Treating Severe Asthma

February 13, 2014

Treating Severe Asthma

  1. David J. Amrol, MD

A new guideline for diagnosing severe asthma and addressing factors that can make it difficult to treat

  1. David J. Amrol, MD

Sponsoring Organizations: The European Respiratory Society/American Thoracic Society (ERS/ATS)

Target Population: Primary care providers, pulmonologists, allergists

Background and Objective

Most patients with asthma can be managed effectively with current medications; however, in 5% to 10% of patients, asthma is severe or treatment-resistant. These guidelines update the definition of severe asthma, discuss possible severe-asthma phenotypes, and provide recommendations to guide clinicians in treating children (age, ≥6 years) and adults with severe asthma.

When asthma has been confirmed and comorbidities have been addressed, severe asthma is defined as requiring either high-dose inhaled corticosteroids (ICS) plus a second agent, such as a long-acting β2-agonist (LABA) bronchodilator for the previous year or oral corticosteroids for ≥50% of the previous year for control (or asthma that remains uncontrolled despite this therapy).

Key Points

  • Confirm asthma diagnosis. Evaluate for conditions that can mimic or are associated with asthma (e.g., bronchiolitis, cystic fibrosis, congestive heart failure, allergic bronchopulmonary aspergillosis). Reserve high-resolution computed tomography for atypical presentations.

  • Assess patients for comorbidities and contributory factors: e.g., rhinosinusitis and nasal polyps, psychological factors, vocal cord dysfunction, obesity, smoking, obstructive sleep apnea, hyperventilation syndrome, hormonal influences (premenstrual, menstrual, menopausal), thyroid disorders, symptomatic gastroesophageal reflux disease, drugs (aspirin, nonsteroidal anti-inflammatory drugs, β-blockers, angiotensin-converting–enzyme inhibitors).

  • Identify characteristics of asthma phenotypes (e.g., allergic, eosinophilic, obesity, early- vs. late-onset). Use sputum eosinophil counts in centers equipped to perform this technique.

  • Consider steroid resistance in patients who do not respond to ICS. In addition to high-dose ICS or LABA, consider low-dose theophylline or a long-acting antimuscarinic agent such as tiotropium (Spiriva). In adults, sputum eosinophil counts can be used to guide therapy, but exhaled nitric oxide measurement is not recommended. For allergic asthma, consider a trial of omalizumab (Xolair). Methotrexate and macrolide antibiotics are not recommended. Antifungals should be used only in patients with allergic bronchopulmonary aspergillosis. Bronchial thermoplasty should be performed only in clinical-trial or registry settings because of “very low confidence” in available evidence on its effects in patients with severe asthma.


These guidelines do a good job of discouraging unproven therapies and diagnostic strategies for severe asthma, but evidence-based options are limited for this hard-to-treat population, and sputum eosinophil counts are not available to most clinicians. Patients with severe asthma should be treated in concert with an asthma specialist, with a focus on current guidelines. In patients not controlled on high-dose inhaled corticosteroids and long-acting β2-agonists, omalizumab and tiotropium are my next treatment options.

Editor Disclosures at Time of Publication

  • Disclosures for David J. Amrol, MD at time of publication Consultant / advisory board Dyax Leadership positions in professional societies South Carolina Allergy Society (President)


Reader Comments (5)

Magdi Ammar

Patient educagion is the corner stone for every stage of asthma severity

Dr. V Kantariya MD Physician, Family Medicine/General Practice

Treating Severe Asthma requires strict control of medications errors (wrong indication, no indication, treatment duration too short/too long, incorrect dose, drug-drug interactions not cosidered, drug-disease interactions not considered, errors of omissions ).Choosing Wisely!

Martin Spencer MA CCC-SLP Other Healthcare Professional, Otolaryngology, Ohio ENT

Exclusionary diagnoses could include, morbid obesity (impeding inspiratory diaphragmatic descent), vocal cord dysfunction (and functional variants such as inspiratory thoracic hyperelevation, or sub-sternally inflected tracheobronchial compression) as it is typically refractory to pulmonpathic intervention. We see hundreds of such cases per year that are effectively treated with several sessions of behavioral therapy. This may be the low hanging fruit, but it is commonly not picked.

Paul Chamberlain, BSc Hons, BChiroSc, BAppSc (Clin) Other Healthcare Professional, Pediatric Subspecialty, Melbourne, Australia

What 'behavioural techniques' to you utilise?


glycopyrroniumbromid instead of tiotropium

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