Asthma Severity Classification: Intermittent, Mild/Moderate/Severe Persistent

Asthma severity classification (per GINA/NAEPP guidelines) guides initial treatment intensity. Assessment is based on impairment (symptoms, lung function) and risk (exacerbations) before controller therapy.

Four Severity Levels

Classification	Daytime Symptoms	Nighttime Awakenings	SABA Use for Relief	Activity Limitation	Lung Function (FEV₁/FVC)	Exacerbations Requiring OCS
Intermittent	≤2 days/week	≤2×/month	≤2 days/week	None	>80% predicted; FEV₁/FVC normal	0–1/year
Mild Persistent	>2 days/week but not daily	3–4×/month	>2 days/week but not daily	Minor	>80% predicted	≥2/year
Moderate Persistent	Daily	>1×/week but not nightly	Daily	Some limitation	>60–80% predicted; FEV₁/FVC reduced	≥2/year
Severe Persistent	Throughout the day	Often 7×/week	Several times/day	Extreme limitation	≤60% predicted; FEV₁/FVC reduced	≥2/year

Key Points

• Assign the most severe category in which any feature occurs.
• Lung function: FEV₁ % predicted (pre-bronchodilator) and FEV₁/FVC ratio.
• Children 0–4 years: symptom-based only (no spirometry).
• Classification applies before starting long-term control medication.

Treatment Steps (GINA 2023+)

• Step 1 (Intermittent): As-needed low-dose ICS-formoterol (preferred) or SABA alone (less preferred).
• Step 2 (Mild Persistent): Daily low-dose ICS + as-needed SABA or as-needed ICS-formoterol.
• Step 3 (Moderate Persistent): Low-dose ICS-LABA maintenance + as-needed SABA or medium-dose ICS or low-dose ICS-formoterol maintenance & reliever (MART).
• Step 4 (Severe Persistent): Medium/high-dose ICS-LABA + as-needed SABA; consider add-on LAMA, biologic (anti-IgE, anti-IL5/5R, anti-IL4Rα, anti-TSLP).
• Step 5: Referral for phenotype assessment, biologics, oral corticosteroids (minimize).

Assessing Control (After Treatment Started)

Separate from severity. Use ACT, ACQ, or GINA symptom control tool. Adjust step up/down based on control + risk factors.

Special Considerations

• Comorbidities (rhinosinusitis, GERD, obesity, anxiety) worsen control.
• Occupational triggers may require workplace modification.
• Pregnancy: maintain control; budesonide preferred ICS.