Chronic airway inflammation with variable reversible airflow obstruction and bronchial hyperresponsiveness.
History taking
- • Episodic wheeze, cough, breathlessness, chest tightness — worse at night/early morning
- • Triggers: allergens, exercise, cold, URTI, NSAIDs, occupational
- • Family/personal history of atopy, eczema, allergic rhinitis
- • Inhaler technique, adherence, prior exacerbations, ED visits
Examination
- • Tachypnoea, accessory muscle use, audible wheeze
- • Prolonged expiration, polyphonic wheeze
- • Severe attack: silent chest, cyanosis, exhaustion
Red flags
- • PEF <33% best, SpO₂ <92%, silent chest, cyanosis, bradycardia → life-threatening
- • Inability to complete sentences
- • Previous ICU admission or intubation
Differential diagnosis
- • COPD, bronchiectasis, vocal cord dysfunction
- • Heart failure ('cardiac asthma'), foreign body, ABPA
- • Eosinophilic granulomatosis with polyangiitis
Recommended investigations
- • Peak expiratory flow (PEF) diary — diurnal variation >10%
- • Spirometry with bronchodilator reversibility (FEV1 ↑ >12% and >200 mL)
- • FeNO if available; CBC for eosinophils, IgE
- • CXR to exclude alternatives
Diagnosis
- • Compatible symptoms + documented variable expiratory airflow limitation
Initial treatment / management
- • GINA stepwise — preferred Track 1: ICS-formoterol as reliever AND maintenance
- • Avoid SABA-only therapy
- • Trigger avoidance, smoking cessation, vaccination (flu, pneumococcal)
- • Written asthma action plan with PEF zones
Prescription examples
- • Budesonide-Formoterol 200/6 inhaler — 1 puff BD + 1 puff PRN (max 12/day)
- • If pure SABA: Salbutamol inhaler 100 µg — 2 puffs PRN with spacer
- • Acute exacerbation: Oral Prednisolone 40 mg OD x 5 d
- • Antibiotics ONLY if bacterial infection evident
Follow-up advice
- • Review at 4–8 weeks then 3–6 monthly
- • Check inhaler technique at every visit
- • Step down therapy after 3 months of good control
Patient counselling
- • Inhaler technique demonstration with spacer
- • Trigger identification and avoidance
- • Recognise worsening: ↑ reliever use, night waking, fall in PEF
Referral criteria
- • Diagnostic uncertainty, severe/refractory asthma
- • Frequent exacerbations or oral steroid dependency
- • Occupational asthma evaluation
Clinical pearls
- • SABA monotherapy is associated with increased mortality — avoid
- • Always check inhaler technique before stepping up
- • Suspect ABPA in poorly controlled asthma with central bronchiectasis and eosinophilia
References
- • GINA Global Strategy for Asthma Management 2024
- • BTS/SIGN Asthma Guideline 2019
Educational outpatient guide — verify against local guidelines before clinical use.
