You’re working in the ED on a warm spring day and a 22 year-old female is brought in by EMS for respiratory distress. She has a past medical history of Asthma and Depression. She has been compliant with medications at home. While you are starting her on duo-nebs and placing an IV to give steroids, you look at her home medication list and see Flucticasone (Flovent). Which category of asthma do you suspect this patient has based of her medications?
A. Intermittent
B. Mild Persistent
C. Moderate Persistent
D. Severe Persistent

Answer: B- Mild Persistent- Patient is on Flovent, which is a daily steroid used for patients with mild persistent asthma.

An important component in evaluating asthma patients is understanding the severity of their asthma at baseline. Patients requiring daily inhalers and steroids have worsening disease at baseline and may require more interventions during acute asthma exacerbation. These are the four categories of asthma and their recommended treatments:

Intermittent:
• Traits:
o Daytime Symptoms less than twice per week
o Nighttime symptoms less than twice per month
o Normal FEV
o Exacerbations less than once per year
• Intervention: Step 1
Mild Persistent:
• Traits:
o Daytime symptoms more than twice per week but less than seven days per week
o Nighttime awakenings 3-4x per month
o FEV normal
o Over 2 exacerbations in one year
• Intervention: Step 2
Moderate Persistent:
• Traits-
o Daily asthma symptoms
o Nighttime awakenings at least once per week
o SABA usage daily
o FEV1 60-80% predicted
o More than 2 exacerbations per year
• Intervention: Step 3
Severe Persistent:
• Traits:
o Symptoms are persistent throughout the day
o Nightly awakenings
o SABA use multiple times per day
o FEV1 o More than two exacerbations per year
• Intervention: Steps 4-6

Summary of Medications:
• SABA- short acting beta agonist (i.e. albuterol)- acts on B2 receptors to cause bronchodilation
• ICS- inhaled corticosteroids (i.e. Fluticasone, Budesonide, Beclomethasone-> Flovent, Pulmicort, Qvar)- decreases inflammation in the airway and decreases response to antigens
• LABA- long acting beta agonist (Salmeterol, Formoterol)- acts on beta 2 receptors to cause bronchodilation
• ICS-LABA- combination steroid and long acting beta agonist:
o Fluticasone/Salmeterol (Advair)
o Budesonide/Formoterol (Symbicort)
o Mometasone/Formoterol (Dulera)
o Fluticasone/Vilanterol (Breo Ellipta)
• LTRA- leukotriene receptor antagonist (i.e. montelukast)- blocks pro-inflammatory cascade
• Monoclonal Antibodies- Omalizumab (Xolair)

For more information on the management of an acute asthma exacerbation read the following EM daily post: http://emdaily.cooperhealth.org/content/core-asthma-management#

Resources:
Cydulka, R. K. (2016). Pulmonary Disorders, Asthma. In Tintinalli's emergency medicine: A comprehensive study guide(8th ed., pp. 468-475). New York, NY: Mc Graw-Hill Education.
Editorial Team March 7, 2. (2016, March 7). Asthma prevention and control medications. Retrieved April 01, 2021, from https://asthma.net/treatment/prevention
Expert panel Report 3 (EPR-3): Guidelines for the diagnosis and management of ASTHMA–SUMMARY report 2007. (2007). Journal of Allergy and Clinical Immunology, 120(5). doi:10.1016/j.jaci.2007.09.029