Asthma Stages: How to Determine Severity, Symptom Control, and Attack Risk

Asthma is a chronic airway disease in which inflammation and narrowing of the bronchi cause coughing, wheezing, shortness of breath, and chest tightness. These symptoms can be rare or frequent, mild or severe, but symptom frequency alone does not always accurately predict the risk of a severe attack. The World Health Organization notes that asthma can have a fluctuating course: symptoms come and go, worsening at night, with physical activity, viral infections, exposure to smoke, dust, pollen, mold, animal dander, strong odors, and other irritants. [1]

In the past, asthma was often divided into four "grades" based on symptoms: intermittent, mild persistent, moderate persistent, and severe persistent. This classification system is still found in textbooks, older medical documents, and some national guidelines, but current international guidelines use a more practical approach: asthma severity is assessed based on the amount of treatment needed to achieve good control and prevent exacerbations. [2]

This change is important because a person with infrequent symptoms may still be at high risk of a severe exacerbation, particularly if they have had previous hospitalizations, received frequent courses of systemic glucocorticosteroids, overused a rapid-acting bronchodilator inhaler, or have poor adherence to anti-inflammatory treatment. Joint guidance from the British Thoracic Society, the National Institute for Health and Care Excellence, and the Scottish Intercollegiate Guidelines Network recommends actively identifying patients with such risk factors and tailoring follow-up to their risk level, not just their presenting symptoms. [3]

The modern question isn't simply "what is the severity of asthma?" but rather: how well is the disease controlled, what is the likelihood of exacerbations, what level of treatment is needed, is there persistent limitation of lung function, how correctly is the person using their inhaler, and are there any factors that make asthma appear more severe. This approach protects against two mistakes: underestimating the danger in a patient with rare symptoms and overestimating the severity in a patient who poorly uses their inhaler or continues to be exposed to triggers. [4]

Therefore, in this article, the term "asthma grades" will be examined in its modern sense: mild, moderate, and severe asthma based on required therapy; symptom control; risk of exacerbations; objective breathing parameters; and a separate category of difficult-to-treat and severe asthma. This does not replace an in-person diagnosis, but it helps to understand why two people with similar coughs may require completely different treatment strategies. [5]

Approach to assessment	How it was before	How is it customary to evaluate now?	Practical meaning
By symptoms	Frequency of daytime and nighttime symptoms	Symptoms are taken into account, but are not the only criterion	Symptoms are important, but don't always reflect risk.
By lung function	Forced expiratory volume in 1 second and peak expiratory flow rate	Used as part of the overall assessment	Needed to confirm diagnosis and control risk
For treatment	Often secondary	Severity is assessed by the therapy needed to control	Helps differentiate between mild, moderate and severe asthma
Regarding exacerbations	Sometimes they were counted separately	Exacerbations are a key risk factor	Even rare symptoms do not exclude danger
According to inhalation technique	Often underestimated	Checked at every asthma-related contact	Errors can mimic severe asthma

Source of table data: Global Asthma Initiative and British Thoracic Society guidelines, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network. [6] [7]

Modern severity levels: mild, moderate and severe asthma

In modern thinking, mild asthma is not necessarily "safe." Mild asthma is typically defined as a disease that is well controlled with minimal anti-inflammatory therapy, such as steps 1-2 of the Global Asthma Initiative strategy. In 2025-2026, the key idea remains the same: even with mild asthma, patients need access to an anti-inflammatory inhaler, because airway inflammation can persist even with rare symptoms. [8]

Moderate asthma is a condition in which more regular maintenance therapy, often a combination therapy of an inhaled glucocorticosteroid and a long-acting bronchodilator, is required for good control. In adults and adolescents, current guidelines often use a single combination inhaler containing an inhaled glucocorticosteroid and formoterol for both maintenance and symptom relief. [9]

Severe asthma is more than just frequent symptoms. The Global Asthma Initiative defines severe asthma as a subgroup of difficult-to-treat asthma: disease that remains uncontrolled despite optimized treatment with high-dose inhaled glucocorticosteroids and long-acting beta-2 agonists, proper inhalation technique, good adherence, and elimination of significant risk factors, or that worsens with attempts to reduce high-dose treatment. [10]

This definition makes severe asthma a "retrospective" diagnosis: it cannot be reliably diagnosed on the basis of complaints alone. First, the diagnosis must be confirmed, respiratory function assessed, inhalation technique verified, alternative causes of shortness of breath and cough excluded, and smoking, vaping, occupational irritants, mold, air pollution, comorbidities, and psychological factors assessed. Only then can one say that asthma is truly severe, rather than appearing severe due to correctable causes. [11]

A major practical error is to assume that "mild" asthma means no risk, while "severe" asthma is defined solely by the severity of an attack. In practice, mild asthma can lead to a severe exacerbation if the patient uses only a fast-acting bronchodilator and does not receive anti-inflammatory protection; severe asthma, conversely, can be well controlled with high-intensity therapy. Therefore, it is important for the physician to separately record severity, control, and risk. [12]

Modern degree	As is usually understood	What is important not to confuse
Mild asthma	Controlled by minimal anti-inflammatory therapy	Doesn't mean zero risk of severe attack
Moderate asthma	Requires regular maintenance therapy, often in combination	Not determined by daily symptoms alone
Severe asthma	Uncontrolled despite optimized high-intensity therapy or worsens with reduction of high-intensity therapy	It is not made without checking the diagnosis, inhalation technique and adherence
Uncontrolled asthma	Symptoms or flare-ups persist	It may be a consequence of treatment errors rather than true severe asthma.
Difficult to treat asthma	Not controlled at medium or high doses of therapy	Often improves after elimination of modifiable factors

Source of table data: Global Asthma Initiative, British Thoracic Society Guidelines, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network. [13] [14]

Symptom Control: Why It's Not the Same as Severity

Asthma control measures how much the disease currently interferes with a person's asthma: whether there are daytime symptoms, nighttime awakenings, limited physical activity, frequent use of reliever medication, or absences from school or work. Guidelines from the British Thoracic Society, the National Institute for Health and Care Excellence, and the Scottish Intercollegiate Guidelines Network recommend assessing control at every review, including the amount of reliever medication used, courses of systemic glucocorticosteroids, hospitalizations, and emergency department visits. [15]

Complete asthma control in this guideline is defined as the absence of daytime symptoms, nocturnal awakenings, attacks, the need for rescue medication, or activity limitations, as well as normal or near-normal lung function and minimal treatment side effects. This is a very strict benchmark: it shows what to strive for, but does not mean that every single cough automatically requires a sharp increase in therapy. [16]

Control can change more quickly than severity. For example, a patient with mild asthma may temporarily lose control during a viral infection or pollen season, while a patient with severe asthma may be well-controlled with appropriate high-intensity therapy. Therefore, the phrase "Stage 2 asthma" without specifying control is uninformative: the physician needs to know what is happening now and what treatment maintains stability. [17]

Control assessment should include testing actual inhaler use. The guidelines recommend observing the person's use of the inhaler and spacer at each assessment, during deterioration, when the device is changed, and at the patient's request. If technique is incorrect, medication may be delivered to the airways with minimal effect, making the illness appear more severe than it actually is. [18]

Validated questionnaires can be used for standardization: the Asthma Control Test, the Asthma Control Questionnaire, or the Children's Asthma Control Test. These do not replace physical examination, spirometry, and clinical judgment, but they do help detect deterioration and compare symptoms over time. Regular peak flow monitoring is not necessary for all patients, but it can be helpful if included in a personalized action plan. [19]

Control parameter	Good control	Insufficient control	Practical action
Daytime symptoms	None or rare	Frequent, interfere with normal life	Review treatment, triggers, and inhalation technique
Night awakenings	No	There are awakenings due to coughing or shortness of breath	Reconsider anti-inflammatory therapy
Physical activity	Unlimited	The person avoids stress	Assess respiratory control and function
A drug for relief	Rarely needed	Needed frequently or increasingly	Look for deterioration and risk of exacerbation
Exacerbations	No	There are courses of systemic glucocorticosteroids or emergency care	Review the risk level
Inhalation technique	Tested and correct	There are errors	Train and retest

Source of table data: British Thoracic Society guidelines, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network. [20] [21]

Classic 4 degrees: intermittent, mild persistent, moderate persistent, severe persistent

The classic symptom-based classification divides asthma into intermittent and persistent. Intermittent asthma is characterized by infrequent symptoms with relatively calm intervals, while persistent asthma is characterized by a more constant tendency toward symptoms and exacerbations. In the old logic, persistent asthma was further divided into mild, moderate, and severe based on the frequency of daytime symptoms, nighttime awakenings, activity limitations, and lung function. [22]

Intermittent asthma, in the old paradigm, was typically described as symptoms no more than two days a week, nocturnal symptoms no more than twice a month, normal lung function between episodes, and short exacerbations. However, modern practice is more cautious about the term "intermittent" because even rare symptoms do not guarantee the absence of a severe attack, especially if a person is not receiving anti-inflammatory therapy and relies solely on a fast-acting bronchodilator. [23]

Mild persistent asthma, according to the classic definition, is defined as symptoms occurring more than two days a week, but not continuously throughout the day, and nighttime symptoms occurring more than twice a month. This category was useful for initial assessment before treatment, but modern guidelines increasingly emphasize minimally effective anti-inflammatory therapy and exacerbation prevention, rather than solely counting symptomatic days. [24]

Moderate persistent asthma, in the classic model, is typically associated with daily symptoms, more frequent use of reliever medication, nighttime awakenings more than once a week, and a significant impact on activity. In modern assessment, such features remain important, but the clinician should also consider lung function, exacerbations, inflammatory markers, comorbidities, and treatment response for 8-12 weeks after changing therapy. [25]

Severe persistent asthma, according to the old model, described persistent symptoms, frequent nocturnal awakenings, marked limitation of activity, and low respiratory function tests. While this description is now useful as a warning sign, a diagnosis of true severe asthma requires more stringent testing: the disease must remain uncontrolled despite optimized high-dose treatment and elimination of modifiable factors. [26]

Classic category	Typical signs according to the old scheme	How to interpret today
Intermittent asthma	Rare symptoms, long periods of calm	Not automatically considered safe
Mild persistent asthma	Symptoms occur more than 2 days a week, but not all day every day	An anti-inflammatory strategy is needed
Moderate persistent asthma	Daily symptoms, night awakenings, limited activity	It is necessary to evaluate control, risk and level of treatment
Severe persistent asthma	Persistent symptoms, frequent nighttime aggravation, marked limitation	Requires testing for true severe asthma
Any category	Exacerbations are possible	Risk is assessed separately from symptoms.

Source of table data: materials from the National Heart, Lung, and Blood Institute of the United States and the current severe asthma guidelines of the Global Asthma Initiative. [27] [28]

Objective indicators: how breath tests help assess the severity and risk

Asthma symptoms are subjective: one person quickly notices mild shortness of breath, while another adapts to the limited breathing and seeks medical attention late. Therefore, objective tests are important not only for confirming the diagnosis but also for risk assessment. British guidelines recommend using exhaled nitric oxide fraction, blood eosinophils, spirometry with a post-bronchodilator test, peak flowmetry, and, if necessary, bronchoprovocation tests if asthma is suspected. [29]

Spirometry measures how freely air exits the lungs, and the key indicator is the forced expiratory volume in 1 second. To confirm variable bronchial obstruction in adults, an increase in this indicator after bronchodilator administration of 12% and at least 200 milliliters, or 10% or more of the predicted value, is considered diagnostically significant. In children aged 5 to 16 years, an increase of 12% from the baseline or 10% or more of the predicted value is considered significant. [30]

Peak expiratory flow measurement is useful when spirometry is unavailable or delayed. In this case, the patient can measure the value twice daily for 2 weeks; a variability of 20% or more supports a diagnosis of asthma. However, for ongoing assessment of control, regular peak flow measurement is not recommended for everyone unless there are individual reasons, such as incorporating the measurement into a personal action plan. [31]

Fractional nitric oxide (FNO) in exhaled air helps assess type 2 inflammation in the airways. In adults with suspected asthma, a level of 50 ppb or higher supports the diagnosis, while in children aged 5 to 16 years, a level of 35 ppb or higher is considered diagnostic. In established asthma, an elevated level with poor control may indicate poor treatment adherence or the need for increased inhaled glucocorticosteroid therapy. [32]

It's important not to overestimate the value of a single test. Normal spirometry outside of an attack does not always rule out asthma, especially if a person is already taking inhaled glucocorticosteroids, as treatment can normalize the results. Therefore, the severity of asthma is assessed comprehensively: symptoms, exacerbations, lung function, inflammatory markers, treatment response, inhalation technique, and comorbid conditions. [33]

Method	What does it show?	How does it help in assessing the degree?
Spirometry	Bronchial patency and forced expiratory volume in 1 second	Helps confirm obstruction and assess lung function
Post-bronchodilator test	Reversibility of bronchial constriction	Supports the diagnosis of asthma
Peak expiratory flow rate	Home or serial assessment of respiratory variability	Useful when spirometry is delayed or in an action plan
Fraction of nitric oxide in exhaled air	Eosinophilic airway inflammation	Helps confirm the diagnosis and assess the inflammatory component
Blood eosinophils	Sign of type 2 inflammation	Important in the diagnosis and selection of therapy for severe asthma
Bronchoprovocation test	Bronchial hyperreactivity	Used if the diagnosis remains in doubt

Source of table data: British Thoracic Society guidelines, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network. [34]

Treatment steps as a practical way to understand asthma severity

Treatment stages are not the same as "disease grades," but they help to modernize the assessment of asthma severity. If asthma is well controlled with minimal therapy, it is considered mild; if more intensive maintenance therapy is needed for control, it is considered moderate; if high doses and additional medications are required, or control is not achieved, it may be considered severe. [35]

For people aged 12 years and older, UK guidelines recommend a low-dose combination inhaler with an inhaled glucocorticosteroid and formoterol as needed for symptom relief in newly diagnosed asthma. If a person has severe symptoms at onset, regular night awakenings, or severe exacerbations, treatment can be initiated with low-dose maintenance and reliever therapy using a single combination inhaler. [36]

If asthma is not controlled with low-dose therapy as needed, switch to low-dose maintenance and reliever therapy; if control is not achieved with this, a moderate dose is used. If control is not achieved with a moderate dose despite good adherence, the physician should check the fractional nitric oxide in exhaled air and blood eosinophils, and if either indicator is elevated, refer the patient to an asthma specialist. [37]

A short-acting beta-2 agonist, such as salbutamol, should not be the sole treatment for asthma. Current guidelines clearly state that people of any age with asthma should not be prescribed a short-acting beta-2 agonist without also receiving an inhaled glucocorticosteroid. This is because the bronchodilator relieves spasms but does not treat the underlying inflammation. [38]

For children aged 5 to 11 years, the starting regimen differs: a low-dose inhaled glucocorticosteroid twice daily and a short-acting beta-2 agonist as needed are typically recommended. If control is inadequate, maintenance and reliever therapy with a single inhaler, the addition of a leukotriene receptor antagonist, or combination therapy may be considered, but the choice depends on the child's age, ability to use the device, and the licensing status of the specific drug. [39]

Level of therapy	What could this mean for gravity?	Practical conclusion
Minimal anti-inflammatory therapy as needed	More often corresponds to mild asthma	Risk management is needed even if symptoms are rare
Low-dose maintenance therapy	Mild or moderate asthma depending on the answer	Assess symptoms after 8-12 weeks
Moderate supportive therapy	More often moderate asthma	Check commitment, technique and triggers
High-dose therapy	Possible severe or difficult-to-treat asthma	A specialized assessment is needed
Biological therapy or systemic glucocorticosteroids	Usually severe asthma after phenotyping	Requires specialist supervision

Source of table data: Global Asthma Initiative and British Thoracic Society guidelines, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network. [40] [41]

Difficult-to-treat and severe asthma: where is the line?

Difficult-to-treat asthma is a condition in which the disease remains uncontrolled despite the use of moderate- to high-dose inhaled glucocorticosteroids with a second controller medication, often a long-acting beta-2 agonist, or requires such therapy to maintain control. The Global Asthma Initiative emphasizes that this does not mean a "difficult patient": in many cases, the cause is incorrect inhalation technique, poor adherence, smoking, comorbidities, exposure to irritants, or misdiagnosis. [42]

Severe asthma is a narrower category. It remains uncontrolled despite optimized high-dose therapy, demonstrated adherence, proper inhalation technique, and management of associated factors, or worsens when high-dose therapy is tapered. Therefore, severe asthma should not be automatically diagnosed for everyone with frequent cough or nocturnal shortness of breath. [43]

Before classifying asthma as severe, alternative diagnoses should be excluded: chronic obstructive pulmonary disease, bronchiectasis, heart failure, vocal cord dysfunction, chronic rhinosinusitis with postnasal drip, gastroesophageal reflux disease, anxiety attacks, and occupational respiratory diseases. British guidelines specifically recommend considering alternative diagnoses and comorbidities before initiating or changing therapy. [44]

Patients with suspected severe asthma require phenotyping: assessment of allergy, blood eosinophils, fractional nitric oxide in exhaled air, exacerbation frequency, dependence on systemic glucocorticosteroids, concomitant polypous rhinosinusitis, and other signs of type 2 inflammation. This is not necessary to "complicate the diagnosis," but to select additional treatments, including biologics. [45]

Biologic agents are considered for severe asthma after a specialized assessment and not as a replacement for basic inhaled therapy. Options may include agents that target immunoglobulin E, interleukin-5, interleukin-5 receptor, interleukin-4 receptor, and thymic stromal lymphopoietin; the choice depends on the phenotype, age, availability, safety, and the criteria of the specific health system. [46]

State	What does it mean?	What needs to be done
Uncontrolled asthma	Symptoms, exacerbations, or limitations persist	Check diagnosis, treatment, triggers and technique
Difficult to treat asthma	Control is poor at medium or high doses of therapy	Look for correctable causes and associated diseases
True severe asthma	Control is poor despite optimized high-dose therapy	Refer to a specialist and phenotype
Asthma with frequent exacerbations	2 or more courses of systemic glucocorticosteroids per year or hospitalization	Strengthen risk assessment and revise plan
High inflammatory profile asthma	Eosinophils or nitric oxide fraction are elevated	Consider specialized therapy

Source of table data: Global Asthma Initiative guidelines for difficult-to-treat and severe asthma, British Thoracic Society guidelines, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network. [47] [48]

Asthma levels in children and adolescents

In children, the severity of asthma is more difficult to determine than in adults because symptoms can mimic viral wheezing, and young children cannot always perform adequate spirometry. Guidelines from the British Thoracic Society, the National Institute for Health and Care Excellence, and the Scottish Intercollegiate Guidelines Network indicate that in children under 5 years of age, diagnosis is difficult due to the limitations of objective tests, so treatment often begins as a trial course followed by regular reassessment. [49]

In children under 5 years of age with suspected asthma and significant symptoms, an 8- to 12-week trial of a low-dose inhaled glucocorticosteroid twice daily with a short-acting beta-2 agonist as needed may be considered. If symptoms resolve, the drug can be stopped and re-evaluated after 3 months; if symptoms return or the child experiences a severe episode, regular therapy can be resumed.[50]

In children aged 5 to 11 years, objective tests are more often available, including fractional nitric oxide in exhaled air, spirometry with a post-bronchodilator test, and peak flowmetry. Treatment typically begins with a low-dose inhaled glucocorticosteroid twice daily and an as-needed reliever, and if control is insufficient, the next steps are progressed. [51]

In adolescents, assessing asthma severity is complicated by behavior and real-life factors, such as school, sports, embarrassment about inhaler use, irregular schedules, smoking or vaping, and missed maintenance treatments. Therefore, the guidelines recommend asking adolescents about smoking and vaping, discussing future careers, and considering factors that interfere with inhaler use in school and social situations. [52]

In 2026, the World Health Organization released updated guidelines for asthma management in children and adolescents aged 0 to 19 years, including acute exacerbations, severe exacerbations, rational use of medications, inhaled glucocorticosteroids, and maintenance and reliever therapy. This confirms the general trend: childhood asthma should be managed not only by cough frequency, but also by risk, age, availability of inhalers, family training, and the child's ability to properly adhere to treatment. [53]

Age	Features of the degree assessment	A practical approach
Under 5 years old	Objective tests are often impossible	Trial treatment and regular review of diagnosis
5-11 years	Possible nitric oxide fraction, spirometry, peak flowmetry	Assess symptoms, respiratory function, and response to treatment
12-18 years old	Added issues include commitment, school, sports, smoking, and vaping.	Test real barriers to treatment
Any age	Severity is not just about the frequency of the cough.	Consider exacerbations and risk
Children with hospitalizations	High risk of adverse outcomes	More active monitoring or specialist is required

Source of table data: British Thoracic Society, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network and World Health Organization 2026 guidelines for asthma in children and adolescents. [54] [55]

How can a patient understand that the severity of asthma has changed?

Reasons to suspect a worsening condition include increased frequency of symptoms, nighttime awakenings, decreased tolerance of physical activity, needing relief medication more often than usual, or no longer working as quickly as before. The World Health Organization emphasizes that asthma symptoms can vary in severity and periodically worsen significantly, leading to an attack or exacerbation. [56]

The increasing demand for fast-acting bronchodilators is particularly alarming. British guidelines highlight excessive use of short-acting beta-2 agonists—more than two inhalers per year—as a risk factor for poor outcomes. This doesn't mean that the third inhaler per se is dangerous, but it is a strong signal: asthma is likely under-controlled. [57]

An even more serious sign is two or more courses of systemic glucocorticosteroids in a year, two or more emergency department visits, or any hospitalization due to asthma. In this situation, the diagnosis, inhalation technique, triggers, ongoing therapy, and written action plan should not be limited to the description "seasonal worsening": it is necessary to review the diagnosis, inhalation technique, triggers, ongoing therapy, and written action plan. [58]

After starting or changing treatment, current guidelines recommend assessing the response after 8-12 weeks. This period helps determine whether the therapy is truly working, whether a step-up is needed, whether the current regimen can be maintained, or whether further evaluation is required. If asthma is consistently well controlled, reducing maintenance therapy is discussed at the annual review and is done gradually, with an interval of at least 8-12 weeks between the next reduction. [59]

Every patient should have a personalized written action plan. It should explain what medications are used daily, what to do if symptoms worsen, what triggers to avoid, when to contact a doctor, and when to seek emergency care. The National Heart, Lung, and Blood Institute in the United States describes such a plan as a written document that lists medications, signs of an attack, actions to take if symptoms worsen, criteria for seeking medical attention, and emergency contact information. [60]

Sign	What could it mean?	What to do
Night awakenings	Loss of control	Contact your doctor to review your treatment.
A common remedy for relief	Insufficient anti-inflammatory protection	Check therapy and inhalation technique
Load limitation	Possible deterioration of respiratory function	Assess control and perform tests
2 or more courses of systemic glucocorticosteroids per year	High risk of exacerbations	An active revision of tactics is needed
Hospitalization	A very significant risk factor	A post-discharge plan and specialist follow-up are needed.
Deterioration after reduction of treatment	Perhaps the treatment was reduced too quickly.	Return to the doctor and update the plan

Source of table data: British Thoracic Society guidelines, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network, and materials from the National Heart, Lung, and Blood Institute of the United States. [61] [62]

FAQ

How many degrees of bronchial asthma are there?

The old symptom classification typically distinguished four categories: intermittent, mild persistent, moderate persistent, and severe persistent asthma. In modern practice, mild, moderate, and severe asthma are more commonly defined based on the amount of treatment needed for control, with ongoing symptom control and the risk of exacerbations assessed separately. [63]

Is mild asthma safe asthma?

No. Mild asthma is usually controlled with minimal treatment, but this does not mean there is no risk of a severe attack. The Global Asthma Initiative 2026 emphasizes the need for access to anti-inflammatory inhalers for all people with asthma, as they help control the inflammatory basis of the disease and prevent attacks. [64]

How to distinguish moderate asthma from severe asthma?

Moderate asthma is usually controlled with regular, moderate-intensity maintenance therapy, while severe asthma remains uncontrolled despite optimized high-dose therapy, proper inhalation technique, good adherence, and elimination of associated factors. Therefore, severe asthma is a diagnosis after testing, not simply a description of common symptoms. [65]

Is it possible to determine the severity of asthma without spirometry?

A preliminary assessment of symptoms and risk can be performed, but a full evaluation requires objective data if testing is available. Current guidelines recommend using exhaled nitric oxide fraction, blood eosinophils, post-bronchodilator spirometry, peak flowmetry, and, if necessary, a bronchoprovocation test. [66]

What is more important: symptoms or exacerbations?

Both parameters are important, but they answer different questions. Symptoms reflect current control, while exacerbations indicate the risk of future severe events; a patient with relatively infrequent symptoms but with hospitalization or repeated courses of systemic glucocorticosteroids is considered to be at increased risk. [67]

Why can't you treat with salbutamol alone?

Salbutamol and other short-acting beta-2 agonists rapidly dilate the bronchi but do not treat airway inflammation. Current guidelines specifically recommend against prescribing short-acting beta-2 agonists to people of any age with asthma without concomitant inhaled glucocorticosteroids. [68]

Can asthma severity decrease?

Yes, if asthma is well controlled, your doctor may discuss tapering maintenance therapy. However, the reduction should be gradual: guidelines recommend waiting at least 8-12 weeks before the next step down, agreeing on monitoring and updating your personal action plan in advance. [69]

What does uncontrolled asthma mean?

Uncontrolled asthma means persistent frequent symptoms, nighttime awakenings, activity limitations, and a high need for medication for relief or exacerbation. However, uncontrolled asthma is not always truly severe: adherence, inhaler technique, triggers, comorbidities, and the correct diagnosis must first be assessed. [70]

How do you know if you need an asthma specialist?

Referral to a specialist is especially important in cases of uncontrolled asthma on moderate or high levels of therapy, frequent exacerbations, hospitalization, suspected occupational asthma, questionable diagnosis, or the need for biological therapy. The guideline recommends referral for people with asthma that is uncontrolled on high-dose inhaled glucocorticosteroids. [71]

Are the degrees of asthma in children the same as in adults?

The general concepts are similar, but diagnosis and treatment vary by age. In children under 5 years of age, objective testing is often impossible; in children aged 5 to 11 years, the initial treatment approach differs from that in adults; and in adolescents, it is especially important to consider smoking, vaping, school, sports, and actual inhaler use. [72]

Key points from experts

Professor Helen K. Reddel, MBBS, PhD, Chair of the Scientific Committee of the Global Asthma Initiative, Macquarie University, University of Sydney, Sydney Local Health District. The key practical message of current guidelines is that asthma severity should be assessed not only by the patient's self-reported symptoms, but by the amount of treatment needed to control and prevent exacerbations. This is particularly important for mild asthma, because rare symptoms do not preclude the risk of a severe attack. [73]

Professor Arnaud Bourdin, University of Montpellier, Department of Respiratory Diseases, member of the scientific committee of the Global Asthma Initiative. The key message for severe asthma: before considering the disease truly severe, it is necessary to confirm the diagnosis, correct inhaler technique errors, check adherence, smoking, vaping, occupational exposures, mold, air pollution, and comorbidities. Without this verification, the patient may be mistakenly classified as severe asthma. [74]

Dr. Francine Ducharme, University of Montreal, Centre Hospitalier Universitaire Sainte-Justine, member of the scientific committee of the Global Asthma Initiative. For children, the key message is that asthma severity cannot be generalized from adult regimens without taking age into account. Preschoolers often require a trial of therapy and a reassessment of the diagnosis; school-age children can more widely utilize objective testing; and for adolescents, adherence and real-life barriers to treatment must be considered. [75]

Professor Stephen Fowler, Professor of Respiratory Medicine and Consultant Respiratory Physician, University of Manchester and Manchester University National Health Service Foundation Trust, Adult Expert, British Thoracic Society Guidelines Committee, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network. Practice statement: Asthma assessment should rely on objective tests and repeated assessment of control, rather than self-reported symptoms, because symptoms may be under- or over-reported by the patient. [76]

Dr Ian Sinha, Consultant Paediatric Respiratory Specialist, Alder Hey Children's Hospital, Liverpool, and a paediatric expert on the British Thoracic Society Guidelines Committee, the National Institute for Health and Care Excellence, and the Scottish Intercollegiate Guidelines Network. For paediatric practice, the key message is: if a child is not responding to treatment, inhaler technique, adherence, home environment, mould, smoke, cold housing, and the possibility of an alternative diagnosis should be sequentially assessed, rather than simply automatically increasing the dose. [77]

Result

The severity of asthma cannot be reliably determined solely by the frequency of cough or shortness of breath. Modern assessment involves three layers: severity based on treatment volume, current symptom control, and the risk of future exacerbations. Therefore, diagnosis should answer three questions: how intensive is the treatment needed, how well is the disease currently controlled, and whether there are any signs of high risk. [78]

The most practical modern regimen is as follows: mild asthma is controlled with minimal anti-inflammatory therapy; moderate asthma requires regular maintenance treatment; severe asthma remains uncontrolled despite optimized high-dose therapy or worsens when it is tapered. Any level requires a written action plan, inhalation technique testing, trigger assessment, and regular treatment reviews. [79]