<p>Most people with asthma do well on inhaled therapy, but a small subgroup continues to have breakthrough symptoms requiring additional visits and therapies. John J. Oppenheimer, MD, outlines a practical approach to uncontrolled asthma that starts with confirming the diagnosis and then addresses treatable traits such as comorbidities, adherence, and inhaler technique, all while recognizing that reported symptoms may not reliably reflect risk in every patient.</p>

In my experience, the majority of patients with asthma are easily controlled. Most have mild to moderate asthma, and, once you convince them that they have a chronic illness that requires some form of proactive therapy, they generally do quite well. You put them on an ICS, and they often do wonderfully. Their lung function will often come back to normal or near normal, their use of rescue bronchodilators will diminish, their exercise ability will improve, and they will see a reduction in their triggers. However, for some people, despite the use of an ICS, they still have breakthrough symptoms. In these patients, we would escalate the dose of the ICS and likely add another controller therapy, such as a LABA or a LABA/LAMA combination therapy.

<br>

Typically, the patients who may be uncontrolled are those who are in the subgroup with more severe asthma, which is a very small population, although other patients with difficult-to-treat asthma might also fall into this category. The first thing I do to determine whether a patient has uncontrolled asthma is stratify whether they have control of their symptoms. And, if they are experiencing symptoms such as nocturnal awakening, exercise-induced symptoms, and/or a frequent need for β2-agonist treatment, urgent care, and/or oral steroids, the first thing I ask is whether the individual really has asthma. There is a wonderful study highlighting that these patients may actually have other illnesses. Confirming whether a patient truly has asthma requires obtaining a history, performing a physical examination, and testing objective measures, specifically of lung function.

<br>

If I have determined that the patient has asthma, the next question is: Do they have associated comorbidities making their asthma worse? Associated comorbidities may include reflux, sleep apnea, obesity, sinusitis, and nonadherence. You are never going to gain control of a patient’s asthma until you treat their related underlying ailments.

<br>

An important consideration for a patient with uncontrolled asthma is to confirm not only that they are on the correct therapy but also that they are taking that therapy correctly. We often think of the nonadherent patient as being somebody who is not taking their medicine; however, many people may be taking their medicine but doing it poorly. For example, if the patient is relying on an inhaled therapy but has poor hand-lung coordination or is not holding their breath long enough for the inhaled medicine to settle, this may cause a reduction in efficacy and the appearance of uncontrolled asthma. If the patient is on an ICS, do they need to have a LABA added, or a LABA with a LAMA? Or do they need to be on a biologic?

<br>

Our understanding of the disease’s underlying pathophysiology has expanded dramatically, and we now have a growing array of highly effective biologic agents to improve control. With these innovations, clinicians must deepen their understanding of each patient’s specific asthma phenotype and endotype, as biologic therapies require a more precise alignment between mechanism and disease biology.

<br>

One of the things that is important to acknowledge is that some individuals with asthma may have a blunted perception of their dyspnea. This was demonstrated in a study in which investigators looked at a group of people with asthma and stratified them based on their perception of dyspnea. They identified 3 subgroups of patients. The first group perceived their level of dyspnea in a normal way. The second group included patients who were hyperresponsive; they were super perceivers of dyspnea. The last group included patients who were poor perceivers of dyspnea. The disconnect with poor perceivers means that they may not complain of shortness of breath, yet they are frequently in the hospital or needing oral steroids. For a patient like that who has poor perception of dyspnea, my standard of care would be to add an objective measure of lung function since they cannot perceive when they are getting “in trouble.”

<br>

We often try to use a one-size-fits-all approach for patients with asthma, but it really is a very complicated illness. And, for those who have poor control, it is an even more complex issue.