# Asthma

- [GINA](https://ginasthma.org/gina-reports/)
- EPR3
- [ATS/ERS management of severe asthma](https://erj.ersjournals.com/content/early/2019/09/19/13993003.00588-2019)
- [NEJM 2017 Severe and Difficult to treat asthma](https://www.nejm.org/doi/10.1056/NEJMra1608969)

## Definitions
Atopy: predisposition to generate IgE vs environmental antigens. 

Mechanisms of asthma: 

- type 2 = allergic / eosinophilic. Generally assocaited with elevated FeNO and Blood Eosinophilia
- non type-2 = neutrophilic and other. Less responsive to inhaled corticosteroid. More often later onset, associated with obesity, and preferential effects women. 

## Diagnosis
Symptoms

- varying in intensity
- nocturnal (but never early at night) 
- exposure provoked
- wheeze/cough/tightness

##Assessment

severity: determines initial treatment
controlled (assess with a std questionnaire)
- impairment (symptoms are well/not well/very poorly controlled). peak flow not helpful
- risk (number of exacerbations)

##Management
Have asthma action plan:

If well controlled for 3 weeks (months? per NHLBI), step down therapy.

Mild asthma (either intermittent or persistent) - can use symbicort (budesonide / formoterol - because the formoterol is fast onset)
- the idea is to avoid a lot of ICS use. 

Singulair = black box warnings (neuropsychiatric)

When severe, look for other things (e.g. IgE, Eos elevated for IL-5 and IL-4 respectively). 

#### Reliever
Both GINA 2020 and NHLBI update recommend budesonide-formoterol over albuterol in a variety of circumstances. Why? 

-SABA use masks insufficient ICS. Increasing ICS can avert exacerbations, SABAs can't.
-poor adherence to ICS with intermittent symptoms when separate
-safety concerns from SABA overuse

https://erj.ersjournals.com/content/53/4/1802223

![alt](https://photos.collectednotes.com/photos/5187/b5e55f2e-202f-4e1a-805f-f75bb8532bc2)