Asthma - clinical fact sheet and MCQ

Overview 

Asthma is a long-term, inflammatory condition of the airways, with episodes of wheezing, breathlessness, chest tightness, and coughing. It results from airway hyperresponsiveness and persistent inflammation, triggered by allergens, environmental irritants, respiratory infections, and or physical exertion. 

In Australia, asthma is common and affects about one in nine people. In 2021–22, there were over 56,000 emergency department visits and 25,500 hospital admissions for asthma. Older women, particularly those over 75 years, are at the highest risk of severe complications, including death. 

The aims of asthma management are to achieve effective symptom control, minimise the likelihood of exacerbations, and prevent chronic complications.

Optimal asthma care involves pharmacological and non-pharmacological strategies. 

Diagnosis of asthma in adults

Clinical asthma is a history of:

• wheeze

• shortness of breath

• chest tightness

• cough

and documented variable and reduced expiratory airflow limitation.

Other causes of the above symptoms must be excluded, particularly if symptoms persist despite asthma treatment. Amongst other considerations, common differential diagnoses include:

• chronic obstructive pulmonary disease (onset >40 years old, history of COPD risk factors, persistent shortness of breath)

• cardiovascular conditions (chest tightness and dyspnoea on exertion, sudden symptom onset)

• inducible laryngeal obstruction (dry cough triggered by irritants or exercise, associated voice change)

• post-nasal drip (if cough is the primary symptom and other signs of allergic rhinitis)

• bronchiectasis (history of recurrent infections, productive cough)

Diagnosis of asthma is made using spirometry.

1. Spirometry should be performed before and after bronchodilator use to confirm reversible airflow limitation.

2. Normal spirometry results do not exclude asthma, particularly when the patient is asymptomatic.

3. A positive bronchodilator response is defined as an increase in forced expiratory volume within one second (FEV1) of ≥200 mL and ≥12% from baseline.

Source: National Asthma Council Australian Asthma Handbook 

Asthma management

The table below summarises how to select and adjust medication for your adult and adolescent patients: 

Source: National Asthma Council Australian Asthma Handbook

1. Acute asthma: 

• acute asthma exacerbations in primary care should be managed with repeated doses of salbutamol via a puffer metered dose inhaler  (pMDI) with a spacer or if required, a nebuliser.

• initiate systemic corticosteroids  within one hour of presentation for moderate to severe exacerbations (prednisolone 37.5–50 mg, then repeat each morning on second and subsequent days  (total 5–10 days) 

• if SpO2 below 92%, provide oxygen therapy with a target of 93–95%

• patients presenting with life-threatening asthma (eg, reduced consciousness, cyanosis) should be transferred immediately to higher-level care

• after an acute asthma episode, follow up within 3–5 days to review and optimise management

2. Long-term management principles:

• to reduce airway inflammation and prevent exacerbations, inhaled corticosteroids (ICS) are the cornerstone of asthma management

• most newly diagnosed asthma can be managed with either:

• as-needed low-dose ICS-formoterol (a long-acting beta2 agonist (LABA) combination), or

• regular low-dose ICS with as-needed short-acting beta2 agonists (SABA)

• excessive reliance on SABA is associated with increased risk of severe exacerbations and hospitalisation and flags the need for review of asthma control. It should only be used alone in newly diagnosed patients if symptoms occur less than twice monthly and there are no risk factors for flare-ups.

• provide a personalised written asthma action plan to guide patients in adjusting their medication based on symptoms

• ensure the patient is properly educated on inhaler use and the importance of adhering to prescribed medications

• video demonstrations about the correct use of inhalers are available here 

• identify and remove/manage triggers, including

• cigarette smoke

• allergens

• moulds

• air pollution

• irritants

• aspirin (requires specialist assessment)

3. Monitoring and stepwise management:

• adjust treatment based on the level of symptom control, risk factors, and exacerbation history

• escalating therapy should only be considered after assessing adherence, inhaler technique, and modifiable risk factors

• step-down of treatment can be considered if good control is maintained for at least 2–3 months

• perform routine spirometry annually, or more frequently in patients with severe asthma or frequent exacerbations

• patients using maintenance ICS should rinse their mouth after each use to prevent oral candidiasis

4. Refractory and severe asthma:

• refractory asthma should be assessed for contributing factors such as poor adherence, inhaler technique, and comorbidities before escalating treatment

• severe asthma may require referral for biologic therapies such as monoclonal antibodies targeting IgE or eosinophilic pathways

• consider and address factors such as social disadvantage and mental health conditions, which can contribute to poor asthma control 

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References/ resources

National Asthma Council Australia. Asthma in adults. 2024. (last viewed February 2025).

National Asthma Council. Starting treatment and reviewing response in adults and adolescents. (last viewed February 2025).

National Asthma Council. Steps in the diagnosis of asthma in adults. (last accessed February 2025). 

National Asthma Council. Version 2.0 Key figures and tables. (last accessed February 2025). 

NB Medical Education. Hot Topics GP Update Autumn/Winter 2024. Pp594-605.