Asthma Management
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Direct answer
Asthma is a variable, reversible airway disease managed by control, not severity labels: every patient needs regular inhaled corticosteroid-containing therapy, and the modern reliever is a rapid-acting combination of low-dose inhaled corticosteroid with formoterol rather than a short-acting beta-agonist used alone. Treatment steps up when control fails and steps down after a stable period, with add-on options in severe disease. Acute severe asthma is an emergency treated with oxygen, repeated nebulised salbutamol with ipratropium, early systemic corticosteroids, and magnesium or ventilatory support in refractory cases.
What you must remember
- Diagnosis rests on variable respiratory symptoms plus demonstrable reversibility — an FEV1 rise of at least 12 per cent and 200 mL after bronchodilator — or equivalent peak-flow variability; normal spirometry between symptoms does not exclude asthma.
- The central safety change: salbutamol-only reliever therapy is out; the preferred reliever is low-dose inhaled corticosteroid with formoterol, which lowers exacerbation risk, while every symptomatic patient takes a regular inhaled corticosteroid.
- Stepwise control-based treatment: low-dose inhaled corticosteroid with formoterol as maintenance and reliever, stepping up the dose or adding a long-acting beta-agonist-containing combination before considering add-ons such as montelukast or tiotropium.
- Before every step-up, check inhaler technique, adherence, trigger exposure (smoke, dust mite, occupational agents) and comorbid rhinitis or reflux — the commonest reasons for "refractory" asthma.
- Acute severe asthma: high-flow oxygen, nebulised salbutamol repeated at 20-minute intervals with ipratropium added in the first hour, systemic corticosteroids within the first hour, and intravenous magnesium sulphate for poor response.
- Danger signs include silent chest, cyanosis, exhaustion, confusion, a normal or rising PaCO2 and bradycardia — any one demands senior review and escalation toward intensive care.
- Every discharged patient leaves with a written or printed action plan, a review date, a confirmed controller prescription and demonstrated inhaler technique — readmission follows technique failure more often than drug failure.
Common confusion
Candidates confuse asthma control with severity and reach for oral steroid maintenance, which modern guidance reserves for the lowest possible doses in refractory disease. A second confusion is the reliever strategy — using salbutamol alone as the sole therapy is now explicitly unsafe, and questions testing this reflex are common. Distinguish acute severe asthma from COPD by history and reversibility, and remember that a normal PaCO2 in a distressed asthmatic is ominous, not reassuring, since it signals fatigue.
Exam-focused takeaway
FMGE asthma questions test the sequence: the wheezy young patient with nocturnal symptoms and reversibility is asthma; first therapy is an inhaled corticosteroid-based regimen, not a sole bronchodilator; and the acute case gets oxygen, nebulised salbutamol with ipratropium, early systemic steroid and magnesium if failing. Learn the danger signs and the threshold for intensive care by the physiological markers — silent chest, rising PaCO2, exhaustion. Inhaler-technique and adherence checking is the answer to the "uncontrolled despite therapy" stem, a favourite in every session.
Frequently asked questions
How is asthma diagnosed?
By variable symptoms plus reversible obstruction — an FEV1 increase of at least 12 per cent and 200 mL after bronchodilator — or peak-flow variability across symptoms.
Why is salbutamol-only treatment no longer recommended?
Reliever-only therapy leaves airway inflammation untreated and raises exacerbation risk; a low-dose inhaled corticosteroid with formoterol is the preferred reliever and controller strategy.
What is the first-hour treatment of acute severe asthma?
Oxygen, nebulised salbutamol repeated at 20-minute intervals with ipratropium, and systemic corticosteroids given early.
Which features mark life-threatening asthma?
Silent chest, cyanosis, exhaustion or confusion, bradycardia, a normal or rising PaCO2 and hypotension — demanding immediate escalation.
What should every asthma discharge include?
A written action plan, confirmed controller therapy with correct inhaler technique, trigger advice and an early review appointment.