Chronic asthma

Last updated: June 2023

Clinical features

• Asthma should be suspected in patients with recurrent respiratory symptoms (wheezing, chest tightness, shortness of breath and/or cough) of variable frequency, severity and duration, disturbing sleep, and causing the patient to sit up to breathe. These symptoms may appear during or after exercise.
• Chest auscultation may be normal or demonstrate diffuse sibilant wheezes.
• A personal or family history of atopy (eczema, allergic rhinitis/conjunctivitis) or a family history of asthma increases probability of asthma but their absence does not exclude asthma.
• Patients with typical symptoms of asthma and a history of disease that is characteristic of asthma should be considered as having asthma after exclusion of other diagnoses.

• Any identified asthma risk factor (e.g. allergen, pollution, tobacco smoke exposure) should be eliminated where possible. The assessment of the frequency of symptoms and limitations of daily activities determines the treatment.

Treatment

The mainstay of long-term treatment are inhaled corticosteroids (ICS) and long-acting beta-2 agonists (LABA). LABAs should never be used alone but always in combination with an ICS. Combination inhalers are preferred, when available.

In addition to long-term treatment, salbutamol (short-acting beta-2 agonist, SABA) and combination inhalers can be used to reduce bronchoconstriction if the patient is symptomatic.

Treatment is started at the step most appropriate to initial severity then, re-evaluated and adjusted according to clinical response. An intervening severe asthma attack or loss of control necessitates treatment reassessment.

The inhaler is chosen according to age. In children, a spacer should be used. Instructions on inhaler technique and information on asthma attack symptoms should be provided.

Long-term treatment of asthma according to severity in children 6 years and over and adults [1] Citation 1. Global INitiative for Asthma. Global Strategy for Asthma Management and Prevention. 2022 update.
https://ginasthma.org/gina-reports/ [Accessed 23 January 2023] [2] Citation 2. WHO Pocket book of primary health care for children and adolescents: guidelines for health promotion, disease prevention and management from the newborn period to adolescence. WHO Regional Office for Europe; 2022.
https://www.who.int/europe/publications/i/item/9789289057622 [Accessed 23 January 2023]

The doses vary according to the severity of asthma. Find the lowest possible effective dose necessary to both relieve symptoms and avoid local and systemic adverse effects.

salbutamol MDI 100 micrograms/puff (SABA):

• Children and adults: 2 to 4 puffs up to 4 times daily if necessary

salmeterol MDI 25 micrograms/puff (LABA):

• Children 6 to 11 years: 2 puffs 2 times daily (max. 4 puffs daily)
• Children 12 years and over and adults: 2 to 4 puffs 2 times daily (max. 8 puffs daily)

budesonide/formoterol MDI 80/4.5 micrograms/puff (ICS/LABA combination):

• Children 6 to 11 years:
  • when symptomatic: 1 puff
  • long-term treatment, very low-dose: 1 puff once daily
  • long-term treatment, low-dose: 1 puff 2 times daily

In all cases, do not exceed 8 puffs daily.

beclometasone/formoterol MDI 100/6 micrograms/puff (ICS/LABA combination):

• Children 12 years and over and adults:
  • when symptomatic: 1 puff
  • long-term treatment, low-dose: 1 puff 2 times daily
  • long-term treatment, medium-dose: 2 puffs 2 times daily

In all cases, do not exceed 8 puffs daily.

Do not restrict exercise. If exercise is a trigger for asthma attacks, administer 1 or 2 puffs of salbutamol or beclometasone/formoterol 10 minutes beforehand.

In pregnant women, poorly controlled asthma increases the risk of pre-eclampsia, eclampsia, haemorrhage, in utero growth retardation, premature delivery, neonatal hypoxia and perinatal mortality. Long-term treatment should be continued under close monitoring.

If symptoms have not been well controlled for a period of 2 to 3 months, check inhalation technique and adherence before changing to a stronger treatment.

If symptoms have been well controlled for a period of at least 3 months (the patient is asymptomatic or the asthma attacks are well controlled): try a step-wise reduction in medication.