per GINA Guidelines

What kind of Asthmatic are you?

Mild Intermittent Asthma

  • symptoms two or fewer times a week
  • normal peak flow between flare-ups
  • flare-ups brief, intensity varies
  • nighttime symptoms that wake you two or fewer times a
  • FEV1 or peak flow greater than or equal to
    80% predicted
  • peak flow varies less than 20% (the difference between
    morning and
    afternoon readings is less than 20%)

Mild Persistent Asthma

  • symptoms more than two times a week but fewer than once a


  • flare-ups may limit activity
  • nighttime symptoms that wake you more than twice a
  • FEV1 or peak flow greater than or equal to
    80% predicted
  • peak flow varies from 20% to 30% (the difference
    between morning and afternoon readings is
    between 20% and 30%)

Moderate Persistent Asthma

  • symptoms daily; use of


  • flare-ups two or more times a week that limit
  • symptoms at night that wake you more than once a
  • FEV1 or peak flow greater than 60% and less
    than 80% predicted
  • peak flow variability is greater than 30% (the
    between morning and afternoon readings is more than

Severe Persistent Asthma

  • symptoms constant and limit activity
  • flare-ups frequent during day and night
  • FEV1 or peak flow equal to or less than
    60% predicted
  • peak flow variability greater than 30% (the difference between
    morning and afternoon readings is more than 30%)

Classifying asthma phenotypes based on Cluster Analysis :

Currently, there’s a push in the scientific community to come up with a better asthma classification system.

The National Asthma Education and Prevention Program and GINA (Global Initiative for Asthma) guidelines divide asthma severity based on lung function ( mainly FEV1), daytime and nocturnal symptoms, and frequency of rescue bronchodilator . There is increasing evidence however, that this approach does not reflect all the many complexities observed in populations with asthma and also does not reflect the heterogeneous characteristics of this disease. Identification of heterogeneity and classification of asthma by phenotypes provides a foundation from which to understand disease causality and ultimately to develop management approaches that lead to improved asthma control while avoiding adverse effects and decreasing the risk of serious asthma outcomes (e.g., exacerbations and loss of pulmonary function).

In that regard, SARP researchers ( including my personal pulmonologist, Dr Wenzel) through cluster analysis of the asthmatics who have participated in SARP, have now identified 5 distinct groups of asthmatics, and may have identified a 6th. It’s important to note, that this was not a population study, so we still have a long way to go, but I think we’re on the right path.

What Cluster do you belong in?

Cluster 1

Fifteen percent of those tested are in this group. This cluster is characterized by younger, predominantly female subjects with childhood onset/atopic asthma and normal lung function. Forty percent of these subjects were receiving no controller medications, and those on asthma medications were most often on two or fewer controller therapies, with a combination of inhaled corticosteroids (ICS) and long-acting ?-agonists most frequently reported. HCU was infrequent in this group, with nearly 70% reporting no need for any urgent physician or emergency department visits, oral corticosteroid bursts, or hospitalizations in the past year. Despite a lack of exacerbations requiring urgent evaluation, 30 to 40% of Cluster 1 subjects reported daily symptoms and rescue bronchodilator use This group contains the youngest and potentially most active subjects, suggesting that symptoms may be primarily exercise related.
Cluster 2

The largest group (44% of subjects), it consists of slightly older subjects, two-thirds female, with primarily childhood onset/atopic asthma. This group is distinguished by baseline prebronchodilator lung function that is relatively normal (65% with an FEV1 >80% predicted) or can be reversed to normal (>80% predicted) in nearly all of the subjects (94%). Medication use is more prevalent in this group, with fewer subjects not receiving controller medications (26%), a shift toward increased numbers of controllers (29% on three or more drugs), and higher doses of ICS (28% on high-dose ICS). HCU, asthma symptoms, and reported albuterol use were similar to those observed in Cluster 1, although Cluster 2 was treated with a greater number of asthma medications.
Cluster 3

Is the smallest cluster (8% of subjects). It is markedly different from the other clusters and consists mainly of older women (mean age, 50 years; range, 34–68 years) with the highest body mass index [BMI] (58% with BMI >30) and late-onset asthma (all older than 23 years of age), who are less likely to be atopic (64%). Despite a shorter reported duration of asthma, subjects in this cluster have decreased baseline pulmonary function (71% with FEV1 <80% predicted), and only 64% are able to attain this benchmark after bronchodilators. These subjects report complicated medical regimens, with more than half describing treatment with three or more asthma drugs (one of which is frequently high-dose ICS) and 17% receiving regular systemic corticosteroids. Despite this increased reliance on medications, they report more HCU (especially the need for oral corticosteroid bursts) and daily asthma symptoms that approach levels reported by subjects in Clusters 4 and 5. Subjects in Cluster 3 report symptoms and HCU that appear to be out of proportion to their degree of airflow obstruction. This result suggests an important relationship between obesity, level of symptoms, and HCU in this group of subjects. Clusters 4 and 5

The remaining 33% of subjects are grouped in Clusters 4 and 5. Nearly 70% of subjects in Cluster 4 and 80% of subjects in Cluster 5 fulfill the ATS workshop criteria for severe asthma. Subjects are equally divided between these two clusters, but Cluster 4 is characterized by equal representation of both genders and many subjects with childhood onset (72%) and atopic disease (83%), whereas Cluster 5 consists of more women (63%) with mainly later-onset disease (69% late onset) and less atopy (66%). Clusters 4 and 5 are characterized by a long duration of disease, with those in Cluster 5 having the longest duration. Clusters 4 and 5 differ in the level of baseline lung function and the magnitude of response to bronchodilators. Subjects in Cluster 4 have severe reductions in pulmonary function at baseline (mean FEV1 57% predicted), but 40% of subjects are able to reverse to the near normal range (>80% predicted) after six to eight puffs of albuterol. In contrast, subjects in Cluster 5 have the most severe airflow limitation at baseline (mean FEV1 43% predicted), and, despite some response to maximum bronchodilator testing, 94% of subjects remain with a FEV1 <80% predicted. In both clusters, lung function is abnormal despite the use of multiple asthma medications; 55 to 70% are receiving three or more asthma drugs, and 60 to 80% are on high–dose ICS with subjects in Cluster 5 treated more frequently with systemic corticosteroids (47%) than were subjects in Cluster 4 (39%). HCU was similar in both Clusters 4 and 5, with nearly half of subjects reporting three or more oral CS bursts and an additional 25% reporting inpatient hospitalization in the past year for a severe exacerbation. Nearly 40% of subjects in Clusters 4 and 5 report a history of a prior ICU admission for asthma in their lifetime. Not unexpectedly, 70% of subjects in these groups report daily symptoms and poor quality of life. A potential sixth cluster was a subset of Cluster 5 consisting of 31 subjects who showed a phenotype that was intermediate between Clusters 4 and 5. These individuals were somewhat younger, were more atopic, and showed more bronchodilator reversibility than the remaining 85 subjects in Cluster 5.

14 thoughts on “Asthma Classifications

  1. I like the new classification structure. I definitely fall into Cluster 3, except that my BMI is 25. I’m a 54 year old woman. who has only asthma for 6 months (following a bad cold, pneumonia and a pleural effusion), but already my pulmonologist diagnosed me with chronic obstructive asthma. I was wondering in your opinion what are the implications of that diagnosis so soon in the game? I ‘ve already been hospitalized for an asthma attack. And what is HCU?


    1. Hi Andrea, thanks for writing.

      I dont know about your particular asthma, but I would say that 6 months is way too soon to call any disease “chronic”. It is true though, that a large segment of the asthma population develops asthma, sometimes severe, after the age of 40, most are female.
      You might want to contact Dr Sally Wenzel at UPMC as she authored the study you’re citing.

      Sorry, Im not familiar with the term HCU.

      Take care!

  2. Hello!
    I’m having trouble pinpointing which cluster I would be in!
    Im 22, female and my bmi is 26.7.
    I was diagnosed with asthma when I was 8 and have been on salbutamol, beclamethasone, pulmicort, symbicort and a variety of tablets that supposedly help with allergies. I have been hospitalized several times in the past, use my salbutamol more than 10 times a day and often wake up in the night due to asthma symptoms.

    I recently went to my doctor to complain that the medications I am currently on are not helping me nearly as much as I need and he told me that my asthma should not be this bad for someone my age?
    I now have a respiratory clinic appointment coming up next week

    Hope you are well!

  3. This makes so much more sense!! I am cluster 4. I have severe asthma, but it always seemed different from other severe asthmatics. With a lot of medication and care, I can have a normal life. And xolair! Cluster 4 should be named the “xolair cluster”…we are the people xolair was designed for. Everything about me is very allergic, asthma is just one part of it! My initially poor lung function is pretty reversible with a lot of medicine, and life was getting pretty crappy (two ICU hospitalizations, average 4 stays/year) …until xolair came around. Treating allergies helps treat asthma, too….sometimes when things get out of control it is because I’ve developed another food allergy or need another sinus surgery.

    1. Lisa! I’m with you. I also have severe asthma, but with the correct medication and my xolair treatments twice a month I’m able to keep any asthma attacks down. From 2005 – 2009, I was having asthma attacks at least once a month. Since 2009, I’ve been much better with xolair!!

  4. How interesting.. I’ve been asthmatic all my life except when I was a kid it was just called bronchitis but I was finally correctly diagnosed at 50 with severe intermittent asthma with many exacerbations from viruses (I drove a 40′ 78 passenger transit style school bus and with all the kids I was sick constantly). At about age 59 I slipped into being a severe asthmatic using nebs 2xdaily on good days and it gets worse from there. My FEV1 on a common morning is 40% of my normal even with Flovent and Dulera daily. I’ve had immunology with little benefit and wish there were something that would make my breathing normal. Part of the problem these days is the cost of meds, I am now retired and they are expensive. It has affected my life, but I get out every other day for a walk with our dog, I garden, I still do my photography but less so because of breathing and an OTJ injury that has left me partially disabled. While there are difficulties, I find beauty and joy in daily life…

  5. I could just cry. Had to be hospitalized last week of Jan 2017 for 3 days. My asthma was severe and I had also gone into acute respiratory distress due to an allergic reaction to fresh ginger root.
    I can’t seem to feel better yet and am so concerned that this might be an ongoing problem.
    My GP handled the emergency and a pulmonologist saw me. I was given massive doses of steroids and asthma treatments. Should I regularly see an asthma/allergist along with my MD? Read the asthma recovery steps and they all apply to me…so glad I ran across this site.

    1. Hi Suzanne, Sorry to hear that. Yeah, you should definitely follow up with a pulmonologist, and if you dont have one already , you might consider keeping an epipen around.
      Recovery from a bad asthma flare is never easy, but Im sure you’ll start feeling better soon. I dont know your medical history, but hopefully this is just a one time occurrence for you. Take care!

  6. Hi, Im a 16 year old Asthmatic who has been to hospital twice this year only days apart, i had a small flare up before i had my really bad attack . I know that my Asthma can be related to an infection(that i got as a child) that is stuck inside the cartilage in my chest, (I forgot what the medical term was), but I am currently on to types of preventers, a double dose Seretide puffer(2 puffs twice a day) and tablets(once a day), i was on another preventer but it was too weak for my lungs and didn’t help me anymore so i had to go up in puffers. I also have to take my inhaler before i sleep, so that i can at least get 3 to 4 hours sleep without struggling to breathe. i at least have 3 to 4 little flare ups each week, but most of them are cause by people spraying Deodorant or smoke in the air. but i do need help knowing what kind of cluster would I be in?

  7. Hi, Sorry to hear about your asthma. It sounds to me like you have severe asthma, but Im not sure what phenotype you have because you’re so young. I hope you can get it under control, or better yet, out it all together. Xx

  8. Hi, I found this interesting, but my daugther doesn’t seem to fall in any normal cluster. She was hospitalized with asthma 4 times last year, in the ICU…… before that it was controlled with steroids to a certain degree. But at age 13 she stopped responding to presdisone. Would love your feedback.

    1. So sorry to hear about your Daughter’s asthma. Unfortunately, some people just have really severe asthma. If you’re referring to the cluster analysis from the severe asthma research program a few years back, it probably wouldn’t apply. They studied mostly older adults. Im assuming your child has a good pulmonology team following her and theyve ruled out other condidtions? Have they considered any of the new biologic drugs? Wish I could offer more insight, but I think you’re on the right track by asking lots questions.


Leave a Reply

Your email address will not be published. Required fields are marked *

WordPress Anti-Spam by WP-SpamShield

This site uses Akismet to reduce spam. Learn how your comment data is processed.