Q. 1 Severity of asthma from the point of view of long term treatment can be graded using the following criteria over a period of time: (i) Symptoms of airflow obstruction; (ii) Night time symptoms; (iii) Peak expiratory flow (including diurnal variation). Based on these the grades of mild intermittent, mild persistent, moderate persistent and severe persistent are made analogous to the steps of a staircase. In the context, certain classifications are needed: (a) The duration of time over which the symptoms are observed is not specified. (b) Whether the decision is made based on patient’s recollection of symptoms at first presentation or physician’s observation over that period needs to be addressed; (c) Patients presenting for the first time are often already on medication from another physician. In such cases, assessment of the severity of asthma can be fallacious.

R.W. Thergaonkar,
New Delhi.

The assessment of severity of asthma in a child who has never been put on long term prophylaxis is usually based on the recall of frequency and severity of symptoms (day and night time) in recent past. Most consensus guidelines are silent on the length of period of recall; however the common practice is to assess the symptoms in the past 8-12 weeks. It must be added that knowing the trend of severity of disease in a patient since the onset of disease is important for an overall assessment. While recall in past 8-12 weeks is a good basis for assessing severity and to appropriately decide the drug therapy at the present moment, a recall of as long a period as possible may be more useful e.g., a child with seasonal asthma may be graded at higher severity during the offending season while overall the disease on this case may not be as severe as perennial asthma. The situation gets more clouded if the patient is already on treatment when being evaluated by you. As there is a vast variation in treatment practices, nonavailability of symptom diary and inability to correctly recall symptoms in the absence of training of the parent, it is not uncommon to grade the severity prospectively keeping the child under follow-up. If such a patient is already on prophylactic therapy non response may not be necessarily due to more severe disease but could be due to incorrect dosage, wrong selection of device or poor inhalation technique.

Q. 2 It may so happen that a prolonged requirement of rescue medication (e.g., nebulised b2 agonist, systemic steroids) is felt necessary. In such cases, the point in time needs to be specified at which the physician decides that (s)he is dealing with a patient who is now suffering from a higher grade of asthma rather than a prolonged acute exacerbation.

R.W.Thergaonkar,
New Delhi.