Asthma / PFT / EIB diagnostic & treatment pathway

Decision points

• Spirometry result?
• Exertional respiratory symptoms?
• Severe / uncontrolled despite optimization?

Do-not-miss pitfalls

• Do not diagnose EIB from exertional dyspnea alone, consider ILO/VCD, deconditioning, cardiac disease, anemia.
• Do not escalate to a biologic before confirming diagnosis, adherence, technique, exposures, and comorbidities.
• Do not use the legacy 12%+200 mL bronchodilator rule as primary, the 2022 standard is >10% of predicted.
• Do not prescribe SABA-only treatment, use an ICS-containing reliever paradigm.
• Do not overinterpret small bronchodilator changes if effort/quality is poor, and do not ignore a fixed obstruction or abnormal inspiratory loop.

Evidence & citations

1. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2024/2025 reports (no SABA monotherapy; ICS-formoterol reliever). GINA 2024/2025
2. Stanojevic S, Kaminsky DA, Miller MR, et al. ERS/ATS technical standard on interpretive strategies for routine lung function tests. Eur Respir J. 2022;60(1):2101499. PMID 34949706
3. Parsons JP, Hallstrand TS, Mastronarde JG, et al. An official ATS clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013;187(9):1016-1027. PMID 23634861
4. Dweik RA, Boggs PB, Erzurum SC, et al. An official ATS clinical practice guideline: interpretation of exhaled nitric oxide (FeNO). Am J Respir Crit Care Med. 2011;184(5):602-615. PMID 21885636