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Allergy 1555: 50.

7-11 Conwight 0 MunksParird I Y Y 5

Printed i n Denmark - all rights reserved
ISSN 0108-1675
ISBN 87-16-15187-5

Definition, diagnosis, classification of type and

severity of asthma

Bronchial asthma is clinically characterized by cells play a role, including mast cells and
episodes of wheezing, dyspnea, and reversible air- eosinophils. In susceptible individuals, this in-
way constriction; physiologically, by an increase flammation causes symptoms that are usually
in airway responsiveness (airway hyperresponsive- associated with widespread, but variable, air-
ness) (4); histologically, by airway mucosal in- way obstruction, which is often reversible
flammation, epithelial injury, infiltration of either spontaneously or with treatment. The
eosinophils, lymphocytes, and mast cells (65, 41), airway inflammation causes an associated in-
and hypertrophy of bronchial smooth muscle; crease in airway responsiveness to a variety of
and immunologically, by the production of IgE stimuli.”
antibody to environmental allergens (69). None 3. Definition proposed by this Guideline Committee
of these features are specific to asthma. Despite (for bronchial asthma that requires continuous
great efforts in the past, neither a precise defi- treatment for the management of asthmatic
nition nor a diagnostic standard has been estab- symptoms): “Bronchial asthma is a disorder of
lished. This is because of the large variety of fac- the airways characterized by widespread and
tors that make up the profile of asthma, and its variable obstruction and chronic inflammation.
wide range of severity, that is, from almost Airway obstruction varies from a mild, to a fa-
healthy patients with mild asthma, to those with tally severe grade, and is reversible either spon-
the most severe form who experience repeated taneously or with treatment. Airway inflam-
near fatal exacerbations. mation is associated with the infiltration of many
cells, including mast cells, eosinophils, and T
Definition of asthma lymphocytes, damage to the bronchial epithel-
ium, and with an increase in airway responsive-
Since a definition of asthma has not yet been es- ness to a variety of stimuli.”
tablished, as mentioned above, two provisional
definitions recently prepared are quoted here, in Diagnosis of asthma
addition to our own.
Asthma is easily diagnosed in patients mani-
1. Definition of asthma proposed by the Compre- festing typical exacerbation. However, it may be
hensive Research Group A (sponsored by the difficult to differentiate in cases of complete re-
Ministry of Education (chairman: Terumasa
Miyamoto) (54). Participating research mem-
Table 1. Diagnostic criteria for asthma
bers and concerned parties held a debate on 9
January 1988, but failed to reach a conclusion 1. Spasmodic dyspnea, wheezing, and cough
and closed the discussion with the following (especially at night and in early morning), onset at rest and disappear-
statement by the chairman: “Asthma is a dis- ance during remission
2. Reversible airway obstruction
ease characterized by an increase in airway re- shown by change in FEV, and PEF; reversible spontaneously and after
sponsiveness and manifestation of recurrent treatment
dyspnea due to widespread airway obstruction. 3. Airway hypersensitivity
The severity of airway obstruction changes shown by increase in airway responsiveness to acetylcholine, metha-
spontaneously or with treatment. Those whose choline and histamine (49, 103, 13)
4. Atopic predisposition
symptoms are similar but due to a pulmonary (diagnosis of atopic asthma) shown by presence of IgE antibody to
or cardiovascular disease are excluded.” environmental allergens
2. Definition proposed in the International Consen- 5. The above mentioned symptoms are not due to organic lung diseases
sus Report on Diagnosis and Management of or cardiovascular diseases
6. Presence of airway inflammation
Asthma (63): “Asthma is a chronic inflamma- shown by increase in eosinophils and Creola bodies in sputum (56)
tory disorder of the airways in which many
Table 2. Classification of severity of asthma exacerbation (asthma attack)

Severity of asthma PEF, FEVl

exacerbation (attack) Dyspnea Speech Daily life Cyanosis Consciousness (for reference)

Wheezing/chesl Dyspnea on exertion Normal Almost normal Absent Normal >80% Of

tightness predicted value
Mild (mild attack) Present, but able to as- Almost normal Slightly difficult Absent Normal 70-80°/o
sume a supine position
Moderate (moderate Present, orthopnea Slightly difficult Difficult (barely able Absent Normal 50-70%
attack) to go to the bath-
Severe (severe at- Present, too severe to Difficult Impossible Present Normal or disturb- <so%
tack) move ance of conscious-
ness, urinary incon-

1. Severity of exacerbation is primarily determined by degree of dyspnea. Other items, including PEF and FEV1, are for reference.
2. Individual should be assigned to most severe grade in which feature occurs.

mission or in those accompanied by other chronic development at night and in the early morning,
obstructive pulmonary diseases (COPD). The cri- and by their recurrence after asymptomatic inter-
teria for diagnosis, as well as definition, are not vals. Dyspnea may develop with exercise or exer-
yet fully agreed, but the foremost criteria iden- tion, even though absent at rest.
tified by our committee are as shown in Table 1.
Reversible airway obstruction
Recursence of spasnzodic dyspneu, Ivheezing und Reversible airway obstruction, which may develop
cough (especially cil niglzr und in tliv eurlj
extensively in the airways, causes episodes of
morn iizg )
wheezing or dyspnea. This ranges from a mild
Although episodes of wheezing and dyspnea may form detected only by expiratory flow measure-
be observed in various other cardiopulmonary ment alterations, to more severe and possibly
diseases, asthma is characterized by their frequent near fatal exacerbation.

Table 3. Classification of severity of asthma

of exacer- PEF, FEVl before Corticosteroid requirement
Severity Clinical features bation Activity treatment (for reference) (for reference)

Mild Wheezing , coughing * Evident Normal >80°h of predicted value

Dyspnea Variability< 20%
<1-2 exacerbation/week
Nocturnal symptoms: 1-2imonth
Otherwise asymptomatic
Moderate Exacerbation: >2/week Hardly Frequently disturbed 60-80% of predicted value Beclomethasone:
Limited daily life or disturbed sleep evident Variability: 20-30% 200-800 pg (1200 pg)
Nocturnal symptoms: >2/month
Chronic symptoms requiring inhalation
of p,-agonist almost every day
Severe (Even during treatment) None Limited ~ 6 0 %of predicted value Prednisolone > I 0 mg/day
Frequent exacerbation Variability: >30% Prednisoione 5 mg+600
Persistent symptoms pgiday, or more
Frequent nocturnal symptoms
Limited daily life

* Even when observed more than three times a week, case is classified as "Mild'.

Table 4. Classification of severity of asthma according to Japanese Society of Allergology (Jpn J Allerg 1994: 43: 71-80)
Part I. Grade of asthma exacerbation

PEF (Yo) for

Grade of exacerbation Dyspnea Speech Daily living Cyanosis Consciousness reference*,*

A Severe Present: too severe to Difficult Impossible Present Disturbance of consciousness Too severe to
(severe attacks) move Urinary incontinence m easure
B Moderate Present: orthopnea Moderately Difficult Absent Normal <50%
(moderate attacks) difficult
C Mild Present, but able to assume Almost Slightly Absent Normal 50-70%
(mild attacks) supine position normal difficult
D1 Wheezes Wheezes only Normal Almost normal Absent Normal >70%
D2 Tightness of chest Dyspnea on rapid move- Normal Normal Absent Normal >70%
N Absent No dyspnea on rapid move- Normal Normal Absent Normal >80%

1. Grade of asthma exacerbation is primarily determined by degree of dyspnea. Other times are for reference.
2. Individual should be assigned to most severe grade in which any feature occurs.
* Predicted values are based on spirometry (Jpn J Thoracic Dis 1993: 31 (3)). Percentage of personal best values is recommended to be used,
with same peak-flow meter for each patient.
* * This value is applicable to patients over 50 years of age.

Table 4, Part II. Severity of asthma

1) Severity of “the past one year“ is determined by asthmatic symptom for arbitrarily selected 4-week period during period of exacerbation of
2) Severity of asthma is determined by combination of grades of asthma symptoms described above, and their frequency

Severity of asthma exacerbation

Frequency of exacerbation
(days/weeks) A (severe) B (moderate) C (mild) D1, 2 (wheezes only, tightness of chest)

1) 5-7 Severe Severe Moderate’ Moderate‘

2) 3 - 4 Severe Moderate’ Moderate2 Mild
3) 1-2 Severe Moderate’ Mild Mild

1. Following cases should be classified as “severe”: 1) more than one severe attack accompanied by loss of consciousness; 2) steroid dependency
(>I0 mg/day of oral prednisolone or equivalent); 3) steroid dependency (>5 mg/day of prednisolone and its equivalent plus >600 pg/day
of inhaled corticosteroid).
2. Following cases should be classified as “moderate”: 1) steroid dependency with any doses of oral corticosteroids or parenteral corticosteroids;
2) steroid dependency with >400 kg/day of inhaled corticosteroids.
3. Cases that can be controlled by bronchodilators only should be classified as “mild”.

FEVl and PEF show >20% variation in daily tidal breathing, by the method of Cockcroft et al.
values and after inhalation of a P2-agonist or It is desirable that there is no marked airway ob-
administration of theophylline. struction on the measurement of these thresholds,
because there is a significant correlation between
FEV, and PEF vary significantly between ex- baseline FEVl and the thresholds. Profound reduc-
acerbation and remission stages. tions in acetylcholine thresholds in patients in
whom FEV, and PEF show almost the predicted
value during periods of remission are findings sug-
Airway hypersensitivity (increase in airway gestive of asthma.
responsiveness) (49, 103, 13)
Asthmatic patients develop airway constrictive re- Presence of atopic predisposition (69)
sponses to even weak stimuli (those to which a
healthy person will not respond). This responsive- The presence of an IgE antibody to various en-
ness can be evaluated quantitatively according to vironmental allergens indicates an atopic predis-
the following: acetylcholine threshold by the stan- position. If the immediate-type skin test, RAST, or
dard method of the Japanese Society of Allergolo- inhalation-challenge tests are positive to allergens,
gy; Dminby asthmography; PC20 and PD20hista- the patient is classified as having atopic type
mine or methacholine by a dosimetry method; or asthma.

Table 5. Goals of asthma management
Asthma classification based on etiology
1. Enable patients to enjoy normal life, comparable to that of healthy
persons Asthma can be classified into two types, atopic (IgE-
2. Maintain respiratory function as close as possible to normal levels, mediated or extrinsic) and nonatopic (non-IgE-med-
that is, daily PEF variation less than 1Ooh and PEF values over 80% iated or intrinsic). Many atopic asthma patients have
of predicted value IgE antibodies to environmental allergens, including
3. Prevent cough and dyspnea at night and in early morning and en-
sure that patient sleeps well
house-dust mites. In these patients, exposure to such
4. Prevent asthma exacerbation allergens induces airway inflammation, resulting in
5. Avoid asthmatic death airway hyperresponsiveness, and precipitation of
6. Minimize side-effects from asthma medication asthmatic attacks. Avoidance of causal allergens, im-
munotherapy with them, and antiallergic drugs are
effective in atopic asthma patients.
Table 6. Management required to attain asthma management goals
Asthma classification based on severity
1. Regular follow-up care to monitor changes in symptoms and pro- (Tables 2-4)
vide appropriate treatment
2. Offer information to patient to establish partnership between doctor On the basis of the severity and frequency of asthma
and patient symptoms, daily PEF value and its daily variation,
3. Keep asthma diary and perform PEF measurements to determine
asthma severity, and to assess subjective symptoms and airway ob- and the kinds of therapy and dosage required to
struction objectively control daily symptoms, asthma can be classified
4. Avoid and control triggers of exacerbation and of airway inflam- into three degrees of severity: mild, moderate, and
mation severe. There are several classifications of severity of
5. Establish medication plans for management of chronic asthma
6. Establish plans for treating and managing acute and severe attacks
chronic asthma, i.e., that developed by the Japanese
and symptom exacerbation Society for Allergology or as stated in the Interna-
7. Provide prospective strategies for long-term management tional Consensus Report. A common feature of
these is that mild asthma is defined as that with
sporadic wheezing and mild symptoms (mild at-
tack) which can be primarily terminated with as-
needed use of bronchodilators (63,55).
Asthma symptoms should not be clue to organic
Patients are defined as having severe asthma when
lung or cardiovascular diseases
their daily life is severely restricted by frequent epi-
If asthmatic symptoms are considered to depend sodes of moderate to severe asthma symptoms
on organic pulmonary or cardiovascular diseases, (moderate to severe attack). Oral prednisolone 10
this disorder is not described as asthma. However, mg or more, or a corresponding (rather large) dose
a comprehensive diagnosis should be made in such of an inhaled corticosteroid, is needed to control
borderline cases. asthma symptoms in patients in this group.
Moderate asthma includes a wide range of pa-
tients between mild and severe asthma, showing
Presence of airwa?’ inj7arnmation (56)
chronic symptoms with moderate exacerbation
An increase in eosinophils and Creola bodies (a (moderate attack) more than twice a week. Their
cluster of exfoliated epithelial cells) in sputum indi- daily life and sleep are frequently disturbed. Con-
cates the existence of airway inflammation. Similar tinuous use of bronchodilators and anti-inflamma-
findings are observed in bronchoalveolar lavage tory drugs is needed.
fluid. A decision on the classification of severity of
asthma is based on the symptoms when the patient
is not being treated. However, because most patients
Criteria for. diagnosis
are under treatment at the time of their visit, doctors
If criteria (1) ( 2 ) ,and (5) (Table 1) are met, a diag- should assume the severity from the history of
nosis of asthma is strongly indicated. If values of symptoms and treatment, start treatment according
FEVl and PEF are over 80% in remission and the to the assumption, and reach the appropriate level
change in values is not remarkable, and if criteria of treatment by stepping up or stepping down.
( l ) , ( 3 ) , and (5) are met, the same conclusion can
be reached. If criterion (4) is met, atopic asthma The goals of asthma management
(IgE-dependent or extrinsic asthma) is suggested. (Tables 5 and 6)
If criterion ( 1 ) is not met, a diagnosis of asthma
cannot be made. Criterion (6) has an additive Asthma is a multifactorial disease, the patho-
meaning to the diagnosis of chronic asthma. genesis of which is not known at present. Thus, it

is usually difficult to attain a cure only by the re- and preventative and symptomatic pharmacologic
moval of the causes (risk factors). Current asthma therapies which suppress the airway inflammation
management includes the avoidance and removal inducing airway hyperresponsiveness and airway
of causes of airway inflammation which increase narrowing. The aim of this management is the re-
airway hyperresponsiveness, avoidance and re- covery of the normal level of daily activity and
moval of stimuli which induce airway constriction normal lung function.