Asthma is a common, chronic respiratory condition, but its severity varies significantly. A small subset of patients (5% to 10%) experience severe asthma, a form of the disease difficult to control. Severe asthma often remains symptomatic despite high-dose standard therapy. Because these complex cases carry a greater risk of frequent exacerbations, hospitalizations, and a reduced quality of life, they require specialized medical attention and advanced treatment options.
Understanding Severe Asthma
Severe asthma is formally defined as asthma requiring high-dose inhaled corticosteroids combined with a second controller medication, such as a long-acting beta-agonist. It is characterized by remaining uncontrolled despite the consistent use of these maximum standard therapies. Patients often experience continuous symptoms, necessitating frequent use of quick-relief inhalers or continuous oral steroid tablets.
This disease level differs from mild or moderate asthma because it involves inflammatory pathways that resist conventional inhaled medications. Specialists must look beyond standard drug regimens to identify and target the specific type of inflammation present. A diagnosis of severe asthma is often one of exclusion, requiring other issues like poor inhaler technique or co-existing conditions to be ruled out first.
Primary Specialists Who Treat Severe Asthma
The primary specialists treating severe asthma are Pulmonologists and Allergists/Immunologists, often working together. Pulmonologists specialize in lung and respiratory system diseases, managing the mechanical and structural aspects of severe asthma. They typically lead specialized centers, focusing on optimizing lung function and managing complex respiratory issues.
Allergists and Immunologists focus on immune system conditions, which frequently drive severe asthma inflammation. They are experts in identifying specific allergic triggers and assessing the immune response fueling the disease. These specialists collaborate closely, as allergies are often a significant underlying factor exacerbating symptoms.
Specialized severe asthma care involves a multidisciplinary team to address all facets of the condition. This team includes respiratory therapists, who assist with breathing exercises and proper inhaler technique, and specialized pharmacists, who manage complex medication schedules. This coordinated approach ensures all contributing factors are addressed.
Specialized Diagnostic Procedures
Specialists use advanced testing to “phenotype” severe asthma, classifying the specific biological characteristics driving the disease to guide treatment. Advanced pulmonary function testing (PFTs) goes beyond basic spirometry to measure lung capacity and air trapping. This comprehensive testing reveals the degree of airflow obstruction and hyperresponsiveness defining the disease severity.
Measuring inflammation markers is essential. The fractional exhaled nitric oxide (FeNO) test is a non-invasive breath test assessing nitric oxide in exhaled air. Elevated FeNO levels mark type 2 inflammation, often associated with eosinophilic asthma.
Blood tests check for specific inflammatory cell counts and antibodies. High blood eosinophil counts suggest eosinophilic asthma, a subtype responsive to targeted therapies. Immunoglobulin E (IgE) levels are also measured, as elevated levels indicate an allergic component that may be targeted with anti-IgE treatment.
Advanced Treatment Strategies
The treatment of severe asthma moves beyond maximizing inhaled therapy to include highly targeted interventions. Biologic therapies represent a major advance; they are injectable or infused medications that target specific inflammatory proteins or cells. Examples include blocking IgE action or neutralizing inflammatory messengers like interleukin-5 (IL-5) or the combination of IL-4 and IL-13. These treatments are selected based on the specific inflammatory phenotype identified through specialized diagnostic tests.
The goal of this targeted approach is to control inflammation more effectively, reducing the need for long-term oral corticosteroids. Chronic oral steroid use carries a risk of systemic side effects, and biologics minimize this exposure. The choice of biologic is a precise decision, matching the drug’s mechanism of action to the patient’s unique biological markers.
In addition to pharmacological treatments, Bronchial Thermoplasty (BT) may be considered for select adult patients. This minimally invasive intervention is performed via a bronchoscope, delivering controlled thermal energy to the airway walls. The heat reduces thickened airway smooth muscle, minimizing the airway’s ability to constrict and reducing hyperresponsiveness. BT is typically reserved for patients who remain symptomatic despite optimized inhaled medication or who have not responded well to biologic therapy.
Coordinating Care and Referral
Accessing specialized care usually begins with a referral from a primary care physician (PCP). PCPs manage mild-to-moderate asthma but recognize when a patient meets the criteria for severe, uncontrolled disease. Guidelines recommend referral when asthma remains uncontrolled despite conventional therapy or when the patient experiences frequent, severe exacerbations.
Once under specialist care, the specialist works in co-management with the PCP for seamless long-term monitoring. The specialist develops the advanced treatment strategy, while the PCP handles routine care and medication refills, maintaining the patient’s overall health record. This coordinated approach ensures the patient benefits from both the PCP’s general oversight and the specialist’s specific expertise.