What Is Severe Asthma?

The classification of “severe asthma” refers to patients who require high-dose inhaled glucocorticoid (GC) to maintain asthma control or who never achieve control despite that treatment.

People with severe asthma struggle to manage their day-to-day activities. They experience a heavy burden of symptoms, exacerbations and medication side effects. The symptoms can be unpredictable and occur during the day and night. If severe asthma symptoms aren’t controlled effectively, it can be very debilitating. Frequent shortness of breath, wheezing, chest tightness and cough interfere with day-to-day living, sleeping and physical activity. Patients often have frightening and unpredictable exacerbations also called asthma attacks or severe flare-ups.

According to NIH guidelines, severe asthma includes the following features

• Symptoms that occur throughout the day
• Being woken up by symptoms, often seven nights per week (in those five years of age and older)
• For children four years of age and younger, being woken up by symptoms on more than one night per week
• Symptoms that require short-acting beta 2-agonist therapy several times per day
• Symptoms that significantly limit a person’s regular activities
• A forced expiratory volume 1 (FEV 1) measurement of less than 60 percent of usual (in those five years of age and older)

The symptoms associated with a severe asthma attack include

• A bluish tint to the lips, face or fingernails
• Feeling the need to stand up or sit to try and breathe more easily
• Feeling confused or agitated
• Being unable to speak in full sentences
• Feeling very short of breath and unable to inhale or exhale fully
• Rapid breathing
• Symptoms that don’t get better even after using a rescue inhaler

There is no single treatment or solution as everyone is affected differently. The prescribed medications may be the same for someone who has milder asthma, but the medications may be used at a much higher dose. Treatment of severe asthma focuses on trying to control the symptoms. The patient receives prescribed medication and treatment to manage airway inflammation and to prevent lung damage. They will also be advised to reduce the risk of coming into contact with asthma triggers.

In addition to inhalers to treat and prevent asthma attacks, those who have severe asthma may be prescribed other treatments. Treatment options include the following

• Long-acting bronchodilators (LBAs): These can be added to a preventer inhaler and help keep the airways open for at least 12 hours.
• Leukotriene receptor antagonists (LTRAs): A nonsteroid tablet that helps calm inflamed airways, blocks the effects of leukotrienes (inflammatory molecules) and helps with allergies.
• Long-acting muscarinic receptor antagonists (LAMAs): A form of long-acting bronchodilator that can work for 12 to 24 hours.
• Long-acting beta-agonists (LABAs): Another form of long-acting bronchodilator that is used to relax the muscles in the airways.
• Slow-release theophylline: A nonsteroid tablet that helps to relax the smooth muscles in the airways, enabling air to more easily flow through.
• Short-acting beta 2-agonists: A form of quick relief medication that can be used when asthma symptoms occur.
• Daily steroids: These are prescribed in tablet or liquid form and are a type of anti-inflammatory medicine. They work by helping to reduce sensitivity in the airways.
• Monoclonal antibodies (also called mAbs or biologics): A newer form of medication for severe uncontrolled asthma. They work by blocking the activity of immune system chemicals that trigger airway inflammation.
• Bronchial thermoplasty: In some cases, bronchial thermoplasty might be recommended. Bronchial thermoplasty is delivery of controlled, therapeutic radiofrequency energy to the airway wall. This heats the tissue, reducing the amount of smooth muscle present in the airway wall, and it widens the airways.