Doctors classify asthma into four main stages or levels of severity. The symptoms of different asthma stages can vary in severity and frequency.

Asthma is a long-term condition that affects a person’s airways and can make it hard to breathe. The symptoms may worsen or improve over time. Doctors use categories, or stages, to decide on a treatment plan. As symptoms change, they may adjust the plan.

This article explores the symptoms of each stage or category and the treatment options to help manage them.

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Asthma can be either intermittent or persistent. When symptoms arise occasionally, a person has intermittent asthma. Symptoms of persistent asthma occur more often.

The four main asthma categories are:

  • intermittent
  • mild persistent
  • moderate persistent
  • severe persistent

However, asthma does not always get worse. Persistent asthma can sometimes become intermittent or vice-versa. Severe persistent asthma become mild, or mild persistent asthma can become severe.

Medication can also help manage symptoms to reduce their severity and frequency.

The symptoms of asthma are the same at every stage, but their frequency and severity differ.

The main symptoms of asthma include:

We explore each asthma stage in detail below. These details are for people aged 12 years and above. Below 12 years, a doctor may use different criteria.

This is the least severe type. Doctors sometimes call it mild intermittent asthma.

For a person with intermittent asthma, the signs and symptoms will be as follows:

Symptom frequency2 days a week or less
Nighttime awakeningstwice per month or less
Severityno impact on regular activities
Lung capacityresult of a forced expiratory volume (FEV) lung capacity test is 80% or more of typical values
Inhaler useuse of a short-acting beta agonist (SABA) inhaler to manage symptoms on two or fewer days each week

This is the least severe form of persistent asthma.

Symptoms for a person with mild persistent asthma will be as follows:

Symptom frequencymore than twice a week but not every day
Nighttime awakeningsthree or four times per month
Severityminor impact on regular activities
Lung capacityresult of a forced expiratory volume (FEV) lung capacity test is 80% or more of typical values
Inhaler useuse of a SABA inhaler to manage symptoms more than twice a week but not daily

This is the second most severe form of asthma.

A person with moderate persistent asthma can expect the following:

Symptom frequencydaily
Nighttime awakeningsmore than once a week but not every night
Severitysome impact on regular activities
Lung capacityresult of a forced expiratory volume (FEV) lung capacity test is 60–80% of typical values
Inhaler usedaily use of a SABA inhaler

Severe persistent asthma is the most serious form.

A person with this type of asthma will experience the following:

Symptom frequencydaily, throughout the day
Nighttime awakeningsevery night or nearly every night
Severitysignificant impact on regular activities
Lung capacityresult of a forced expiratory volume (FEV) lung capacity test is below 60% of typical values
Inhaler useuse of a SABA inhaler several times a day, possibly with other medication

Acute asthma is when asthma becomes severe on a specific occasion. People with persistent asthma can have acute attacks.

Doctors classify acute asthma as follows:

  • acute severe asthma
  • life-threatening asthma
  • near-fatal asthma

Asthma that occurs with an extreme allergic reaction, known as anaphylaxis, can be life-threatening. It needs immediate medical attention.

Anaphylaxis: Symptoms and what to do

Anaphylaxis is a severe allergic reaction that can be life threatening. The symptoms develop suddenly and include:

  • hives
  • swelling of the face or mouth
  • wheezing
  • fast, shallow breathing
  • a fast heart rate
  • clammy skin
  • anxiety or confusion
  • dizziness
  • vomiting
  • blue or white lips
  • fainting or loss of consciousness

If someone has these symptoms:

  1. Check whether they are carrying an epinephrine pen. If they are, follow the instructions on the side of the pen to use it.
  2. Dial 911 or the number of the nearest emergency department.
  3. Lay the person down from a standing position. If they have vomited, turn them onto their side.
  4. Stay with them until the emergency services arrive.

Some people may need more than one epinephrine injection. If the symptoms do not improve in 5–15 minutes, or they come back, use a second pen if the person has one.

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Current guidelines recommend a stepwise treatment plan for asthma. This involves stepping up or stepping down treatments, depending on how severe a person’s asthma is.

Inhaled corticosteroids (ICSs) are an effective treatment for many people, but some may need additional treatment — such as beta-2 agonists — for long-term management. Albuterol is an example of a beta-2 agonist.

In some cases, a doctor may also recommend biologic drugs or allergy shots.

Corticosteroids reduce inflammation, while beta-2 agonists help relax the muscle and keep the airways open. Biologic drugs act on the immune system in people with allergy-related asthma.

Each treatment step aligns with a different asthma type. People with more severe asthma may need several medications.

Intermittent asthma: Step 1

A person with Intermittent asthma treatment may use a SABA inhaler.

This delivers drugs such as ventolin, a bronchodilator, which helps keep the airways open. Also known as a rescue inhaler, a SABA inhaler can relieve symptoms rapidly when needed.

Most people do not need additional medication at this stage.

Mild persistent asthma: Step 2

Daily use of long-term controller medications can help reduce symptoms of mild persistent asthma.

A doctors may prescribe a low-dose ICS for this purpose. A person may also use a SABA inhaler to relieve symptoms as needed.

Moderate persistent asthma: Step 3

Doctors also prescribe long-term daily medication for moderate persistent asthma, but they may be different from those used for milder forms.

A doctor may prescribe either a medium-dose ICS or a combination of a low-dose ICS and a long-acting beta agonist (LABA).

Trelegy Ellipta is an example of a combination drug. It combines vilanterol, a LABA with fluticasone, a corticosteroid.

Other options include a low-dose ICS along with an LTRA (leukotriene receptor antagonist), such as montelukast (Singulair).

In addition, a person can use a SABA inhaler when needed to relieve symptoms.

Is Trelegy Ellipta expensive and are there other options?

Moderate to severe persistent asthma: Step 4

If symptoms become more severe, a doctor will change the controller medications.

Options for moderate to severe persistent asthma include:

  • a medium-dose ICS plus a LABA
  • a medium-dose ICS plus an LTRA
  • a medium-dose ICS plus theophylline

A SABA inhaler can also relieve symptoms when needed.

Severe persistent asthma: Step 5

For more severe persistent asthma, a doctor may combine a high-dose ICS and a LABA.

They may also consider biologic or biosimilar drugs that dampen the response of the immune system. Examples include omalizumab (Xolair) or mepolizumab (Nucala). These are injectable drugs that may help people with allergy-related asthma.

Severe persistent asthma: Step 6

If symptoms of severe persistent asthma have not responded to the previous treatments, the doctor may prescribe a high-dose ICS alongside both a LABA and an oral corticosteroid.

They may also recommend a biologic drug.

Acute asthma

If a person has a severe attack and is unable to breath, this may be a sign of anaphylaxis.

The first step will be to use their inhaler, if they have one. If they cannot do this alone, a bystander may help them.

At the same time, someone should call the emergency services as the person will may need professional medical treatment.

Asthma is a long-term condition that can be described in stages, grades or levels. The severity and frequency of symptoms can change, depending on various factors. Medication can help manage asthma.

In some cases, asthma can become life-threatening. Anyone with sudden, severe symptoms will need emergency medical help.

Anyone with asthma should follow a doctor’s recommendations regarding treatment and when to seek help. They may also consider wearing a medical identity bracelet or similar.

Here are some questions people often ask about asthma stages.

How many levels or stages of asthma are there?

Asthma can be intermittent or persistent. Intermittent asthma is mild, but persistent asthma can be mild, moderate, or severe. Acute asthma can result from anaphylaxis. This type of attack needs immediate medical attention.

How do you know if asthma is moderate or severe?

People with moderate persistent asthma have daily symptoms during flare-ups that can last several days. The person may wake up once a week in the night with symptoms. Without medication, their lungs will be working around 60–80% of typical lung function.

Severe asthma is less common. Symptoms occur daily and the person will wake often in the night. Lung function is below 60% of typical. Symptoms severely affect the person’s daily activities.

Doctors classify four main categories of asthma, which help guide the treatment options. They may step up or step down treatment, according to how asthma progresses.

People with asthma can work with a doctor on treatment plan that manages their symptoms effectively.

Long-term asthma management may also involve reducing exposure to allergens and irritants, such as cigarette smoke.