In a text book world...

...how would mild, moderate, and severe asthma be defined?

Cheers

Emz

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I'm going to let a medical-type person have a crack at this one, 'cos it's very tricky.

When we get a summary of the kids who will be on each Kick Asthma holiday, it lists their asthma as either mild, moderate or severe. The trouble is, this rating is usually chosen by the parent - so a child listed as having ""severe"" asthma can be anything from being on a sub-cut infusion right down to having a brown inhaler (yes, really)!

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Hope you are feeling better now, Crazybaby, and have got your follow-up and care sorted out - it sounded like you had a really rough deal.

In a text book world, there aren't really any agreed definitions of mild, moderate or severe asthma.

The classification of ""Brittle"" asthma is still also hotly-disputed, and tends to be over-used (incorrectly) by professionals outside of the specialist field of asthma management.

The BTS guidelines have a crack at categorising the stages of asthma, but don't divide it into mild/moderate/severe - simply into descriptive terms according to medication use. Have a look here: brit-thoracic.org.uk (go to ""Guidelines"" then ""Guidelines since 1997"" then ""Asthma"")

CathBear

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I took this from a website, i dont think im allowed to post links but this is what it said:

Mild Asthma

Mild asthma is generally spasmodic or seasonal. Breathlessness is usually mild, and attacks are infrequent. Once or twice a month you may find that you wheeze or cough during the night or when exposed to triggers such as exercise or having a cold. Between these episodes, you will probably experience no symptoms at all.

Treatment is almost always with the use of a bronchodilator (reliever medication) which you use to ease the symptoms. However, if you find that you are using these medications more than three or four times a week, inform your doctor. You may have moderate asthma, which calls for a more aggressive treatment program.

Moderate Asthma

Episodes of moderate asthma usually occur once or twice a week. You may experience nocturnal asthma, waking in the night with coughing, and wheezing. Exercise can also trigger moderate symptoms. In some cases, wheezing, coughing, and difficulty in breathing may last for several days at a time. Occasionally, you may require emergency care.

Inhaled steroid medications are prescribed to prevent cases of moderate asthma, while inhaled beta-agonists are used when symptoms occur. This preventer medication is taken daily whether you have asthma symptoms or not. Treating asthma this way is similar to brushing your teeth daily to prevent tooth decay. An occasional short burst of oral steroids may be needed when you are unable to control your condition.

Severe Asthma

Asthma rules the lives of severe asthmatics. Asthma symptoms are continuous, or you experience frequent attacks. Severe asthma can affect your overall level of activity and cause frequent nighttime symptoms. You may require hospitalization or occasional emergency treatment.

Symptoms are made worse by factors such as exercise and cold air. Daily preventive treatment is prescribed and reliever medications are also needed daily. Following severe attacks, steroid tablets (eg prednisone) are given to control the condition. You may require hospitalisation or occasional emergency care.

Brittle Asthma

Brittle asthma is an extremely severe form of the disease that is unpredictable. It is rare, affecting only approximately one in 2000 asthmatics.

Brittle asthmatics experience sudden, very serious and often life threatening attacks. This can occur in spite of being on heavy doses of medication. Many will be on regular maintenance doses of steroid tablets for long periods of time and nebulisers will be used to take bronchodilators.

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hi crazybaby

hope you are feeling better, you could try typing the word asthma or asthma stages on the internet, I tried that before and found it quite helpful.

Lejaya

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Hi there everyone,

I don't know where you got the information that you posted, Haagendaz, but I would be interested to have the link (posting links is not usually a problem provided you are not advertising a product or service). Wherever it's from, I would be extremely wary of this information.

As CathBear has already said, there are no universally accepted definitions for mild, moderate and severe asthma among medical professionals. Because asthma is such a heterogeneous condition, and can manifest itself in so many ways, it is extremely difficult to come up with definitions that can be consistently applied to all cases. Do we define severity of asthma by amount of medication needed, level of symptoms, worst ever attack, degree of interference in normal life, numbers on peak flow or spirometry, or any of dozens of other ways?

The British Thoracic Society does categorize *attacks* - into moderate, severe, life-threatening and near-fatal - by looking at physiological indices such as peak flow, heart rate and respiratory rate, as well as symptoms and signs. Even then, these definitions have to be applied extremely carefully, and are often considered to be only appropriate for use by a healthcare professional. There may well be other factors involved during an acute attack which might influence the signs looked at, so categorization of an attack is not straight-forward. Categorization of an attack is not necessarily used to directly influence treatment - having had a severe attack does not necessarily imply that one will be on high levels of treatment, or that one has severe asthma by any other definition. These categories are really only used by healthcare professionals to give some indication, along with other data, of the risk to the patient in the future.

It is perfectly possible for someone who might be considered to have mild asthma by other measurements to have a severe attack, and it is equally possible for someone with severe asthma by some measures never to have had a severe attack.

The British Thoracic Society does also define stages of treatment - the Steps 1 to 5 that have been described previously on these boards. Again, these can give some insight into the severity of the person's asthma, but they do not tell the whole story - it is possible for someone who is on a high level of treatment to be very well controlled by this, and be able to maintain a fairly normal quality of life, whereas someone else who is on less treatment may have asthma that has a significant impact on their life.

The BTS Guidelines can be seen in full here: brit-thoracic.org.uk/c2/upl...

In addition to these general points, there are a couple of statements in the descriptions that Haagendaz has posted that I have to disagree with specifically. The first is the assertion that 'asthma rules the lives of severe asthmatics'. Whilst this is sadly true for many of us with severe asthma, it is not always the case, and it is a pretty discouraging and pessimistic statement. There are people who post regularly on this forum who have severe asthma by most of the possible definitions, but still manage to maintain jobs, do volunteer work, participate in charity events, have families, have active hobbies and social lives, and generally participate in life without being 'ruled' by their asthma. I myself have had a diagnosis of brittle asthma from a specialist tertiary referral centre for around 12 years, and have managed to go to medical school, qualify as a doctor, and practice medicine for several years in this time - even now, although I am not able to work, I have an active life with many diverse interests, hobbies, goals and activities, and I would by no means say that asthma 'rules' my life. It is not always easy, by any means, living with severe asthma, but to make the blanket statement that severe asthma 'rules lives' belittles the efforts of every severe asthmatic on this board.

The section on brittle asthma also causes me some concern - I realise that this definition is likely to be taken from a site that caters for non-medics, and it therefore can't be expected to be a strict medical definition. However, there is a precise medical definition for the two types of brittle asthma. The term is often overused by physicians and patients alike to describe any asthma that does not respond to treatment quite as readily as usual. This definition reinforces that, in a sense, by giving a fairly vague and woolly description rather than by stressing that brittle asthma is a specific condition with strict criteria.

The statement that brittle asthmatics always require nebulised bronchodilator treatment also causes me some concern. Whilst it is true that the majority of brittle asthmatics will have nebulisers, it is not always the case, and some people who do not fit the strict definitions of brittle asthma may benefit from nebuliser treatment. The decision for someone to have home nebuliser treatment is a very individual one, and one that must be considered very carefully by the person's doctors, because having a home nebuliser in the wrong circumstances can be dangerous. It is not a treatment to be applied in a blanket fashion to a diagnosis, without individual assessment.

I hope this clears up a few points - to reiterate, and as CathBear has said early on in this thread, there is no accepted definition of mild, moderate or severe asthma. Any website that tries to proclaim one is in danger of being highly misleading, and deciding a level of treatment according to a perception of whether an asthmatic is mild, moderate or severe is potentially dangerous. There are many other factors to be considered.

Haagendaz, I am in no way trying to criticise you in my response to your post. I do realise that the text you quoted was taken from a website and was posted in all good faith to try to answer the question. It does perhaps high-light, though, the dangers of relying too much on information gleaned from sites that may not be very reliable. If in doubt, always check that sites with medical information are by reliable groups, such as Asthma UK, and preferably that the information provided is accurately referenced from equally reliable sources.

Hope this helps clear up some of these issues

Take care all

Em H

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Here is the link: buteyko.co.nz/asthma/facts/...

As both you and Cathbear stated, there is no universally accepted definition for it, however, it gives a general idea of what the different stages could be. I read the guidelines on the british thoracic society website, and as you said, they talk abotu the severity of asthma attacks, which do not indicate the severity of your asthma. But as i said, it was just to get a general idea.

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I'm familiar with that particular website, and I really wouldn't suggest that anyone bases their understanding of asthma on it.

Even as a general idea, the stages described are very misleading, for the reasons I've described. I can understand why people feel the need to try to catagorise their asthma, but creating artificial catagories and trying to use them to determine what treatment is appropriate is potentially dangerous.

Em

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So if there is no real category, then how do doctors categorise it? When i moved, and got a copy of all my medical documents it stated that i had moderate asthma... However, it didnt state why?! So what do they base it upon?

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Most of the time, respiratory physicians don't tend to really categorize it, except by using simple factual descriptive phrases referring to treatment level, such as 'steroid-dependent asthma' or 'BTS Stage 4 asthma'. Of course, brittle asthma is something of an exception, since there is a precise definition, albeit one that's not universally recognised by doctors. 'Chronic asthma' is another one that I've seen used, which again is just a description of the chronicity of the symptoms.

I suspect that the GP's reference to moderate asthma was probably based on knowledge of most of the factors I described before, such as amount of medication needed, level of symptoms, worst ever attack, degree of interference in normal life, numbers on peak flow or spirometry and so on. I don't think most people would have a problem with this, in the context of all of your other medical records that give the other important details about your condition, although I personally would still consider it to be fairly meaningless. Upon being seen by a doctor for the first time, whether it be a new GP or an A&E doctor, just telling them that you have 'moderate asthma' would not usually be sufficient, and a good doctor will still ask lots of other questions to clarify things a bit more.

The real problem comes, though, when people assign these categories on a fairly arbitrary basis and then use them to dictate treatment, as the website quoted appears to do. This is really inappropriate, and indeed dangerous, as it could lead to people getting the wrong treatment. This is why I object so much to the wording of the website - there is no problem, in principal, with people referring to themselves as having 'mild', 'moderate' etc asthma (indeed, we do it ourselves on here in our profiles!) as long as it is recognised that it is not a medical description, and that it is not sufficent, on its own, to give very much information at all about the problems someone might experience, the amount of medication they are on, or the treatment they might receive in an emergency.

Hope this makes it a bit clearer why I, and indeed most doctors, object to some of the classifications that are to be found on the net.

Take care all

Em

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sorry about all the questions, but after having lived in numerous different countries having experienced different approaches on asthma i find it interesting hearing different views on the subject.

When i lived in the states it seemed like they categorised it more spesifically than in the UK. I saw a consulant there and thats who put down that i had moderate asthma. In school, when I had to fill out field trip forms i had to check whether i had exercise induced, mild, moderate, or severe asthma. So it seems like there should be some way of categorising it. Does it vary from country to country then?

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Don't worry about asking questions, Haagendaz, it's good to generate discussion!

To the best of my knowledge (and I have read the medical literature on asthma fairly extensively, and the majority of it comes from the States) there is no officially medically recognised definition of the different catagories of asthma in the US either. The American Thoracic Society and the American College of Chest Physicians certainly don't have readily available systems of categorization.

Organisations will frequently attempt to impose categories, and I can understand how a non-medical organisation such as a school could feel that categorization was important, as they obviously like to have an idea of the severity of your asthma in order to best care for you. However, the interpretation of the words used to describe severity of asthma is so variable that often these catagories are meaningless. As PeakSteve has said in the first response to this thread, someone's definition of severe asthma can vary from being on subcut terbutaline and having had multiple ICU admissions to being on a steroid inhaler, essentially Step 2 (out of 5) of the BTS guidelines!

As there is no universally accepted medical categorization, perhaps it is inevitable that individuals and organisations will attempt to generate one, but finding a system that the majority of respiratory physicians will agree with, takes into account all the important factors that I have previously mentioned, and is medically meaningful in terms of having an impact on prognosis and treatment, would be a virtually impossible task.

Hope this helps

Em

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An interesting debate!

From another medical perspective, classification of asthma is essentially meaningless. As PeakSteve and EmH say, self-classifications vary wildly according to perception; and classifications according to drugs used can paint a false picture for someone who is very well controlled on a significant amount of medication.

The American Thoracic Society give a definition of Chronic Severe Asthma but don't classify asthma other than this (that I know of - I prepare to be corrected). Going by their definitions, I'd be classified as chronic severe - but I wouldn't classify myself as that, because I have good functional status and am reasonably well-controlled. Call it a psychological trick if you will; on a similar vein, putting labels on people can be singularly unhelpful and, sometimes, damaging to them. If we had a sound classification, which everyone (including non-medical organisations) went by, then it may have some more meaning; but that doesn't take into account the personal factor of how you function on that level of medication, how frequent your exacerbations, and what's happened to you asthma-wise previously.

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so then how come my old consulant wrote that i had moderate asthma? and why don't they just classify it once and for all? wouldnt that stop all this confusion?

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I did try to answer both those questions in my previous posts, Haagendaz...

'i suspect that the GP's [or consultant's] reference to moderate asthma was probably based on knowledge of most of the factors I described before, such as amount of medication needed, level of symptoms, worst ever attack, degree of interference in normal life, numbers on peak flow or spirometry and so on. I don't think most people would have a problem with this, in the context of all of your other medical records that give the other important details about your condition, although I personally would still consider it to be fairly meaningless. Upon being seen by a doctor for the first time, whether it be a new GP or an A&E doctor, just telling them that you have 'moderate asthma' would not usually be sufficient, and a good doctor will still ask lots of other questions to clarify things a bit more.'

'finding a system that the majority of respiratory physicians will agree with, takes into account all the important factors that I have previously mentioned, and is medically meaningful in terms of having an impact on prognosis and treatment, would be a virtually impossible task.'

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Ooooh, it's more difficult than I thought - I literally thought there would be a ""text book"" way of classifying asthma...hmmm.

Reason I ask is that, whilst I know it's not essential, or even important, to classify severity of asthma, I am adament that I only have mild asthma, if nothing else so that I feel more in control and less ""at the hands"" of it if that makes any sense, whilst my partner is equally adament that it is bordering on severe (himself a childhood asthmatic). He has seen my regular attacks, was there at my hospital admission, and prompts me to take my meds if needs be, so he's informed of my condition. Perhaps I'm being stubborn? I guess i just want to prove him wrong to some degree But like I said, it's unimportant and just a point of interest to help me get my head around what I find to be a confusing situation, given that this time last year I was still only on Ventolin and Becotide :S

If you don't mind, I'd like to ask another couple of questions:

1) Can you grow out of asthma?

2) What does Atrovent do? I take inhaled Atrovent 8 puffs a day, but am unsure as to it's action...I understand it isn't a steroid, but is it a long-acting reliever or more of a preventer (in the traditional sense of the term)?

3) Is it possible that reduced lung capacity can adversely affect asthma?

Thanks for all your replies, and for your concern - I am feeling much better thank you, the attacks are still happening but I think I may be getting somewhere!

Take care, sorry for more questions

Emz x

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Thank you Emily, and sorry that im repeating myself, i sort of forgot that you had already answered them.

As for you crazybaby, im sure other people can give much more detailed answers but here is my attempt

1. Yes, you can grow out of asthma

2. Atrovent is a preventer, and it helps keeping your airways open at all times

3. I am not entirely sure, but I'd love to know. I have tiny lungs.

I am glad that you are getting better though.

Take care!

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Hi Crazybaby,

To try to answer your questions:

1) 'Growing out' of asthma is possible, but is less common than people tend to think. Young children (under fives) tend to be prone to getting wheeze with viral infections, so in most cases where children have 'grown out' of asthma, they probably actually had virally induced wheeze rather than asthma in the first place. Sometimes children do genuinely grow out of asthma as they hit puberty, although it can then come back in later life. Asthma can also often get a lot less severe as children get older. In general, though, if you've still got asthma by the time you're a young adult, you're probably stuck with it - although, again, the severity can fluctuate dramatically throughout your life.

2) Ipratropium (Atrovent) is not a preventer - it's a long-acting reliever with a slower mode of onset than salbutamol and terbutaline (typically 30 - 60 mins) so it's not suitable for use on its own in an acute attack. It's not a beta-2 agonist like salbutamol, terbutaline, salmeterol or formoterol; instead, it works on a slightly different part of the autonomic nervous system, the nervous system that controls how wide the airways are. It works very well for some people, and not so well for others. It's usually given 4 times a day - it shouldn't need to be given more often than that, as it lasts 4 - 6 hours, and the side effects usually stop it being given more frequently.

3) Reduced lung capacity is not usually a feature of asthma in itself, although lung capacity measurements can be affected if you have severe bronchospasm when you do the lung function tests. Lung capacity can be reduced in other diseases, typically in fibrotic lung diseases. Some people also just naturally have lower lung capacity than would be predicted for their age, height and sex - like peak flow, the 'normal range' is not always normal for everyone. If someone has low lung capacity, it should not particularly affect asthma symptoms, as such, in that it will not increase wheeze and tightness. If lung capacity is significantly lower than normal, though, it might cause breathlessness in its own right, and it may also mean that the person has lower respiratory reserve, meaning that an asthma attack might have more of an affect on the individual than a similar severity attack would on someone with normal lung capacity.

Hope this helps

Em H

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Thanks for answering those questions for me, very helpful.

EmH, you mention the side effects of Atrovent - what are these? And similarly, is it common to have put on weight and gotten the considerable munchies whilst on a fairly short (couple months long) course of pred?

Ta in advance x

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The most common side effects of ipratropium are dry mouth, headache and nausea. More rarely, and on higher doses (eg nebulised rather than inhaled), palpitations, constipation, difficulty passing urine, blurred vision and acute angle-closure glaucoma can occur.

The risk of eye-related side effects can be reduced by using a mouthpiece rather than a mask for nebs, so that less of the vapour gets into the eyes. Acute glaucoma is usually only a problem in people who have other reasons to be susceptible to angle-closure glaucoma (age, female sex, family history, Asian race). Steroids can also increase the risk of glaucoma but this is generally a different type of glaucoma, acute open angle glaucoma. The symptoms of acute glaucoma are an intensely painful, red eye with reduced visual acuity, often associated with headache, vomiting and being systemically unwell.

The effects of prednisolone vary hugely from person to person. Some people certainly find that a relatively short course will produce increased appetite and weight gain, whereas for other people, it will take longer. For some, it may not happen at all. It is certainly possible that a course of a couple of months will have this effect.

Hope this helps

Em H

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Thanks EmH for your reply

Luckily I'm not on nebulised iprotropium, although when I was admitted I was, so I've just gotta sweat out three more weeks of pred and try and shift some of this weight lol...

Emz x