Airway Components
      • Comorbidity Components
      • Risk Factor Components
    • Translation & Implementation
    • Case Studies
    • Presentations
    • Videos
    • Relevant Links
    • Key References

Diagnosis Overview

Home Diagnosis & Assessment Diagnosis Overview

A diagnosis of severe asthma requires a systematic approach to determine:

  1. Should a diagnosis of asthma be applied?
  2. Is the asthma severe?

Confirm Diagnosis of Asthma
Confirm Asthma is Severe
Confirm Diagnosis of Asthma

Asthma is:

  • Symptoms due to intermittent, variable airway narrowing that is often triggered by environmental stimuli (e.g. exercise, cold air, allergens etc.)
  • Reversible airflow obstruction measured by at least 1 of the following (For more information see Lung Function Assessments):
    • Acute bronchodilator reversibility (uncommonly positive i.e. insensitive)
    • Spontaneous variability in spirometry during clinic/surgery/lab visits
    • Airway hyperresponsiveness measured by bronchial provocation testing
    • Peak flow variability

There is a long list of alternate diagnosis that cause ‘asthma-like symptoms’ (Chung et al. 2014). For the full list, see Table 6 (pg. 356) of the 2014 International ATS / ERS Guidelines

A thorough assessment is critical. A confident diagnosis of asthma requires:

  • A history compatible with the definition above
  • Clinical questionnaires may be useful for screening, documentation for research purposes or objective measurement of changes
  • Physical examination
    • Upper airway examination
    • Excludes alternate diagnoses
  • Variable airflow obstruction (as above)
  • Assessment for comorbidities, which may impact on symptom severity and perception as well as treatment responsiveness

Confirm Asthma is Severe

Severe asthma is:

  • The presence of uncontrolled asthma symptoms due to variable airflow obstruction despite being on optimal treatment (Chung et al. 2014). For more information see Severe Asthma – Overview
  • Treatment will be a minimum of ICS and LABA, ±LTRA, ±intermittent or continuous oral corticosteroids. For more information see Medications – Overview

Determine if treatment is optimal:

  • Poor adherence and inhaler technique explain the vast majority of poor control or ‘difficult-to-treat’ asthma (Engelkes et al. 2015)
  • Assess adherence to medications
    • This may require several visits and should be performed at every visit
    • Multiple input is valuable: GP, Specialist, Asthma Educator, Pharmacists (although only practical where there is a case manager in the clinic)
    • Consider objective assessments (e.g. dosimeters)
  • Assess inhaler technique
    • Useful instructional videos are available here

The following tools are useful for confirming a diagnosis of asthma and excluding other causes of symptoms:

Diagnostic Tools - For All Patients
Diagnostic Tools - Useful in a Severe Asthma Assessment
Diagnostic Tools - Optional
Diagnostic Tools - For All Patients
  • Lung function testing to confirm variable obstruction as detailed above
    • Acute bronchodilator reversibility
    • Spontaneous variability in spirometry during clinic/surgery/lab visits
    • Airway hyperresponsiveness measured by bronchial provocation testing
    • Peak flow variability.
Diagnostic Tools - Useful in a Severe Asthma Assessment
  • ‘Standard lung function’ – spirometry pre- and post- bronchodilator, lung volumes, diffusing capacity. For more information see Lung Function Assessments
  • Bronchial challenge test
  • Chest X-ray
Diagnostic Tools - Optional

The following tools and tests may be used, based on the clinical assessment and results of the basic tests above.

  • Peak flow diary (Boezen et al. 1994, Quanjer et al. 1997) For more information see Asthma Education
    • Day-to-day variability in healthy adults is < ±8% of the mean. g. for a mean PEF of 500LPM, variability beyond 460-540 LPM is abnormal.
    • Collect ≥2 weeks of daily recordings, discarding the first 3 days (learning effect)
    • Either bd or morning recordings may be taken
  • Bronchoscopy (rarely necessary and mostly used for research purposes)
  • Allergy testing: Skin prick testing or radioallergosorbent test (RAST)
  • Blood assessment to rule out vasculitis

HRCT chest to assess for associated bronchiectasis, emphysema or another diagnosis that will impact on symptom severity. For more information see Imaging

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Last Updated on February 11, 2019

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