asthma attack experience essay

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Stanford University School of Medicine blog

Breathing: A reflection on living with asthma

We played cards sometimes, my mother and I, during my childhood asthma attacks in the middle of the night. I would creep past the bathroom door and to my parents' bedroom door. Mom , I would whisper. Mom .

That's all I needed to say. She came to the living room, where I waited for her, and stayed up the rest of the night to watch me breathe.

Watching me breathe meant making decisions about whether to call the doctor in the middle of the night or take me into his office in the morning.

Sometimes I put my hands on my head, fingers clasped together because latching them and pressing down on my head created more energy to suck in the next breath. As I grew older, I avoided placing my hands on my head, afraid to tip my mother off about how bad the attack was.

For a long and harrowing attack, she woke my father to drive me out into the night air, which we thought helped with the breathing. We meandered through the neighborhoods bordering the hospitals, looping repeatedly down certain streets, our leisurely pace a sham, because really, he remained close to those hospital entrances in case my breathing worsened, propelling us both into the light and warmth of the busy Emergency Departments.

Sometimes watching me meant making honey, lemon and whiskey toddies, or, if we had no whiskey, just honey and lemon, so the hot liquid could break up the phlegm in my chest. But often, as I sipped on my honey and lemon, my mother rubbed my back and shoulders, which were always hunched down with the effort of breathing. Or pounded between my shoulder blades, another strategy to break up the phlegm.

If the breathing became easier, either on its own or because I'd had some of the medicine stockpiled in our cupboard, and the rattling and wheezing diminished, my mother would pull out the cards. She still needed to watch my progress; neither one of us could rest yet. We would play two-handed Euchre. Or double solitaire.

I don't know how my mother's level of anxiety fluctuated when she watched me breathe through the night, but she never smoked in the house during my asthma attacks. For intense attacks, after waking my father, she might take a break from watching me and go into the backyard with a cigarette to look at the sky. She never fretted in front of me. She remained calm and positive.

During my senior year of high school, after a stressful week of classes, a swine flu shot, and a complicated AP chemistry experiment, I suffered an asthma attack, the worst I'd had in years. My pediatrician instructed the hospital to admit me straight to a floor. Some bureaucratic glitch delayed the delivery of one of those injections I needed to open my airways and help me breathe. My mother, summoned from work, told me to keep going, just a bit longer. Later, I told her, "I think you kept me alive." She told me that she'd never been so worried. She'd thought for sure I was dying.

Years later, when she died, her own breathing remained silent until near the end. Small puffs of sound emerged from her lips, like the snore puffs she'd made on those nights I'd returned from college for a visit and lay awake with the hums and creaks of my childhood home. In the hospital, as she lay dying, her brain stem already dead, I couldn't encourage her as she exhaled her last puffs. I just listened.

"Living is about the breathing," I might have said to my mother on one of those nights I clambered through an attack. We both knew that. But sometimes it helped to hear things aloud.

This piece, originally in  longer form , is part of an ongoing collaboration with Months to Years, a nonprofit quarterly publication that showcases nonfiction, poetry and art exploring mortality and terminal illness.

Dawn Newton, a writer in East Lansing, Michigan, was diagnosed with stage IV lung cancer in November 2012 and has lived with asthma all her life. Her memoir, Winded: A Memoir in Four Stages, will be published in October by Apprentice House Press at Loyola University Maryland. Her blog is at www.dawnmarienewton.com .

Photo by Alfonso Cerezo  

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Asthma essay full guide: Introduction, outline, examples

This essential guide to writing an asthma essay will help any student master the craft of producing a successful written work. From researching and outlining your ideas on the subject to developing an argument and ensuring the paper is correctly formatted, this article outlines the key steps of creating a great essay about asthma.

What is Asthma

Asthma is a chronic lung condition that causes difficulty breathing, wheezing, and coughing. It is an inflammatory disorder of the airways that affects 10-15% of the population worldwide and most commonly occurs in children and adolescents. In those affected by asthma, their airways will become swollen, constricted, and filled with mucus, making it difficult to breathe normally.

When someone experiences an asthma attack, also known as an exacerbation or flare-up, their symptoms can worsen, resulting in further difficulty breathing and other physical changes such as a rapid heartbeat or chest tightness. Common triggers for asthmatic attacks include exercise, dust mites, strong smells, or cigarette smoke. The severity of these asthma attacks can range from mild to life-threatening, depending on the individual’s sensitivity to triggers.

Causes of Asthma

The most common causes of asthma are allergies and environmental triggers such as smoke or air pollution. Allergens like pollen, pet dander, and dust mites can induce an allergic reaction in some individuals, leading to inflammation in their airways.

Exposure to tobacco smoke has been shown to increase the risk of asthma in children who have not yet developed the condition. Other environmental pollutants , such as cleaning products or aerosol sprays, may also trigger an attack by irritating a person’s lungs.

Symptoms of Asthma

Common symptoms of asthma include

• Wheezing, which sounds like a whistling noise when you breathe; chest tightness – feeling like something heavy is pressing on your chest;
• Coughing – either dry or wet coughs that are worse at night
• Difficulty breathing – feeling out of breath when doing everyday activities such as climbing stairs or walking uphill

Other less common signs may include fatigue, loss of appetite, anxiety or panic attacks, facial swelling, and excessive mucus production in your throat.

Asthma assessment and plan

An asthma assessment includes collecting information about the patient, such as their symptoms, triggers, medications, and lifestyle factors that may influence their condition. This information helps healthcare providers develop an effective treatment plan for each individual patient.

The plan may include lifestyle changes such as avoiding allergens or physical activity; taking preventive medications; or emergency treatments if needed. An effective asthma management plan should also include regular follow-up appointments with healthcare providers to review progress, adjust medications if necessary and ensure the patient is managing their condition properly.

Treatments for Asthma

Following an asthma assessment and diagnosis, inhaled medications are often used for daily management and quick relief when experiencing an attack. Inhaled corticosteroids reduce inflammation in the airways, while long-acting bronchodilators help keep airways open for up to 12 hours after use. Oral medications can control asthma symptoms and may be prescribed when inhalers do not suffice.

Writing an asthma essay

Writing an asthma assignment can be daunting, especially if you are unfamiliar with the condition. Asthma is a chronic respiratory disorder that affects your breathing and can make it difficult to do even simple activities such as walking or talking.

To write a successful essay on asthma, it is essential to understand the basics of the condition and its effects.

• Research what causes asthma and who is at risk of developing it
• Familiarize yourself with the treatments available for managing symptoms and preventing attacks
• Brainstorm ideas for your essay
• Consider writing about how the condition has impacted your life or someone close to you personally or professionally
• You could also focus on how recent advancements in medical technology have improved treatment options for people living with this condition

Asthma essay outline

Writing an asthma essay can be challenging, but having a well-defined outline can make the task much easier. An outline will help you organize your essay and ensure it covers all essential aspects of the condition. Here are some tips to help you create an effective strategy for your asthma essay.

• Start by deciding on a thesis statement for the essay. This should provide an overview of what you plan to cover in the paper and guide your argument throughout
• Begin organizing information into main points or ideas that support each argument. These points should be clearly stated and supported with evidence from reliable sources such as research studies or medical journals
• Write out detailed sub-points to further explain each main point or idea in greater detail. Include quotes and examples to support each point or argument effectively.

Asthma essay introduction

The introduction should begin by grabbing the reader’s attention. Use exciting facts or questions related to asthma to help engage the audience in your work. It is also important to provide background information regarding asthma, so readers understand why this topic is essential. Be sure to include reliable data, such as statistics on mortality rates or prevalence among different populations.

Asthma essay body paragraphs

The first step when writing an asthma essay body paragraph is to determine what your main points are going to be and how you plan on presenting them in the body of your essay. Once you have selected this, you’ll need to research and collect information about these points. This could include articles, studies, statistics, or any other sources that may be relevant.

It is vital to organize your thoughts logically, so they flow together nicely when writing the actual body paragraphs. Start each paragraph with an introductory sentence that introduces the perspective you will discuss in that particular paragraph.

After this, provide evidence and supporting details for your argument, which should come from the research gathered earlier. Finally, conclude each paragraph by summarizing the main points and tying them together into one solid conclusion or argument.

Asthma essay conclusion

The primary goals of an asthma essay conclusion are to summarize your main points, draw a valid conclusion based on those points, and provide a sense of closure for your reader. Start by briefly summarizing each point you made throughout your paper. Then clearly state your overall conclusion about the topic in one or two sentences.

This is where you provide a final perspective or opinion on the issue you discussed in the body of your paper. Finally, end with a thought-provoking statement or idea that will leave readers reflecting on their views on asthma and its treatments or implications.

 Reflective essay on asthma

A reflective essay on asthma is an insightful and personal exploration of the experience of living with the condition. Reflecting on how this condition has impacted your life can bring a greater understanding and acceptance.

When writing a reflective essay on asthma, consider your personal experience with the condition, including symptoms they may have experienced in times of exacerbation and any treatments they may have pursued to alleviate those symptoms. You should also reflect upon how this condition has affected them physically and mentally, highlighting both positive and negative aspects.

Tips on how to write a Reflective essay on asthma

Writing a nursing essay on asthma can be an eye-opening experience for many. It allows the writer to reflect on their experiences with asthma and how it has impacted their life and will enable them to share that experience with others. Here are some tips on how to write a reflective essay about asthma:

• It is crucial to understand what an asthma attack feels like and its effects to communicate the experience in writing effectively
• Consider what aspects of your experience with asthma you would like to focus on. Are there specific events that stand out as particularly pivotal? Do you want to discuss the impact of living with this condition? Or perhaps explore how your lifestyle has changed since having asthma?
• Think deeply about any emotions associated with this topic
• Writing down what you feel physically and emotionally during an attack can help develop a more personal account of their experience
• Try to keep a journal throughout the writing process in which you record any thoughts or observations related to asthma that come into your head
• Consider researching treatments or therapies that have worked for others who have had asthma. This will give them a better understanding of how they can manage their symptoms while also giving readers insight into the treatment options available

Asthma essay topic ideas

• The impact of asthma on one’s lifestyle and day-to-day activities
• Various treatments available for controlling asthma symptoms
• The different types of asthma and their symptoms
• The psychological effects of living with asthma
• Air pollution as a factor in causing or worsening existing cases of asthma in specific populations
• Advances in technology and new devices available to help asthmatics manage their conditions
• The current state of knowledge about asthma research, emerging treatments, technologies, and management strategies
• The impact of better diagnosis methods and medications
• The impact of poverty on access to medical care
• How society views those who suffer from this illness

Bottom line

Asthma is a severe respiratory condition affecting millions of people worldwide. It can be managed with lifestyle changes, medications, and other treatments. This guide has provided an overview of asthma, including helpful information on its cause, symptoms, diagnosis, and treatment options, and how best to write an asthma essay.

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Home — Essay Samples — Nursing & Health — Pathophysiology — A Comprehensive Exploration of Asthma

A Comprehensive Exploration of Asthma

• Categories: Pathophysiology

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Words: 1260 |

Published: Feb 13, 2024

Words: 1260 | Pages: 3 | 7 min read

Table of contents

Acute asthma, chronic asthma, impact of gender on pathophysiology, diagnosis and treatment.

• Centers for Disease Control and Prevention (2018). Asthma. Retrieved from https://www.cdc.gov/nchs/fastats/asthma.htm
• Dodge, R., R., & Burrows, B. (2018). The prevalence and incidence of asthma-like symptoms in a general population sample. Am Rev Respir Dis 2018; 122:567–75.
• Holgate, S., T. (2017). Genetic and environmental interaction in allergy and asthma. J Allergy Clin Immunol 2017; 104: 1139–46
• Lemanske, R., F., & Busse., W., W. (2017). Asthma: Clinical expression and molecular mechanisms. J Allergy Clin Immunol. 2017, 125: S95-102. 10.1016/j.jaci.2009.10.047.
• Mandhane, P., J., Greene, J., M., Cowan, J., O., et al. (2015). Sex differences in factors associated with childhood and adolescent-onset wheeze. Am J Respir Crit Care Med 2015; 172:45–54
• Thomas, A., O., Lemanske, R.., F., & Jackson, D., J. (2014). Infections and their role in childhood asthma inception. Pediatr Allergy Immunol. 2014; 25: 122–128
• Wright, A., L., Stern, D., A., Kauffmann, F., et al. (2016). Factors influencing gender differences in the diagnosis and treatment of asthma in childhood: the Tucson Children' s Respiratory Study. Pediatr Pulmonol 2016; 41:318–25.
• Wright, A., L., Stern, D., A., Kauffmann, F., et al. (2016). Factors influencing gender differences in the diagnosis and treatment of asthma in childhood: the Tucson Children's Respiratory Study. Pediatr Pulmonol 2016; 41:318–25.

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• Published: 16 October 2014

A woman with asthma: a whole systems approach to supporting self-management

• Hilary Pinnock 1 ,
• Elisabeth Ehrlich 1 ,
• Gaylor Hoskins 2 &
• Ron Tomlins 3  

npj Primary Care Respiratory Medicine volume  24 , Article number:  14063 ( 2014 ) Cite this article

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A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and international and national guidelines emphasise the importance of providing a written asthma action plan. Effective implementation of this recommendation for the lady in this case study is considered from the perspective of a patient, healthcare professional, and the organisation. The patient emphasises the importance of developing a partnership based on honesty and trust, the need for adherence to monitoring and regular treatment, and involvement of family support. The professional considers the provision of asthma self-management in the context of a structured review, with a focus on a self-management discussion which elicits the patient’s goals and preferences. The organisation has a crucial role in promoting, enabling and providing resources to support professionals to provide self-management. The patient’s asthma control was assessed and management optimised in two structured reviews. Her goal was to avoid disruption to her work and her personalised action plan focused on achieving that goal.

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A 35-year-old sales representative attends the practice for an asthma review. Her medical record notes that she has had asthma since childhood, and although for many months of the year her asthma is well controlled (when she often reduces or stops her inhaled steroids), she experiences one or two exacerbations a year requiring oral steroids. These are usually triggered by a viral upper respiratory infection, though last summer when the pollen count was particularly high she became tight chested and wheezy for a couple of weeks.

Her regular prescription is for fluticasone 100 mcg twice a day, and salbutamol as required. She has a young family and a busy lifestyle so does not often manage to find time to attend the asthma clinic. A few weeks previously, an asthma attack had interfered with some important work-related travel, and she has attended the clinic on this occasion to ask about how this can be managed better in the future. There is no record of her having been given an asthma action plan.

What do we know about asthma self-management? The academic perspective

Supported self-management reduces asthma morbidity.

The lady in this case study is struggling to maintain control of her asthma within the context of her busy professional and domestic life. The recent unfortunate experience which triggered this consultation offers a rare opportunity to engage with her and discuss how she can manage her asthma better. It behoves the clinician whom she is seeing (regardless of whether this is in a dedicated asthma clinic or an appointment in a routine general practice surgery) to grasp the opportunity and discuss self-management and provide her with a (written) personalised asthma action plan (PAAP).

The healthcare professional advising the lady is likely to be aware that international and national guidelines emphasise the importance of supporting self-management. 1 – 4 There is an extensive evidence base for asthma self-management: a recent synthesis identified 22 systematic reviews summarising data from 260 randomised controlled trials encompassing a broad range of demographic, clinical and healthcare contexts, which concluded that asthma self-management reduces emergency use of healthcare resources, including emergency department visits, hospital admissions and unscheduled consultations and improves markers of asthma control, including reduced symptoms and days off work, and improves quality of life. 1 , 2 , 5 – 12 Health economic analysis suggests that it is not only clinically effective, but also a cost-effective intervention. 13

Personalised asthma action plans

Key features of effective self-management approaches are:

Self-management education should be reinforced by provision of a (written) PAAP which reminds patients of their regular treatment, how to monitor and recognise that control is deteriorating and the action they should take. 14 – 16 As an adult, our patient can choose whether she wishes to monitor her control with symptoms or by recording peak flows (or a combination of both). 6 , 8 , 9 , 14 Symptom-based monitoring is generally better in children. 15 , 16

Plans should have between two and three action points including emergency doses of reliever medication; increasing low dose (or recommencing) inhaled steroids; or starting a course of oral steroids according to severity of the exacerbation. 14

Personalisation of the action plan is crucial. Focussing specifically on what actions she could take to prevent a repetition of the recent attack is likely to engage her interest. Not all patients will wish to start oral steroids without advice from a healthcare professional, though with her busy lifestyle and travel our patient is likely to be keen to have an emergency supply of prednisolone. Mobile technology has the potential to support self-management, 17 , 18 though a recent systematic review concluded that none of the currently available smart phone ‘apps’ were fit for purpose. 19

Identification and avoidance of her triggers is important. As pollen seems to be a trigger, management of allergic rhinitis needs to be discussed (and included in her action plan): she may benefit from regular use of a nasal steroid spray during the season. 20

Self-management as recommended by guidelines, 1 , 2 focuses narrowly on adherence to medication/monitoring and the early recognition/remediation of exacerbations, summarised in (written) PAAPs. Patients, however, may want to discuss how to reduce the impact of asthma on their life more generally, 21 including non-pharmacological approaches.

Supported self-management

The impact is greater if self-management education is delivered within a comprehensive programme of accessible, proactive asthma care, 22 and needs to be supported by ongoing regular review. 6 With her busy lifestyle, our patient may be reluctant to attend follow-up appointments, and once her asthma is controlled it may be possible to make convenient arrangements for professional review perhaps by telephone, 23 , 24 or e-mail. Flexible access to professional advice (e.g., utilising diverse modes of consultation) is an important component of supporting self-management. 25

The challenge of implementation

Implementation of self-management, however, remains poor in routine clinical practice. A recent Asthma UK web-survey estimated that only 24% of people with asthma in the UK currently have a PAAP, 26 with similar figures from Sweden 27 and Australia. 28 The general practitioner may feel that they do not have time to discuss self-management in a routine surgery appointment, or may not have a supply of paper-based PAAPs readily available. 29 However, as our patient rarely finds time to attend the practice, inviting her to make an appointment for a future clinic is likely to be unsuccessful and the opportunity to provide the help she needs will be missed.

The solution will need a whole systems approach

A systematic meta-review of implementing supported self-management in long-term conditions (including asthma) concluded that effective implementation was multifaceted and multidisciplinary; engaging patients, training and motivating professionals within the context of an organisation which actively supported self-management. 5 This whole systems approach considers that although patient education, professional training and organisational support are all essential components of successful support, they are rarely effective in isolation. 30 A systematic review of interventions that promote provision/use of PAAPs highlighted the importance of organisational systems (e.g., sending blank PAAPs with recall reminders). 31 A patient offers her perspective ( Box 1 ), a healthcare professional considers the clinical challenge, and the challenges are discussed from an organisational perspective.

Box 1: What self-management help should this lady expect from her general practitioner or asthma nurse? The patient’s perspective

The first priority is that the patient is reassured that her condition can be managed successfully both in the short and the long term. A good working relationship with the health professional is essential to achieve this outcome. Developing trust between patient and healthcare professional is more likely to lead to the patient following the PAAP on a long-term basis.

A review of all medication and possible alternative treatments should be discussed. The patient needs to understand why any changes are being made and when she can expect to see improvements in her condition. Be honest, as sometimes it will be necessary to adjust dosages before benefits are experienced. Be positive. ‘There are a number of things we can do to try to reduce the impact of asthma on your daily life’. ‘Preventer treatment can protect against the effect of pollen in the hay fever season’. If possible, the same healthcare professional should see the patient at all follow-up appointments as this builds trust and a feeling of working together to achieve the aim of better self-management.

Is the healthcare professional sure that the patient knows how to take her medication and that it is taken at the same time each day? The patient needs to understand the benefit of such a routine. Medication taken regularly at the same time each day is part of any self-management regime. If the patient is unused to taking medication at the same time each day then keeping a record on paper or with an electronic device could help. Possibly the patient could be encouraged to set up a system of reminders by text or smartphone.

Some people find having a peak flow meter useful. Knowing one's usual reading means that any fall can act as an early warning to put the PAAP into action. Patients need to be proactive here and take responsibility.

Ongoing support is essential for this patient to ensure that she takes her medication appropriately. Someone needs to be available to answer questions and provide encouragement. This could be a doctor or a nurse or a pharmacist. Again, this is an example of the partnership needed to achieve good asthma control.

It would also be useful at a future appointment to discuss the patient’s lifestyle and work with her to reduce her stress. Feeling better would allow her to take simple steps such as taking exercise. It would also be helpful if all members of her family understood how to help her. Even young children can do this.

From personal experience some people know how beneficial it is to feel they are in a partnership with their local practice and pharmacy. Being proactive produces dividends in asthma control.

What are the clinical challenges for the healthcare professional in providing self-management support?

Due to the variable nature of asthma, a long-standing history may mean that the frequency and severity of symptoms, as well as what triggers them, may have changed over time. 32 Exacerbations requiring oral steroids, interrupting periods of ‘stability’, indicate the need for re-assessment of the patient’s clinical as well as educational needs. The patient’s perception of stability may be at odds with the clinical definition 1 , 33 —a check on the number of short-acting bronchodilator inhalers the patient has used over a specific period of time is a good indication of control. 34 Assessment of asthma control should be carried out using objective tools such as the Asthma Control Test or the Royal College of Physicians three questions. 35 , 36 However, it is important to remember that these assessment tools are not an end in themselves but should be a springboard for further discussion on the nature and pattern of symptoms. Balancing work with family can often make it difficult to find the time to attend a review of asthma particularly when the patient feels well. The practice should consider utilising other means of communication to maintain contact with patients, encouraging them to come in when a problem is highlighted. 37 , 38 Asthma guidelines advocate a structured approach to ensure the patient is reviewed regularly and recommend a detailed assessment to enable development of an appropriate patient-centred (self)management strategy. 1 – 4

Although self-management plans have been shown to be successful for reducing the impact of asthma, 21 , 39 the complexity of managing such a fluctuating disease on a day-to-day basis is challenging. During an asthma review, there is an opportunity to work with the patient to try to identify what triggers their symptoms and any actions that may help improve or maintain control. 38 An integral part of personalised self-management education is the written PAAP, which gives the patient the knowledge to respond to the changes in symptoms and ensures they maintain control of their asthma within predetermined parameters. 9 , 40 The PAAP should include details on how to monitor asthma, recognise symptoms, how to alter medication and what to do if the symptoms do not improve. The plan should include details on the treatment to be taken when asthma is well controlled, and how to adjust it when the symptoms are mild, moderate or severe. These action plans need to be developed between the doctor, nurse or asthma educator and the patient during the review and should be frequently reviewed and updated in partnership (see Box 1). Patient preference as well as clinical features such as whether she under- or over-perceives her symptoms should be taken into account when deciding whether the action plan is peak flow or symptom-driven. Our patient has a lot to gain from having an action plan. She has poorly controlled asthma and her lifestyle means that she will probably see different doctors (depending who is available) when she needs help. Being empowered to self-manage could make a big difference to her asthma control and the impact it has on her life.

The practice should have protocols in place, underpinned by specific training to support asthma self-management. As well as ensuring that healthcare professionals have appropriate skills, this should include training for reception staff so that they know what action to take if a patient telephones to say they are having an asthma attack.

However, focusing solely on symptom management strategies (actions) to follow in the presence of deteriorating symptoms fails to incorporate the patients’ wider views of asthma, its management within the context of her/his life, and their personal asthma management strategies. 41 This may result in a failure to use plans to maximise their health potential. 21 , 42 A self-management strategy leading to improved outcomes requires a high level of patient self-efficacy, 43 a meaningful partnership between the patient and the supporting health professional, 42 , 44 and a focused self-management discussion. 14

Central to both the effectiveness and personalisation of action plans, 43 , 45 in particular the likelihood that the plan will lead to changes in patients’ day-to-day self-management behaviours, 45 is the identification of goals. Goals are more likely to be achieved when they are specific, important to patients, collaboratively set and there is a belief that these can be achieved. Success depends on motivation 44 , 46 to engage in a specific behaviour to achieve a valued outcome (goal) and the ability to translate the behavioural intention into action. 47 Action and coping planning increases the likelihood that patient behaviour will actually change. 44 , 46 , 47 Our patient has a goal: she wants to avoid having her work disrupted by her asthma. Her personalised action plan needs to explicitly focus on achieving that goal.

As providers of self-management support, health professionals must work with patients to identify goals (valued outcomes) that are important to patients, that may be achievable and with which they can engage. The identification of specific, personalised goals and associated feasible behaviours is a prerequisite for the creation of asthma self-management plans. Divergent perceptions of asthma and how to manage it, and a mismatch between what patients want/need from these plans and what is provided by professionals are barriers to success. 41 , 42

What are the challenges for the healthcare organisation in providing self-management support?

A number of studies have demonstrated the challenges for primary care physicians in providing ongoing support for people with asthma. 31 , 48 , 49 In some countries, nurses and other allied health professionals have been trained as asthma educators and monitor people with stable asthma. These resources are not always available. In addition, some primary care services are delivered in constrained systems where only a few minutes are available to the practitioner in a consultation, or where only a limited range of asthma medicines are available or affordable. 50

There is recognition that the delivery of quality care depends on the competence of the doctor (and supporting health professionals), the relationship between the care providers and care recipients, and the quality of the environment in which care is delivered. 51 This includes societal expectations, health literacy and financial drivers.

In 2001, the Australian Government adopted a programme developed by the General Practitioner Asthma Group of the National Asthma Council Australia that provided a structured approach to the implementation of asthma management guidelines in a primary care setting. 52 Patients with moderate-to-severe asthma were eligible to participate. The 3+ visit plan required confirmation of asthma diagnosis, spirometry if appropriate, assessment of trigger factors, consideration of medication and patient self-management education including provision of a written PAAP. These elements, including regular medical review, were delivered over three visits. Evaluation demonstrated that the programme was beneficial but that it was difficult to complete the third visit in the programme. 53 – 55 Accordingly, the programme, renamed the Asthma Cycle of Care, was modified to incorporate two visits. 56 Financial incentives are provided to practices for each patient who receives this service each year.

Concurrently, other programmes were implemented which support practice-based care. Since 2002, the National Asthma Council has provided best-practice asthma and respiratory management education to health professionals, 57 and this programme will be continuing to 2017. The general practitioner and allied health professional trainers travel the country to provide asthma and COPD updates to groups of doctors, nurses and community pharmacists. A number of online modules are also provided. The PACE (Physician Asthma Care Education) programme developed by Noreen Clark has also been adapted to the Australian healthcare system. 58 In addition, a pharmacy-based intervention has been trialled and implemented. 59

To support these programmes, the National Asthma Council ( www.nationalasthma.org.au ) has developed resources for use in practices. A strong emphasis has been on the availability of a range of PAAPs (including plans for using adjustable maintenance dosing with ICS/LABA combination inhalers), plans for indigenous Australians, paediatric plans and plans translated into nine languages. PAAPs embedded in practice computer systems are readily available in consultations, and there are easily accessible online paediatric PAAPs ( http://digitalmedia.sahealth.sa.gov.au/public/asthma/ ). A software package, developed in the UK, can be downloaded and used to generate a pictorial PAAP within the consultation. 60

One of the strongest drivers towards the provision of written asthma action plans in Australia has been the Asthma Friendly Schools programme. 61 , 62 Established with Australian Government funding and the co-operation of Education Departments of each state, the Asthma Friendly Schools programme engages schools to address and satisfy a set of criteria that establishes an asthma-friendly environment. As part of accreditation, the school requires that each child with asthma should have a written PAAP prepared by their doctor to assist (trained) staff in managing a child with asthma at school.

The case study continues...

The initial presentation some weeks ago was during an exacerbation of asthma, which may not be the best time to educate a patient. It is, however, a splendid time to build on their motivation to feel better. She agreed to return after her asthma had settled to look more closely at her asthma control, and an appointment was made for a routine review.

At this follow-up consultation, the patient’s diagnosis was reviewed and confirmed and her trigger factors discussed. For this lady, respiratory tract infections are the usual trigger but allergic factors during times of high pollen count may also be relevant. Assessment of her nasal airway suggested that she would benefit from better control of allergic rhinitis. Other factors were discussed, as many patients are unaware that changes in air temperature, exercise and pets can also trigger asthma exacerbations. In addition, use of the Asthma Control Test was useful as an objective assessment of control as well as helping her realise what her life could be like! Many people with long-term asthma live their life within the constraints of their illness, accepting that is all that they can do.

After assessing the level of asthma control, a discussion about management options—trigger avoidance, exercise and medicines—led to the development of a written PAAP. Asthma can affect the whole family, and ways were explored that could help her family understand why it is important that she finds time in the busy domestic schedules to take her regular medication. Family and friends can also help by understanding what triggers her asthma so that they can avoid exposing her to perfumes, pollens or pets that risk triggering her symptoms. Information from the national patient organisation was provided to reinforce the messages.

The patient agreed to return in a couple of weeks, and a recall reminder was set up. At the second consultation, the level of control since the last visit will be explored including repeat spirometry, if appropriate. Further education about the pathophysiology of asthma and how to recognise early warning signs of loss of control can be given. Device use will be reassessed and the PAAP reviewed. Our patient’s goal is to avoid disruption to her work and her PAAP will focus on achieving that goal. Finally, agreement will be reached with the patient about future routine reviews, which, now that she has a written PAAP, could be scheduled by telephone if all is well, or face-to-face if a change in her clinical condition necessitates a more comprehensive review.

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Pinnock, H., Ehrlich, E., Hoskins, G. et al. A woman with asthma: a whole systems approach to supporting self-management. npj Prim Care Resp Med 24 , 14063 (2014). https://doi.org/10.1038/npjpcrm.2014.63

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• Published: 22 November 2022

Patient experience of moderate asthma attacks: qualitative research in the USA and Germany

• Maggie Tabberer   nAff1 ,
• Jane R. Wells 2 ,
• Dale Chandler 2 ,
• Linda Abetz-Webb 3 ,
• Shiyuan Zhang   ORCID: orcid.org/0000-0001-8523-0419 4 ,
• Wilhelmine Meeraus   nAff1 ,
• Andy Fowler 1 &
• David Slade 5  

Journal of Patient-Reported Outcomes volume  6 , Article number:  117 ( 2022 ) Cite this article

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There is limited information available on the impact of moderate asthma exacerbations, often called “asthma attacks” (i.e., those not requiring hospitalisation or treatment with systemic corticosteroids) on patients’ lives. This multi-country qualitative study explored the patient experience of these events.

Semi-structured concept elicitation interviews were conducted in the USA and Germany with adult patients with asthma who had experienced a moderate asthma exacerbation in the prior 30 days. Physicians with experience in managing patients with asthma were also interviewed. Interviews explored patients’ experience of symptoms and impact of moderate exacerbations and associated exacerbation triggers and treatment patterns. Physicians were also asked about their interpretation of a clinical definition and treatment of a moderate exacerbation.

Twenty-eight patient (n = 20 in the USA, n = 8 in Germany) and six physician (n = 3 in the USA, n = 3 in Germany) interviews were conducted. During their moderate exacerbation, all patients reported experiencing shortness of breath, which many considered to be severe and the most bothersome symptom. Wheezing was also reported by all patients and considered severe by two thirds of patients. Most patients also reported coughing and chest tightness. All or almost all patients reported that moderate exacerbation caused fatigue/tiredness and impacted their physical functioning, emotional functioning, activities of daily living and work/school life. Most patients reported using rescue or maintenance inhalers to alleviate symptoms of the exacerbation. Conceptual saturation (i.e., the point at which no new concepts are likely to emerge with continued data collection) was achieved. Findings were used to develop a patient-focused conceptual model of the experience of moderate asthma exacerbations, outlining concepts related to triggers, symptoms, impact, and treatment from the patient perspective. Physician data was consistent with patient reports and complemented the conceptual model.

Conclusions

Findings from concept elicitation interviews highlight the increased frequency, duration and severity of asthma symptoms and increased rescue medication use during moderate asthma exacerbations compared with the typical daily asthma experience, which have a substantial impact on patients’ lives.

Asthma is a heterogeneous chronic inflammatory respiratory disease characterised by episodes of shortness of breath, wheezing, chest tightness and/or cough, and by variable expiratory airflow limitation that places a high burden on both patients and healthcare systems [ 1 ]. Patients with asthma may experience exacerbations of their symptoms and airflow limitation of varying severity, that impact health-related quality of life (HRQoL) and in some cases may be life-threatening [ 2 , 3 , 4 ]. Consequently, the Global Initiative for Asthma (GINA) and the USA National Institute of Health’s National Asthma Education and Prevention Program [ 5 ] have identified key long-term goals of asthma management, including good symptom control and minimizing the future risk of exacerbations, airflow limitation, hospitalisation, and side effects of treatment. To achieve these goals, a stepwise approach to asthma management is recommended, with treatment selection based on the severity of asthma and a continuous cycle of assessment, adjustment of treatment, and review of treatment response [ 1 ].

Although asthma exacerbations are typically more common and more severe when the underlying disease is uncontrolled or very poorly controlled [ 6 – 8 ], they can also occur in patients with otherwise mild or well-controlled asthma [ 1 ]. Exacerbation severity may be determined based on symptom changes, medication use, and/or other healthcare interventions. In 2009, a joint statement from the American Thoracic Society (ATS)/European Respiratory Society (ERS) on asthma control and exacerbations defined a moderate exacerbation as a deterioration in symptoms and lung function and increased rescue bronchodilator use lasting for ≥ 2 days [ 9 ]. According to the ATS/ERS statement, moderate exacerbations require a change in the treatment to prevent progression to a severe exacerbation, but they are not considered severe enough to warrant systemic corticosteroid use and/or hospitalization [ 9 ]. This definition also aligns with the European Medicines Agency guidance for clinical trials [ 10 ]. While the ATS/ERS definition is undoubtedly useful, characterization of the severity of an asthma exacerbation can be challenging in clinical practice because it is reliant in part on patient-reported deterioration in asthma control and changes in treatment that may not have been recorded in the clinic. This can be problematic because identification and appropriate treatment of a moderate asthma exacerbation may help to prevent its escalation to a severe event [ 11 ]. While steps have been taken to create a standard definition for the severity of asthma exacerbations, there remains substantial variability in the definitions used across research studies and a consensus on the most appropriate definition has not yet been reached.

A more specific, prospective definition of a moderate exacerbation is needed for use in clinical trials in order to more accurately measure the effect of a particular treatment on exacerbation risk [ 11 ]. Development of an accurate and consistent definition of a moderate asthma exacerbation requires in-depth information from the patients themselves on how these exacerbations manifest. There is limited available information regarding the impact of moderate exacerbations on patients and their daily lives. Furthermore, to the best of our knowledge, there is no published literature relating to the “lived experience” of moderate asthma exacerbations. To bridge this knowledge gap, qualitative interviews were conducted with adults with asthma and also with a group of physicians, to explore the patient experience of moderate asthma exacerbations. These findings will add to the understanding of the patient’s experience of the signs and symptoms of moderate exacerbations and the impact these have on functioning and HRQoL, as well as help to interpret existing measures of moderate exacerbations used in clinical studies.

Study design

This was a cross-sectional qualitative interview study conducted in the USA and Germany (GSK study ID: 209379). Participants included patients with moderate or severe asthma who had experienced a moderate asthma exacerbation within the past 30 days, and physicians with experience of managing patients with asthma. Participants took part in semi-structured concept elicitation telephone interviews for both patients and physicians and explored the patient experience of a moderate asthma exacerbation, including symptoms, exacerbation triggers, impact, and treatment. Ethical approval was obtained from Copernicus, a centralised Independent Review Board (IRB) in the USA with oversight for conduct of the study in the USA and Germany.

Participant recruitment, screening, and eligibility criteria

Patients were identified by general practitioners, allergists, or pulmonologists from two regions in the USA (Chicago, IL and Los Angeles, CA) and one in Germany (Cologne and the surrounding North Rhine-Westphalia state). We originally intended the study to also include Spain; however, amendments were made to the protocol due to the ongoing COVID-19 pandemic, leading to cancellation of patient and clinician interviews in Spain. The interviews planned for Spain were reallocated to Germany and the USA. Patients were contacted by telephone or approached during scheduled or exacerbation-related appointments to determine if they had experienced a moderate exacerbation in the prior 30 days. Patients who wished to participate in the study provided written informed consent. The recruiting physician then completed the screener to provide additional details regarding the patients’ clinical information and medical history, which was then shared with a third-party recruitment agency who contacted the patient to collect demographic information and confirm eligibility. Recruitment quotas pertaining to age, sex, country, race, education, Asthma Control Test (ACT) score and medication step needed to maintain control were employed to ensure a diverse and representative sample of patients (Additional file 2 : Table S1). All screened patients were therefore reviewed and approved prior to entering the study.

Eligible patients were aged ≥ 18 years with moderate or severe asthma at minimum maintenance treatment with inhaled corticosteroids (ICS)/long-acting β 2 -agonists (LABA) (GINA Step ≥ 2) and had experienced a moderate exacerbation within 30 days of recruitment. We aimed to recruit a total of 32 patients; if conceptual saturation was not achieved, we planned to conduct additional patient interviews. Patients were allowed to remain on their regular asthma maintenance medications. For recruitment purposes, a moderate exacerbation was defined as a deterioration in asthma symptoms, deterioration in lung function, or increased rescue bronchodilator use lasting ≥ 2 days that was not severe enough to warrant systemic corticosteroid use (or additional systemic corticosteroid use for those on regular systemic corticosteroid treatment) for > 2 days or an event that, when recognised, should have resulted in a temporary change in treatment in an effort to prevent the exacerbation from becoming severe.

To ensure the patients could recall their experience of the moderate exacerbation and not other conditions or events, patients were excluded if they had a history or current diagnosis of any clinically significant pulmonary diseases or abnormalities other than asthma (not including allergies or rhinitis), or had experienced a severe asthma exacerbation (defined as deterioration of asthma requiring the use of systemic corticosteroids for ≥ 3 days, and/or a hospitalisation/emergency department visit [not routine care]) within the past 90 days. Patients who were prescribed/had taken oral corticosteroids (OCS; or additional OCS for those on regular systemic corticosteroid treatment) to treat asthma for > 2 days within the past 30 days were excluded. Patients with a diagnosed onset of asthma at aged ≥ 40 years and current/former smokers (with a history of ≥ 10 pack years) who are more likely to have chronic obstructive pulmonary disease as a comorbidity were also excluded. Full eligibility criteria are provided in the Additional file 1 : Supplementary Methods.

This study was conducted in 2020 during the COVID-19 pandemic. Patients with COVID-19 symptoms at screening would have been excluded as having “other respiratory conditions” and thus were ineligible to participate in the study. On the day of the interview, interviewers enquired if patients had developed COVID-19 symptoms during confirmatory screening before the interview. No patient interviews were rescheduled or terminated due to COVID-19.

Third-party recruitment agencies identified and recruited physicians who then provided written informed consent. Eligible physicians specialised in managing and treating adult patients with asthma and regularly (i.e. monthly) saw patients with asthma. These physicians were not involved in recruiting patients for this study.

Concept elicitation interviews

We used grounded theory methods to ensure that the resulting conceptual model best reflects patients’ experiences of moderate asthma exacerbations [ 12 ]. This approach also satisfied the guidance set out by the US Food and Drug Administration on best practice in conducting qualitative research and methods for eliciting information from patients [ 13 ]

The concept elicitation interviews lasted for 60 min and were conducted via telephone [ 14 ]. Interviews started with open-ended questions about a patient’s most recent exacerbation, providing opportunity for spontaneous report of concepts, followed by more focused questions to cover all concepts of interest. Patient interview topics included: language used to describe exacerbations, their duration, frequency and triggers, symptoms, impact on functioning and HRQoL, and steps taken to treat the exacerbation. Patients were asked about specific symptoms, shortness of breath, difficulty breathing, wheezing, coughing, chest tightness, phlegm/mucus, and chest pain if not discussed spontaneously. Comparison of the most recent exacerbation with more severe exacerbations (if experienced) was also discussed.

Physician interview topics included patients’ experiences of moderate asthma exacerbations, interpretation of a clinical definition of a moderate exacerbation, and patient treatment.

To ensure that all topics of interest were discussed, the interviews were conducted using a semi-structured guide, whereby development was led by experts in qualitative HRQoL research (Adelphi Values) with input from expert physicians. All interviews were audiorecorded and transcribed verbatim for the purpose of subsequent analysis. All identifiable information (e.g., names, locations) was removed from the transcripts such that they were fully pseudonymised. The German interviews were conducted by a native German speaker using a translated guide and also audiorecorded. The audiofiles were transcribed in German and then translated into English for subsequent analysis.

The findings from the patient interviews were used to develop a conceptual model outlining the patient experience and associated impact of moderate asthma exacerbations. The physician data was used to contextualise and support the patient results but was not used directly in the development of the model.

Data analyses

Using grounded theory methods, interview transcripts were subject to thematic analysis through continuous data-driven coding and using Atlas.ti 8 software (Scientific Software Development GmbH, Berlin, Germany), a software package designed to facilitate the storage, coding, and analysis of qualitative data. Further information on thematic analysis and coding process is provided in the Additional file 1 : Supplementary Methods. Patient sociodemographic and clinical characteristics were summarised using descriptive statistics (e.g., n values, means and min/max, range statistics). Conceptual saturation (i.e., the point at which no new concepts are likely to emerge with continued data collection) was monitored to confirm the adequacy of sample size [ 15 , 16 ].

Analysis of the patient interview results was also conducted to explore these concepts in subgroups stratified by country (USA, Germany), sex (male, female), asthma severity (GINA Step 2, Step 3, Step 4), and allergies (yes, no).

Patient characteristics

A total of 31 patients took part in the telephone interviews, 23 patients from the USA (between February and April 2020) and 8 patients from Germany (between September and October 2020). Three USA patients were excluded from the main analysis because descriptions of their asthma exacerbations during the interview violated the eligibility criteria (asthma exacerbations were too severe or too mild). All recruitment quotas were met (Additional file 2 : Table S1).

Sociodemographic and clinical characteristics are shown in Table 1 . The mean (standard deviation [SD]) age of the sample was 41.8 (15.8) years, there were slightly more females (n = 16; 57%), and the majority of patients were White/Caucasian/European (n = 20; 71%). The mean (SD) ACT score was 14.11 (3.49), indicating very poorly controlled asthma, and more than half the patients required GINA medication Step 4 or 5 to maintain asthma control. Allergies were the most common comorbidity. The most commonly prescribed maintenance medications were ICS/LABA single inhaler and leukotriene receptor antagonists.

Description, duration, and frequency of moderate exacerbations

Just under half of patients described their recent exacerbation as an “asthma attack” with fewer patients using the term “flare up” (Table 2 ). No patients spontaneously referred to their experience as an exacerbation. Patients most frequently reported that the exacerbation lasted 2–3 days (Table 2 ). A substantial number of patients reported that they had experienced moderate exacerbations once every 1–2 months or once every 3–4 months (Table 2 ), as a patient highlighted when asked, “ How frequently do you get these flare-ups?” “Um, not, not regularly. I’d say maybe every couple months. ” (US-05).

Patients reported being in recovery from an asthma exacerbation when having residual/persisting symptoms that were worse than typical, but no longer acutely part of the exacerbation. One patient replied that the moderate exacerbation lasted” probably three to four days” when asked “ So, how long did this last if you had to gauge from right from the start until you felt completely back to normal, how long did this asthma attack last for you?” (US-03).

The reported durations consider the patients’ perceived full length of the exacerbation from onset to full recovery.

Triggers of moderate asthma exacerbations

Patients reported one or more triggers of their exacerbation. The most frequently reported triggers for a moderate exacerbation were environmental factors, such as change in weather, cold air, and humidity; followed by exercise or other kinds of physical activity; allergens such as pets; emotions; and irritants, such as poor air quality. Few patients reported respiratory infection/common cold as triggers. A patient described the trigger of an exacerbation: “ I actually think that was this change in the weather again. So, from the warm season back to the somewhat cooler [weather] again. Because I always have problems anyway with dry air due to the central heating .” (Germany-29).

Symptoms of moderate asthma exacerbations

An overview of reported moderate exacerbation symptoms is shown in Fig.  1 ; patient quotes describing why symptoms were bothersome are shown in Table 3 . Shortness of breath was reported by all patients as a symptom of the exacerbation and by almost all patients spontaneously. Difficulty breathing was considered conceptually the same as “shortness of breath” by the majority of patients and by all the physicians. Patients considered shortness of breath to be severe or moderate to severe during the exacerbation. Duration ranged from a few minutes until medication was taken, to the full 3 days of the exacerbation to recovery with most patients reporting shortness of breath lasting for up to 3 h during the exacerbation. Shortness of breath was reported to be the first symptom experienced by the majority of patients or to occur within the first 30 min of the onset of the exacerbation and prompted many patients to use rescue/additional maintenance inhaler. Shortness of breath was also reported to be the most bothersome symptom in the majority of patients, as described by one patient: “But when this shortness of breath comes, especially if it’s the middle of the day, then it’s super disruptive.” (Germany-31).

Symptoms of moderate asthma exacerbations. Note : Shortness of breath, wheezing, difficulty breathing, coughing, chest tightness, phlegm/mucus, and chest pain were probed by the interviewer. All other symptoms were only reported spontaneously and because of that, corresponding columns are nonstacked

Wheezing was also reported by all patients, the majority of whom reported the symptom spontaneously. Wheezing was reported to be one of the first symptom to occur by few patients and usually in conjunction with shortness of breath. Patients considered the symptom to be severe or moderate during the exacerbation, ranging from a few minutes to the length of the moderate exacerbation.

The majority of patients reported shortness of breath and wheezing as part of their typical day with asthma, but when part of an exacerbation, patients reported the symptom as more frequent, lasting longer, and more severe as indicated by a patient: “…it was like a very drowning, a very drowning sensation, like, like I said, um, you just can’t breathe and it just, um, overpowers everything that you have going, I’m trying to, you know, gasp for breath and it’s hard.” (US-04).

Most patients also reported coughing (with many patients reporting this spontaneously), chest tightness (with just over half of patients reporting this spontaneously) and phlegm/mucus (with less than half of patients reporting this spontaneously). The symptoms of a moderate exacerbation was described as: “It just gets a harder and harder cough where it makes my chest feel very sore at the end.” (US-04).

Impact of moderate asthma exacerbations

All patients reported that their moderate exacerbation resulted in fatigue/tiredness, with half of patients reporting this spontaneously), and almost all patients reported impact on physical functioning (exercising, walking, and climbing stairs) (n = 27; n = 24 spontaneously) and emotional functioning (n = 27; n = 19 spontaneously). Anxiety/worry was reported by the majority of patients and anxiety/stress was associated with an exacerbation of symptoms in over a third of patients. The majority of patients reported impact on sleep (n = 26; n = 21 spontaneously), which included nighttime awakenings and difficulty falling asleep. Shortness of breath and coughing were most frequently reported as causing the biggest impact on sleep. Most patients also reported impact on activities of daily living (ADL) (n = 25; n = 20 spontaneously); social life and relationships (n = 22; n = 13 spontaneously) including ability to participate in social activities; and impact on work/school, such as absences. Fewer patients reported a financial impact due to their recent exacerbation (none spontaneously). Additionally, some patients identified coughing as a symptom that was bothersome and had social and work impact. Although not identified as severe or as bothersome as shortness of breath, coughing caused an irritation to patients during the course of the moderate exacerbation. However, some patients also reported that coughing was related to phlegm/mucus and chest pain/discomfort, with chest pain/discomfort being reported as a bothersome symptom for the few patients who did experience it. Figure  2 summarises the number of patients reporting each impact spontaneously and when probed by the interviewer; patient quotes describing the impact of exacerbations are shown in Table 4 . The most impactful aspects of a moderate exacerbation were primarily related to symptoms, with shortness of breath/difficulty breathing the most frequently reported symptom as described by a patient who said: “Yes, the difficulty breathing, in other words, the shortness of breath, that is the worst thing of all.” (Germany-26).

Impact of moderate asthma exacerbations. ADL activities of daily living

Comparison of recent exacerbation to a previous worse exacerbation

When asked to compare the worst exacerbation they have ever had to their recent exacerbation, the majority of patients reported having experienced a worse exacerbation, and almost half of patients reported that the worse exacerbation lasted longer, ranging from 3 days to 2 months. Patients reported that the symptoms of the worse exacerbation were more severe including shortness of breath, chest pain/tightness, wheezing, or that symptoms in general were more severe. Patients most commonly reported that different from their most recent moderate exacerbation, they were prescribed a course of OCS during the worse exacerbation and/or that they were hospitalised.

Treatment steps for moderate asthma exacerbations

Most patients reported using a rescue inhaler (short-acting β 2 -agonist), with more than half of patients increasing the use of a maintenance inhaler to alleviate their symptoms and the impact of a moderate exacerbation. Some patients consulted an healthcare professional (HCP) or visited a hospital or a physician. Some patients also reported nonpharmacological management, including rest, breathing control, and walking (Fig.  3 ). Approximately a third of patients reported having an asthma action plan in place with their HCP to manage an asthma exacerbation.

Pharmacological and nonpharmacological management reported by patients for their moderate asthma exacerbations. HCP healthcare professional

Subgroup analyses

Exacerbation symptoms stratified by country, sex, asthma severity, and presence of allergies.

Exacerbation symptoms reported were consistent across the country, sex, asthma severity, and allergy subgroups explored. Minor differences (e.g., feeling light-headed was only reported in the USA and eye swelling was only reported in Germany) in some reported symptoms were observed between countries though all core symptoms were consistent, and the impact of moderate exacerbations were similar across both the USA and German patient samples.

Conceptual saturation

Conceptual saturation for patient interviews was achieved with the 31 patients recruited: most concepts were spontaneously elicited before the last set of five interviews (36/37 concepts; 97%), with 76% of concepts (28/37) identified in the first three sets of interviews and 95% of concepts (35/37) identified by the fourth set (Additional file 1 : Fig. S1A). For the physician interviews, the majority of the concepts were spontaneously elicited before the last set of two interviews (15/16 concepts; 94%) (Additional file 1 : Fig. S1B). These results show that new concepts were unlikely to emerge with further interviews and indicates adequacy of the sample size.

Conceptual model

Findings from the interviews were used to develop a patient-focused conceptual model showing patient experience of the triggers, symptoms, treatment, and impact of moderate exacerbation and the links between these (Fig.  4 ).

Conceptual model of the patient experience of a moderate asthma attack (moderate exacerbation) a . a Model was developed based on interviews with 8 German and 20 USA patients and on ATS/ERS definition of a moderate exacerbation. ATS American Thoracic Society; ERS European Respiratory Society

Physician interviews

Six physicians participated in the qualitative interviews, four pulmonary specialists (one from the USA and three from Germany) and two allergists (both from the USA). Physicians working in community and public hospitals (n = 2), private practices (n = 3), and public/private practices (n = 1) were represented. Physicians had a mean (SD) of 19 (8.6) years of experience managing patients with asthma.

Similar to the patients’ reports, four physicians noted that their patients most commonly described their moderate exacerbations in terms of specific symptoms (e.g., shortness of breath, chest tightness, and difficulty breathing). Two reported the use of the term “asthma attack” and one the use of “flare” and, four physicians reported that their patients would not use the term “exacerbation.” Physicians tended to report that moderate exacerbations were lengthier in duration compared with patients (2–3 days), with three physicians reporting that a moderate exacerbation would last 3–5 days on average and three adding that the moderate exacerbation could last up to 2 weeks.

In addition, physicians reported that moderate exacerbations occurred less frequently than reported by patients, with half of the physicians reporting that they occurred about 2–3 times per year (as opposed to 3–12 times per year as reported by patients). Allergens were reported to be a major trigger for moderate exacerbations by all physicians followed by illness (cold and flu) reported by four physicians.

Symptoms and impact of moderate exacerbations reported by physicians were generally the same as those reported by patients; shortness of breath, difficulty breathing, coughing, chest tightness, and phlegm/mucus were reported by all physicians, as were impact on sleep, physical functioning, work/school, ADL, social life and relationships, emotional functioning, fatigue/tiredness, and finances. Similar to findings from patient interviews, all the physicians reported that shortness of breath and difficulty breathing were the same concept. Treatment steps physicians would expect a patient to take to treat their moderate exacerbation were also in accordance with patient findings, with rescue inhaler and maintenance inhaler both mentioned by four physicians. However, in contrast to patient findings (9 patients; 32%), all physicians reported that their patients would have an asthma action plan in place developed with their physician to manage their asthma exacerbation.

This qualitative study characterised the patient experience of moderate asthma exacerbations and the resulting conceptual model illustrates patient experience of exacerbations, including the triggers, symptoms, impact, and treatments and connections between these concepts. Findings from the physician interviews were generally consistent with patient reports. The conceptual model illustrates that patients experience both a deterioration in symptoms and increased rescue bronchodilator use during a moderate exacerbation, which is consistent with the joint ATS/ERS definition of a moderate exacerbation [ 9 ]. Further, it provides an in-depth characterization of symptoms and their debilitating impact on patients’ HRQoL.

Our aim of including both North American and European participants was to ensure we obtained a breadth of patient and physician insight into moderate exacerbations and their impact, which may vary according to location, and be influenced by language and cultural factors. Conducting this research in a North American country and in Europe enabled the research to explore similarities and differences in the patient experience between these two countries .

During the interviews, patients reported a core set of symptoms that included shortness of breath (difficulty breathing) and wheezing, experienced by every patient, as well as one or a combination of coughing, chest tightness, phlegm/mucus, and chest pain/discomfort. In line with the ATS/ERS definition of a moderate exacerbation [ 9 ], patients in the current study reported that the symptoms of shortness of breath and wheezing, in particular, differed from their typical experience of these symptoms during the moderate exacerbation event, specifically presenting with a higher level of severity, greater frequency, and longer duration. Building on the identification of symptoms associated with a moderate exacerbation, patients often reported the point at which their exacerbation symptoms were experienced in comparison with other symptoms, suggesting that the order in which symptoms manifest was important to them. Shortness of breath (difficulty breathing) and wheezing were most frequently reported as the first symptoms experienced during the moderate exacerbation. Interestingly, while most patients reported shortness of breath to be the most bothersome symptom during the moderate exacerbation, wheezing was not considered as bothersome despite being equally prevalent among the patients. This may be because shortness of breath is more frightening to patients when compared to wheezing. This is consistent with a qualitative interview study conducted in patients with asthma where shortness of breath was the most difficult symptom reported by patients followed by chest tightness, coughing, and wheezing [ 17 ]. The order of exacerbation symptoms noted here may be helpful for patients and physicians to discriminate moderate exacerbations from asthma daily symptoms, and also to decide treatment needs during a moderate exacerbation.

In this study, the majority of patients and all physicians reported that shortness of breath and difficulty breathing were conceptually the same and, based on this, these two concepts were described together and interpreted as synonymous. In contrast, previous patient-centered research that explored this in-depth with adults and adolescents with asthma described “shortness of breath” and “difficulty breathing” as being related and suggested they can be grouped together with wheezing under “breathing symptoms” but are conceptually distinct [ 18 ].

While in-day and day-to-day variability of exacerbation symptoms were explored with probes during the interviews, these concepts were not spontaneously reported to any great extent by patients. Because the interviews were based on patient recall of symptoms, real-time data capture using an app may be a useful tool to explore this concept in the future.

A key objective of this study was to explore the impact of moderate exacerbation symptoms on patients’ HRQoL. Shortness of breath, as the most common exacerbation-related symptom, was often cited as having the greatest impact. Shortness of breath limited patients’ physical functioning and was also a common cause of emotional impact, often eliciting a sense of anxiety and fear, which in turn was often reported to further exacerbate the symptoms such as shortness of breath. The range of impact reported as a result of a moderate exacerbation in this study reflects daily patient-reported experiences of asthma in the literature [ 19 , 20 ] highlighting that, as with symptoms, day-to-day impact are exacerbated during a moderate asthma exacerbation.

Patient–physician discordance regarding the frequency and severity of asthma symptoms has been reported in the literature [ 21 , 22 ]. In the current study, physicians tended to report lengthier but less frequent moderate exacerbations than did the patients. Physician data were consistent with the mean duration of 11.1–12.1 days reported for a moderate exacerbation in the CAPTAIN study, which assessed the annualised rate of moderate and/or severe asthma exacerbations (key secondary endpoint) [ 23 ]. These differences between patients and physicians’ perception on the length of a moderate exacerbation could perhaps be attributed to patients defining the end of an exacerbation as the time when they are able to resume activities as opposed to when their symptoms return to pre-exacerbation levels. Additionally, there was a discordance in frequency with patients experiencing three times as many moderate exacerbations than reported by physicians. This discrepancy could perhaps be associated with the fact that patients may not often seek care for what they perceive as a moderate exacerbation, and as a result could be self-treating. These results suggest that moderate asthma exacerbations are underrecognised in clinical practice.

Patient interviews highlighted that the most common terms used by patients to describe an asthma exacerbation were “asthma attack” and “flare up.” This suggests that while the exacerbation did not meet the definition of severe in terms of required treatment, patients regarded this event as distinct from daily experience of asthma and also disruptive of their daily life. Although, none of the patients used the term “exacerbation” to describe the event, the concept of moderate exacerbation was consistent with the patients’ experience of an “asthma attack” or “flare up.” This suggests that it may be beneficial for clinicians to consider the terminology used to describe a moderate exacerbation with their patients.

Only a third of patients reported that they had an asthma action plan in place with their HCP, highlighting a potential need to seek additional treatment for an exacerbation in these patients. While all of the physicians interviewed reported that their patients would have such a plan, this is likely to be related to their specialist practice. As asthma action plans are generally used to cover symptom variability, and moderate exacerbation treatment is subsumed under general asthma management, there might be a need for a treatment specific plan to handle moderate exacerbations. Despite the reported differences between patient and physician perceptions of the patient experience of a moderate exacerbation, in general the symptoms and impact reported by patients were also reported by physicians, supporting their clinical relevance and the relevance of the ATS/ERS definition of a moderate exacerbation [ 9 ]. Notably, this definition was applied in recent Phase III clinical trials (including CAPTAIN) that were part of the network meta-analysis studying the benefits of triple therapy in patients with uncontrolled asthma. The CAPTAIN study assessed the effects of once-daily single-inhaler triple therapy with an ICS/LABA/long-acting muscarinic receptor antagonist (fluticasone furoate/umeclidinium/vilanterol) in patients with inadequately controlled asthma despite ICS/LABA treatment [ 23 ]. In our study and in CAPTAIN, the ATS/ERS definition was adapted slightly to include an increase in systemic corticosteroids (less than double the maintenance dose) for patients who were already receiving systemic corticosteroid treatment. While systemic corticosteroid use is usually associated with severe exacerbations [ 9 ], this change was made to reflect the use of systemic corticosteroids in clinical practice for exacerbations that would otherwise be defined as moderate. In this study, only one patient reported taking OCS (for ≤ 2 days) to treat their moderate exacerbation. In the CAPTAIN study, changes in lung function were similar for moderate and severe exacerbations while symptom scores were slightly higher for severe exacerbations [ 24 ].

The study had a number of strengths including a sample with demographic and clinical diversity in terms of age, sex, race, education level, disease severity and control, and treatment step. As conceptual saturation is typically achieved in as few as 12 individual interviews in a relatively homogenous population [ 15 , 16 ], a sample of 28 was adequate to fulfil study objectives. Indeed, in our study, almost all spontaneously reported concepts were mentioned before the final set of interviews. As such it is unlikely that any additional interviews in a similar population would reveal further concepts. Nonetheless, there are some study limitations to consider. First, this was a qualitative study and the extent to which any qualitative research can be generalised should be considered. The findings obtained from the participant interviews cannot necessarily be extrapolated or generalised to the wider asthma population. The asthma population included those with moderate/severe asthma who were treated with ICS/LABA (with or without additional controller therapies) and those with diagnosed asthma onset younger than age 40 years. While this ensured that only moderate exacerbations due to asthma were captured, results from this specific population are not necessarily generalizable to the wider asthma population. Furthermore, smokers were excluded from participation in this study to also minimise smoking as a potential confounding factor. It should, however, be recognised that it is reported that around one-fifth of patients with asthma do smoke and that differences in the way patients experience moderate asthma exacerbation may exist between smokers and nonsmokers. The timing of the study is also an important factor because interviews were conducted during the global COVID-19 pandemic. This is likely to have changed patients’ usual daily activities and may have affected their experience with exacerbations given that some may have had increased anxiety during this period and access to their usual healthcare resources may have been impacted, although this was not reported in interviews. Finally, although our study gives significant insights into how patients are impacted by moderate exacerbations, it only included patients from two countries. Patient interviews in other countries and regions (e.g., Asia) would be useful in the future to ensure cross-cultural applicability of our results, and to study the impact of seasonality on moderate asthma exacerbations in other geographic areas because patients frequently reported environment and allergens as triggers of these events.

Findings from these qualitative interviews highlight that the frequency, severity, and duration of core asthma symptoms increase during a moderate asthma exacerbation, as does rescue/maintenance medication use. Moderate exacerbations result in fatigue/tiredness and impact sleep, physical and emotional functioning, and ADL, and that can lead to emotional distress. Given their impact on patients and cost to healthcare systems, moderate exacerbations should be given greater prominence. With a minor adaptation (increase in the maintenance dose of OCS), the conceptual model is consistent with the definition of a moderate exacerbation in the ATS/ERS guidelines [ 9 ], and provides an in-depth patient perspective on the symptom and HRQoL impact experienced during a moderate asthma exacerbation.

Availability of data and materials

Pseudonymized individual participant data and study documents can be requested for further research from http://www.clinicalstudydatarequest.com .

Abbreviations

Asthma Control Test

Activities of daily living

American Thoracic Society

European Respiratory Society

Global Initiative for Asthma

Healthcare professional

• Health-related quality of life

Inhaled corticosteroids

Independent Review Board

Long-acting β 2 -agonists

Oral corticosteroids

Short-acting β 2 -agonist

Standard deviation

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Acknowledgements

We would like to thank the participants of the study for their valuable contributions.

This study was funded by GSK (study 209379). The funders of the study had a role in study design, data analysis, data interpretation, and writing of the report.

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Maggie Tabberer & Wilhelmine Meeraus

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Andy Fowler

Patient-Centered Outcomes, Adelphi Values, Bollington, Cheshire, UK

Jane R. Wells & Dale Chandler

Patient-Centred Outcomes Assessments Ltd, Bollington, Cheshire, UK

Linda Abetz-Webb

GSK Collegeville, 1250 S. Collegeville Rd, Collegeville, PA, 19426, USA

Shiyuan Zhang

GSK, Research Triangle Park, NC, USA

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The authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors, take responsibility for the integrity of the work as a whole, contributed to the writing and reviewing of the manuscript, and have given final approval for the version to be published. MT, JRW, DC, WZ, WM, AF and LA-W contributed to the conception or design of the study. DC also contributed to data acquisition and all authors contributed to data analysis and interpretation. All authors had full access to the data in this study and take complete responsibility for the integrity of the data and accuracy of the data analysis. Editorial support (in the form of writing assistance, including preparation of the draft manuscript under the direction and guidance of the authors, collating and incorporating authors’ comments for each draft, assembling tables and figures, grammatical editing and referencing) was provided by Scott Chambers and Lucia Correia, of Fishawack Indicia Ltd, UK, part of Fishawack Health, and was funded by GSK. All authors read and approved the final manuscript.

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SZ, AF and DS are employees of GSK and hold stock/shares in GSK. MT and WM were employees of GSK at the time of the study and hold stocks/shares in GSK. JRW and DC are employed by Adelphi Values, which received funding from GSK for study conduct and data analysis. LA-W is an employee of Patient-Centred Outcomes Assessments Ltd and is an independent consultant to Adelphi Values. No funding was provided to Adelphi Values or Patient-Centred Outcomes Assessments Ltd for manuscript development.

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Tabberer, M., Wells, J.R., Chandler, D. et al. Patient experience of moderate asthma attacks: qualitative research in the USA and Germany. J Patient Rep Outcomes 6 , 117 (2022). https://doi.org/10.1186/s41687-022-00506-2

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Introduction

Background and significance, surveillance and reporting, epidemiological analysis, screening and guidelines, plan: integrating evidence.

Asthma is an illness that disproportionately affects many adults and children globally. In 2019, 262 million people had asthma, causing 461 000 deaths (WHO, 2020). Scholars have done asthma-related research to provide information on causes, symptoms, therapies, and asthma mitigation. This study will describe asthma as a chronic condition, including its symptoms and signs, incidences, surveillance, reporting, epidemiological analysis, screening, prevention, and prevalence by state and national statistics.

Asthma is a lung disorder that makes it hard to breathe occasionally. Many people experience symptoms during childhood, though they can occur at any age. Asthma is caused by inflammation and subsequent muscular tightening around the narrow airways in the lungs, causing further narrowing of these passageways, leading to symptoms such as wheezing, coughing, chest tightness, and difficulty breathing (He et al., 2020). These symptoms and signs come and go and tend to be more intense at night or when exercising. Symptoms might be worsened by a variety of other typical triggers, including virus infections, weather fluctuations, fumes, smoke, dust, animal feathers and fur, tree and grass pollen, perfumes, and harsh soaps. Asthma has a variety of symptoms and pathogenesis, including acute, subacute, or chronic inflammation of the airways, intermittent blockage of airflow, and hyperresponsiveness of the bronchi (Sullivan et al., 2016). Mucus secretion and airway edema can lead to airflow restriction and bronchial reactivity (Sullivan et al., 2016). Mucus hypersecretion, epithelial desquamation, smooth muscle hyperplasia, airway remodeling, and mononuclear cells and eosinophils are all varying degrees.

Asthma prevalence has been shown to vary under various factors. It is higher in girls at 6.0% than in boys at 5.7% in the U.S., where it impacts more than 25 million people, including 8.4% of adults and 5.8% of children (CDC, 2020). There are 10.4% of women and 6.2% of males with asthma (CDC, 2020). Prevalence is higher among African Americans at 11.6% than Whites at 9.3% and lowest among Hispanics at 6.7% (CDC, 2017). In 2020, the CDC found that 7.4% of Texan adults and 7% of youngsters were currently dealing with asthma. Approximately ten individuals in the United States die every day from the illness (CDC, 2020). There were 232 fatalities in Texas in 2018, representing an annual mortality rate of 8.3 per 1,000,000 residents (CDC, 2019). The table below describes the CDC’s data about asthma prevalence in Texas and the United States.

Table 1: Prevalence Of Asthma In the U.S. & Texas

Information gathered through public health monitoring is used to inform and improve programs and policies to reduce disease incidence and mortality rates. Surveillance information on the prevalence of asthma in the United States is compiled from various sources, including the Behavioral Risk Factor Surveillance System (BRFSS) and the National Health Interview Survey (Pickens et al., 2018). The local burden of asthma has been estimated in several states and towns using surveys or administrative data, including Medicaid claims data and hospitalization (Benka-Coker, 2018). All these are accurate and credible sources of surveillance data and reports.

Cases of asthma have been identified using administrative data such as outpatient, pharmaceutical, or hospital billing data. Prevalence monitoring in schools has shown to be a fruitful exercise as most children are evaluated by school-based surveillance systems because they are present at school (Benka-Coker, 2018). In the U.S., laboratories and healthcare professionals report cases of communicable disease to state or local health centers as part of the country’s primary public health surveillance system, which relies on a passive, notifiable disease monitoring system (Haghiri et al., 2019). Compared to systems that rely on administrative data, this method often provides a timelier response and can facilitate the reporting of instances or clusters of cases.

Occupational asthma has prompted the creation of the Sentinel Event Notification System for Occupational Risks (SENSOR), which functions similarly to a system for reporting communicable diseases. It is currently conducted in ten states and includes a team of sentinel healthcare practitioners who are likely to meet an instance of occupational asthma reporting specified health events (Moloney, 2022). The results of SENSOR have led to the discovery of additional triggers for asthma in the workplace, but it does not collect data on the incidences of asthma in children or adult-onset asthma unrelated to work (Moloney, 2022). The SENSOR system offers helpful data on the prevalence of asthma in the workplace.

This section focuses on asthma – a chronic disease (What) that seriously affects children and adults (Who). Some of the most extensive asthma statistics come from high-income countries (Where) like the UK, Canada, Germany, New Zealand, and Australia, with severe asthma having a prevalence of 2-10% for the years 2017-2020 (When) (Stern et al., 2020). An estimated 23.4 million people have asthma, including 7 million children (Batra, 2022). If those without asthma are not counted, the prevalence of exercise-induced bronchial asthma is between 3 and 10%; if individuals with chronic asthma are included, it rises to 15% (Dharmage et al., 2019). Asthma morbidity and its prevalence appear to be on the rise, especially among children younger than six (Stothers, 2022). Interestingly, about two-thirds of those with asthma have their condition identified before they turn 18 (Stern et al., 2020). Therefore, prevalence changes with the country, sex, and even age.

Various factors contribute to developing asthmatic symptoms at any age (Why). While heredity plays a significant part in predicting susceptibility to developing asthma, environmental factors, rather than race, contribute more significantly to the disease (Dharmage et al., 2019). Air pollution, urbanization, passive smoking, and shifts in exposure to environmental allergens are among the factors that have been suggested as causes (Stothers, 2022). Most children with asthma see improvement or complete resolution of their condition by the time they are young adults because airway reactivity and poorer pulmonary function levels contribute to higher asthma rates in young patients (Stern et al., 2020). Hence, prevalence is higher among children than adults because most of the young ones will recover.

Asthma costs can be broken down into two categories: direct costs and indirect costs. Expenses considered “direct” are associated with hospital stays, doctor visits, nurses, ambulance rides, prescriptions, lab work, diagnostics, and preventative measures (Nunes et al., 2017). The costs associated with morbidity cannot be directly measured, such as the time and energy a parent or caregiver invests in caring for an asthmatic kid. Expenditures on prescription drugs and hospital stay accounted for the bulk of direct medical costs, significantly higher than indirect costs (Nunes et al., 2017). Direct medical expenditures may rise, but the total cost of treatment may go down if indirect costs fall by an even more significant amount due to better clinical outcomes.

Diagnosis begins with a discussion between the patient and the doctor regarding symptoms and general health. The doctor asks about existing symptoms and any possible triggers. The doctor carries out different types of screening, including spirometry, challenge tests, lung tests in children, and exhaled nitric oxide tests (Saglani & Menzie, 2019). For patients aged five years and above, spirometry is the standard diagnostic procedure that evaluates the inhaling and exhalation volumes and air rates (Louis et al., 2022). Asthma causes airway narrowing, so if the patient’s vital signs are below average for someone of the patient’s age, it may indicate that the patient needs medical attention. If the patient has asthma, the doctor may request that the patient inhale a medication to relax the patient’s airways before repeating a lung function test (Louis et al., 2022). Signs of marked improvement after this treatment suggest the possibility of asthma.

Since spirometry is a rather effective diagnostic tool, it is essential to analyze some of its characteristics. Thus, the research by Meneghini et al. (2017) showed that “the specificity of spirometric abnormality for detecting asthma was 90%, sensitivity was 23%, positive predictive value was 22%, and negative predictive value was 91%” (p. 428). These findings show that this test can be used only in specific cases like screening workers exposed to pollutants, but for most patients, this test is not enough because of its low sensitivity. However, since spirometry has a high NPV, it is likely that when the test is negative, a patient does not have asthma. Noticeably, spirometry shows higher levels of specificity than some other tools. Overall, spirometry is relatively cheap and rather common (Aaron et al., 2018). Patients not diagnosed using spirometry have higher overall costs than those who use this method.

The American Thoracic Society (ATS) and the European Respiratory Society (ERS) have published a standardized spirometry protocol. One indicator of airway obstruction is the fraction of one second’s forced expiratory volume divided by one’s forced vital capacity (FEV1/FVC) (Graham et al., 2019). Asthma is characterized by reversible physiological airflow restriction and airway diameter changes; spirometry should be the first step in the diagnostic process.

To control asthma, it is important to uncover and discuss its primary, secondary, and tertiary interventions that can be used by a nurse practitioner after graduation. The primary intervention is to position the patient properly, check the vital signs, and administer bronchodilators and oxygen if needed (Issel et al., 2021). These methods will help the nurse mitigate the asthma attack. Then, for the secondary intervention, the medical worker should use long-term control drugs like inhaled corticosteroids, prednisone, and budesonide (Sobieraj et al., 2018). These preventative asthma drugs target the inflammation of the airways, which is the root cause of asthma symptoms.

Finally, the education of patients is the tertiary method a nurse has to implement. Asthma interventions targeting teenagers and children must be customized to their specific conditions. Teens and kids in rural areas are more likely to benefit from interventions that include school-based health education programs and nurse services for asthma treatment (Horner et al., 2016). Rural children’s asthma outcomes are most likely to improve from interventions that go beyond encouraging strict adherence to prescribed medications. Positive results have been seen from interventions that boost healthcare providers’ understanding of asthma and its treatment (Estrada & Ownby, 2017). Programs with the most effects have trained primary care physicians and school nurses to better educate their patients about asthma and its management.

In order to ensure that the interventions have utility and that they are useful, I will incorporate their key aspects and components when treating the patients (Issel et al., 2021). I will also identify the patients that benefit from each type of intervention. I will also record and analyze specific conditions under which each intervention achieves maximum results (Issel et al., 2021). It will be possible to integrate health policy advocacy efforts, namely, the creation of school-based preventive programs to reduce the number of accidents among children.

In conclusion, the paper has discussed vital issues relating to asthma by collecting and interpreting data from previous research sources. The report has described and defined critical terms related to asthma, provided a background review, and discussed its signs and symptoms. The symptoms and signs identified are breathing difficulty, coughing, chest tightness, and wheezing (He et al., 2020). The paper has also discussed numerous approaches to monitor and survey disease prevalence, such as primary public health and sentinel surveillance system (Moloney, 2022). Epidemiological analysis, screening, and guidelines associated with asthma have also been discussed. Since statistics show that over 20 million people have asthma in America, this is a rather serious public health issue (Batra, 2022). Finally, the paper has provided a plan discussing the key interventions that can be incorporated to mitigate asthma. The interventions discussed are providing health care education, quick-relief efforts, and long-term asthma medications (Sobieraj et al., 2018). Healthcare education provided in schools also ensure that children and teenage cases are properly managed.

Aaron, S. D., Boulet, L. P., Reddel, H. K., & Gershon, A. S. (2018). Underdiagnosis and overdiagnosis of asthma. American Journal of Respiratory and Critical Care Medicine , 198 (8), 1012-1020. Web.

Batra, M., Vicendese, D., Newbigin, E., Lambert, K. A., Tang, M., Abramson, M. J., & Erbas, B. (2022). The association between outdoor allergens–pollen, fungal spore season, and high asthma admission days in children and adolescents. International Journal of Environmental Health Research , 32 (6), 1393-1402. Web.

Benka-Coker, W. O., Gale, S. L., Brandt, S. J., Balmes, J. R., & Magzamen, S. (2018). Optimizing community-level surveillance data for pediatric asthma management . Preventive Medicine Reports , 10 , 55-61. Web.

Centers for Disease Control and Prevention (CDC). (2020). Recent national asthma data . Web.

Centers for Disease Control and Prevention (CDC). (2017). Adult asthma data: BRFSS prevalence tables and maps. Web.

Dharmage, S. C., Perret, J. L., & Custovic, A. (2019). Epidemiology of asthma in children and adults. Frontiers in Pediatrics , 7 , 246. Web.

Estrada, R. D., & Ownby, D. R. (2017). Rural asthma: Current understanding of the prevalence, patterns, and interventions for children and adolescents. Current Allergy and Asthma Reports , 17 (6), 1-8. Web.

Graham, B. L., Steenbruggen, I., Miller, M. R., Barjaktarevic, I. Z., Cooper, B. G., Hall, G. L., & Thompson, B. R. (2019). Standardization of spirometry 2019 update. An official American thoracic society and European respiratory society technical statement. American Journal of Respiratory and Critical Care Medicine , 200 (8), e70-e88. Web.

Haghiri, H., Rabiei, R., Hosseini, A., Moghaddasi, H., & Asadi, F. (2019). Notifiable diseases surveillance system with a data architecture approach: A systematic review. Acta Informatica Medica , 27 (4), 268. Web.

He, Z., Feng, J., Xia, J., Wu, Q., Yang, H., & Ma, Q. (2020). Frequency of signs and symptoms in persons with asthma. Respiratory Care , 65 (2), 252-264. Web.

Horner, S. D., Brown, A., Brown, S. A., & Rew, D. L. (2016). Enhancing asthma self‐management in rural school‐aged children: A randomized controlled trial. The Journal of Rural Health , 32 (3), 260-268. Web.

Issel, L. M., Wells, R., & Williams, M. (2021). Health Program Planning and Evaluation: A Practical Systematic Approach to Community Health . Jones & Bartlett Learning.

Louis, R., Satia, I., Ojanguren, I., Schleich, F., Bonini, M., Tonia, T., & Usmani, O. S. (2022). European Respiratory Society guidelines for the diagnosis of asthma in adults. European Respiratory Journal . Web.

Meneghini, A. C., Paulino, A. C. B., Pereira, L. P., & Vianna, E. O. (2017). Accuracy of spirometry for detection of asthma: A cross-sectional study. Sao Paulo Medical Journal, 135 , 428-433. Web.

Moloney, M. (2022). Promoting evidence-based asthma diagnosis and surveillance using electronic tools.

Nunes, C., Pereira, A. M., & Morais-Almeida, M. (2017). Asthma costs and social impact. Asthma Research and Practice , 3 (1), 1-11. Web.

Pickens, C. M., Pierannunzi, C., Garvin, W., & Town, M. (2018). Surveillance for certain health behaviors and conditions among states and selected local areas—behavioral risk factor surveillance system, United States, 2015 . MMWR Surveillance Summaries , 67 (9), 1. Web.

Saglani, S., & Menzie-Gow, A. N. (2019). Approaches to asthma diagnosis in children and adults. Frontiers in pediatrics , 7 , 148. Web.

Sobieraj, D. M., Weeda, E. R., Nguyen, E., Coleman, C. I., White, C. M., Lazarus, S. C., & Baker, W. L. (2018). Association of inhaled corticosteroids and long-acting β-agonists as controller and quick relief therapy with exacerbations and symptom control in persistent asthma: a systematic review and meta-analysis. Jama , 319 (14), 1485-1496.

Stern, J., Pier, J., & Litonjua, A. A. (2020). Asthma epidemiology and risk factors. In Seminars in immunopathology (Vol. 42, No. 1, pp. 5-15). Springer Berlin Heidelberg.

Stothers, B. (2022). Examining the effect of salbutamol use in ozone air pollution by people with asthma and/or exercise-induced bronchoconstriction. The University of British Columbia.

Sullivan, A., Hunt, E., MacSharry, J., & Murphy, D. M. (2016). The microbiome and the pathophysiology of asthma. Respiratory Research , 17 (1), 1-11. Web.

World Health Organization (WHO). (2020). Chronic respiratory diseases: Asthma. Web.

• Airway (Tracheal) Trauma Management
• Emphysema: Cellular and Molecular Physiology
• Pulmonary Function Testing in Chronic Obstructive Disease
• Asthma Definition and Its Diagnostics
• Analysis and Application of Clinical Practice Guidelines
• Chronic Obstructive Pulmonary Disease in Vulnerable Settings
• Pulmonary Diagnostic Testing
• Oxygen Therapy for COPD (Pulmonology) Patients
• Asthma Treatment Algorithm for Patients
• Preventing Ventilator-Associated Pneumonia
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IvyPanda. (2023, November 27). Asthma: Epidemiological Analysis and Care Plan. https://ivypanda.com/essays/asthma-epidemiological-analysis-and-care-plan/

"Asthma: Epidemiological Analysis and Care Plan." IvyPanda , 27 Nov. 2023, ivypanda.com/essays/asthma-epidemiological-analysis-and-care-plan/.

IvyPanda . (2023) 'Asthma: Epidemiological Analysis and Care Plan'. 27 November.

IvyPanda . 2023. "Asthma: Epidemiological Analysis and Care Plan." November 27, 2023. https://ivypanda.com/essays/asthma-epidemiological-analysis-and-care-plan/.

1. IvyPanda . "Asthma: Epidemiological Analysis and Care Plan." November 27, 2023. https://ivypanda.com/essays/asthma-epidemiological-analysis-and-care-plan/.

Bibliography

IvyPanda . "Asthma: Epidemiological Analysis and Care Plan." November 27, 2023. https://ivypanda.com/essays/asthma-epidemiological-analysis-and-care-plan/.

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After your asthma attack

What to do after your asthma attack, how to recover well, and how to lower your risk of another attack. 

On this page

Book an urgent follow-up appointment, your asthma medicines, update your asthma action plan, take time to rest and recover, how to avoid another attack.

This information is for adults. Find out more about  your child’s asthma attack recovery .

Even if you’re feeling better now, it’s important to have a follow-up appointment at your GP surgery as soon as possible after your asthma attack.

Around 1 in 6 people treated for an asthma attack need hospital care again within two weeks.  Studies show that a follow-up appointment can help you avoid another attack.

Together you and your GP or nurse can talk about your asthma attack, what triggered it, and how you can lower your risk.

Book your follow up appointment now

• If you had an asthma attack you dealt with yourself at home, ask for a same-day appointment.
• If you had an asthma attack and were treated by paramedics, but did not need to go to hospital, ask for a same day appointment.
• If you had an asthma attack and were treated in hospital, ask for an appointment no later than two working days after hospital treatment. 

Once you’ve had your urgent follow-up appointment, remember to make the most of your routine asthma reviews too.

An asthma review at least once a year helps you manage your asthma well. You and your GP or nurse can make sure you’re doing all you can to lower your risk of asthma symptoms and attacks.

We know from calls to our Helpline that it's hard to get a GP appointment sometimes. Tell your GP surgery that guidelines recommend an urgent appointment to lower your risk of another attack.

We have more advice  about getting a GP appointment . 

Use your follow-up appointment to talk about any medicines you may have been prescribed for your asthma attack. You can also talk about your usual asthma medicines.

Steroid tablets for your asthma attack

If you went to hospital and were given steroid tablets to treat your asthma attack, your GP or nurse can check how you’re getting on with these.

A short course of  steroid tablets , usually prednisolone, treats the inflammation and swelling in your airways, and can lower your risk of another attack. You will usually need to take these for at least five days.

Always finish the course to give yourself the best chance of a full recovery. We know a lot of people worry about side effects from steroid tablets. But a short course is unlikely to cause any harmful side effects, and it’s important that you treat the inflammation in your airways.

Find out more about  taking steroids for your asthma . 

Have you had two or more courses of steroids in a year?

If you have asthma and need two or more short courses of steroids in a year, or your symptoms keep coming back when you finish taking them, you should ask your GP for a referral to a specialist clinic.

You may have  difficult to control asthma , or need tests to see if you have  severe asthma .  Staff at a specialist asthma clinic can give you extra support to help you stay well.

Find out more about  specialist asthma care . 

Your usual asthma medicines

At your follow-up appointment, you can also talk about your usual asthma medicines. Together with your GP or nurse you can see if these are still working well for you. 

Taking your asthma medicines as prescribed, and  using the right inhaler technique , could lower your risk of having another attack.

Speak to your GP or nurse if you’ve been finding it hard to take your usual asthma medicines every day, or if you’re not sure how to use your inhalers.

Your GP, nurse or pharmacist can check you’re using your inhaler correctly. You can also check your inhaler technique now by  watching our short inhaler videos .

You may need to change your usual asthma medicines, or use a different type of inhaler, to help you manage your asthma symptoms more easily.

Find out  more about changing medicines .

After your asthma attack, ask your GP or nurse to update your  asthma action plan with you. You can add any new medicines or triggers, and talk about what to do if you notice symptoms getting worse.

An asthma action plan makes it easier to manage your symptoms, so you’re less likely to need hospital treatment for an asthma attack.

If you’ve never had an asthma action plan, now’s the time to get one. It’s easy to download a free asthma action plan. Ask your GP or nurse to help you fill it in.

Find out more about asthma action plans and  download a plan now .

People can feel shocked and frightened after an asthma attack, and it can help to talk about what’s happened. Debby Waddell, Respiratory Nurse Specialist, Asthma + Lung UK.

Asthma attacks can leave you feeling physically and emotionally tired. It may take time before you feel ready to get back to your usual activities.

It’s important to give yourself time to rest and recover. Ask family and friends for help where you can. And talk to your GP or nurse about getting back to work or starting to exercise again.

You may need to build up any activity slowly. We have advice on  different levels of activity .

If you work, talk to your employer about taking time off to make sure you’re fully better before coming back to work. Explain that it can take some time to recover after an asthma attack. You can ask your doctor or nurse for a note saying you need time off work after your attack. This is called a  fit note or sick note. 

Find out more about  working with a lung condition . 

Your emotional wellbeing

An asthma attack can be a frightening experience. As well as taking care of your physical health, it’s worth thinking about  your emotional well-being too.

Some people find it helps to talk to people with similar experiences on our online forums or by joining one of  our support groups .

You can also  call our Helpline and talk through your experience with one of our respiratory nurse specialists. 

 Managing your asthma well

The best way to lower your risk of another asthma attack is to take steps to manage your asthma well every day.

You can do this by:

• using an  asthma action plan
• taking your  asthma medicines as prescribed
• using  good inhaler and spacer technique
• making sure you have repeat prescriptions set up, so you always have the medicines you need for your asthma
• going for regular  asthma reviews
• knowing  your triggers , and avoiding them when you can
• keeping active for healthy lungs
• Looking after your  mental health and wellbeing .

Find out more about the best ways to  manage your asthma .

Recognising the signs and symptoms of an asthma attack

An asthma attack can happen suddenly. But it’s more likely that symptoms start getting worse gradually over a few days. That’s why it’s so important to be aware of your own signs and symptoms.

As soon as you notice symptoms are getting worse, make an appointment to speak to your GP or nurse. They can help you manage your symptoms better and lower your risk of an asthma attack.

Find out more about the signs and symptoms to look out for and  why your symptoms may get worse .

If you have an asthma attack, follow our  emergency asthma attack advice .

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An asthma attack is a sudden worsening of asthma symptoms. Asthma is a long-term condition that makes breathing difficult because airways in the lungs become narrow. Symptoms of asthma attack include coughing, wheezing, tightness in the chest and difficulty getting enough air.

These symptoms happen because muscles around airways tighten up, the airways become irritated and swollen, and the lining of the airways produces a fluid called mucus. All of these factors make it difficult to breathe.

People who already have a diagnosis of asthma usually have an asthma action plan. This tells them what medicines to take if they have an asthma attack and when to get emergency care. People who do not have a diagnosis or don't have a treatment plan should get emergency care if they have these symptoms.

Frequent asthma attacks show that a person's asthma is not under control. A healthcare professional might make changes in medicines and the asthma action plan to improve control.

An asthma attack also is called an asthma exacerbation or asthma flare-up.

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Symptoms of asthma attacks may include:

• Shortness of breath.
• Chest tightness or pain.

Severe symptoms also may include:

• Gasping for breath.
• Difficulty speaking because of shortness of breath.
• Straining of chest muscles to breathe.
• Worse symptoms when lying on the back.
• Severe sweating.

The result of an at-home test, called a peak flow meter, can be an important sign of an asthma attack. This device measures how quickly you can force air out of your lungs. Peak flow readings are usually a percentage of how your lungs work at their best. This is called your personal best peak flow.

An asthma action plan often includes steps to take based on a peak flow reading. A reading below 80% of a best peak flow can be a sign of an asthma attack.

When to see a doctor

An asthma action plan tells you when to call your healthcare professional and when to get emergency care. A plan has three parts with color codes:

• Green. The green zone of the plan is for times you are feeling well and have no asthma symptoms. The plan tells you what dose of long-term control medicine to take every day. It also tells you how many puffs of a quick-relief inhaler to take before you exercise. If you use a peak flow meter, readings should be 80% or higher of your best.
• Yellow. The yellow zone tells you what to do if you have asthma symptoms. It explains when to use a quick-relief inhaler and how many puffs to take. It also describes what to do if your symptoms don't improve and when to call your care team. Peak flow readings are 50% to 79% of your best.
• Red. The red zone tells you to get emergency care when symptoms are severe or if symptoms worsen or don't improve after using a quick-relief inhaler. Peak flow readings are below 50% of your personal best.

If you do not have an asthma action plan, get emergency care if quick-relief medicine is not helping symptoms.

Checkups for asthma control

It's important to keep regular appointments with your healthcare professional. If your asthma is under control, you may be able to take lower doses of medicine. If you are using a rescue inhaler too often to treat asthma attacks, you may need changes to your asthma action plan. These might include taking a new medicine or higher doses of a medicine.

More Information

• Asthma attack video

Asthma is usually a lifelong disease of inflammation in the lungs caused by an overactive immune system. Inflammation in the lungs includes the tightening of muscles around airways, swelling of tissues in the airways and the release of mucus that can block airways. When this happens, it's difficult to breathe.

Asthma attacks occur when something triggers the immune system to take action. Triggers may include:

• Allergic reaction to pollen, pets, mold, cockroaches and dust mites.
• Colds, the flu or other illnesses affecting the nose, mouth and throat.
• Tobacco smoke.
• Cold, dry air.
• A condition called gastroesophageal reflux disease (GERD) that results in stomach acids entering the tube between the mouth and stomach.
• Pollution or irritating chemicals in the air.
• Pain relievers, such as aspirin and nonsteroidal anti-inflammatories, and some other medicines.
• Depression or anxiety.

Risk factors

Anyone who has asthma is at risk of an asthma attack. Factors that can increase the risk include:

• Poorly controlled allergies.
• Exposure to triggers in the environment.
• Not taking daily asthma medicines.
• Incorrect use of inhaler.
• Long-lasting depression or anxiety.
• Other long-term illnesses, such as heart disease or diabetes.

Complications

Asthma attacks affect both a person's health and quality of life. Problems may include:

• Missed days of school or work.
• Frequent emergency or urgent care visits.
• Interrupted sleep.
• Limits on regular exercise or recreational activities.

Severe asthma attacks can cause death. Life-threatening asthma attacks are more likely for people who frequently use quick-relief medicines, have had emergency room visits or hospital stays to treat asthma, or have other long-term illnesses.

An important step to prevent an allergy attack is to follow your asthma action plan:

• Take your long-term asthma control medicine every day.
• Take peak flow readings as directed.
• Take your quick-relief medicine before exercise as directed.
• Use quick-relief medicine as stated in your plan.
• Keep track of how often you use quick-relief medicine.

Your input on how well the plan is working helps your healthcare professional adjust the treatment to prevent asthma attacks.

Other steps to prevent asthma attacks include the following:

• Avoid triggers as much as possible.
• Stay indoors when there are poor air quality warnings.
• Get tested for possible allergies and take allergy medicines as directed.
• Wash your hands frequently to lower the risk of getting a cold or the flu.
• Keep current on vaccinations, including annual flu and COVID-19 shots, and others recommended by your healthcare professional.
• Get treatment for depression, anxiety or related conditions.
• If you smoke, quit.
• Wear a mask while cleaning.
• Cover your mouth with a scarf or mask on cold days.
• Asthma: Colds and flu
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• Fanta CH, et al. Acute exacerbations of asthma in adults: Home and office management. https://www.uptodate.com/contents/search. Accessed Aug. 7, 2023.
• Fanta CH, et al. Acute exacerbations of asthma in adults: Emergency department and inpatient management. https://www.uptodate.com/contents/search. Accessed Aug. 7, 2023.
• Learn More Breathe Better (LMBB): Monitoring your asthma. National Heart, Lung, and Blood Instititute. https://www.nhlbi.nih.gov/resources/lmbb-monitoring-your-asthma-fact-sheet. Accessed Aug. 9, 2023.
• Asthma (adult). AskMayoExpert. Mayo Clinic; 2023.
• Expert panel report 3 (EPR-3): Guidelines for the diagnosis and management of asthma. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma. Accessed Aug. 8, 2023.
• Asthma: Diagnosis. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/asthma/diagnosis. Accessed Aug. 10, 2023.
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• Assessment and...

Assessment and management of adults with asthma during the covid-19 pandemic

Read our latest coverage of the coronavirus pandemic.

• Related content
• Peer review
• Thomas Beaney , academic clinical fellow in primary care 1 ,
• David Salman , academic clinical fellow in primary care 1 ,
• Tahseen Samee , specialist registrar in emergency medicine 2 ,
• Vincent Mak , consultant in respiratory community integrated care 3
• 1 Department of Primary Care and Public Health, Imperial College London, London, UK
• 2 Barts Health NHS Trust, London, UK
• 3 Imperial College Healthcare NHS Trust, London, UK
• Correspondence to: T Beaney Thomas.beaney{at}imperial.ac.uk

What you need to know

In patients with pre-existing asthma, a thorough history and structured review can help distinguish an asthma exacerbation from covid-19 and guide management

In those with symptoms of acute asthma, corticosteroids can and should be used if indicated and not withheld on the basis of suspected covid-19 as a trigger

Assessment can be carried out remotely, ideally via video, but have a low threshold for face-to-face assessment, according to local arrangements

A 35 year old man contacts his general practice reporting a dry cough and increased shortness of breath for the past three days. He has a history of asthma, for which he uses an inhaled corticosteroid twice daily and is now using his salbutamol four times a day. Because of the covid-19 outbreak, he is booked in for a telephone consultation with a general practitioner that morning.

Asthma is a condition commonly encountered in primary care, with over five million people in the UK prescribed active treatment. 1 While seemingly a routine part of general practice, asthma assessment is a particular challenge in the context of the covid-19 pandemic, given the overlap in respiratory symptoms between the two conditions and the need to minimise face-to-face assessment. Over 1400 people died from asthma in 2018 in England and Wales, 2 while analyses of non-covid-19 deaths during the covid-19 outbreak have shown an increase in deaths due to asthma, 31 highlighting the need to distinguish the symptoms of acute asthma from those of covid-19 and manage them accordingly.

This article outlines how to assess and manage adults with exacerbations of asthma in the context of the covid-19 outbreak ( box 1 ). We focus on the features differentiating acute asthma from covid-19, the challenges of remote assessment, and the importance of corticosteroids in patients with an asthma exacerbation.

Asthma and covid-19: what does the evidence tell us?

Are patients with asthma at higher risk from covid-19.

Some studies, mostly from China, found lower than expected numbers of patients with asthma admitted to hospital, suggesting they are not at increased risk of developing severe covid-19. 3 4 5 However, these reports should be viewed cautiously, as confounding by demographic, behavioural, or lifestyle factors may explain the lower than expected numbers. Recent pre-print data from the UK suggest that patients with asthma, and particularly severe asthma, are at higher risk of in-hospital mortality from covid-19. 6 In the absence of more conclusive evidence to indicate otherwise, those with asthma, particularly severe asthma, should be regarded as at higher risk of developing complications from covid-19. 7

Can SARS-CoV-2 virus cause asthma exacerbations?

Some mild seasonal coronaviruses are associated with exacerbations of asthma, but the coronaviruses causing the SARS and MERS outbreaks were not found to be. 8 9 In the case of SARS-CoV-2 virus, causing covid-19, data from hospitalised patients in China did not report symptoms of bronchospasm such as wheeze, but the number of patients with pre-existing asthma was not reported. 10 More recent pre-print data from hospitalised patients in the UK identified wheeze in a minority of patients with Covid-19. 11 Given the overlap of symptoms, such as cough and shortness of breath, until further published data emerges, SARS-CoV-2 may be considered as a possible viral trigger in patients with an asthma attack.

What you should cover

Challenges of remote consultations.

Primary care services have moved towards telephone triage and remote care wherever possible to minimise the risk of covid-19 transmission. This brings challenges to assessment as visual cues are missing, and, unless the patient has their own equipment, tests involving objective measurement, such as oxygen saturation and peak expiratory flow, are not possible. In mild cases, assessment via telephone may be adequate, but, whenever possible, we recommend augmenting the consultation with video for additional visual cues and examination. 12 However, many patients, particularly the elderly, may not have a phone with video capability. If you are relying on telephone consultation alone, a lower threshold may be needed for face-to-face assessment.

Presenting symptoms

Start by asking the patient to describe their symptoms in their own words. Note whether they sound breathless or struggle to complete sentences and, if so, determine whether immediate action is required. If not, explore what has changed, and why the patient has called now. The three questions recommended by the Royal College of Physicians—asking about impact on sleep, daytime symptoms, and impact on activity—are a useful screening tool for uncontrolled asthma. 13 Alternative validated scores, such as the Asthma Control Questionnaire and Asthma Control Test, which include reliever use, are also recommended. 14 In assessing breathlessness, the NHS 111 symptom checker contains three questions—the answers may arise organically from the consultation, but are a useful aide memoire:

Are you so breathless that you are unable to speak more than a few words?

Are you breathing harder or faster than usual when doing nothing at all?

Are you so ill that you’ve stopped doing all of your usual daily activities?

Consider whether an exacerbation of asthma or covid-19 is more likely. Both can present with cough and breathlessness, but specific features may indicate one over the other (see box 2 ). Do the patient’s current symptoms feel like an asthma attack they have had before? Do symptoms improve with their reliever inhaler? Do they also have symptoms of allergic rhinitis? Pollen may be a trigger for some people with asthma during hay fever season.

History and examination features helping distinguish asthma exacerbation from covid-19 10 11 14 15 16

Exacerbation of asthma*.

Improvement in symptoms with reliever inhaler

Diurnal variation

Absence of fever

Coexisting hay fever symptoms

Examination:

Reduced peak expiratory flow

Close contact of known or suspected case

Dry continuous cough

Onset of dyspnoea 4-8 days into illness

Flu-like symptoms including fatigue, myalgia, headache

Symptoms not relieved by inhaler

Absence of wheeze

Peak expiratory flow may be normal

*Note SARS-CoV-2 infection may be a trigger for an asthma exacerbation

Risk factors and medications

To assess the risk of deterioration, ask specifically about any previous hospital admissions for asthma and about oral corticosteroid use over the past 12 months. Does the patient have any other high risk conditions or are they taking immunosuppressive drugs? Ask the patient if they smoke and take the opportunity to offer support to quit.

Are they prescribed an inhaled corticosteroid (ICS) or a long acting β agonist (LABA) and ICS combination inhaler? Are they using this regularly? Are they using a spacer device, and do they have a personal asthma action plan to guide management?

Psychosocial factors

Taking a psychosocial history can be more challenging over the telephone, where cues are harder to spot. Lessons from asthma deaths have shown that adverse psychosocial factors are strongly associated with mortality. 14 17 These include a history of mental health problems, lack of engagement with healthcare services, and alcohol or drug misuse, along with employment and income problems. Social isolation is also a risk factor, which may be exacerbated during social distancing measures. 17 The covid-19 outbreak is an anxious time for many patients, and symptoms of anxiety can contribute to the overall presentation.

Examination

In remote assessment, video can help guide decision making, and we recommend its use in asthmatic patients presenting with acute symptoms. First, assess the general appearance of the patient. A fatigued patient sitting up in bed, visibly breathless, and anchoring their chest will raise immediate concerns, as opposed to someone who is walking around while talking. Vocal tone and behaviour may indicate any contributing anxiety. Observe if the patient can speak in complete sentences, listen for audible wheeze, and count the respiratory rate. Assess the work of breathing, including the use of accessory muscles, and consider the use of a chaperone where appropriate. The Roth score is not advocated for assessment of covid-19 or asthma. 18

Further objective assessment can be made, such as measuring peak expiratory flow (PEF). If the patient does not have a PEF device at home, one can be prescribed, though this may not be feasible in an acute scenario. We recommend that PEF technique be witnessed via video to assess reliability. Silent hypoxia may be a feature of covid-19, and oxygen saturations should be measured if this is a concern. 19 In some regions, oxygen saturation probe delivery services are being implemented, which may facilitate this. Heart rate can also be provided by the patient if they use conventional “wearable” technology, although, given the potential inaccuracies with different devices, the results should not be relied on. 20 If time allows, inhaler technique can also be checked.

What you should do

Determine the most likely diagnosis.

Decide on the most likely diagnosis on the basis of the history and clinical features (see box 2 and fig 1 ) or consider whether an alternative or coexisting diagnosis is likely, such as a bacterial pneumonia or pulmonary embolus. If you suspect covid-19 without asthmatic features, manage the patient as per local covid-19 guidance.

Assessment and management of patients with known asthma during the covid-19 outbreak 14

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Determine severity and decide if face-to-face assessment is necessary

If asthmatic features are predominant, determine severity and treat according to Scottish Intercollegiate Guidelines Network (SIGN) and British Thoracic Society (BTS) guidance ( fig 1 ). 14 If the patient cannot complete sentences or has a respiratory rate ≥25 breaths/min, treat the case as severe or life threatening asthma and organise emergency admission. A peak expiratory flow (PEF) <50% of best or predicted or a heart rate ≥110 beats/min also indicate severe or life threatening asthma. If the patient does not meet these criteria, treat as a moderate asthma attack—a PEF of 50-75% of best or predicted helps confirm this. If they do not have a PEF meter, or if you are unsure as to severity, brief face-to-face assessment to auscultate for wheeze and assess oxygen saturations can help confirm the degree of severity and determine if the patient may be suitable for treatment at home with follow-up. Do not rely solely on objective tests and use clinical judgment to decide on the need for face-to-face assessment, based on knowledge of the patient, risk factors, and any adverse psychosocial circumstances.

Wheeze has been reported as a presenting symptom in a minority of patients with confirmed covid-19, and it may be difficult to rule out the presence of SARS-CoV-2 via remote assessment. 11 We recommend that, when a face-to-face assessment is needed, it should take place via local pathways in place to safely assess patients with suspected or possible covid-19—for example, at a local “hot” clinic. At present, performing a peak flow test is not considered to be an aerosol generating procedure, but the cough it may produce could be, so individual risk assessment is advised. 21 Consider performing PEF in an open space or remotely in another room via video link. Any PEF meter should be single-patient use only and can be given to the patient for future use.

Initial management when face-to-face assessment is not required

For moderate asthma exacerbations, advise up to 10 puffs of a short acting β agonist (SABA) inhaler via a spacer, administered one puff at a time. There is no evidence that nebulisers are more effective: 4-6 puffs of salbutamol via a spacer is as effective as 2.5 mg via a nebuliser. 22 Alternatively, if the patient takes a combined inhaled corticosteroid and long acting β agonist (LABA) preparation, then maintenance and reliever therapy (MART) can be used according to their action plan. 14 Management of an acute exacerbation should not rely solely on SABA monotherapy, so advise patients to follow their personal asthma action plan and continue corticosteroid treatment (or start it if they were not taking it previously) unless advised otherwise ( box 3 ). Antibiotics are not routinely recommended in asthma exacerbations.

Risks and benefits of inhaled and oral corticosteroids in asthma and covid-19

There is substantial evidence for the benefits of steroids in asthma. Regular use of inhaled steroids reduces severe exacerbations of asthma 23 and the need for bronchodilators, 24 while the prompt use of systemic corticosteroids during an exacerbation reduces the need for hospital admissions, use of β agonists, 25 and relapses. 26

The evidence for corticosteroid use in early covid-19 is still emerging. A systematic review of steroid use in SARS reported on 29 studies, 25 of which were inconclusive and four of which suggested possible harm (diabetes, osteoporosis, and avascular necrosis) but no reported effects on mortality. 27 WHO have cautioned against the use of systemic corticosteroids for the treatment of covid-19 unless indicated for other diseases. 28

In light of the strong evidence of benefits in patients with asthma, inhaled and oral corticosteroids should be prescribed if indicated in patients with symptoms of bronchoconstriction. Steroids should not be withheld on the theoretical risk of covid-19 infection, in line with guidance from the Primary Care Respiratory Society (PCRS), British Thoracic Society (BTS), and Global Initiative for Asthma (GINA). 15 22 29

Response to initial SABA or MART treatment can be assessed with a follow-up call at 20 minutes. If there is no improvement, further treatment may be necessary at a local hot clinic for reviewing possible covid-19, emergency department, or direct admission to an acute medical or respiratory unit depending on local pathways. For those who do respond, BTS-SIGN and GINA advise starting oral corticosteroids in patients presenting with an acute asthma exacerbation (such as prednisolone 40-50 mg for 5-7 days). 14 15 There is an increasing move in personalised asthma action plans to early quadrupling of the inhaled corticosteroid dose in patients with deteriorating control for up to 14 days to reduce the risk of severe exacerbations and the need for oral steroids. 15 30 However, there may be a ceiling effect on those who are already on a high dose of inhaled corticosteroid (see BTS table 14 ), so quadrupling the dose may not be effective in this group of patients. A personalised asthma action plan is an extremely helpful guide to treatment and should be completed or updated for all patients.

Follow-up and safety-netting

We recommend that all patients with moderate symptoms are followed up via remote assessment within 24 hours. Asthma attacks requiring hospital admission tend to develop relatively slowly over 6-48 hours. 14 However, deterioration can be more rapid, and symptoms can worsen overnight. Patients should be advised to look out for any worsening breathing or wheeze, lack of response to their inhalers, or worsening PEF. They should receive clear advice on what to do, including use of their reliever, and who to contact (such as the local out-of-hours GP provider, 111, or 999). With potential long waits for remote assessment, particularly out of hours, they should be advised to have a low threshold to call 999 if their symptoms deteriorate. If covid-19 infection is also suspected, advise them to isolate for seven days from onset of symptoms and arrange testing, according to the latest guidance. 7

How this article was created

We performed a literature search using Ovid, Medline, and Global Health databases using the search terms (asthma OR lung disease OR respiratory disease) AND (coronavirus OR covid-19)). Articles from 2019-20 were screened. We also searched for specific guidelines, including NICE, British Thoracic Society, Scottish Intercollegiate Guidelines Network, Primary Care Respiratory Society, European Respiratory Society, International Primary Care Respiratory Group, Global Initiative for Asthma, and the American Academy of Allergy, Asthma and Immunology.

Education into practice

Do you feel confident in completing personalised asthma plans in collaboration with patients?

How often do you start or increase inhaled corticosteroids in patients at initial presentation with an exacerbation of asthma?

If you manage a patient with acute asthma remotely, what safety netting advice would you give and how could you check understanding?

How patients were involved in the creation of this article

No patients were involved in the creation of this article.

This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.

Contributors: TB and TS conceived the article. TB, DS, and TS carried out the literature review and wrote the initial drafts. All four authors contributed to editing and revision, and VM provided expert advice as a respiratory specialist. All authors are guarantors of the work.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Commissioned, based on an idea from the author; externally peer reviewed.

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• ↵ Primary Care Respiratory Society. PCRS Pragmatic Guidance: Diagnosing and managing asthma attacks and people with COPD presenting in crisis during the UK Covid 19 epidemic. 2020. https://www.pcrs-uk.org/sites/pcrs-uk.org/files/resources/COVID19/PCRS-Covid-19-Pragmatic-Guidance-v2-02-April-2020.pdf .
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• ↵ Centre for Evidence-Based Medicine. Question: Should the Roth score be used in the remote assessment of patients with possible COVID-19? Answer: No. 2020. https://www.cebm.net/covid-19/roth-score-not-recommended-to-assess-breathlessness-over-the-phone/ .
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• ↵ Public Health England. Guidance: COVID-19 personal protective equipment (PPE). 2020. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe .
• ↵ British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/ .
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• ↵ World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance 13th March 2020. 2020. https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf .
• ↵ Global Initiative for Asthma (GINA). 2020 GINA report, global strategy for asthma management and prevention. 2020. https://ginasthma.org/gina-reports/ .
• McKeever T ,
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• ↵ Office for National Statistics. Analysis of death registrations not involving coronavirus (COVID-19), England and Wales: 28 December 2019 to 1 May 2020. Release date: 5 June 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/analysisofdeathregistrationsnotinvolvingcoronaviruscovid19englandandwales28december2019to1may2020/technicalannex .

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• Continuing Education Activity

Asthma is a chronic inflammatory respiratory condition characterized by hallmark symptoms of intermittent dyspnea, cough, and wheezing. However, due to the nonspecific nature of these symptoms, distinguishing asthma from other respiratory illnesses can sometimes be challenging. A confirmed diagnosis of asthma relies on consistent respiratory symptoms and the identification of variable expiratory airflow obstruction documented on spirometry. Clinicians prioritize symptom control and prevention of future exacerbations through tailored treatment, considering symptom frequency, severity, and potential risks in a step-wise approach. Early recognition and intervention of asthma exacerbations are crucial to prevent the progression of asthma to severe, life-threatening stages. Fatalities related to asthma highlight missed opportunities in recognizing disease severity and escalating therapy, emphasizing the critical role of continual patient education and routine symptom control assessment for successful long-term management. 

The development of asthma, often presenting in childhood, involves a complex interplay of genetic and environmental factors associated with atopy. Researchers strive to develop predictive systems for identifying individuals at risk of continued symptoms into adulthood. Despite significant advancements in understanding the underlying genetic loci, environmental triggers, and risk factors, clinical strategies remain lacking to mitigate the risks of persistent asthma development into adolescence and adulthood. This activity covers the epidemiology, pathophysiology, and assessment of asthma, along with initiating pharmacological treatment and developing monitoring strategies tailored for adolescents and adults. These strategies closely align with evidence-based recommendations from the National Asthma Education and Prevention Program and the Global Initiative for Asthma.

• Identify the hallmark symptoms of asthma, including dyspnea, cough, and wheezing.
• Implement evidence-based treatment strategies for asthma management, considering individual patient characteristics and preferences.
• Assess asthma severity, control, and exacerbation risk regularly during follow-up visits.
• Collaborate with interdisciplinary healthcare team members to optimize asthma care and patient outcomes.
• Introduction

Asthma is a prevalent chronic inflammatory respiratory condition affecting millions of people worldwide and presents substantial challenges in both diagnosis and management. This respiratory condition is characterized by inflammation of the airways, causing intermittent airflow obstruction and bronchial hyperresponsiveness. The hallmark asthma symptoms include coughing, wheezing, and shortness of breath, which can be frequently exacerbated by triggers ranging from allergens to viral infections. The prevalence and severity of asthma are determined by a complex interplay between genetic and environmental factors. Despite treatment advancements, disparities persist in asthma care, with variations in access to diagnosis, treatment, and patient education across different demographics.

The development of asthma, often presenting in childhood, is associated with other atopic features, such as eczema and hay fever. [1] [2] [3]  Severity varies from intermittent symptoms to life-threatening airway closure. Healthcare professionals establish a definitive diagnosis through patient history, physical examination, pulmonary function testing, and appropriate laboratory testing. Spirometry with a post-bronchodilator response (BDR) is the primary diagnostic test. Treatment focuses on providing continued education, routine symptom assessment, access to fast-acting bronchodilators, and appropriate controller medications tailored to disease severity.

Asthma manifests with diverse phenotypes, likely influenced by intricate interactions between genetic and environmental factors. [4] [5]  Genomewide association studies have linked childhood-onset asthma to markers near the ORMDL sphingolipid biosynthesis regulator 3 ( ORMDL3 ) and gasdermin B ( GSDMB ) genes on chromosome 17q21, encoding ORM1-like protein 3 and gasdermin-like protein. [6]  Other associations include genes such as interleukin-33 ( IL33 ), IL-1 receptor-like 1 ( IL1R1 ) genes, and a novel susceptibility locus at the IF-inducible protein X ( PYHIN1 ) gene, particularly affecting individuals of African descent. [7]  

The EVE Consortium also identifies a susceptibility locus for thymic stromal lymphopoietin ( TSLP ), an epithelial cell–derived cytokine implicated in asthma-related inflammation initiation. [8]  Asthma patients exhibit higher TSLP expression in their airways compared to healthy controls. Additional genetic loci involved in asthma include major histocompatibility complex class II DQ α1 ( HLA-DQA1 ), HLA-DQB1 antisense RNA 1 ( HLA-DQB1 ), Toll-like receptor 1 ( TLR1 ), IL-6 receptor ( IL6R ), zona pellucida-binding protein 2 ( ZPBP2 ), and gasdermin A ( GSDMA ).

Genetics may also be pivotal in asthma treatment. The hydroxy-δ-5-steroid dehydrogenase, 3-beta- and steroid δ-isomerase 1 ( HSD3B1 ) genotype is associated with glucocorticoid resistance among patients. In addition, single-nucleotide polymorphisms in protein kinase cGMP-dependent 1 ( PRKG1 )   and SPATA13 antisense RNA 1 ( SPATA13-AS1 )   are associated with BDR in Black children. [9]

Differing concordance rates among monozygotic twins suggest that exposure to environmental factors has an essential role in the development of asthma. Specific alleles have different effects depending on the environmental exposures. For example, exposure to secondhand smoke associates variations in the  N -acetyltransferase 1 ( NAT1 ) gene with the development of asthma in children. A study involving 983 children with single-nucleotide polymorphisms related to  ORMDL3  and  GSDMB  at chromosome locus 17q21 reveals that the same genotype poses genetic risk while also offering environmental protection. [10]

Risk Factors

Risk factors for asthma development encompass exposures throughout a patient's lifespan, including the perinatal period. The most substantial known risk factor is atopy, which is characterized by the genetic tendency to produce specific immunoglobulin E (IgE) antibodies in response to common environmental allergens. Nearly one-third of children with atopy will develop asthma later in life. 

Prenatal and Perinatal Factors

Prematurity is the most crucial risk factor influencing asthma incidence during this period. [11] [12] [13] [14]  Preterm birth, occurring before 36 weeks, is associated with an elevated risk of asthma throughout childhood, adolescence, and adulthood. Researchers posit that impaired lung development in preterm infants, even in those without early respiratory complications, increases the long-term risk of asthma. [15] Exposure to maternal smoking during pregnancy causes diminished pulmonary function in newborns and an increased probability of developing childhood asthma. Moreover, smoking during pregnancy correlates with several adverse pregnancy outcomes, including premature delivery, further elevating the asthma risk.

The incidence of childhood asthma increases with a maternal age of 20 or younger and decreases with a maternal age of 30 or older. Maternal diet during pregnancy holds significance, with researchers suggesting that vitamin D deficiency contributes to early-life wheezing and asthma primarily by impacting the immune function of various cell types, notably dendritic and T regulatory cells. Additionally, vitamin D plays a role in fetal lung development. [16] [17]  Although some studies present conflicting findings regarding the association between maternal vitamin D levels and childhood asthma, a meta-analysis of 2 large studies indicates that maternal vitamin D intake offers protection against wheezing or asthma in offspring up to the age of 3. [16]  

The Copenhagen Prospective Studies on Asthma in Childhood (COPSAC2010) reveals that 17% of children born to mothers with diets high in omega-3 polyunsaturated fatty acids developed persistent wheeze or asthma during the first 3 years of life compared to nearly 24% in the group with diets high in omega-6 polyunsaturated fatty acids. Vitamins E and C and zinc may also have protective effects. Administering vitamin C at a dose of 500 mg/d to pregnant mothers appears to offer protection against the harmful effects of tobacco exposure. Offspring of mothers who receive vitamin C supplementation exhibit a wheezing incidence of 28%, while those without vitamin C supplementation have a higher incidence of 47%. [18] [19]

Wheezing caused by viral infections, particularly respiratory syncytial virus and human rhinovirus, may predispose infants and young children to develop asthma later in life. In addition, early-life exposure to air pollution, including combustion by-products from gas-fired appliances and indoor fires, obesity, and early puberty, also increases the risk of asthma. 

The most significant risk factors for adult-onset asthma include tobacco smoke, occupational exposure, and adults with rhinitis or atopy. Studies also suggest a modest increase in asthma incidence among postmenopausal women taking hormone replacement therapy. 

Furthermore, the following factors can contribute to asthma and airway hyperreactivity:

• Exposure to environmental allergens such as house dust mites, animal allergens (especially from cats and dogs), cockroach allergens, and fungi
• Physical activity or exercise
• Conditions such as hyperventilation, gastroesophageal reflux disease, and chronic sinusitis
• Hypersensitivity to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), as well as sulfite sensitivity
• Use of β-adrenergic receptor blockers, including ophthalmic preparations
• Exposure to irritants such as household sprays and paint fumes
• Contact with various high- and low-molecular-weight compounds found in insects, plants, latex, gums, diisocyanates, anhydrides, wood dust, and solder fluxes, which are associated with occupational asthma
• Emotional factors or stress

Aspirin-Exacerbated Respiratory Disease

Aspirin-exacerbated respiratory disease   (AERD) is a condition characterized by a combination of asthma, chronic rhinosinusitis with nasal polyposis, and NSAID intolerance. Patients with AERD present with upper and lower respiratory tract symptoms after ingesting aspirin or NSAIDs that inhibit cyclooxygenase-1 (COX-1). This condition arises from dysregulated arachidonic acid metabolism and the overproduction of leukotrienes involving the 5-lipoxygenase and cyclooxygenase pathways. AERD affects approximately 7% of adults with asthma.

Occupational-Induced Asthma

Two types of occupational asthma exist based on their appearance after a latency period: 

• Occupational asthma triggered by workplace sensitizers results from an allergic or immunological process associated with a latency period induced by both low- and high-molecular-weight agents. High-molecular-weight substances, such as flour, contain proteins and polysaccharides of plant or animal origin. Low-molecular-weight substances, like formaldehyde, form a sensitizing neoantigen when combined with a human protein.
• Occupational asthma caused by irritants involves a   nonallergic or nonimmunological process induced by gases, fumes, smoke, and aerosols.
• Epidemiology

The worldwide incidence of asthma is estimated to affect 260 million individuals. [20] Recent studies examining asthma prevalence across 17 countries reveal varying rates, ranging from 3.4% to 6% for adults and children in India, Taiwan, Kosovo, Nigeria, and Russia, and higher rates of 17% to 33% for Honduras, Costa Rica, Brazil, and New Zealand. [21]  Despite data showing the death rate consistently declining for asthma between 2001 and 2015, asthma continues to account for approximately 420,000 deaths per year. [22]  Factors such as under-prescription of inhaled glucocorticoids and limited access to emergency medical care or specialist care all play a role in asthma-related deaths.

Asthma prevalence in the United States differs among demographic groups, including age, gender, race, and socioeconomic status. The United States Centers for Disease Control and Prevention (CDC) estimates that around 25 million Americans are currently affected by asthma. Among individuals younger than 18, boys exhibit a higher prevalence compared to girls, while among adults, women are more commonly affected than men. Additionally, asthma prevalence is notably higher among Black individuals, with a prevalence of 10.1%, compared to White individuals at 8.1%. Hispanic Americans generally have a lower prevalence of 6.4%, except for those from Puerto Rico, where the prevalence rises to 12.8%. Moreover, underrepresented minorities and individuals living below the poverty line experience the highest incidence of asthma, along with heightened rates of asthma-related morbidity and mortality. 

Similar to worldwide data, the mortality rate of asthma in the United States has also undergone a consistent decline. The current mortality rate is 9.86 per million compared to 15.09 per million in 2001. However, mortality rates remain consistently higher for Black patients compared to their White counterparts. According to the CDC, from 1999 to 2016, asthma death rates among adults aged 55 to 64 were 16.32 per 1 million persons, 9.95 per 1 million for females, 9.39 per 1 million for individuals who were not Hispanic or Latino, and notably higher at 25.60 per 1 million for Black patients.

• Pathophysiology

Asthma is a syndrome characterized by diverse underlying mechanisms and involves intricate interactions among inflammatory and resident airway cells. These mechanisms lead to airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness (see Image.  Pathophysiology of Asthma). 

Airway Inflammation

The activation of mast cells by cytokines and other mediators plays a pivotal role in the development of clinical asthma. Following initial allergen inhalation, affected patients produce specific IgE antibodies due to an overexpression of the T-helper 2 subset (Th2) of lymphocytes relative to the Th1 type. Cytokines produced by Th2 lymphocytes include IL-4, IL-5, and IL-13, which promote IgE and eosinophilic responses in atopy. Once produced, these specific IgE antibodies bind to receptors on mast cells and basophils. Upon additional allergen inhalation, allergen-specific IgE antibodies on the mast cell surface undergo cross-linking, leading to rapid degranulation and the release of histamine, prostaglandin D2 (PGD2), and cysteinyl leukotrienes C4 (LTC4), D4 (LTD4), and E4 (LTE4). [23] [24] This triggers contraction of the airway smooth muscle within minutes and may stimulate reflex neural pathways. Subsequently, an influx of inflammatory cells, including monocytes, dendritic cells, neutrophils, T lymphocytes, eosinophils, and basophils, may lead to delayed bronchoconstriction several hours later. 

Airflow Obstruction

The narrowing of the airway lumen throughout the tracheobronchial tree is caused by the contraction of airway smooth muscle, thickening of the airway wall due to edema, mucus plugging in the airways, and airway remodeling, which collectively contributes to varying levels of airflow obstruction.

Mediators such as histamine and leukotrienes, released from inflammatory cells or through reflex neural pathways, trigger the contraction and relaxation of airway smooth muscle. The precise mechanism leading to airway hyperresponsiveness, characterized by an excessive tightening of the airway's smooth muscles in response to various physical, chemical, or environmental triggers, remains unclear. Some researchers propose alterations in breathing patterns where smooth muscles contract excessively or fail to relax adequately during deep breaths as a potential explanation.

Airway remodeling, which involves thickening of the basement membrane, deposition of collagen, and shedding of epithelial cells, can lead to irreversible changes in the airways. This process accelerates the decline in lung function, particularly in individuals with severe and early-onset asthma. [25]  In addition, remodeling contributes to the heightened bronchial sensitivity observed in asthma.

Arachidonic acid metabolism by the enzyme 5-lipoxygenase (5-LO) leads to the generation of leukotrienes, which serve as potent bronchoconstrictors. The metabolism of arachidonic acid by the 2 cyclooxygenase (COX) isoforms—COX-1 and COX-2—generates prostaglandins and thromboxanes. PGD2 is a potent bronchodilator, while PGE2 suppresses the production of leukotrienes. Patients with AERD have dysregulated arachidonic acid metabolism, causing decreased production of PGE2 and loss of control of leukotriene production. [26]

Patients with occupational-induced asthma can undergo an immunologically mediated response similar to those without occupational-induced asthma. Alternatively, others may present with nonimmunological occupational asthma. The possible underlying mechanisms of the nonimmunological form are denudation of the airway epithelium, direct β-2 adrenergic receptor inhibition, or elaboration of substance P by injured sensory nerves.

• History and Physical

The 4 cardinal symptoms associated with asthma are wheezing, cough (often worse at night), shortness of breath, and chest tightness. Individuals may experience 1 or more of these symptoms. Asthma symptoms typically occur intermittently, lasting for hours to days, and resolve upon the removal of triggers or the administration of asthma medications. Nighttime exacerbation of symptoms or onset triggered by exercise, cold air, or allergen exposure suggests asthma. In contrast to exertional dyspnea, which manifests shortly after beginning exertion and resolves within 5 minutes of cessation, exercise-induced asthma symptoms typically emerge around 15 minutes into activity and dissipate within 30 to 60 minutes afterward. Patients may also have a history of other forms of atopy, such as eczema and hay fever.

During patient history-taking, healthcare professionals should inquire about particular triggers that exacerbate symptoms. Common household triggers include dust, animals, and infestations of rodents and cockroaches. Some individuals may experience intermittent asthma symptoms related to their work shifts. A strong family history of asthma and allergies, or a personal history of atopic conditions and childhood asthma symptoms, suggests asthma in patients exhibiting suggestive symptoms.

Physical Examination

During physical examination, widespread, high-pitched wheezes are a characteristic finding associated with asthma. However, wheezing is not specific to asthma and is typically absent between acute exacerbations. Findings suggestive of a severe asthma exacerbation include tachypnea, tachycardia, a prolonged expiratory phase, reduced air movement, difficulty speaking in complete sentences or phrases, discomfort when lying supine due to breathlessness, and adopting a "tripod position." [27]  The use of the accessory muscles of breathing during inspiration and pulsus paradoxus are additional indicators of a severe asthma attack.

Healthcare professionals may identify extrapulmonary findings that support the diagnosis of asthma, such as pale, boggy nasal mucous membranes, posterior pharyngeal cobblestoning, nasal polyps, and atopic dermatitis. Nasal polyps should prompt further inquiry about anosmia, chronic sinusitis, and aspirin sensitivity to evaluate for AERD. Although AERD is uncommon in children or adolescents, the presence of nasal polyps in a child with lower respiratory disease should prompt an evaluation for cystic fibrosis. Clubbing, characterized by bulbous fusiform enlargement of the distal portion of a digit, is not associated with asthma and should prompt evaluation for alternative diagnoses. Please see StatPearls' companion resource, " Nail Clubbing ," for further information.

Intermittent symptoms consistent with asthma, in addition to wheezing observed during physical examination, strongly indicate asthma. Confirming the diagnosis involves the exclusion of alternative diagnoses and a demonstration of variable airflow limitation, usually seen in spirometry. 

Spirometry assesses forced expiratory volume in 1 second (FEV 1 ) and forced vital capacity (FVC) by measuring a maximal inhalation followed by rapid and forceful exhalation into a spirometer. Asthma typically presents as an obstructive pattern on spirometry, indicated by a reduced FEV 1 to FVC ratio. [28] Additionally, a visual examination of the expiratory flow-volume loop can reveal an obstructive pattern. A scooped, concave appearance in the expiratory portion of the flow-volume loop indicates diffuse intrathoracic airflow obstruction characterizes asthma. In rare cases where complete exhalation is impossible, the FEV 1 /FVC ratio may appear normal, falsely suggesting a restrictive pattern if not assessed along with flow-time curves.

Patients showing airflow limitations on spirometry receive 2 to 4 puffs of a short-acting bronchodilator like albuterol, followed by repeat spirometry in 10 to 15 minutes. According to the European Respiratory Society/American Thoracic Society guidelines, a positive BDR is determined by a change in FEV 1 or FVC compared to their predicted value. Clinicians calculate the patient's BDR using the formula:

BDR=([Post-bronchodilator value – Pre-bronchodilator value] × 100) / Predicted value of either FEV 1 or FVC

Increases exceeding 10% are considered significant. [28]  

According to the Global Initiative for Asthma, a significant BDR is indicated by an increase in the FEV 1  of 12% or 200 mL or more. In addition, the slow vital capacity, or the maximal amount of air exhaled in a relaxed expiration from full inspiration to residual volume over 15 seconds, may also be helpful when the FVC is reduced and airway obstruction is present. During slow exhalation, airway narrowing is less pronounced, and the patient can produce a larger vital capacity. In cases of restrictive disease, both slow and fast exhalations result in reduced vital capacity.

Spirometry results may be normal in asymptomatic individuals or those with cough-variant asthma. Bronchodilator responsiveness is evident in asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, non-cystic fibrosis bronchiectasis, and bronchiolitis. However, patients with asthma may yield false negative results if they are on chronic controller medications, exhibit underlying airway remodeling, have minimal symptoms during testing, or have recently used bronchodilators before the test. Ideally, clinicians should conduct baseline spirometry before commencing treatment. [29] [30]

Bronchoprovocation Testing

During bronchoprovocation testing, clinicians induce bronchoconstriction using inhaled methacholine or mannitol, exercise, or eucapnic hyperventilation of dry air. This testing method can be beneficial for patients presenting with atypical symptoms or an isolated cough. Patients receive incremental doses of the provocative agent followed by spirometry to generate a dose-response curve. A fall in FEV 1  of 20% or more from baseline with the standard dose of methacholine or a decline of 15% or more with the standard dose of hypertonic saline, mannitol, or hyperventilation indicates a positive test. [31]  Clinicians may also conduct additional provocative testing using exercise, aspirin, and exposure to environmental triggers encountered in the workplace.

Peak Flow Meter

Although consistent reductions of 20% during symptomatic periods, followed by a gradual return to baseline as symptoms resolve, indicate asthma, clinicians typically use peak flow measurement to monitor patients with known asthma rather than for initial diagnosis. To measure peak flow, the patient takes a maximal breath and seals the peak flow meter between their lips before blowing forcefully for 1 to 2 seconds. Please see StatPearls' companion resource, " Peak Flow Measurement ," for additional information regarding peak flow measurement and its clinical significance in the evaluation and management of asthma.

Patients repeat this process 3 times, recording the highest reading as the current peak flow measurement. Patients can compare their recorded values to established graphs based on age and height for adults and height for adolescents to determine their predicted value. Notably, reduced peak flow values are not specific to asthma. Patients with either an obstructive or restrictive pattern on spirometry can have decreased peak flow values. Additionally, the accuracy of results is highly contingent on patient effort. 

Exhaled Nitric Oxide

Eosinophilic airway inflammation causes an upregulation of nitric oxide synthase in the respiratory mucosa,  leading to elevated nitric oxide levels in exhaled breath. In certain asthma patients, the fractional exhaled nitric oxide (FE NO ) surpasses levels observed in individuals without asthma. A FE NO of measurement exceeding 40 to 50 ppb can aid in confirming an asthma diagnosis. 

Pulse Oximetry

Pulse oximetry can help assess the severity of an asthma attack or monitor for deterioration. Notably, pulse oximetry measurements may exhibit a lag, and the physiological reserve of many patients implies that a declining oxygen level on pulse oximetry is a late stage, indicating an increasingly unwell or peri-arrest patient.

No specific laboratory tests are necessary for diagnosing asthma. However, patients who present with a severe asthma exacerbation should undergo a complete blood count to evaluate eosinophil levels and check for anemia, which may be the underlying cause of the patient's dyspnea. A significantly elevated eosinophil count should prompt further investigation for conditions, including parasitic infections such as Strongyloides , drug reactions, and syndromes characterized by pulmonary infiltrates with eosinophilia. These syndromes include allergic bronchopulmonary aspergillosis, eosinophilic granulomatosis with polyangiitis, and hypereosinophilic syndrome (see Image.  Allergic Bronchopulmonary Aspergillosis on CT Scan). 

Non-smoking patients who present with irreversible airflow obstruction should undergo serum α1-antitrypsin level testing to rule out emphysema caused by homozygous α1-antitrypsin deficiency. Allergy testing may prove beneficial for patients experiencing symptoms upon exposure to specific allergens. Clinicians should obtain total serum IgE levels in patients with moderate-to-severe persistent asthma, particularly when considering treatment with anti-IgE monoclonal antibodies or when there is suspicion of allergic bronchopulmonary aspergillosis. Please refer to the Treatment/Management  section for further details on anti-IgE monoclonal antibodies.

Chest radiographs in asthma patients are often normal; however, during acute exacerbations, abnormal findings such as hyperinflation, pneumomediastinum, and bronchial thickening may be observed (see Image.  A Chest Radiograph Depicting Asthma). A chest radiograph is recommended for patients aged 40 or older with new-onset, moderate-to-severe asthma to rule out conditions that can mimic asthma, such as a mediastinal mass with tracheal compression or heart failure.

Additional indications for chest radiography include patients experiencing symptoms that are difficult to control, fever, chronic purulent sputum production, persistently localized wheezing, hemoptysis, weight loss, clubbing, inspiratory crackles, significant hypoxemia, and moderate or severe airflow obstruction that does not reverse with bronchodilators. High-resolution computed tomography is necessary to clarify any abnormalities noted on chest radiographs or for patients with other suspected conditions that may not be well visualized on routine radiographs.

Evaluation During an Acute Exacerbation

Each patient should undergo a rapid assessment of their vital signs, including oxygen saturation. Measuring the peak flow can indicate the severity of the exacerbation and monitor the response to therapy. Predicted peak flow measurements vary based on age and height; however, a peak flow below 200 L/min indicates severe obstruction except in patients aged 65 or older or with very short stature. A peak flow measurement below 50% predicted or the patient's personal best is considered severe, while between 50% and 70% is considered moderate. Chest radiographs are not uniformly necessary unless the diagnosis of acute asthma exacerbation is uncertain, the patient requires hospitalization, or evidence of a comorbid condition is present.

Identification of Patients at Risk of Fatal or Near-Fatal Asthma

Most asthma-related deaths are preventable if risk factors are identified and addressed early. Major risk factors that place patients at high risk for future fatal asthma exacerbations include:

• A recent history of poorly controlled asthma
• A prior history of near-fatal asthma
• A history of endotracheal intubation for asthma 
• A history of intensive care unit admission for asthma

Minor risk factors include exposure to aeroallergens and tobacco smoke, illicit drug use, older patients, aspirin sensitivity, long duration of asthma, and frequent hospitalizations for asthma-related issues.

• Treatment / Management

Patient Education

Multiple sources of patient education are available. According to the National Asthma Education and Prevention Program's Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, personalized education from the patient's primary clinician is especially impactful. Studies reveal that such education reduces the number of asthma exacerbations and hospitalizations. Healthcare professionals should provide culturally specific asthma education that includes understanding asthma and its symptoms, identifying the patient's specific triggers, and strategies for their avoidance. Each patient should understand how to properly use an inhaler and be familiar with medications that serve as rescue options, those used for symptom control, and those that may fulfill both roles. Clinicians should inquire about any obstacles hindering medication adherence and work collaboratively with patients to overcome concerns or barriers, thus enhancing overall adherence.

Although the data on effectiveness are limited, a general consensus among experts exists that individuals with asthma should possess a personalized "action plan" to follow at home (please refer to the link to an action plan download in the  Deterrence and Patient Education section). This action plan provides a structured maintenance medication regimen and delineates steps to take when symptoms exacerbate. Clinicians develop an action plan based on symptoms or peak flow readings and divide it into 3 zones—green, yellow, and red. 

Patients in the green zone are asymptomatic, with peak flows at 80% or higher than their personal best. They feel well and continue with their long-term control medication. Peak flow readings falling within the yellow zone range between 50% and 79% of the patient's personal best, accompanied by symptoms such as coughing, wheezing, and shortness of breath, which begin to interfere with activity levels. In the red zone, patients experience peak flow readings below 50% of their best, severe shortness of breath, and an inability to perform everyday activities.

Asthma Severity

Guidelines established by the National Asthma Education and Prevention Program (NAEPP) and the Global Initiative for Asthma (GINA) determine therapy based on the frequency and severity of asthma symptoms, the degree of respiratory impairment, and the risk of future exacerbations. Risk factors contributing to future exacerbations include frequent asthma symptoms, a history of intensive care unit admission for asthma, obesity, poor medication adherence, chronic rhinosinusitis, and a low FEV 1 . The severity categories and treatment guidelines vary based on age. This activity will address asthma severity and management in adolescents and adults aged 12 or older. Please see StatPearls' companion resource, " Pediatric Asthma ," for additional information regarding the treatment of asthma in infants and children. 

Every patient should have access to a bronchodilator with a rapid onset of action. Traditionally, this has been a short-acting β-agonist (SABA) such as albuterol. However, GINA recommends a low-dose glucocorticoid/formoterol inhaler, such as 80 to 160 mcg budesonide/4.5 mcg formoterol inhaled by mouth 1 or 2 times daily,  for asthma symptoms. Notably, this is an off-label indication for this preparation.

Treatment progresses in a stepwise manner, with the highest severity category in which the patient experiences any symptoms, designating the treatment category from which the patient receives treatment (see Image.  Asthma Severity Classification by National Asthma Education and Prevention Program). Tables 1 and 2 below include the NAEPP and GINA asthma severity classifications and treatment initiation guidelines based on the patient's symptoms and lung function.

Table 1. National Asthma Education and Prevention Program: Expert Panel Working Group Initial Asthma Therapy in Adolescents and Adults.

Abbreviations: FEV 1 , forced expiratory volume in 1 second; ICS, inhaled corticosteroid; LABA, long-acting β-agonist; LAMA, long-acting muscarinic antagonist; LTRA, leukotriene receptor antagonist; SABA, short-acting β-agonist.

Table 2. Global Initiative for Asthma Initial Asthma Therapy in Adolescents and Adults.

Abbreviations: ICS, inhaled corticosteroid; LABA, long-acting β-agonist; LAMA, long-acting muscarinic antagonist; LTRA, leukotriene receptor antagonist; OCS, oral corticosteroid; SABA, short-acting β-agonist.

Routine follow-up every 1 to 6 months is necessary to ensure adequate symptom management. Upon reevaluation, patients facing inadequate asthma symptom management, exacerbations necessitating systemic glucocorticoids, or those at high risk of exacerbation on their current therapy level should escalate to the next level of therapy. Therapy adjustments proceed incrementally until symptoms are adequately managed. After maintaining control for 3 to 6 months, clinicians may consider gradual therapy reduction following the stepwise protocols outlined by GINA or NAEPP guidelines.

Severe Asthma

Adults and adolescents with severe asthma that remains uncontrolled despite Step 4 recommended therapy should receive a LAMA, such as tiotropium, alongside their inhaled glucocorticoid and LABA regimen. Clinicians should direct these patients for phenotypic assessment and consideration for biological therapy options. Anti-IgE monoclonal antibody therapy with omalizumab may be helpful for those still experiencing inadequate control and possessing documented sensitivity to a perennial allergy with IgE levels ranging between 30 and 700 IU/mL.

Patients with severe eosinophilic asthma who are not adequately controlled can utilize mepolizumab and reslizumab, monoclonal antibodies against IL-5, benralizumab, a monoclonal antibody against the IL-5 receptor α-subunit, and dupilumab a monoclonal antibody against the IL-4 receptor α-subunit. Tezepelumab is a human monoclonal IgG2-λ antibody that binds to TSLP, preventing its interaction with the TSLP receptor complex. [32]

Acute Exacerbation

Patients experiencing an acute asthma exacerbation may manage symptoms at home or need urgent medical care depending on their symptom severity and risk factors for fatal asthma. These risk factors include prior life-threatening exacerbations, exacerbations despite glucocorticoid use, more than 1 asthma-related hospitalization or 3 emergency room visits in the past year, and comorbidities such as cardiovascular or chronic lung disease. Immediate medical attention is warranted for patients showing significant breathlessness, inability to speak beyond short phrases, reliance on accessory muscles, or peak flow measurements at 50% or less of their baseline measurement.

All patients require a fast-acting β-agonist. Potential options include the LABA formoterol combined with ICS, the SABA albuterol combined with budesonide, or albuterol alone. Combination with ICS is the preferred choice. Albuterol dosing is 2 to 4 puffs from a metered dose inhaler (MDI) at home and 4 to 8 puffs in the office with a valved holding chamber or spacer every 20 minutes for 1 hour as needed. Albuterol may also be nebulized. ICS-formoterol dosing is 1 to 2 puffs every 20 minutes for 1 hour as required, with a maximum of 8 puffs per day. 

Patients whose symptoms improve after administering a bronchodilator and whose peak flow returns to 80% of their baseline or better can continue to manage their symptoms at home. Oral glucocorticoids equivalent to 40 to 60 mg prednisone daily for 5 to 7 days are warranted for the following patients:

• Those experiencing recurrent symptoms over the following 1 to 2 days.
• Those whose peak flow remains less than 80% of their normal baseline (high-dose ICSs are an alternative).
• If they do not improve after 1 to 3 doses of a fast-acting bronchodilator.
• If they have recently completed a course in OCS.
• Those who are on a maximal dose of controller medications.

Patients with a peak flow value of 50% or lower despite administering a bronchodilator or continuing to worsen should seek immediate medical care while continuing to administer their fast-acting bronchodilator. 

Office management is similar to home management, with the addition that according to GINA guidelines, all patients with oxygen saturation below 90% should receive oxygen to maintain saturation above 92% or 95% for pregnant individuals. Albuterol treatment can be administered via an MDI or nebulizer, with a dosage of 4 to 8 puffs or 2.5 to 5 mg every 20 minutes for 1 hour, respectively. Research comparing the efficacy of an MDI combined with a valved-holding chamber to nebulizer delivery, both administering the same β-agonist but with significantly lower doses via MDI, demonstrates similar enhancements in lung function and risk reduction for hospitalization. [33] [34] [35]  

If oral glucocorticoids are unavailable, intramuscular steroids such as triamcinolone suspension (40 mg/mL) 60 to 100 mg can be an alternative. However, it is noteworthy that intramuscular glucocorticoids have a delayed onset of action of 12 to 36 hours. Patients meeting certain criteria such as a respiratory rate of 30 breaths per minute, a heart rate of more than 120 bpm, a continued peak flow of less than 50% predicted, oxygen saturation of less than 90%, or the inability to speak in full sentences should be transferred to the emergency department. 

Patients who can be sent home from the office should have their controller medications advanced in 1 step. In addition, it is essential to review the correct use of their inhaler, discuss trigger avoidance strategies, ensure they have an asthma action plan, and emphasize the importance of adhering to their controller medication.

Emergency Department Care

Within the first hour, patients should receive 3 treatments of an inhaled SABA, such as albuterol, via a nebulizer or MDI, followed by repeat dosing every 1 to 4 hours. In addition to a SABA, patients with severe asthma exacerbations should also receive inhaled ipratropium, a short-acting muscarinic antagonist (SAMA), at a dosage of 500 µg by nebulization or 4 to 8 puffs by MDI, every 20 minutes for 3 doses, and then hourly as needed for up to 3 hours. Current guidelines recommend discontinuing SAMA therapy once the patient requires hospital admission, except in specific cases such as refractory asthma requiring treatment in the intensive care unit, concurrent treatment with monoamine oxidase inhibitors due to potential increased toxicity from sympathomimetic therapy due to impaired drug metabolism, presence of COPD with an asthmatic component, or asthma triggered by β-blocker therapy.

As with outpatient management, patients also receive glucocorticoids equivalent to 40 to 60 mg of prednisone daily for 5 to 7 days. A systematic review reveals no difference between a higher dose and a longer course when compared to a lower dose with a shorter course of prednisone or prednisolone. [36]  Oral and intravenous glucocorticoids have equivalent effects when administered in comparable doses. Intravenous steroids are necessary for patients with impending or actual respiratory arrest or who are intolerant of oral glucocorticoids. Some clinicians administer higher doses of glucocorticoids for severe asthma exacerbations based on their expert opinion and concern that a lower dose might be insufficient in a critically ill patient. 

Magnesium sulfate

Per GINA guidelines, magnesium is not recommended for routine use in asthma exacerbations. However, a 1-time dose of 2 g given intravenously over 20 minutes reduces hospitalization rates in adults with an FEV 1  less than 25% to 30% predicted on presentation and in those who fail to respond to initial treatment and continue to have hypoxemia. Nebulized MgSO 4  is not beneficial in the management of an acute asthma exacerbation.

A Cochrane Database review in 2014 concluded that a single infusion of intravenous MgSO 4 for patients not responding to conventional therapy results in improved lung functions and fewer hospital admissions. [37]  However, in a recent systematic review, the comparison of the same studies, eliminating those involving children and those containing only abstracts, revealed conflicting results. The review examined the effects of intravenous and nebulized MgSO 4 . Although 3 out of 9 studies addressing treatment with intravenous MgSO 4 found a significant effect on lung function compared to placebo, these results are not statistically significant. [38]  Only 2 of the 8 studies investigating hospital admission rates reveal a significant effect of MgSO 4 . [38]  Conversely, 6 of the 9 studies investigating treatment with nebulized MgSO 4 compared to placebo reveal a favorable effect on the FEV 1  and peak expiratory flow rate. [38]  These results somewhat contradict the Cochrane Database review conducted in 2014, which evaluated the same studies. [37]  

An additional study reveals a small benefit of adding inhaled magnesium to inhaled albuterol plus ipratropium in reducing hospital admissions but no significant improvement in peak expiratory flow when added to inhaled albuterol plus ipratropium or inhaled albuterol alone. [39]  

Intubation or Noninvasive Ventilation

Indications for intubation and mechanical ventilation or noninvasive ventilation include the following:

• Slowing of the respiratory rate
• Depressed mental status
• Inability to maintain respiratory effort
• Inability to cooperate with the administration of inhaled medications
• Worsening hypercapnia and associated respiratory acidosis
• Inability to maintain oxygen saturation above 92% despite face mask supplemental oxygen

A 1- to 2-hour trial of bilevel noninvasive positive pressure ventilation is appropriate for patients with an acute asthma exacerbation, but clinicians should maintain a low threshold for intubation. [40] [41]  

Additional Therapies

Occasionally, nonstandard therapies, such as ketamine, halothane, helium-oxygen mixtures, extracorporeal membrane oxygenation, and parenteral terbutaline, can be helpful for certain patients. However, these therapies are not routinely utilized due to limited evidence of efficacy. The indication for parenteral epinephrine is asthma associated with anaphylaxis and angioedema.

All patients who are smokers should be educated on the benefits of smoking cessation and provided with appropriate support and resources. Empiric antibiotics are not recommended since most infections triggering asthma exacerbations are viral. According to both GINA and NAEPP guidelines, intravenous methylxanthines such as theophylline are deemed ineffective and are no longer part of the standard of care. [42]

• Differential Diagnosis

The differential diagnoses for asthma include the following conditions:

• Bronchiectasis
• Bronchiolitis
• Chronic obstructive pulmonary disease
• Chronic sinusitis
• Cystic fibrosis
• α1-antitrypsin deficiency
• Aspergillosis
• Exercise-induced anaphylaxis
• Foreign body aspiration
• Heart failure
• Gastroesophageal reflux disease
• Tracheomalacia
• Pulmonary embolism
• Pulmonary eosinophilia
• Sarcoidosis
• Upper respiratory tract infection
• Vocal cord dysfunction
• Eosinophilic granulomatosis with polyangiitis
• Bronchogenic carcinoma
• Post-viral tussive syndrome
• Eosinophilic bronchitis
• Cough induced by angiotensin-converting enzyme inhibitors
• Bordetella pertussis infection
• Interstitial lung disease
• Recurrent oropharyngeal aspiration

The development and prognosis of asthma involve a complex interplay of genetic and environmental factors. Social determinants of health, such as poor housing quality and indoor and outdoor pollution, profoundly impact asthma prognosis. In the United States, asthma is a chronic illness characterized by a significant racial and ethnic disparity in both prevalence and prognosis. Underrepresented racial and ethnic minorities, as well as individuals living below the poverty line, experience higher morbidity rates, increased emergency room visits, hospitalizations, and mortality due to asthma. [43] [44]  Additionally, lack of access to healthcare—whether due to difficulties in accessing clinicians or lack of insurance—further exacerbates prognosis-related challenges.

The international asthma mortality rate reaches as high as 0.86 deaths per 100,000 persons in certain countries. The overall prognosis is predominantly linked to lung function, with mortality rates 8 times higher among individuals in the bottom 25% of lung function. Several factors contribute to a poorer prognosis, including inadequate asthma management, age 40 or older, a history of more than 20 pack-years of cigarette smoking, blood eosinophilia, and FEV1 of 40% to 69% of predicted values

• Complications

The complications related to asthma include disease-related complications and adverse effects of glucocorticoids, LTRA, and endotracheal intubation. The following list contains complications associated with asthma:

• Decline in lung function
• Osteoporosis
• Adrenal suppression
• Hypertension
• Peptic ulcer
• Sleep disorders
• Obstructive sleep apnea
• Mood disorders
• Cardiac arrest
• Respiratory failure or arrest  
• Pneumothorax
• Aspiration [45]
• Consultations

Healthcare professionals should seek consultation with an asthma specialist in pulmonology or allergy when the diagnosis of asthma is uncertain, the patient's symptoms remain poorly controlled, medication adverse effects become intolerable, or the patient experiences frequent exacerbations. Accessing appropriate specialist care aids in excluding alternate diagnoses, determining the need for additional diagnostic testing, and effectively escalating medical therapy.

• Deterrence and Patient Education

Patient education plays a pivotal role in the effective management of asthma by clinicians. To deter exacerbations and improve patient outcomes, clinicians should emphasize the importance of adherence to medication regimens, avoidance of triggers, and regular monitoring of symptoms. Educating patients about asthma triggers, such as allergens, air pollution, and tobacco smoke, can empower them to make informed lifestyle choices. Furthermore, clinicians should highlight the significance of having an asthma action plan, which outlines steps to take during worsening symptoms or exacerbations. See the National Heart and Lung Institute's website, " Asthma Action Plan ," for a printable version of an action plan.

Patient education should also prioritize the recognition of early warning signs of an asthma attack and prompt seeking of medical attention when necessary. Routine follow-up visits for patients with active asthma are recommended, occurring every one to six months, contingent on the severity of asthma and adequacy of control. During these follow-up visits, clinicians should assess asthma control, lung function, exacerbations, inhaler technique, adherence, adverse effects of medication, quality of life, and patient satisfaction with care. By instilling a comprehensive understanding of asthma management strategies and fostering proactive patient involvement, clinicians can significantly reduce the burden of asthma and enhance patient well-being.

• Enhancing Healthcare Team Outcomes

Asthma is characterized by complex pathophysiology involving airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness. The condition presents various signs and symptoms, such as wheezing, coughing, shortness of breath, and chest tightness. Wheezing may not always be present, particularly in cases primarily affecting small airways, and its absence does not exclude asthma. Additionally, a cough might be the sole symptom, especially one that occurs or worsens at night. Diagnostic evaluation involves spirometry, assessing lung function parameters such as FEV1 and FVC, measuring peak flow, and possibly conducting bronchoprovocation testing in some individuals.

Treatment strategies include trigger avoidance, ensuring access to rescue medications, and personalized pharmacological interventions, with inhaled corticosteroids being the preferred controller medication. Patient education, regular assessment of symptom control, and adherence to treatment plans are crucial components in effectively managing asthma. Adequate patient readiness and preparation, including the development of an asthma action plan, help minimize illness severity and optimize patient outcomes by promoting self-management and reducing healthcare utilization.

Enhancing patient-centered care, outcomes, patient safety, and team performance in asthma management demands a strategic approach. Each healthcare team member should possess the necessary clinical expertise to diagnose and treat asthma effectively, which involves interpreting spirometry findings and customizing treatment plans according to individual patient needs. Adhering to evidence-based guidelines and protocols will ensure uniform practices across healthcare settings. 

Effective interprofessional communication enables the exchange of information, collaborative decision-making, and seamless care transitions. Each healthcare team member, including physicians, advanced care practitioners, nurses, pharmacists, respiratory therapists, and social workers, contributes unique skills to asthma care, further enriching interdisciplinary collaboration. By fostering a culture of collaboration, communication, and coordination, healthcare professionals can deliver comprehensive, patient-centered asthma care, decreasing morbidity and mortality and enhancing team performance.

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Pathophysiology of Asthma. Figure A displays the location of the lungs and airways in the body. Figure B shows a cross section of a normal airway. Figure C illustrates a cross section of an airway during asthma symptoms National Institutes of Health

A Chest Radiograph Depicting Asthma. The image depicts both anterior and lateral radiographs of a patient with asthma. The image highlights the presence of pneumomediastinum and increased bronchovascular markings. Contributed by H Shulman, MD

Allergic Bronchopulmonary Aspergillosis on CT Scan. Computed tomography (CT) images reveal bronchiectasis in both upper lobes of a patient with bronchial asthma, indicative of allergic bronchopulmonary aspergillosis. Contributed by M Salahuddin, MD

Asthma Severity Classification by The National Asthma Education and Prevention Program. Contributed by R Chabra, DO

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Mary Cataletto declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Hashmi MF, Cataletto ME. Asthma. [Updated 2024 May 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Asthma is a major noncommunicable disease (NCD), affecting both children and adults, and is the most common chronic disease among children.
• Inflammation and narrowing of the small airways in the lungs cause asthma symptoms, which can be any combination of cough, wheeze, shortness of breath and chest tightness.
• Asthma affected an estimated 262 million people in 2019 (1) and caused 455 000 deaths.
• Inhaled medication can control asthma symptoms and allow people with asthma to lead a normal, active life.
• Avoiding asthma triggers can also help to reduce asthma symptoms.
• Most asthma-related deaths occur in low- and lower-middle-income countries, where under-diagnosis and under-treatment is a challenge.
• WHO is committed to improving the diagnosis, treatment and monitoring of asthma to reduce the global burden of NCDs and make progress towards universal health coverage.

Asthma is a chronic lung disease affecting people of all ages. It is caused by inflammation and muscle tightening around the airways, which makes it harder to breathe.

Symptoms can include coughing, wheezing, shortness of breath and chest tightness. These symptoms can be mild or severe and can come and go over time.

Although asthma can be a serious condition, it can be managed with the right treatment. People with symptoms of asthma should speak to a health professional.

Asthma is often under-diagnosed and under-treated, particularly in low- and middle-income countries.

People with under-treated asthma can suffer sleep disturbance, tiredness during the day, and poor concentration. Asthma sufferers and their families may miss school and work, with financial impact on the family and wider community. If symptoms are severe, people with asthma may need to receive emergency health care and they may be admitted to hospital for treatment and monitoring. In the most severe cases, asthma can lead to death.

Symptoms of asthma can vary from person to person. Symptoms sometimes get significantly worse. This is known as an asthma attack. Symptoms are often worse at night or during exercise.

Common symptoms of asthma include:

• a persistent cough, especially at night
• wheezing when exhaling and sometimes when inhaling
• shortness of breath or difficulty breathing, sometimes even when resting
• chest tightness, making it difficult to breathe deeply.

Some people will have worse symptoms when they have a cold or during changes in the weather. Other triggers can include dust, smoke, fumes, grass and tree pollen, animal fur and feathers, strong soaps and perfume.

Symptoms can be caused by other conditions as well. People with symptoms should talk to a healthcare provider.

Many factors have been linked to an increased risk of developing asthma, although it is often difficult to find a single, direct cause.

• Asthma is more likely if other family members also have asthma – particularly a close relative, such as a parent or sibling.
• Asthma is more likely in people who have other allergic conditions, such as eczema and rhinitis (hay fever).
• Urbanization is associated with increased asthma prevalence, probably due to multiple lifestyle factors.
• Events in early life affect the developing lungs and can increase the risk of asthma. These include low birth weight, prematurity, exposure to tobacco smoke and other sources of air pollution, as well as viral respiratory infections.
• Exposure to a range of environmental allergens and irritants are also thought to increase the risk of asthma, including indoor and outdoor air pollution, house dust mites, moulds, and occupational exposure to chemicals, fumes or dust.
• Children and adults who are overweight or obese are at a greater risk of asthma.

Asthma cannot be cured but there are several treatments available. The most common treatment is to use an inhaler, which delivers medication directly to the lungs.

Inhalers can help control the disease and enable people with asthma to enjoy a normal, active life.

There are two main types of inhaler:

• bronchodilators (such as salbutamol), that open the air passages and relieve symptoms; and
• steroids (such as beclometasone) that reduce inflammation in the air passages, which improves asthma symptoms and reduces the risk of severe asthma attacks and death.

People with asthma may need to use their inhaler every day. Their treatment will depend on the frequency of symptoms and the types of inhalers available.

Using an inhaler can be difficult, especially for children and during emergency situations. Using a spacer device makes it easier to use an aerosol inhaler. This helps the medicine to reach the lungs more easily. A spacer is a plastic container with a mouthpiece or mask at one end and a hole for the inhaler in the other. A homemade spacer, made from a 500ml plastic bottle, can be as effective as commercially manufactured spacers. 

Access to inhalers is a problem in many countries. In 2021, bronchodilators were available in public primary health care facilities in half of low- and low-middle income countries, and steroid inhalers available in one third.  

It is also important to raise community awareness to reduce the myths and stigma associated with asthma in some settings.

People with asthma and their families need education to understand more about their asthma. This includes their treatment options, triggers to avoid, and how to manage their symptoms at home.

It is important for people with asthma to know how to increase their treatment when their symptoms are worsening to avoid a serious attack. Healthcare providers may give an asthma action plan to help people with asthma to take greater control of their treatment. 

WHO response

Asthma is included in the WHO Global Action Plan for the Prevention and Control of NCDs and the United Nations 2030 Agenda for Sustainable Development.

WHO is taking action to extend diagnosis of and treatment for asthma in a number of ways.

The WHO Package of Essential Noncommunicable Disease Interventions (PEN) was developed to help improve NCD management in primary health care in low-resource settings. PEN includes protocols for the assessment, diagnosis and management of chronic respiratory diseases (asthma and chronic obstructive pulmonary disease), and modules on healthy lifestyle counselling, including tobacco cessation and self-care.

Reducing tobacco smoke exposure is important for both primary prevention of asthma and disease management. The Framework Convention on Tobacco Control is enabling progress in this area as are WHO initiatives such as MPOWER and mTobacco Cessation.

Air pollution is an important risk factor for asthma, causing new cases and making existing disease worse. WHO has developed training for health care workers on air pollution which highlights this link and offers practical advice to reduce and mitigate exposure.  

1. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019 . Lancet. 2020;396(10258):1204-22

Global health estimates 2019

NCD country capacity survey

Global action plan for the prevention and control of noncommunicable diseases 2013–2020

The 2030 Agenda for Sustainable Development

WHO package of essential noncommunicable (PEN) disease interventions for primary health care

WHO Framework Convention on Tobacco Control

Be Healthy, Be Mobile: A handbook on how to implement mTobaccoCessation

Global Alliance against Chronic Respiratory Diseases (GARD)

WHO's work on chronic respiratory diseases

Chronic respiratory diseases programme