Severe persistent asthma with status asthmaticus.Care & specialists in India

Asthma is not curable but is highly controllable in the great majority of patients. With daily inhaled corticosteroid-containing therapy and a written action plan, most people live without symptom-limited activity and have rare exacerbations. About 30-40% of children with asthma experience remission during adolescence, but adult-onset asthma usually persists. The condition is best thought of as similar to high blood pressure — a long-term diagnosis that is managed, not eliminated.

Patients describe an asthma attack as tightness or banding across the chest, an inability to take a full breath, audible wheeze on breathing out, and a dry, hacking cough. Severe attacks make speaking in full sentences difficult and produce visible use of neck and chest muscles to breathe. Symptoms usually build over hours to days but can escalate within minutes in severe asthma.

Asthma typically starts in childhood, is episodic, and shows substantial reversibility of airflow obstruction with a bronchodilator. COPD usually begins after age 40 in smokers, produces progressive dyspnea, and has fixed airflow obstruction with limited reversibility. Some older patients have features of both — known as asthma-COPD overlap — and require individualised treatment.

The most frequent triggers are viral respiratory infections, allergens (house dust mite, cat and dog dander, pollen, mould), exercise, cold air, tobacco smoke, air pollution, NSAIDs in aspirin-exacerbated respiratory disease, strong odours, and emotional stress. Identifying personal triggers and avoiding them where possible is part of every asthma action plan.

Diagnosis combines a typical history of variable wheeze, breathlessness, chest tightness, or cough with objective evidence of reversible airflow obstruction. Spirometry showing a post-bronchodilator FEV1 rise of 12% and 200 mL confirms reversibility. FeNO at or above 40 ppb supports T2-high inflammation; if baseline spirometry is normal, methacholine or mannitol challenge can confirm airway hyperresponsiveness.

Reliance on short-acting beta-agonists such as salbutamol without inhaled corticosteroids was linked to higher exacerbation and asthma death rates (SABINA programme; Suissa NEJM 2000). GINA 2024 now recommends inhaled corticosteroid-formoterol as the reliever from Step 1 onward, because adding the steroid at the moment of symptoms suppresses the underlying inflammation that drives future attacks.

Most adults and adolescents with asthma should now use an inhaled corticosteroid-formoterol inhaler (most commonly budesonide-formoterol 200/6) as both reliever and maintenance — a regimen known as MART. The exact step level and additional add-ons depend on symptom frequency, lung function, and response. Inhaler technique should be checked at every appointment because up to 70% of patients use devices incorrectly.

Inhaled corticosteroids at standard doses are the safest effective long-term therapy for asthma. Local side effects are oral thrush and hoarseness, both reduced by using a spacer and rinsing the mouth. In children, ICS therapy produces a modest 1-1.5 cm reduction in adult height, but this is more than offset by the substantial reduction in exacerbations and uncontrolled asthma. Systemic effects are rare at standard doses.

Biologics are monoclonal antibodies that block specific drivers of asthma inflammation. Omalizumab targets IgE (allergic asthma), mepolizumab, reslizumab, and benralizumab target the IL-5 pathway (eosinophilic asthma), dupilumab blocks IL-4 and IL-13 signalling (T2-high or steroid-dependent asthma), and tezepelumab blocks the upstream alarmin TSLP and works across phenotypes. They are reserved for severe asthma uncontrolled on high-dose inhalers.

Biologics are considered when asthma remains uncontrolled despite high-dose inhaled corticosteroid plus a second controller, when the patient has had two or more severe exacerbations per year, or when oral corticosteroids are required regularly. Biomarker thresholds differ by drug — eosinophils 300 cells/µL or more for anti-IL-5 agents, eosinophils 150 or FeNO 25 ppb for dupilumab, and any phenotype for tezepelumab.

Yes — exercise-induced bronchoconstriction affects up to 90% of people with asthma and around 10% of the general population. Symptoms peak 5-15 minutes after stopping exercise and resolve within 30-60 minutes. Pre-treatment with an inhaled corticosteroid-formoterol reliever 15 minutes before exercise, daily controller therapy, and a 10-15 minute warm-up substantially reduce symptoms.

About 10% of adult asthmatics have aspirin-exacerbated respiratory disease (AERD), where NSAIDs trigger severe bronchospasm within 30-60 minutes of ingestion. AERD typically presents with the triad of asthma, chronic rhinosinusitis with nasal polyps, and NSAID-induced respiratory reactions. Patients with AERD should avoid all NSAIDs and use paracetamol or COX-2-selective drugs only after specialist advice.

Yes — and continuing inhalers is safer than stopping them. Uncontrolled asthma during pregnancy increases the risk of pre-eclampsia, preterm birth, low birth weight, and perinatal mortality more than any inhaled controller does. Inhaled corticosteroids (budesonide has the longest safety record), short and long-acting bronchodilators, and oral prednisone when needed for exacerbations are all considered acceptable in pregnancy.

Roughly 30-40% of children with asthma experience remission during adolescence, particularly those with mild disease, no allergic sensitisation, and no family history of asthma. Another 30-40% have persistent asthma into adulthood, and around 20% remit and later relapse. Severe childhood asthma and multiple early allergic sensitisations predict persistence and warrant ongoing follow-up into adulthood.

An asthma action plan is a personalised written document with three zones: green (well controlled — continue daily treatment), yellow (symptoms or peak flow 50-80% of personal best — step up reliever and start oral steroid if instructed), and red (severe symptoms or peak flow below 50% — emergency treatment). Action plans reduce hospital admissions and asthma deaths and are now recommended by GINA, NICE, and BTS/SIGN for every patient with asthma.

Asthma kills around 455,000 people worldwide each year (GBD 2019). Most deaths are preventable with controller therapy and a written action plan, and over 90% of deaths occur in low- and middle-income countries where inhaled corticosteroids remain inaccessible. In high-income countries, deaths are concentrated in patients with severe asthma, recent exacerbations, frequent SABA use, and poor follow-up.

Call emergency services or go to the emergency department if breathing is so difficult you cannot speak in full sentences, if your lips or fingers turn blue, if you become drowsy or confused, if peak flow stays below 50% of personal best after a reliever burst, or if your symptoms do not improve within 60 minutes of starting your action plan. Do not drive yourself — call an ambulance.

Well-controlled asthma rarely causes permanent damage. Years of poorly controlled disease, however, drive airway remodeling — thickening of the airway wall and partial loss of bronchodilator reversibility. The most important step to prevent this is daily controller therapy started early and continued long-term, especially through adolescence when adherence often slips.

Severe asthma is defined as asthma that remains uncontrolled despite optimised high-dose inhaled corticosteroid plus a second controller, or that requires this treatment to remain controlled. It affects roughly 3-5% of asthmatics but accounts for over 50% of asthma healthcare costs. Severe asthma should be managed in dedicated clinics with access to biologic therapy and multidisciplinary support.

No — for almost all patients, a metered-dose inhaler with a spacer delivers as much drug to the lungs as a nebuliser, faster and at lower cost. Nebulisers are useful only when severe breathlessness prevents inhaler coordination, in young children unable to use a spacer with mask, or in emergency settings. Most home nebuliser use can be safely replaced by an inhaler-spacer combination.

Generic inhaled corticosteroids and budesonide-formoterol cost roughly USD 30-80 per month at retail in the United States and are far cheaper in most other countries. In India and other emerging markets, generic ICS-formoterol inhalers are available for under USD 10 per month. Biologic therapy for severe asthma costs roughly USD 25,000-40,000 per year and is typically covered by insurance once specialist criteria are met.