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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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Treatment strategies for asthma: reshaping the concept of asthma management

• Alberto Papi 1 , 7 ,
• Francesco Blasi 2 , 3 ,
• Giorgio Walter Canonica 4 ,
• Luca Morandi 1 , 7 ,
• Luca Richeldi 5 &
• Andrea Rossi 6  

Allergy, Asthma & Clinical Immunology volume  16 , Article number:  75 ( 2020 ) Cite this article

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Asthma is a common chronic disease characterized by episodic or persistent respiratory symptoms and airflow limitation. Asthma treatment is based on a stepwise and control-based approach that involves an iterative cycle of assessment, adjustment of the treatment and review of the response aimed to minimize symptom burden and risk of exacerbations. Anti-inflammatory treatment is the mainstay of asthma management. In this review we will discuss the rationale and barriers to the treatment of asthma that may result in poor outcomes. The benefits of currently available treatments and the possible strategies to overcome the barriers that limit the achievement of asthma control in real-life conditions and how these led to the GINA 2019 guidelines for asthma treatment and prevention will also be discussed.

Asthma, a major global health problem affecting as many as 235 million people worldwide [ 1 ], is a common, non-communicable, and variable chronic disease that can result in episodic or persistent respiratory symptoms (e.g. shortness of breath, wheezing, chest tightness, cough) and airflow limitation, the latter being due to bronchoconstriction, airway wall thickening, and increased mucus.

The pathophysiology of the disease is complex and heterogeneous, involving various host-environment interactions occurring at various scales, from genes to organ [ 2 ].

Asthma is a chronic disease requiring ongoing and comprehensive treatment aimed to reduce the symptom burden (i.e. good symptom control while maintaining normal activity levels), and minimize the risk of adverse events such as exacerbations, fixed airflow limitation and treatment side effects [ 3 , 4 ].

Asthma treatment is based on a stepwise approach. The management of the patient is control-based; that is, it involves an iterative cycle of assessment (e.g. symptoms, risk factors, etc.), adjustment of treatment (i.e. pharmacological, non-pharmacological and treatment of modifiable risk factors) and review of the response (e.g. symptoms, side effects, exacerbations, etc.). Patients’ preferences should be taken into account and effective asthma management should be the result of a partnership between the health care provider and the person with asthma, particularly when considering that patients and clinicians might aim for different goals [ 4 ].

This review will discuss the rationale and barriers to the treatment of asthma, that may result in poor patient outcomes. The benefits of currently available treatments and the possible strategies to overcome the barriers that limit the achievement of asthma control in real-life situations will also be discussed.

The treatment of asthma: where are we? Evolution of a concept

Asthma control medications reduce airway inflammation and help to prevent asthma symptoms; among these, inhaled corticosteroids (ICS) are the mainstay in the treatment of asthma, whereas quick-relief (reliever) or rescue medicines quickly ease symptoms that may arise acutely. Among these, short-acting beta-agonists (SABAs) rapidly reduce airway bronchoconstriction (causing relaxation of airway smooth muscles).

National and international guidelines have recommended SABAs as first-line treatment for patients with mild asthma, since the Global Initiative for Asthma guidelines (GINA) were first published in 1995, adopting an approach aimed to control the symptoms rather than the underlying condition; a SABA has been the recommended rescue medication for rapid symptom relief. This approach stems from the dated idea that asthma symptoms are related to bronchial smooth muscle contraction (bronchoconstriction) rather than a condition concomitantly caused by airway inflammation. In 2019, the GINA guidelines review (GINA 2019) [ 4 ] introduced substantial changes overcoming some of the limitations and “weaknesses” of the previously proposed stepwise approach to adjusting asthma treatment for individual patients. The concept of an anti-inflammatory reliever has been adopted at all degrees of severity as a crucial component in the management of the disease, increasing the efficacy of the treatment while lowering SABA risks associated with patients’ tendency to rely or over-rely on the as-needed medication.

Until 2017, the GINA strategy proposed a pharmacological approach based on a controller treatment (an anti-inflammatory, the pillar of asthma treatment), with a SABA as an additional rescue intervention. The reliever, a short-acting bronc hodilator, was merely an addendum , a medication to be used in case the real treatment (the controller) failed to maintain disease control: SABAs effectively induce rapid symptom relief but are ineffective on the underlying inflammatory process. Based on the requirement to achieve control, the intensity of the controller treatment was related to the severity of the disease, varying from low-dose ICS to combination low-dose ICS/long-acting beta-agonist (LABA), medium-dose ICS/LABA, up to high-dose ICS/LABA, as preferred controller choice, with a SABA as the rescue medication. As a result, milder patients were left without any anti-inflammatory treatment and could only rely on SABA rescue treatment.

Poor adherence to therapy is a major limitation of a treatment strategy based on the early introduction of the regular use of controller therapy [ 5 ]. Indeed, a number of surveys have highlighted a common pattern in the use of inhaled medication [ 6 ], in which treatment is administered only when asthma symptoms occur; in the absence of symptoms, treatment is avoided as patients perceive it as unnecessary. When symptoms worsen, patients prefer to use reliever therapies, which may result in the overuse of SABAs [ 7 ]. Indirect evidence suggests that the overuse of beta-agonists alone is associated with increased risk of death from asthma [ 8 ].

In patients with mild persistent disease, low-dose ICS decreases the risk of severe exacerbations leading to hospitalization and improves asthma control [ 9 ]. When low-dose ICS are ineffective in controlling the disease (Step 3 of the stepwise approach), a combination of low-dose ICS with LABA maintenance was the recommended first-choice treatment, plus as-needed SABA [ 3 , 10 ]. Alternatively, the combination low-dose ICS/LABA (formoterol) was to be used as single maintenance and reliever treatment (SMART). The SMART strategy containing the rapid-acting formoterol was recommended throughout GINA Steps 3 to 5 based on solid clinical-data evidence [ 3 ].

The addition of a LABA to ICS treatment reduces both severe and mild asthma exacerbation rates, as shown in the one-year, randomized, double-blind, parallel-group FACET study [ 11 ]. This study focused on patients with persistent asthma symptoms despite receiving ICS and investigated the efficacy of the addition of formoterol to two dose levels of budesonide (100 and 400 µg bid ) in decreasing the incidence of both severe and mild asthma exacerbations. Adding formoterol decreased the incidence of both severe and mild asthma exacerbations, independent of ICS dose. Severe and mild exacerbation rates were reduced by 26% and 40%, respectively, with the addition of formoterol to the lower dose of budesonide; the corresponding reductions were 63% and 62%, respectively, when formoterol was added to budesonide at the higher dose.

The efficacy of the ICS/LABA combination was confirmed in the post hoc analysis of the FACET study, in which patients were exposed to a combination of formoterol and low-dose budesonide [ 12 ]. However, such high levels of asthma control are not achieved in real life [ 5 ]. An explanation for this is that asthma is a variable condition and this variability might include the exposure of patients to factors which may cause a transient steroid insensitivity in the inflammatory process. This, in turn, may lead to an uncontrolled inflammatory response and to exacerbations, despite optimal controller treatment. A typical example of this mechanism is given by viral infections, the most frequent triggers of asthma exacerbations. Rhinoviruses, the most common viruses found in patients with asthma exacerbations, interfere with the mechanism of action of corticosteroids making the anti-inflammatory treatment transiently ineffective. A transient increase in the anti-inflammatory dose would overcome the trigger-induced anti-inflammatory resistance, avoiding uncontrolled inflammation leading to an exacerbation episode [ 13 , 14 , 15 ].

Indeed, symptoms are associated with worsening inflammation and not only with bronchoconstriction. Romagnoli et al. showed that inflammation, as evidenced by sputum eosinophilia and eosinophilic markers, is associated with symptomatic asthma [ 16 ]. A transient escalation of the ICS dose would prevent loss of control over inflammation and decrease the risk of progression toward an acute episode. In real life, when experiencing a deterioration of asthma control, patients self-treat by substantially increasing their SABA medication (Fig.  1 ); it is only subsequently that they (modestly) increase the maintenance treatment [ 17 ].

Mean use of SABA at different stages of asthma worsening. Patients have been grouped according to maintenance therapy shown in the legend. From [ 17 ], modified

As bronchodilators, SABAs do not control the underlying inflammation associated with increased symptoms. The “as required” use of SABAs is not the most effective therapeutic option in controlling a worsening of inflammation, as signaled by the occurrence of symptoms; instead, an anti-inflammatory therapy included in the rescue medication along with a rapid-acting bronchodilator could provide both rapid symptom relief and control over the underlying inflammation. Thus, there is a need for a paradigm shift, a new therapeutic approach based on the rescue use of an inhaled rapid-acting beta-agonist combined with an ICS: an anti-inflammatory reliever strategy [ 18 ].

The symptoms of an exacerbation episode, as reported by Tattersfield and colleagues in their extension of the FACET study, increase gradually before the peak of the exacerbation (Fig.  2 ); and the best marker of worsening asthma is the increased use of rescue beta-agonist treatment that follows exactly the pattern of worsening symptomatology [ 19 ]. When an ICS is administered with the rescue bronchodilator, the patient would receive anti-inflammatory therapy when it is required; that is, when the inflammation is uncontrolled, thus increasing the efficiency of the anti-inflammatory treatment.

(From [ 19 ])

Percent variation in symptoms, rescue beta-agonist use and peak expiratory flow (PEF) during an exacerbation. In order to allow comparison over time, data have been standardized (Day-14 = 0%; maximum change = 100%)

Barriers and paradoxes of asthma management

A number of barriers and controversies in the pharmacological treatment of asthma have prevented the achievement of effective disease management [ 20 ]. O’Byrne and colleagues described several such controversies in a commentary published in 2017, including: (1) the recommendation in Step 1 of earlier guidelines for SABA bronchodilator use alone, despite asthma being a chronic inflammatory condition; and (2) the autonomy given to patients over perception of need and disease control at Step 1, as opposed to the recommendation of a fixed-dose approach with treatment-step increase, regardless of the level of symptoms [ 20 ]. Other controversies outlined were: (3) a difficulty for patients in understanding the recommendation to minimize SABA use at Step 2 and switch to a fixed-dose ICS regimen, when they perceive SABA use as more effective; (4) apparent conflicting safety messages within the guidelines that patient-administered SABA monotherapy is safe, but patient-administered LABA monotherapy is not; and (5) a discrepancy as to patients’ understanding of “controlled asthma” and their symptom frequency, impact and severity [ 20 ].

Controversies (1) and (2) can both establish an early over-dependence on SABAs. Indeed, asthma patients freely use (and possibly overuse) SABAs as rescue medication. UK registry data have recently suggested SABA overuse or overreliance may be linked to asthma-related deaths: among 165 patients on short-acting relievers at the time of death, 56%, 39%, and 4% had been prescribed > 6, > 12, and > 50 SABA inhalers respectively in the previous year [ 21 ]. Registry studies have shown the number of SABA canisters used per year to be directly related to the risk of death in patients with asthma. Conversely, the number of ICS canisters used per year is inversely related to the rate of death from asthma, when compared with non-users of ICS [ 8 , 22 ]. Furthermore, low-dose ICS used regularly are associated with a decreased risk of asthma death, with discontinuation of these agents possibly detrimental [ 22 ].

Other barriers to asthma pharmacotherapy have included the suggestion that prolonged treatment with LABAs may mask airway inflammation or promote tolerance to their effects. Investigating this, Pauwels and colleagues found that in patients with asthma symptoms that were persistent despite taking inhaled glucocorticoids, the addition of regular treatment with formoterol to budesonide for a 12-month period did not decrease asthma control, and improved asthma symptoms and lung function [ 11 ].

Treatment strategies across all levels of asthma severity

Focusing on risk reduction, the 2014 update of the GINA guidelines recommended as-needed SABA for Step 1 of the stepwise treatment approach, with low-dose ICS maintenance therapy as an alternative approach for long-term anti-inflammatory treatment [ 23 ]. Such a strategy was only supported by the evidence from a post hoc efficacy analysis of the START study in patients with recently diagnosed mild asthma [ 24 ]. The authors showed that low-dose budesonide reduced the decline of lung-function over 3 years and consistently reduced severe exacerbations, regardless of symptom frequency at baseline, even in subjects with symptoms below the then-threshold of eligibility for ICS [ 24 ]. However, as for all post hoc analyses, the study by Reddel and colleagues does not provide conclusive evidence and, even so, their results could have questionable clinical significance for the management of patients with early mild asthma. To be effective, this approach would require patients to be compliant to regular twice-daily ICS for 10 years to have the number of exacerbations reduce by one. In real life, it is highly unlikely that patients with mild asthma would adhere to such a regular regimen [ 25 ].

The 2016 update to the GINA guidelines lowered the threshold for the use of low-dose ICS (GINA Step 2) to two episodes of asthma symptoms per month (in the absence of any supportive evidence for the previous cut-off). The objective was to effectively increase the asthma population eligible to receive regular ICS treatment and reduce the population treated with a SABA only, given the lack of robust evidence of the latter’s efficacy and safety and the fact that asthma is a variable condition characterized by acute exacerbations [ 26 ]. Similarly, UK authorities recommended low-dose ICS treatment in mild asthma, even for patients with suspected asthma, rather than treatment with a SABA alone [ 10 ]. However, these patients are unlikely to have good adherence to the regular use of an ICS. It is well known that poor adherence to treatment is a major problem in asthma management, even for patients with severe asthma. In their prospective study of 2004, Krishnan and colleagues evaluated the adherence to ICS and oral corticosteroids (OCS) in a cohort of patients hospitalized for asthma exacerbations [ 27 ]. The trend in the data showed that adherence to ICS and OCS treatment in patients dropped rapidly to reach nearly 50% within 7 days of hospital discharge, with the rate of OCS discontinuation per day nearly double the rate of ICS discontinuation per day (− 5.2% vs. − 2.7%; p < 0.0001 respectively, Fig.  3 ), thus showing that even after a severe event, patients’ adherence to treatment is suboptimal [ 27 ].

(From [ 27 ])

Use of inhaled (ICS) and oral (OCS) corticosteroids in patients after hospital discharge among high-risk adult patients with asthma. The corticosteroid use was monitored electronically. Error bars represent the standard errors of the measured ICS and OCS use

Guidelines set criteria with the aim of achieving optimal control of asthma; however, the attitude of patients towards asthma management is suboptimal. Partridge and colleagues were the first in 2006 to evaluate the level of asthma control and the attitude of patients towards asthma management. Patients self-managed their condition using their medication as and when they felt the need, and adjusted their treatment by increasing their intake of SABA, aiming for an immediate relief from symptoms [ 17 ]. The authors concluded that the adoption of a patient-centered approach in asthma management could be advantageous to improve asthma control.

The concomitant administration of an as-needed bronchodilator and ICS would provide rapid relief while administering anti-inflammatory therapy. This concept is not new: in the maintenance and reliever approach, patients are treated with ICS/formoterol (fast-acting, long-acting bronchodilator) combinations for both maintenance and reliever therapy. An effective example of this therapeutic approach is provided in the SMILE study in which symptomatic patients with moderate to severe asthma and treated with budesonide/formoterol as maintenance therapy were exposed to three different as-needed options: SABA (terbutaline), rapid-onset LABA (formoterol) and a combination of LABA and ICS (budesonide/formoterol) [ 28 ]. When compared with formoterol, budesonide/formoterol as reliever therapy significantly reduced the risk of severe exacerbations, indicating the efficacy of ICS as rescue medication and the importance of the as-needed use of the anti-inflammatory reliever.

The combination of an ICS and a LABA (budesonide/formoterol) in one inhaler for both maintenance and reliever therapy is even more effective than higher doses of maintenance ICS and LABA, as evidenced by Kuna and colleagues and Bousquet and colleagues (Fig.  4 ) [ 29 , 30 ].

(Data from [ 29 , 30 ])

Comparison between the improvements in daily asthma control resulting from the use of budesonide/formoterol maintenance and reliever therapy vs. higher dose of ICS/LABA + SABAZ and steroid load for the two regimens

The effects of single maintenance and reliever therapy versus ICS with or without LABA (controller therapy) and SABA (reliever therapy) have been recently addressed in the meta-analysis by Sobieraj and colleagues, who analysed 16 randomized clinical trials involving patients with persistent asthma [ 31 ]. The systematic review supported the use of single maintenance and reliever therapy, which reduces the risk of exacerbations requiring systemic corticosteroids and/or hospitalization when compared with various strategies using SABA as rescue medication [ 31 ].

This concept was applied to mild asthma by the BEST study group, who were the first to challenge the regular use of ICS. A pilot study by Papi and colleagues evaluated the efficacy of the symptom-driven use of beclomethasone dipropionate plus albuterol in a single inhaler versus maintenance with inhaled beclomethasone and as-needed albuterol. In this six-month, double-blind, double-dummy, randomized, parallel-group trial, 455 patients with mild asthma were randomized to one of four treatment groups: an as-needed combination therapy of placebo bid plus 250 μg of beclomethasone and 100 μg of albuterol in a single inhaler; an as-needed albuterol combination therapy consisting of placebo bid plus 100 μg of albuterol; regular beclomethasone therapy, comprising beclomethasone 250 μg bid and 100 μg albuterol as needed); and regular combination therapy with beclomethasone 250 μg and albuterol 100 μg in a single inhaler bid plus albuterol 100 μg as needed.

The rescue use of beclomethasone/albuterol in a single inhaler was as efficacious as the regular use of inhaled beclomethasone (250 μg bid ) and it was associated with a lower 6-month cumulative dose of the ICS [ 32 ].

The time to first exacerbation differed significantly among groups ( p  = 0.003), with the shortest in the as-needed albuterol and placebo group (Fig.  5 ). Figure  5 also shows equivalence between the as-needed combination therapy and the regular beclomethasone therapy. However, these results were not conclusive since the study was not powered to evaluate the effect of the treatment on exacerbations. In conclusion, as suggested by the study findings, mild asthma patients may require the use of an as-needed ICS and an inhaled bronchodilator rather than a regular treatment with ICS [ 32 ].

(From [ 32 ])

Kaplan Meier analysis of the time to first exacerbation (modified intention-to-treat population). First asthma exacerbations are shown as thick marks. As-needed albuterol therapy = placebo bid plus 100 μg of albuterol as needed; regular combination therapy = 250 μg of beclomethasone and 100 μg of albuterol in a single inhaler bid plus 100 μg of albuterol as needed; regular beclomethasone therapy = 250 μg of beclomethasone bid and 100 μg of albuterol as needed; as-needed combination therapy = placebo bid plus 250 μg of beclomethasone and 100 μg of albuterol in a single inhaler as needed

Moving forward: a new approach to the management of asthma patients

Nearly a decade after the publication of the BEST study in 2007, the use of this alternative therapeutic strategy was addressed in the SYGMA 1 and SYGMA 2 trials. These double-blind, randomized, parallel-group, 52-week phase III trials evaluated the efficacy of as-needed use of combination formoterol (LABA) and the ICS budesonide as an anti-inflammatory reliever in patients requiring GINA Step 2 treatment, with the current reliever therapy (e.g. as-needed SABA) or with low-dose maintenance ICS (inhaled budesonide bid ) plus as-needed SABA, administered as regular controller therapy [ 33 , 34 ].

The SYGMA 1 trial, which enrolled 3849 patients, aimed to demonstrate the superiority of the as-needed use of the combination budesonide/formoterol over as-needed terbutaline, as measured by the electronically-recorded proportion of weeks with well-controlled asthma [ 34 ]. The more pragmatic SYGMA 2 trial enrolled 4215 patients with the aim to demonstrate that the budesonide/formoterol combination is non-inferior to budesonide plus as-needed terbutaline in reducing the relative rate of annual severe asthma exacerbations [ 33 ]. Both trials met their primary efficacy outcomes. In particular, as-needed budesonide/formoterol was superior to as-needed SABA in controlling asthma symptoms (34.4% versus 31.1%) and preventing exacerbations, achieving a 64% reduction in exacerbations. In both trials, budesonide/formoterol as-needed was similar to budesonide maintenance bid at preventing severe exacerbations, with a substantial reduction of the inhaled steroid load over the study period (83% in the SYGMA 1 trial and 75% in the SYGMA 2 trial). The time to first exacerbation did not differ significantly between the two regimens; however, budesonide/formoterol was superior to SABA in prolonging the time to first severe exacerbation [ 33 , 34 ].

The double-blind, placebo-controlled design of the SYGMA trials does not fully address the advantages of anti-inflammatory reliever strategy in patients who often rely on SABAs for symptom relief, so to what extent the study findings could apply to real-life practice settings was unclear.

These limitations were overcome by the results of the Novel START study, an open-label, randomized, parallel-group, controlled trial designed to reflect real-world practice, which demonstrated the effectiveness in mild asthma of budesonide/formoterol as an anti-inflammatory reliever therapy [ 35 ].

In real-world practice, mild asthma patients are treated with an as-needed SABA reliever or with daily low-dose ICS maintenance therapy plus a SABA reliever. In the Novel START study, 668 patients with mild asthma were randomized to receive either as-needed albuterol 100 µg, two inhalations (SABA reliever as a continuation of the Step 1 treatment according to the 2017 GINA guidelines), budesonide 200 µg (ICS maintenance treatment) plus as-needed albuterol (Step 2 therapy of the GINA 2017 guidelines), or 200 µg/6 µg budesonide/formoterol as anti-inflammatory reliever therapy taken as-needed for a 52-week study period.

In this study, the rate of asthma exacerbations for budesonide/formoterol was lower compared with albuterol (51%) and similar to the twice-daily maintenance budesonide plus albuterol, despite a 52% reduction in the mean steroid dose with the single combination inhaler treatment [ 35 ]. In addition, severe exacerbation rate was lower with budesonide/formoterol as compared with as-needed albuterol and regular twice-daily budesonide. These data support the findings of the SYGMA 1 and 2 trials, highlighting the need for a critical re-examination of current clinical practice. Along with the results of the SYGMA trials, they provide convincing evidence of the advantages of the anti-inflammatory reliever strategy, particularly in real-life settings.

The SYGMA 1, SYGMA 2 and the novel START studies complete the picture of the treatment strategies for asthma at any degree of severity, including mild asthma. A growing body of evidence shows that an anti-inflammatory reliever strategy, when compared with all other strategies with SABA reliever, consistently reduces the rate of exacerbations across all levels of asthma severity (Fig.  6 ) [ 28 , 29 , 34 , 36 , 37 , 38 , 39 ].

(Data source: [ 39 ])

Risk reduction of severe asthma attack of anti-inflammatory reliever versus SABA across all levels of asthma severity. Bud = budesonide; form = formoterol; TBH = turbohaler. Data from: 1: [ 36 ]; 2: [ 37 ]; 3: [ 38 ]; 4: [ 28 ]; 5: [ 29 ]; 6: [ 30 ]; 7: [ 34 ]

This evidence set the ground (Fig.  7 ) for the release of the 2019 GINA strategy updates. The document provides a consistent approach towards the management of the disease and aims to avoid the overreliance and overuse of SABAs, even in the early course of the disease. The 2019 GINA has introduced key changes in the treatment of mild asthma: for safety reasons, asthmatic adults and adolescents should receive ICS-containing controller treatment instead of the SABA-only treatment, which is no longer recommended.

Timeline of key randomized controlled trials and meta-analyses providing the supporting evidence base leading to the Global Initiative for Asthma (GINA) 2019 guidelines. GINA global initiative for asthma, MART maintenance and reliever therapy, SMART single inhaler maintenance and reliever therapy

In Step 1 of the stepwise approach to adjusting asthma treatment, the preferred controller option for patients with fewer than two symptoms/month and no exacerbation risk factors is low-dose ICS/formoterol as needed. This strategy is indirectly supported by the results of the SYGMA 1 study which evaluated the efficacy and safety of budesonide/formoterol as needed, compared with as-needed terbutaline and budesonide bid plus as-needed terbutaline (see above). In patients with mild asthma, the use of an ICS/LABA (budesonide/formoterol) combination as needed provided superior symptom control to as-needed SABA, resulting in a 64% lower rate of exacerbations (p = 0.07) with a lower steroid dose (17% of the budesonide maintenance dose) [ 34 ]. The changes extend to the other controller options as well. In the 2017 GINA guidelines, the preferred treatment was as-needed SABA with the option to consider adding a regular low-dose ICS to the reliever. In order to overcome the poor adherence with the ICS regimen, and with the aim to reduce the risk of severe exacerbations, the 2019 GINA document recommends taking low-dose ICS whenever SABA is taken, with the daily ICS option no longer listed.

Previous studies including the TREXA study in children and adolescents [ 40 ], the BASALT study [ 41 ] and research conducted by the BEST study group [ 32 ] have already added to the evidence that a low-dose ICS with a bronchodilator is an effective strategy for symptom control in patients with mild asthma. A recently published study in African-American children with mild asthma found that the use of as-needed ICS with SABA provides similar asthma control, exacerbation rates and lung function measures at 1 year, compared with daily ICS controller therapy [ 42 ], adding support to TREXA findings that in children with well controlled, mild asthma, ICS used as rescue medication with SABA may be an efficacious step-down strategy [ 40 ].

In Step 2 of the stepwise approach, there are now two preferred controller options: (a) a daily low-dose ICS plus an as-needed SABA; and (b) as-needed low-dose ICS/formoterol. Recommendation (a) is supported by a large body of evidence from randomized controlled trials and observations showing a substantial reduction of exacerbation, hospitalization, and death with regular low-dose ICS [ 7 , 8 , 9 , 24 , 43 ], whereas recommendation (b) stems from evidence on the reduction or non-inferiority for severe exacerbations when as-needed low-dose ICS/formoterol is compared with regular ICS [ 33 , 34 ].

The new GINA document also suggests low-dose ICS is taken whenever SABA is taken, either as separate inhalers or in combination. This recommendation is supported by studies showing reduced exacerbation rates compared with taking a SABA only [ 32 , 40 ], or similar rates compared with regular ICS [ 32 , 40 , 41 ]. Low-dose theophylline, suggested as an alternative controller in the 2017 GINA guidelines, is no longer recommended.

Airway inflammation is present in the majority of patients with asthma, and although patients with mild asthma may have only infrequent symptoms, they face ongoing chronic inflammation of the lower airways and risk acute exacerbations. The GINA 2019 strategy recognizes the importance of reducing the risk of asthma exacerbations, even in patients with mild asthma (Steps 1 and 2) [ 4 ]. In this regard, the new recommendations note that SABA alone for symptomatic treatment is non-protective against severe exacerbation and may actually increase exacerbation risk if used regularly or frequently [ 4 ].

The reluctance by patients to regularly use an ICS controller means they may instead try and manage their asthma symptoms by increasing their SABA reliever use. This can result in SABA overuse and increased prescribing, and increased risk of exacerbations.

As part of the global SABINA (SABA use IN Asthma) observational study programme, a UK study examined primary care records to describe the pattern of SABA and ICS use over a 10-year period in 373,256 patients with mild asthma [ 44 ]. Results showed that year-to-year SABA prescribing was more variable than that of ICS indicating that, in response to fluctuations in asthma symptom control, SABA use was increased in preference to ICS use. Furthermore, more than 33% of patients were prescribed SABA inhalers at a level equivalent to around ≥ 3 puffs per week which, according to GINA, suggests inadequate asthma control.

The problem of SABA overuse is further highlighted by two studies [ 45 , 46 ], also as part of the SABINA programme. These analysed data from 365,324 patients in a Swedish cohort prescribed two medications for obstructive lung disease in any 12-month period (HERA).

The first study identified SABA overuse (defined as ≥ 3 SABA canisters a year) in 30% of patients, irrespective of their ICS use; 21% of patients were collecting 3–5 canisters annually, 7% were collecting 6–10, and 2% more than 11 [ 45 ]. Those patients who were overusing SABA had significantly more asthma exacerbations relative to those using < 3 canisters (20.0 versus 12.5 per 100 patient years; relative risk 1.60, 95% CI 1.57–1.63, p < 0.001). Moreover, patients overusing SABA and whose asthma was more severe (GINA Steps 3 and 4) had greater exacerbation risk compared with overusing patients whose asthma was milder (GINA Steps 1 and 2).

The second study found those patients using three or more SABA reliever canisters a year had an increased all-cause mortality risk relative to patients using fewer SABA canisters: hazard ratios after adjustment were 1.26 (95% CI 1.14–1.39) for 3–5 canisters annually, 1.67 (1.49–1.87) for 6–10 canisters, and 2.35 (2.02–2.72) for > 11 canisters, relative to patients collecting < 3 canisters annually [ 46 ].

The recently published PRACTICAL study lends further support to as-needed low-dose ICS/formoterol as an alternative option to daily low-dose ICS plus as-needed SABA, outlined in Step 2 of the guidelines [ 47 ]. In their one-year, open-label, multicentre, randomized, superiority trial in 890 patients with mild to moderate asthma, Hardy and colleagues found that the rate of severe exacerbations per patient per year (the primary outcome) was lower in patients who received as-needed budesonide/formoterol than in patients who received controller budesonide plus as-needed terbutaline (relative rate 0.69, 95% CI 0.48–1.00; p < 0.05). Indeed, they suggest that of these two treatment options, as-needed low-dose ICS/formoterol may be preferred over controller low-dose ICS plus as-needed SABA for the prevention of severe exacerbations in this patient population.

Step 3 recommendations have been left unchanged from 2017, whereas Step 4 treatment has changed from recommending medium/high-dose ICS/LABA [ 3 ] to medium-dose ICS/LABA; the high-dose recommendation has been escalated to Step 5. Patients who have asthma that remains uncontrolled after Step 4 treatment should be referred for phenotypic assessment with or without add-on therapy.

To summarise, the use of ICS medications is of paramount importance for optimal asthma control. The onset and increase of symptoms are indicative of a worsening inflammation leading to severe exacerbations, the risk of which is reduced by a maintenance plus as-needed ICS/LABA combination therapy. The inhaled ICS/bronchodilator combination is as effective as the regular use of inhaled steroids.

The efficacy of anti-inflammatory reliever therapy (budesonide/formoterol) versus current standard-of-care therapies in mild asthma (e.g. reliever therapy with a SABA as needed and regular maintenance controller therapy plus a SABA as-needed) has been evaluated in two randomized, phase III trials which confirmed that, with respect to as-needed SABA, the anti-inflammatory reliever as needed is superior in controlling asthma and reduces exacerbation rates, exposing the patients to a substantially lower glucocorticoid dose.

Conclusions

A growing body of evidence shows that anti-inflammatory reliever strategy is more effective than other strategies with SABA reliever in controlling asthma and reducing exacerbations across all levels of asthma severity. A budesonide/formoterol therapy exposes asthma patients to a substantially lower glucocorticoid dose while cutting the need for adherence to scheduled therapy.

Availability of data and materials

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Abbreviations

Global Initiative for Asthma

Inhaled corticosteroids

Long-acting beta-agonists

Oral corticosteroids

Short-acting beta-agonists

Single inhaler maintenance and reliever treatment

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Acknowledgements

The Authors thank Maurizio Tarzia and Gayle Robins, independent medical writers who provided editorial assistance on behalf of Springer Healthcare Communications. The editorial assistance was funded by AstraZeneca.

No funding was received for this study. The editorial assistance was funded by AstraZeneca.

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Giorgio Walter Canonica

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Papi, A., Blasi, F., Canonica, G.W. et al. Treatment strategies for asthma: reshaping the concept of asthma management. Allergy Asthma Clin Immunol 16 , 75 (2020). https://doi.org/10.1186/s13223-020-00472-8

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Introduction

More than 20 million Americans—young and old alike—have asthma, 1 a condition that is both common and expensive: Direct medical costs for asthma treatment exceed $9.4 billion. 1 Despite availability of effective therapy for controlling asthma, its incidence is increasing; 1 nonetheless, asthma continues to be underdiagnosed and undertreated. Appropriate management of asthma requires:

• correct diagnosis;
• assessment of severity and control
• proper management, including appropriate medication, patient education, and a written action plan
• ongoing monitoring by the patient
• appropriate follow-up; and
• specialty referral where appropriate. 2–4

This article is an overview of the recently revised physician guidelines for asthma care.

There is usually widespread airflow obstruction with these episodic symptoms, which is reversible to varying degrees …

Case Example

A 32-year-old female smoker presents with a seven-day history of “bronchitis.” She states that she experiences a harsh, rattling, non-productive cough with chest tightness three-to-four times each year. She requests a prescription for guaifenesin with codeine and either erythromycin or azithromycin, which was prescribed for her in the past and which usually takes effect after about seven-to-ten days. She is afebrile and has had scant clear nasal discharge for the past three days. She has no chest pain, tightness, or heaviness. Physical examination shows that she has a harsh-sounding, paroxysmal cough without nasal flaring, cyanosis, or retractions. Her respiratory rate is 16 breaths/minute, and pulse oximetry shows 96% saturation on room air. Pulmonary examination shows slight expiratory wheezing and occasional bibasilar rhonchi that clear with coughing. Results of cardiac examination are normal, and no ankle edema is present.

What is the patient's diagnosis? What additional history would be helpful? What additional testing would you perform? How severe is her condition? How do you explain the diagnosis to her? What is the appropriate treatment? What information does the patient need to help prevent recurrence? What is the appropriate follow-up?

Definition of Asthma

Kaiser Permanente's (KP) CMI Asthma Guidelines 3 define asthma:

Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. In susceptible individuals, the inflammation causes recurrent symptoms of breathlessness, wheezing, chest tightness, and cough. There is usually widespread airflow obstruction with these episodic symptoms, which is reversible to varying degrees either spontaneously, or with treatment. The inflammation appears to be linked to an increase in airway hyperresponsiveness to a variety of stimuli. 2, 3

Diagnostic Procedure

To establish the diagnosis of asthma, the clinician must determine that:

• episodic symptoms of airflow obstruction are present
• airflow obstruction is at least partially reversible
• alternative diagnoses are excluded. 2, 3

The diagnosis is usually derived from the patient's medical history and results of physical examination. However, certain cases necessitate further diagnostic evaluation, including spirometry, bronchial inhalation challenge tests, blood and sputum studies, chest x-ray examination, or a combination of these procedures. 2, 3

Performing spirometry before and after use of a bronchodilator is essential for diagnosis and ongoing monitoring of asthma. 2, 3 Often underutilized, spirometry is a reliable way to confirm presence, variability, and reversibility of airflow obstruction as well as to measure change in airflow obstruction as changes are made in therapy and as changes occur in the patient's condition over time. Spirometry is also useful to help exclude other diagnoses frequently confused with asthma ( Table 1 ). 4 Asthma is diagnosed when spirometry shows a clinically significant response to bronchodilator use (>15%), frequently with normalization of values. In the patient above, spirometry would be useful to differentiate asthma from bronchitis, a disease with either fixed or no airflow obstruction. A methacholine challenge test may be useful in patients who have normal spirometry results despite symptoms suggesting asthma.

Differential diagnosis of asthma

Comorbid conditions such as sinusitis, allergy, gastroesophageal reflux disease (GERD), and hypothyroidism may worsen asthma. A smoking history of more than 20 pack-years, even in a patient who has clearly had asthma in the past, should raise suspicion of chronic obstructive pulmonary disease (COPD). Dyspnea alone or exertional chest pain should suggest another diagnosis than asthma—in particular, a diagnosis of cardiac or thromboembolic disease. For patients who comply with recommended therapy, poor response to treatment should also raise suspicion as to the correct diagnosis. Stridor (squeaky sounds over the larynx, especially on inspiration) should suggest vocal cord dysfunction.

Performing spirometry before and after use of a bronchodilator is essential for diagnosis and ongoing monitoring of asthma. 2, 3

Assessment of Asthma Severity

All asthmatic patients should be categorized as having either intermittent or persistent asthma . 4 Intermittent asthma is defined by the National Heart, Lung and Blood Institute (NHLBI) as symptoms ≤2 times per week, asymptomatic and normal peak expiratory flow (PEF) between exacerbations, brief exacerbations (duration varies from a few hours to a few days), and nighttime symptoms ≤2 times per month. This criterion applies only prior to treatment with any asthma medication. The classification of persistent asthma refers to patients who are more symptomatic than intermittent asthma and exhibit an forced expiratory volume in one second (FEV 1 ) of less than 80%, which is consistent with airflow obstruction. 4 Persistent asthma can be further classified as mild, moderate, or severe ( Table 2 ), 4 although treatment is more strongly related to response to medication than to initial severity of disease. The classification system presented in Table 2 should be on the basis of the patient's status before treatment; the classification system is more difficult to use in asthmatic patients already receiving treatment. For that reason, the classification system is best used as a guide. Presence of any symptom in a higher classification places the patient at that higher level. Patients often underreport their nighttime symptoms, so these symptoms must be specifically sought out by clinicians.

Classification of asthma

Patients are at high risk for hospitalization, emergency department visits, and unscheduled medical care if they meet any of the following criteria: 3

• hospitalization for asthma within the prior 12 months
• baseline FEV 1 , forced vital capacity (FVC), or FEV1/FVC <60% of predicted value;
• four or more canisters of short-acting beta-agonists dispensed in 12 months and any use of a systemic corticosteroid agent in the same 12-month period;
• 12 or more canisters of short-acting beta-agonists (or six or more prescriptions for these drugs) dispensed in a 12-month period.

Patients often underreport their nighttime symptoms …

Experience in the KP Northern California, Southern California, Northwest, Colorado and Hawaii Regions has shown that aggressive intervention in this group of asthmatic patients can improve clinical outcome and reduce cost.

Asthma Control

Goals of asthma management are listed in Table 3 . 2

Goals of asthma management

Asthma management includes both drug therapy and patient education 2, 4 and should also include a written action plan. 3

Drug Therapy

For all asthmatic patients, short-acting beta-agonists, such as albuterol, should be available as “rescue medication.” A metered-dose inhaler (MDI) is the most convenient and effective way to deliver albuterol. MDIs are preferred over air-powered nebulizers for ambulatory patients, including those seen in the emergency department as long as they do not potentially need intubation. Use of MDIs is more cost-effective than use of nebulizers, and MDIs use a much lower dose of medication to achieve results equal to those of nebulizers. Short-acting beta-agonists should be used only as needed. Regular dosing—except before exercise in those with exercise-induced bronchospasm—should be avoided. Someone who can teach this skill and who has experience observing patients using MDIs should instruct the patient in proper MDI technique. Experts recommend reviewing MDI technique with patients at least yearly. Use of one or more canisters a month should be recognized as a marker of poor asthma control. 3, 4 The cornerstone of drug therapy is use of inhaled corticosteroids. 3, 4

These “controller medications” can be given either by MDI or by dry powder inhaler (DPI). Newer MDIs deliver corticosteroid agents to the bronchial tree more effectively and use newer chemical propellants that are less harmful to the environment. 3 (A popular ICS option is Qvar as it is the least expensive ICS and thus the recommended first line ICS in most or all KP regions). All patients other than those with solely exercise-induced or mild, intermittent asthma need controller medication. Patients with moderate or severe persistent asthma should preferably use inhaled corticosteroid agents. Patients with mild, persistent asthma may respond well to cromolyn or nedocromil, but many of this subset of asthmatic patients will need inhaled corticosteroid agents. Patients should use the least amount that leads to absence of nocturnal cough and that eliminates the need for rescue medication or reduction in physical activity due to asthma. Most asthma experts recommend that patients begin therapy at a moderate or high dosage to gain control of symptoms, then taper to the lowest dosage needed to maintain asthma control.

Patients with moderate or severe persistent asthma should have oral prednisone available for emergencies.

Other Asthma Medications

In patients using inhaled corticosteroids with breakthrough symptoms (using albuterol two or more times per week or awakening with asthma symptoms two or more times per month) after four weeks of therapy, a long-acting beta-agonist, salmeterol (two puffs twice daily or two puffs only at bedtime if the only breakthrough symptoms are nocturnal), is added to the inhaled corticosteroid agent. This approach is more effective than increasing the steroid dosage (an alternative approach). 3

Leukotriene antagonists and theophylline have limited roles in treating asthma. In general, these medications are reserved for patients in whom asthma cannot be controlled by high dosages of inhaled corticosteroid agents and salmeterol. When these medications are used, their effect should be carefully measured to reduce both cost (when using a Leukotriene antagonist) and potential toxicity (when using theophylline). Specialty consultation should be strongly considered for patients who need these medications. 3

Smoking cessation is especially crucial for asthmatic patients. Smoking increases risk for development of emphysema in asthmatic patients and reduces efficacy of controller medications. 3

All patients with persistent asthma should have a written asthma action plan. 2–4 This plan should list signs and symptoms of worsening asthma and should recommend changes patients can make on their own to address moderate as well as severe exacerbations. Examples of written asthma action plans are available from several sources. 4

As in many chronic diseases, patients may not fully comply with their treatment plans. 3 The clinician should be alert to signs of noncompliance, such as an increasing number of requests to refill prescriptions for beta-agonists or underfilling inhaled corticosteroids; poor asthma control; and hospitalization or need for urgent medical care. If the use of computerized medical records is available, it can be of great value in checking for and in managing noncompliance. Clinicians who detect noncompliance should work with the patient in a nonjudgmental way to help improve compliance.

All patients with asthma should actively monitor their condition. Monitoring can be based on symptoms or on peak flow measurement. A peak flow-based plan may be more effective for patients who reliably measure peak flow daily. Patients monitoring peak flow should be instructed when and how to initiate and adjust their medication and when to visit their physicians or the emergency department.

Follow-up Care

All patients with asthma need regular monitoring by their medical practitioners. 3 Although studies have not determined the optimum frequency of this follow-up care, CMI and other expert panels have concluded that annual visits are appropriate for patients with well-controlled asthma and that more frequent visits are needed for patients with uncontrolled asthma. Follow-up care should be given within a week after an emergency department visit or hospitalization. Follow-up care should be given within four weeks after initiation of therapy or with any significant change in therapy and every two-to-four weeks thereafter until control is obtained. 2, 3

Specialty Referral

Specialty referral should be considered for any asthmatic patient who meets the criteria listed in Table 4 . 3

Criteria for specialty consultation for patients with asthma

All patients with persistent asthma should have a written asthma action plan. 2–4

Case Example: Treatment Approach

For the patient described earlier, the correct diagnosis is probably either chronic bronchitis or asthma. At 32 years of age, the patient is somewhat more likely to have asthma. Her medical history suggests episodic disease that resolves within a couple of weeks, but the clinician should seek confirmation of this diagnosis by seeking additional information about the patient's medical history. A history of nocturnal cough (even between exacerbations), other milder episodes of asthma, and history of allergy, rhinitis, and exposure to substances that precipitate these conditions would lend support to the diagnosis of asthma. Spirometry would be a very important test for confirming the presence of airflow obstruction and properly assessing asthma severity in this patient. A history of ongoing and nocturnal symptoms also would be used to establish asthma severity.

Current therapy can control asthma and may prevent development of irreversible airway changes …

Once a diagnosis of asthma is established and severity is estimated, the patient will need additional information explaining:

• the chronic nature of this disease
• the importance of asthma control
• the importance of ongoing monitoring, possibly including peak flow monitoring
• the need to identify and control exacerbating factors such as dust mites, animal fur and dander, and exposure to pollen; and
• the importance of regular follow-up visits with a single primary care physician.

The patient also needs to receive a firm message relaying the critical importance of smoking cessation to improve medication effectiveness, prevent recurrence, and decrease risk for emphysema. Appropriate support should be given in these smoking cessation efforts. If allergies seem to be a major contributor to asthma, referral for allergy testing should be considered.

For persistent asthma, the patient will need several years of treatment (or lifelong treatment) with a controller medication, the choice of which depends on disease severity. If an inhaled form of corticosteroid agent is given, the patient will need to use a spacer device in addition to rescue medication, typically albuterol, for use only as needed. Demonstration of proper MDI technique and reassessment of technique at the first follow-up visit are critical. The patient will benefit from following a written asthma action plan. This plan may be simple for intermittent asthma but more detailed for persistent asthma, especially if moderate or severe.

The patient must understand the importance of avoiding or eliminating exposure to substances that precipitate asthma flare-ups, and compliance with the treatment plan should be emphasized. Initial follow-up should occur after no more than four to six weeks.

Practice Tips

Asthma is an important chronic disease resulting in clinically significant morbidity, missed days of work or school, substantial costs for emergency care and hospitalization, and sometimes, death. Current therapy can control asthma and may prevent development of irreversible airway changes in asthmatic patients. Key points for diagnosis and treatment of asthma are summarized in Practice Tips.

CMI has recently completed an extensive, evidence-based revision of the adult asthma guideline 2 that provides up-to-date, useful information on asthma diagnosis, prognosis, and treatment. The guidelines also summarize current best practice and present detailed information about a wide variety of issues, including acute care, alternative types of therapy, and ineffective types of therapy. The guidelines include sections for special situations such as exercise-induced asthma and pregnancy. The full document is available on the KP Clinical Library Intranet site: http://cl.kp.org/pkc/national/cmi/programs/asthma/index.html .

Acknowledgments

I would like to thank Peter Cvietusa, MD, Allergist, at the Highlands Ranch Medical Office in Colorado and Patricia deSa, MS, a Care Management Consultant with the Care Management Institute in Oakland, CA, for revising and updating my original manuscript.

• Kaiser Permanente. Adult Asthma Care Management. Business Case, 2006–2008. Oakland, CA: Kaiser Permanente; 2006. [Internal document]. [ Google Scholar ]
• Kaiser Permanente Medical Care Program, Care Management Institute. CMI Pediatric Asthma Guidelines. August 2006.
• Kaiser Permanente Medical Care Program, Care Management Institute. CMI Asthma Guidelines [monograph on the Internet]. Oakland (CA): 2005 April. [cited 2006 Sep 12]. Available from: http://cl.kp.org/pkc/national/cmi/programs/asthma/index.html (password protected) [ Google Scholar ]
• National Heart, Lung, & Blood Institute, National Asthma Education and Prevention Program. Clinical practice guidelines. Expert panel report 2: Guidelines for the diagnosis and management of asthma [monograph on the Internet]. Bethesda (MD): National Institutes of Health, National Heart, Lung, and Blood Institute; 1997. [cited 2006 Sep 12]. (Update on selected topics 2002). Available from: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm . [ Google Scholar ]

173 Asthma Essay Topic Ideas & Examples

🏆 best asthma topic ideas & essay examples, 💡 interesting topics to write about asthma, 📑 good research topics about asthma, 📌 simple & easy asthma essay titles, 👍 good essay topics on asthma, ❓ research questions about asthma.

• SOAP Note for an Asthmatic Patient Today, asthma is known as one of the most common respiratory diseases in the United States, as well as in the whole world.
• Living With a Chronic Disease: Diabetes and Asthma This paper will look at the main effects of chronic diseases in the lifestyle of the individuals and analyze the causes and the preventive measures of diabetes as a chronic disease. We will write a custom essay specifically for you by our professional experts 808 writers online Learn More
• Child Asthma Emergency Department Visits: Plan for the Reduction The population of Central Harlem will be the target of this intervention that aims to decrease the rate of children’s asthma-related ED visits.
• Asthma in Pediatric and Occupational Therapy Treatment The flow peak is more than 80% of the child’s personal best, and less than 30% variability in the day-to-day flow of the peak measurements.
• Asthma Treatment Algorithm for Patients Complete the blanks in the following table to create an algorithm for asthma care using your textbook as well as GINA guidelines.
• Asthma: Pathophysiology, Etiology, Diagnosis, and Complications The pathobiology of asthma remains greatly indeterminate, and its pathophysiology involves abnormalities of the respiratory system organs, including the lungs and the bronchial tree.
• Asthma Exacerbation in Pregnancy The patient has a history of childhood asthma diagnosis, and she is presently exhibiting typical asthma symptoms like wheezing and a nonproductive cough.
• Asthma: Epidemiological Analysis and Care Plan 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.
• Asthma Diagnosis in Pregnant Women It may be essential to modify the type and dose of medication to compensate for the alterations in the female’s metabolism and the severity of her health condition.
• Healthy Lifestyle Interventions in Comorbid Asthma and Diabetes In most research, the weight loss in cases of comorbid asthma and obesity is reached through a combination of dietary interventions and physical exercise programs.
• Clinical Case of Asthma in African American Boy By combining the use of corticosteroids and exercises into the treatment plan, as well as educating the patient and his parents about the prevention and management of asthma attacks, a healthcare practitioner will be able […]
• Asthma From a Clinic Perspective And the prevalence of asthma in the European Union is 9. In UK and Ireland experience some of the greatest rates of asthma in the globe.
• Corticosteroids and Inhalants in Asthma As well as the causes of fatigue and physiological events during an asthma attack, and how the body compensates for an increase in CO2, with a focus on the effects of hypercapnia on the central […]
• The Treatment Modalities of Asthma However, in order to limit susceptibility to the triggers, the patient is advised to take long-term asthma medications on a daily basis.
• Asthma Diagnostics and Treatment According to the Asthma and Allergy Foundation of America, some of the most common symptoms of asthma include cough, wheezing, shortness of breath, chest tightness, and fainting.
• Asthma: Pathophysiology, Symptoms, and Manifestations The primary organ affected by asthma is the lungs, as the disease is caused by airway narrowing and the inability to breathe.
• Asthma: Description, Diagnosis and Treatment First of all, before discussing measures to prevent an increase in the case of the disease, it is necessary to understand the nature of the disease.
• Inflammation’s Role in Asthma Development This work is written in order to study the role of inflammation plays in the development of asthma on the basis of research papers.
• The Use of Tezspire: The Management of Asthma The brochure describes the use of Tezspire, which is a drug used for the management of asthma. The brochure’s target audience is patients with a long history of asthma and their family and caregivers.
• Asthma Treatment in Pediatric Patients: Spacer vs. Conventional Inhaler Computers and the Internet connection have become available to a considerable portion of the population, which equally serves as a facilitator of the new solution implementation.
• Physical Assessment Report for an 18-Years-Old Asthma Patient The boy and his family suspect that he is suffering frequent asthma attacks due to allergies to cold and dust, however none of his members of the family suffer from asthma.
• Use of Scientific Method in Asthma and Allergic Reactions Study As in the case of asthma and allergic reactions investigations, descriptive studies can be used to describe the nature of the relationship between asthma and asthma attack, therefore explaining the cause and effect.
• COVID-19 Susceptibility in Bronchial Asthma by Green et al. The research reflected in the article aims to trace the susceptibility of patients with bronchial asthma to coronavirus disease. It is noted that the receptors that respond to those occurring in the environment are the […]
• Exercise-Induced Asthma in Children The onset of an EIA attack follows a constriction of the airways of the patient after physical exercise. When water shifts from the cells of the epithelium to the airway surface, it causes a release […]
• The Child Asthma Emergency Department Visits The program makes it easy for medical caregivers to carry accurate assessments to pediatric patients. The program is easily scalable, and it is also sustainable, making 5A’s the best solution to Child Asthma Emergency Department […]
• Asthma Among Children of Color in New York City On the other hand, the conditioning of the matter to a particular scope hinders the determination of a rational scientific solution to the core issue.
• Asthma in Relation to Inability to Breathe: A Case Study The shortness of breath is known to be a primary cause of Asthma, whereas the asthmatic state of an individual also has the capabilities of influencing shortness of breath as a result of the lung […]
• Asthma Treatment Options, Long-Term Control, and Complications Speaking of the patient profile, the first aspects that should be mentioned are the peculiarities of asthma disease history and other health conditions that might affect the treatment pattern.
• Occupational Asthma: Case Discussion The primary diagnosis is occupational asthma; the causative agents of the indicated type of the disease are located directly at the person’s workplace.
• The Relationship Between Vitamin D Deficiency and Asthma Disease in Children The reaction of the host on the respiratory infections is closely correlated with the deficiency of the vitamin D [1]. This is because of the suggestion that providing vitamin D supplements to patients with low […]
• Asthma: Culture and Disease Analysis The cause of this condition is thought to be the narrowing of the person’s airways. This, as the experts explain, is a result of the inflammation of the airways in the lungs.
• Relationship Between Asthma and the Body Mass Index The optimal design of the study is the use of questionnaires, since the nature of the research requires the consent of individual respondents in form of writing.
• The Connection Between Asthma and Dust Emissions This is attributed to an increased rise of annual sandstorms and continued constructions that create a huge amount of dust in the air.
• Prevalence of Asthma Due to Climatic Conditions Newhouse and Levetin also conducted a study to find the correlation between the airborne fungal spores, the concentration of pollen, meteorological factors and other pollutants, and the occurrence of rhinitis and asthma.
• Helping African American Children Self-Manage Asthma The purpose of this critique is to analyze the weaknesses of the study. The title of the report Helping African American Children Self-Manage Asthma: The Importance of Self-Efficacy adequately identified the population of interest, namely […]
• Asthma Among the Japanese Population In a report by Nakazawa in which the author sought to determine the trend of asthma mortality among the Japanese population, emotional stress and fatigue emerged as the leading factors for the causation of asthma.
• Informed Consent – Ellen Roche, Asthma Study People interested in taking part in research trials have the right to know risks, benefits, procedures, the aim of the study, and protection of identity. This violation of subjects’ right led to the formation of […]
• Asthma Prevalence: Sampling and Confidence Intervals In the study which was carried out in United States in 2009 amongst the children and adults to show the prevalence of Asthma, a sample of 38,815 and confidence interval of 95% was used.
• Osteopathic Manipulation in Patients With Chronic Asthma This article seeks to criticise the application of osteopathic manipulation in the treatment of asthma patients. The focus is on the intervention of osteopathic manipulation therapy in restoring normal functioning and compliance to the thoracic […]
• 5-Year-Old With Asthma: Developmental Milestones & Care According to his mother, he also regularly grinds his teeth at night.G.J.was delivered normally and the mother had no complications. He could listen to instructions and get whatever he is being asked by his mother.
• Asthma Respiratory Disorder Treatment Asthma etiology is the classification of various risk factors responsible for causing asthma in children and adults. Asthma etiology is the scientific classification of risk factors that cause Asthma in children and adult.
• Genetics and the Asthma Case The allergies she complains of are some of the symptoms associated with asthma. Asthma is also known to attack children below the age of 15 years.
• Childhood Bronchial Asthma: Process & Outcome Measures The evidence that is used to support the adoption of this measure is the guideline on clinical practice, as well as the procedure of formal consensus.
• Biological Basis of Asthma and Allergic Disease The immunological response in asthmatic people fails in the regulation of the production of the Th2 cells and the anti-inflammatory cells.
• Asthma and Medications: The Ethical Dilemma in Treating Children One of the major causes of dilemma, however, is the inability to manage and treat the condition in children under the age of 7 years due to ethical dilemma.
• Educating the Elderly With Asthma The main objective of the given paper is to analyze the reasons of emergence of asthma among the elderly population, as well as research peculiarities of this group’s reaction to this condition as compared to […]
• Exercise-Related Asthma in the 21st Century The study has also reported that almost 48 % of parents recognize the fact that children suffering from asthma have higher probability of the emergence of the typical symptoms of IEB.
• The Nature and Control of Non-Communicable Disease – Asthma Asthma is caused due to the inflammation of the airways which in turn induces cough, wheezing, breathlessness and a feeling of tightness in the chest.
• Application: Asthma The features of the air passage include the bronchi, alveoli and the bronchioles. The pathophysiology of chronic and acute asthma exacerbation describes the process and stages that lead to airway obstruction.
• Asthma in School Going Youth: Effects and Management The control and prevention of adverse effects of asthma are goals of managing asthma as stated in the National Asthma Education and Preventive Program asthma treatment guidelines.
• Asthma in the African American Community The paper will also highlight the effects that the treatment options used by African Americans have on the prevalence of the disease.
• Asthma Definition and Its Diagnostics The geographical area plays a major role in the distribution of the prevalence of asthma and its predisposing factors. There is scientific evidence that the presence of a history of asthma in parents is a […]
• Foot Orthosis, Asthma & Benign Tumor It is a chronic inflammatory disorder of the airways, associated with the following symptoms: variable airflow obstruction and enhanced bronchial responsiveness to a variety of irritants.
• Asthma in School Children in Saudi Arabia The purpose of this paper is to review the current literature on asthmatic disease in Saudi Arabia to accurately determine the epidemiology nature of the condition through community assessment for purposes of compiling a health […]
• Usefulness of Acupuncture in Asthma Treatment The case for the effectiveness of acupuncture in the treatment of asthma is to be further supported by more research studies, since current and past research has been affected by a number of limitations or […]
• Hypertension, Asthma and Glaucoma The assignment of duties is also a difficult task since the victim is forgetful and disoriented, which in this case may lead to delays or failures within the working system.
• The Management of Asthma According to the Australian Bureau of Statistics, the country has the highest prevalence of Asthma in the world. Quick-relief medications are used to manage symptoms that come with acute attacks of asthma-like coughing, tightening of […]
• Treatment of Asthma in Australia The rapid-acting treatments are taken to quicken the process of reversing acute asthmatic attacks by causing the relaxation of the smooth muscles of the bronchial system. These preventers reduce the sensitivity of airways hence swelling […]
• The Asthma and Emphysema Analysis According to Kinsella and others, etiology of emphysema is often associated with smocking, and this led to the hypothesis that emphysema develops with age whereas asthma is mostly prevalent in children.
• Asthma: Causes and Treatment Effects of asthma are more pronounced mostly at night and early in the morning and this results in lack of sleep.
• Acute Asthma: Home and Community-Based Care For Patients It refers to the continuum of care extended to patients from the health facility to the community and homes. An asthma attack is fatal and patients should be encouraged to perform self-administration of medication.
• How Emotions Spark Asthma Attack Although stress and emotions are known to start in a patient’s mind, asthma in itself is a physical disease that affects the patient’s lungs, and stress can create strong physiological reactions which may lead to […]
• Asthma Is a Chronic Inflammatory Disorder Hence the main purpose of the study is to investigate the association of smoking and secondhand smoke with level of asthma control, severity, and quality of life among adult asthmatics.
• Asthma: Leading Chronic Illness Among Children in the US Ample communication was to be provided to the family, Head Start personnel and the Child’s physician in relation to the asthma. A great reduction was seen in the asthma symptoms and emergency.
• Dealing With Asthma: Controversial Methods Because of the enormous speed of the illness spread, dealing with asthma is becoming a burning issue of the modern medicine. This is due to the fact that the muscles of the broche lack the […]
• Social Determinants of Health: Asthma Among Old People in Ballarat On the other hand, Melbourne is the capital city of the State of Victoria with a population of 4 million people, making it the second most populated city in Australia. This is a great challenge […]
• Asthma Investigation: Symptoms and Treatment In patients with asthma, the condition causes the inflammation of air passages that is followed by the significant narrowing of airways.
• Severe Asthma: The Alair Bronchial Thermoplasty System The article focuses on asthma and the treatment that could alleviate the condition. Most of asthma patients are used to having an inhaler with them and this way, there is not much new technology, except […]
• Public & Community Health: Asthma in Staten Island There is borough of Bronx, which is considered to be the poorest, and the case with it has been stated here that asthma is the fate of the residents.
• Clinical Guidelines: Report on Asthma Guideline The guideline illustrates diagnostic procedures for assessment of severity and control of asthma based on presence of airway hypersensitiveness, reversibility of airflow, detailed medical history, respiratory tract, skin and chest examinations, spirometry to assess obstruction, […]
• Clinical Management of Complex Cases in Dentistry: Case of Hypertension With Asthma Understanding the role of various drug interactions and the effect of various drugs on the medical conditions of the patients is of valuable assistance.
• Health, Culture, and Identity as Asthma Treatment Factors She is the guardian of Lanesha and, despite raising another grandson and caring for her elderly mother, she is responsible for the health of the girl.
• The Anti-Inflammatory Role of IL-26 in Uncontrolled Asthma Research findings suggest that the suppression of IL-26 secretion in the lungs would alleviate the anti-inflammatory response associated with uncontrolled asthma.
• Nursing Informatics. Asthma: Health Literacy In the United States of America, bronchial asthma is one of the most common chronic diseases in children with the prevalence rate ranging from 6% to 9%.
• Asthma Pathophysiology and Genetic Predisposition The pathophysiology of this disorder involves one’s response to an antigen and a subsequent reaction of the body in the form of inflammation, bronchospasm, and airway obstruction.
• Asthma: Pathopharmacological Foundations for Advanced Nursing Practice Because of the high prevalence of asthma in the USA, mortality and morbidity rates in the country are also excessive. Asthma is one of the most common diseases in the USA, with high prevalence and […]
• Asthma as Community Health Issue in the Bronx The rate of people, especially children, with asthma in this area is among the highest ones in the city. The issue of asthma in New York and the Bronx, in particular, is connected to multiple […]
• Environmental Factors of Asthma in Abu Dhabi City A countrywide evaluation of the demises related to environmental pollution that takes a significant role in the rising cases of asthma shows UAE as the most affected nations since the discovery of oil in 1958 […]
• Occupational Asthma: Michelle’s Case The first test is not prohibitively expensive, and the patient should be able to afford it if she can pay for the medications.
• Asthma Patient’s Examination and Care Plan HPI: Being discharged from the facility ten weeks ago, the patient reports having shortness of breath, severe wheezing, and coughing. To control symptoms, the patient takes HTCZ and Enalapril.
• Obstructive Pulmonary Disease-Asthma Overlap The purpose of the research was to expand the current knowledge of the overlap syndrome in order to determine its prevalence and risk factors.
• Chronic Asthma and Acute Asthma Exacerbation The consequences of the smooth muscles’ tightening can be aggravated by the thickening of the bronchial wall due to acute edema, cellular infiltration, and remodeling of the airways chronic hyperplasia of smooth muscles, vessels, and […]
• Asthma and Stepwise Management The stepwise approach to asthma treatment and management is a six-step approach, according to which the number and the dose of medications and frequency of management are increased as necessary when symptoms persist and then […]
• Asthma, Its Diagnostics, Treatment and Prevention Hippocrates was the one who labeled the disease as asthma, a Greek word that was used to denote the idea of “wind or to blow”, perhaps an attempt to describe the wheezing sound produced by […]
• Asthma: Evidence-Based Pharmacological Treatment For instance, in children under 6, the development of the disease is typically preceded by the asthma-like symptoms that manifest themselves roughly at the age of three.
• The Evaluation of Evidence Linking Asthma With Occupation Overall, the results of this study supported the initial argument of the authors in regard to the need for frequent updates and modifications of JEMs in order for them to reflect the most relevant and […]
• Pregnant Woman’s Asthma Case The case mentions the decreased effectiveness of the fluticasone MDI that she uses which can also be a clue to her condition. Her patterns of MDI use in the last two months and the bronchospasm […]
• Asthma: Causes and Mechanisms The enlargement of the dense oesinophilic line near the bronchus/airways causes the individual to wheeze and gasp for air. The drugs are mainly used in the rapid opening of the bronchus to enable airflow into […]
• Healthcare: Childhood Asthma and the Risk Factors in Australia From the findings presented above, it is evident that childhood asthma remains a considerable burden in Australia due to socioeconomic, geographic, and health-related issues such as deprived neighbourhoods, decreasing sun exposure and increasing latitude, and […]
• Intubation and Mechanical Ventilation of the Asthmatic Patient in Respiratory The title of the article gives a clear idea of the research question to be investigated. The authors have detailed the processes of intubation and mechanical ventilation in patients with acute asthma.
• Asthma Environmental Causes This essay discusses the measures that can be taken to mitigate environmental causes of asthma. In the US, the government has developed a comprehensive strategy to mitigate environmental causes of asthmatic conditions in children.
• Asthma’s Diagnosis and Treatment The complete occlusion of the airway can lead to growth of a distal at the atelectasis in the lung parenchyma. The level of AHR is connected to the signs of asthma and the urgency of […]
• The Effects Of Asthma On Pregnant African Americans
• Urban Children and Asthma Care Barriers
• Asthma: Asthma and Nocturnal Asthma
• The Health Problem of Asthma in the United States of America
• Asthma: Chronic Inflamatory Obstructive Lung Disease
• Asthma and Food-Allergy Reactions
• Asthma And Exercise Asthmatic Asthmatics Breathing
• Automobile Emissions, Co And Asthma
• Asthma Control and Treatment in Racial and Ethnic Minorities
• Asthma Is The Most Common Chronic Disease Of The Airways
• Inflammatory Mediators Of Asthma And Histamines Biology
• The Impact of Asthma on the Respiratory System, Its Causes, and Treatment
• How Asthma Affects The Airway And Lungs
• Diet and Nutrition for Asthma in a Child
• Urban Asthma And The Neighborhood Environment
• Asthma And Its Pathophysiological Structure
• The Effects of Medication on the Increased Performance of Asthma Patients
• What Parents Need To Know About Asthma
• Employment Behaviors of Mothers Who have a Child with Asthma
• The Genetic and Environmental Components of Asthma
• The Influence of Asthma on the Lives of Students
• Children’s Elevated Risk of Asthma in Unmarried Families: Underlying Structural and Behavioral Mechanisms
• The Effects Of Environmental Tobacco Smoke Among Children With Asthma
• The Effects Of Air Pollution On Children ‘s Asthma Emergency
• Is Improper Use Of The Inhaler Related To Poor Asthma Control
• Asthma Symptoms, Diagnosis, Management & Treatment
• Limitations From Suffering Chronic Asthma
• Causes And Effect Of Allergies And Asthma
• Describe The Main Limitations Suffered By Those With Chronic Asthma
• The Symptoms, Causes and Diagnosis of Asthma
• Negligent: Asthma and Nursing Interventions
• The Signs, Causes and What Triggers Asthma
• The Routine Care for Patients with Coronary Heart Disease, Asthma, Stroke, Irritable Bowel Syndrome, Urinary Tract Infections, Diabetes, and Cervical Cancer
• The Role Of Nurse Management Asthma And School Health Program
• The Scope of Asthma in the General Population and on the Health Care System
• The Most Effective Treatment for an Asthma Exacerbation
• Pathophysiology Of Chronic Asthma And Acute Asthma
• The Use Of Vitamin D Asthmatic Children Effectiveness Of Vitamin Supplements In Childhood Asthma
• The Ways in Which the Symptoms of Asthma Can Be Reduced
• Measures to Minimize Environmental Causes of Asthma
• Inner City Adult Asthma Patients and Risk Factors
• Raising Awareness to Prevent the Rise of Asthma
• Planning and Intervention in the Disease Process of Childhood Asthma
• The Anatomy And Physiology Of Respiratory System And The Diagnosis Of Asthma
• The Causes and Effects of Asthma Sufferers
• The Application of Corticosteroids in the Management of Bronchial Asthma
• Salbutamol: History of Development in Asthma Drug Compounds
• Sensitization To Plant Food Allergens In Patients With Asthma
• The Diagnosis and Treatment of Otitis Media and Asthma
• The Discrepancy between Asthma Cases in Minority and White Communities
• The Chronic Illness in Children Known as Asthma
• Does Childhood Asthma Improve With Age?
• What Are the First Warning Signs of Asthma?
• Which Child Is at Greatest Risk for Asthma?
• What Is the Genetic Predisposition of Asthma?
• Can Occupational Therapy Help With Asthma?
• How to Ventilate Obstructive and Asthmatic Patients?
• What Is a Risk Factor Associated With Childhood Asthma?
• What Type of Approach Is Used in Asthma Management?
• What Is the Difference Between Asthma and Acute Asthma?
• What Are the Pharmacological Treatment of Asthma?
• How Is Asthma Diagnosed?
• Can Asthma During Pregnancy Affect Baby?
• What Are the Three Mechanisms Involved in Asthma?
• How Does Genetics and Environment Affect Asthma?
• How Long Does It Take To Recover From Asthma Exacerbation?
• What Factors Influence the Development of Asthma?
• What Is the Physiological Cause of Asthma?
• What Are the Statistics on Asthma in Australia?
• What Is the Most Serious Type of Asthma?
• What Ethnic Group Is Especially Likely to Have Childhood Asthma?
• What Is a Nursing Care Plan of an Asthmatic Patient?
• Does Asthma Cause Smooth Muscle Hypertrophy?
• Should People With Asthma Use a Humidifier?
• What Is Mechanical Ventilation Asthma?
• What Is the Most Common Allergen to Trigger Asthma?
• What Is the Main Physiological Cause of Asthma?
• What Percent of Asthma Is Caused by Smoking?
• How Long Does the Average Person With Asthma Live?
• Which Drug Is Safe for Asthma in Pregnancy?
• How Many People With Asthma Still Smoke?
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Essay on Asthma

Students are often asked to write an essay on Asthma in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Asthma

What is asthma.

Asthma is a health problem that affects your lungs. It makes it hard for air to move in and out of your lungs. This can make breathing difficult, and sometimes cause coughing, wheezing, or shortness of breath.

Causes of Asthma

Asthma can be caused by many things. Some people are born with it, and others develop it later in life. It can be triggered by things like dust, smoke, or pet hair. Some people also get asthma from exercise or cold air.

Symptoms of Asthma

People with asthma may have trouble breathing, cough a lot, or feel tightness in their chest. They may also get tired easily or have trouble sleeping because of their breathing problems.

Treatment of Asthma

Asthma can be treated with medicines. Some medicines help to open up the airways, while others reduce inflammation. It’s important for people with asthma to take their medicine as directed by their doctor.

Living with Asthma

Living with asthma can be tough, but it’s possible to live a normal life. People with asthma need to avoid triggers like smoke or dust, take their medicine, and see their doctor regularly.

250 Words Essay on Asthma

Asthma is a health problem that makes it hard for you to breathe. This happens because airways in your lungs swell up, fill with mucus, and get smaller. Some people say having asthma feels like trying to breathe out of a straw.

Asthma can be caused by many things. Some people get asthma because it runs in their family. Others might get it from things in the environment, like dust or smoke. Sometimes, it can even be caused by exercise or stress.

If you have asthma, you might cough, wheeze, or feel short of breath. Some people also feel tightness in their chest. It might be harder to breathe at night or after exercise.

Managing Asthma

Even though there is no cure for asthma, it can be managed. Doctors can give medicines that help the airways in the lungs to open up. This makes it easier to breathe. People with asthma also need to avoid things that can trigger their symptoms.

Living with asthma can be hard, but it doesn’t have to stop you from doing things you love. With the right care and management, people with asthma can lead normal, healthy lives. It’s important to talk to a doctor if you think you might have asthma. They can help you understand and manage it better.

In conclusion, asthma is a condition that affects your breathing but can be managed with the right care. If you have any of these symptoms, it’s important to see a doctor.

500 Words Essay on Asthma

Asthma is a sickness that affects your lungs. It makes it hard for you to breathe. If you have asthma, your airways, the tubes that carry air in and out of your lungs, become swollen and sensitive. They react strongly to things you are allergic to or find irritating. When your airways react, they get narrower, and less air flows through to your lung tissue. This causes symptoms like wheezing, coughing, chest tightness, and trouble breathing.

Asthma can be caused by many things. Some people are born with it, while others develop it as they grow up. It can often run in families, meaning if your mom or dad has asthma, you might get it too. Other things that can cause asthma include allergies, pollution in the air, and even exercise. Sometimes, the exact cause of asthma is not known.

Asthma can cause many symptoms. People with asthma often cough a lot, especially at night, which can make it hard to sleep. They may also wheeze, which is a whistling or squeaky sound that happens when you breathe. Other symptoms include feeling short of breath or having a tight feeling in the chest. Sometimes, asthma symptoms can get worse, which is called an asthma attack. During an asthma attack, the airways become even more swollen and the muscles around the airways can tighten, which can cause severe difficulty in breathing.

Asthma can’t be cured, but it can be managed. This means you can live a normal, healthy life even if you have asthma. Doctors often prescribe medicines to help control asthma. These medicines can reduce the swelling in your airways or help relax the muscles around your airways. Some medicines are taken every day to help control asthma, while others are taken only when needed, like during an asthma attack.

If you have asthma, there are things you can do to help manage it. Avoiding things that trigger your asthma, like certain foods or dust, can help. So can taking your medicine as your doctor tells you to. It’s also important to exercise regularly, as this can help keep your lungs healthy. If you have asthma, you should also have a plan for what to do if you have an asthma attack. This might include using a rescue inhaler, going to the hospital, or calling your doctor.

In conclusion, asthma is a common disease that affects many people. Although it can be scary and difficult to deal with, it can be managed with the right treatment and lifestyle changes. If you or someone you know has asthma, it’s important to understand the disease and how to manage it.

That’s it! I hope the essay helped you.

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Advances and recent developments in asthma in 2020

Affiliations.

• 1 Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland.
• 2 Christine Kühne-Center for Allergy Research and Education (CK-CARE), Davos, Switzerland.
• 3 Department of Medical Immunology, Institute of Health Sciences, Bursa Uludag University, Bursa, Turkey.
• 4 Faculty of Medicine, Division of Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey.
• 5 Department of Allergology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.
• 6 Swiss Institute for Bioinformatics (SIB), Davos, Switzerland.
• 7 Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China.
• 8 Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
• 9 Department of Regenerative Medicine and Immune Regulation, Medical University of Bialystok, Bialystok, Poland.
• 10 Faculty of Medicine, Transylvania University, Brasov, Romania.
• PMID: 32997808
• DOI: 10.1111/all.14607

In this review, we discuss recent publications on asthma and review the studies that have reported on the different aspects of the prevalence, risk factors and prevention, mechanisms, diagnosis, and treatment of asthma. Many risk and protective factors and molecular mechanisms are involved in the development of asthma. Emerging concepts and challenges in implementing the exposome paradigm and its application in allergic diseases and asthma are reviewed, including genetic and epigenetic factors, microbial dysbiosis, and environmental exposure, particularly to indoor and outdoor substances. The most relevant experimental studies further advancing the understanding of molecular and immune mechanisms with potential new targets for the development of therapeutics are discussed. A reliable diagnosis of asthma, disease endotyping, and monitoring its severity are of great importance in the management of asthma. Correct evaluation and management of asthma comorbidity/multimorbidity, including interaction with asthma phenotypes and its value for the precision medicine approach and validation of predictive biomarkers, are further detailed. Novel approaches and strategies in asthma treatment linked to mechanisms and endotypes of asthma, particularly biologicals, are critically appraised. Finally, due to the recent pandemics and its impact on patient management, we discuss the challenges, relationships, and molecular mechanisms between asthma, allergies, SARS-CoV-2, and COVID-19.

Keywords: COVID-19; asthma biomarkers; asthma phenotypes; biological therapeutics; comorbidities.

© 2020 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.

Publication types

• Asthma / diagnosis
• Asthma / epidemiology*
• Asthma / therapy
• Comorbidity
• Hypersensitivity / diagnosis
• Hypersensitivity / epidemiology*
• Hypersensitivity / therapy
• Precision Medicine
• Risk Factors

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• Open access
• 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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• Health care

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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DOI : https://doi.org/10.1038/npjpcrm.2014.63

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Asthma Research

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Over the years, and as part of our broader commitment to research on lung diseases, the NHLBI has led and supported asthma research to discover better prevention and treatment options. Research supported by the NHLBI has also helped us understand what leads to and affects asthma, and it has provided doctors with information about what treatments work best for people who have asthma. 

NHLBI research that really made a difference

For nearly 20 years, the NHLBI  Severe Asthma Research Program (SARP)  has transformed our knowledge of severe asthma. Research supported through the program has identified  secondhand smoke, pneumonia, and obesity as key risk factors for asthma . Studies have also found genetic variations linked with severe asthma and biomarkers for asthma severity. Researchers can  request access to the data on dbGaP .

Research funded by the NHLBI

Our  Division of Lung Diseases  and its  Airway Biology and Disease Branch  oversee much of the research on asthma we fund. The Asthma Program supports research related to asthma, including the role of inflammation in the development of asthma, genetics and asthma, and clinical management of asthma in adults and children.

Find  funding opportunities  and  program contacts  for asthma research.

Current research on asthma treatment

• How ventilators may lead to asthma: The NHLBI-funded Post-Vent study will use data collected from the Prematurity-Related Ventilatory Control (Pre-Vent): Role in Respiratory Outcomes NHLBI Collaborative Program to study long-term health outcomes of premature birth and intermittent low oxygen levels shortly after babies are born prematurely. These babies often develop asthma. This study will try to predict which premature babies are most likely to develop asthma. 
• Why medicines work: An NHLBI-funded study is assessing how an antibiotic called azithromycin (AZ) reduces severe wheezing in preschool children seen in the emergency room. While prior studies have shown that AZ benefits these children, it is unclear if the beneficial effects are because of the antibacterial activity of AZ or because of the anti-inflammatory activity of AZ. To help answer this question, this study will compare whether children with bacteria growing in their throats get more benefit from AZ treatment than children who do not have bacteria growing in their throats at the time they go to the emergency room with severe wheezing.
• Personalized medicine: The  Precision Interventions for Severe and/or Exacerbation Prone Asthma Network (PrecISE) is conducting clinical trials to identify personalized medicine approaches that treat severe asthma more effectively. It has established 30 locations nationwide that will test new and approved treatments based on each patient’s specific biology and biomarkers.

Find more NHLBI-funded studies on asthma treatment at NIH RePORTER. 

Learn about one PrecISE study that is looking at treatments that may help support people with severe asthma or asthma that hasn’t responded to traditional treatments: Personalizing treatment for severe asthma .

Current research on asthma biology

The different bacteria in a person’s body can affect the immune system. We support studies to figure out whether different bacteria play a role in developing certain types of asthma.

• Airway cells and asthma: NHLBI-funded research will look at how genes are regulated in airway epithelial cells to better understand how they affect the development of asthma. Epithelial cells line the lung’s airways. As researchers learn more about how changes in the cells lead to asthma, they hope to develop treatments to reprogram the epithelium and prevent or cure asthma and other lung diseases.
• Bacteria in the airways: An AsthmaNet  study found  different bacteria in the airways of people with asthma compared to those without asthma. Some of the observed differences could help predict the response to inhaled steroids. Researchers can  request the data  through our Biologic Specimen and Data Repository Information Coordinating Center.
• Targeted treatments for severe asthma: NHLBI-supported researchers are developing new and personalized approaches to treating severe asthma . The study builds on earlier research which led the researchers’ discovery of three mechanisms that are relevant to severe asthma.

Find more NHLBI-funded studies on asthma biology at NIH RePORTER.

Researchers have identified a key role for the circadian system — the biological clock that controls your sleep/wake cycle: Study of biological clock may explain why asthma worsens at night .

Current research on asthma disparities

African Americans are more likely to develop asthma and three times more likely to die from asthma-related causes than white Americans. Research on this topic is part our broader commitment to addressing  health disparities and inequities . 

• Genetic factors: The  Consortium on Asthma among African-Ancestry Populations in the Americas (CAAPA)  aims to discover genes that confer asthma risk among individuals of African ancestry and to study genetic diversity in populations of African descent. Read  some of the results here  or  request access to the data on dbGaP .
• Comprehensive care for at-risk children: We also fund the  Asthma Empowerment Collaborations to Reduce Childhood Asthma Disparities . We support clinical trials to evaluate programs that provide comprehensive care for children at high risk of poor asthma outcomes, such as low-income minority children. 
• Race, sex, and socioeconomic factors: The NHLBI recently launched the DECIPHeR program to study differences in heart and lung diseases among groups defined by race and ethnicity, sex and/or gender, and socioeconomic status. The first projects began in September 2020, with one project focused on asthma in children in Colorado.  Working with communities across the state, from rural to urban areas in Colorado, researchers will work with school-based asthma navigators and nurses to test a team approach to asthma control in school children in low-income areas.

Find more NHLBI-funded studies on  asthma and health disparities .

An NHLBI-funded study found that African-American boys, but not girls, with higher levels of BPA (Bisphenol A) tended to have more asthma symptoms: Study links exposure to higher levels of BPA plasticizer to more asthma symptoms in black boys .

Asthma research labs at the NHLBI

The  Laboratory of Asthma and Lung Inflammation , located within the  Pulmonary Branch , is focused on developing new treatment approaches for people with severe asthma. Headed by Stewart J. Levine, M.D., the lab’s researchers found a new biological pathway that leads to asthma. They continue to study this pathway, as well as an important molecule in it called apolipoprotein E (ApoE).

“By studying the pathways of the disease, we identified a new biological mechanism that leads to asthma,” explained Stewart J. Levine, M.D. Read the research feature: Disease pathways lead to possible new treatment for severe asthma .

Learn about research opportunities in the lab:

• Post-doctoral Fellowship on Apolipoprotein Pathways in Asthma  
• Graduate Medical Education (GME): NHLBI/UMD Pulmonary-Critical Care Fellowship  

Related asthma programs and guidelines

• The NAEPP’s  Expert Panel Report 4 (EPR-4) Working Group  was established in 2018 to update the 2007  Guidelines for the Diagnosis and Management of Asthma (EPR-3) in focused topic areas. The working group members reviewed the latest research to update the guidelines on treatments and management of asthma, including the role of immunotherapy, the effectiveness of indoor allergen reduction, and the use of fractional exhaled nitric oxide (FeNO). Read  Asthma Management Guidelines: Focused Updates 2020 .
• Learn More Breathe Better®  is a national health education program for asthma, COPD, and other lung and respiratory diseases. The program raises awareness about asthma and other lung conditions and supports the promotion, implementation, and adoption of evidence-based care.  Learn More Breathe Better® Asthma offers a  series of asthma handouts  to patients and caregivers, including tips for talking to your doctor. 
• Since 1989, the  National Asthma Education and Prevention Program (NAEPP)  has worked with medical associations, voluntary health organizations, and community programs to educate patients, healthcare professionals, and the public about asthma.
• The Lung Tissue Research Consortium (LTRC)  provides human lung tissues to qualified investigators for use in their research. The program enrolls patients who are planning to have lung surgery, collects blood and other clinical data from these donors, and stores donated tissue that otherwise would be discarded after the lung surgery. The LTRC provides tissue samples and data at no cost to approved investigators.

Explore more NHLBI research on asthma

The sections above provide you with the highlights of NHLBI-supported research on asthma. You can explore the full list of NHLBI-funded studies on the NIH RePORTER .

To find more studies:

• Type your search words into the  Quick Search  box and press enter. 
• Check  Active Projects  if you want current research.
• Select the  Agencies  arrow, then the  NIH  arrow, then check  NHLBI .

If you want to sort the projects by budget size — from the biggest to the smallest — click on the  FY Total Cost by IC  column heading.

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What to know about asthma and air pollution

Air pollution may worsen asthma symptoms and trigger asthma attacks. Exposure to air pollution when their mother was pregnant and in childhood may also increase a person’s risk of developing asthma. Monitoring air pollution levels can help asthmatics avoid health effects.

People with asthma have airways that are sensitive to various substances, or triggers, in the air. Air pollution and other airborne irritants are among the most common asthma triggers.

Air pollution is the presence of pollutants in the air that are hazardous to humans and other living things.

This article explores how air pollution affects asthma and what people with asthma should know about air pollution.

How does air pollution affect asthma?

Research suggests that air pollution at high concentrations may trigger asthma flares because it inflames and irritates the lining and receptors in a person’s airways. This causes the airways to tighten and swell, a common symptom of asthma.

Air pollution also contains substances that are toxic to the respiratory tract. Exposure to certain pollutants can trigger oxidative stress, a feature seen in severe asthma .

Oxidative stress is a condition where there are too many unstable molecules, known as free radicals , in the body and not enough antioxidants (substances that prevent cell damage) to get rid of them.

It can lead to tissue damage, such as from inflammation and hyperresponsiveness, in a person’s airways. Airway hyperresponsiveness is when a person’s airways are more sensitive to stimuli, such as pollutants, and narrow too much in response.

Ozone, a common air pollutant, triggers asthma attacks and makes it difficult to breathe deeply, as well as reducing lung function.

Learn more about the types and causes of asthma here .

Does air pollution cause people to develop asthma?

A 2020 review suggests that indoor and outdoor air pollution can contribute to the development of asthma.

The effects of oxidative stress due to air pollution can cause genetically susceptible people to develop asthma.

Exposure to traffic-related air pollution (TRAP), particularly during the second trimester of pregnancy, also has links with an increased risk of asthma development in children.

Childhood exposure to TRAP also increases the risk of asthma. A 2020 study found that exposure to air pollution early in life increased a person’s risk of developing asthma from childhood to early adulthood.

A mother’s exposure to secondhand smoke and maternal smoking may also increase an unborn infant’s risk of developing asthma, but genetic predisposition can also play a role.

Read more about the effects of air pollution on pregnancy here .

Which air pollutants affect asthma?

The types of air pollutants that can affect asthma are as follows :

Particulate matter (PM2.5) consists of tiny particles of solids and liquids in the air. These particles can include :

Fine PM2.5 particles typically deposit throughout the respiratory tract, particularly in a person’s small airways and alveoli — tiny air sacs in the lungs.

Larger (coarse) particulate matter mainly deposits in the upper airways. Examples are organic debris from soil, road dust and metals, and roadway particles such as brake wear.

A 2017 study found that those with exposure to coarse particulate matter were more likely to develop asthma and need hospitalization or emergency visits.

Learn more about how the respiratory system works here.

Case studies

Researchers have conducted numerous studies on the association between air pollution and asthma.

A 2017 study found that exposure to specific components of TRAP had a positive association with asthma onset.

Findings from a retrospective study show that air pollution is an independent risk factor for exacerbating asthma in the absence of viral infections.

A study in Denmark found that children with exposure to higher levels of PM2.5 are more likely to develop persistent wheezing and asthma.

Learn more about how pollution from traffic increases death risk here.

What can I use to monitor air quality?

The United States Environmental Protection Agency (EPA) monitors air pollution levels using the Air Quality Index (AQI). AQI levels of 101 or higher are dangerous to people with asthma, but even AQI levels of 50–100 can worsen asthma symptoms.

People with asthma can get more information on the quality of air where they live from AirNow.gov . Many local weather forecasts also warn the public of high air pollution.

Various states and cities across the U.S. also call Action Days when AQI levels are at concerning levels. These levels are as follows:

Learn more about how air pollution can affect health here.

Tips for protection from air pollution

The American Lung Association advises people to take the following steps:

• Check for daily air pollution forecasts in TV weather reports, radio, online, and in newspapers.
• Avoid going outdoors when air pollution is high.
• Avoid exercising near high-traffic areas.
• Use less energy in the home because generating electricity and other energy sources creates air pollution.
• Look for alternatives to driving a car, such as using public transportation, carpooling, walking, or riding a bike.
• Do not burn trash or wood.
• Keep public places tobacco-free, and do not smoke indoors.

When to speak with a doctor

People with asthma can speak with a healthcare professional about the possibility of increasing their medication when air pollution is high. A person can include this in their own or their children’s asthma action plan.

A person should contact a healthcare professional immediately if they experience :

• feeling faint, weak, or dizzy
• finding it challenging to perform their usual routines
• a cough that does not go away
• wheezing , especially if it is different from their usual breathing pattern
• wheezing that does not get better even after taking medications

Frequently asked questions

Here are some common questions about air pollution and asthma.

Which climate is worst for asthma?

Extreme weather and sudden weather changes can irritate the airways. Some types of weather that can trigger asthma symptoms are:

• hot and humid weather
• thunderstorms
• weather conditions with cold, dry air

Learn about other common asthma triggers here .

What are the potential sources of indoor air pollution?

There are many potential sources of indoor air pollution. They typically release gas or particles and include :

• tobacco products
• building materials and furnishings, such as flooring, upholstery, or insulation containing asbestos
• humidification devices and central cooling and heating systems
• personal care and hobby products
• household cleaning products
• excess moisture
• outdoor pollution, such as pesticides and radon

Air pollution is a significant contributor to the development of asthma. It can also trigger and worsen symptoms in people with asthma.

It is vital for people with asthma to stay informed of air pollution levels and take necessary precautions to avoid triggering asthma attacks.

They should also talk with a healthcare professional if they experience any signs that their asthma is worsening.

Last medically reviewed on March 31, 2023

• Respiratory
• Environment / Water / Pollution

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Opinion Guest Essay

An Idyll on the Shores of a Toxic Lake

Supported by

Text by Jaime Lowe

Photographs by Nicholas Albrecht

Ms. Lowe is the author of, most recently, “Breathing Fire: Female Inmate Firefighters on the Front Lines of California’s Wildfires.” Mr. Albrecht is a photographer based in Oakland, Calif.

• March 29, 2024

There are two ways to experience the town of Bombay Beach, Calif., as a visitor: gawk at the spectacle or fall into the vortex. Thousands of tourists cruise through each year, often without getting out of their cars to see decaying art installations left over from an annual mid-March gathering of artists, photographers and documentarians known jokingly as the Bombay Beach Biennale. When I went to the town for the first time in 2021, I was looking for salvation in this weird desert town on the Salton Sea south of Palm Springs and Joshua Tree National Park. I dropped in, felt vibes and left with stories. I stared at the eccentric large-scale art, posted photos on Instagram of ruin porn and a hot pink sign on the beach that said, “If you’re stuck, call Kim.” I posed in front of a mountain of painted televisions, swung on a swing over the edge of the lake’s retreating shoreline and explored the half-buried, rusted-out cars that make up an abandoned ersatz drive-in movie theater. On that trip, it felt as if I were inside a “Mad Max” simulation, but I was only scratching the surface of the town.

I returned in December to try to understand why Bombay Beach remains so compelling, especially as extreme weather — heat, hurricanes and drought — and pollution wreak ever more intense havoc on it. Summer temperatures can reach 120 degrees Fahrenheit, tremors from the San Andreas Fault strike regularly, bomb testing from nearby military facilities can be heard and felt, and the air is so toxic from pesticide use, exhaust fumes, factory emissions and dust rising from the retreating Salton Sea that one study showed asthma rates among children in the region are three times the national average. By the end of the decade, the Salton Sea, California’s largest inland body of water, at about 325 square miles, may lose three-quarters of its volume; in the past 20 years, the sea’s surface area has shrunk about 38 square miles .

But people who live in Bombay Beach stay because the town offers a tight-knit community in the midst of catastrophe. Though its residents contend with environmental adversity on a daily basis, they’re also demonstrating how to navigate the uncertain future we all face — neglect, the fight for scarce resources, destruction of home, the feeling of having no place to go. They are an example of how people can survive wild climate frontiers together.

The 250 or so town residents live in the low desert on the east shore of the Salton Sea, which formed in 1905 when the then-flush Colorado River spilled into a depression, creating a freshwater lake that became increasingly saline. There used to be fish — mullet and carp, then tilapia. In the 1950s and ’60s, the area was marketed as a tourist destination and was advertised as Palm Springs by the Sea. More tourists visited Bombay Beach than Yosemite. There were yacht clubs, boat races and water skiing. It became a celebrity magnet: Frank Sinatra hung out there; so did the Beach Boys and Sonny and Cher.

Eventually, as agricultural runoff kept accumulating in a body of water with no drainage, it became toxic and created a lake with salinity that is now 50 percent greater than that of the ocean. In the 1980s, dead fish washed up on the sand, car ruins rusted in the sun, tires rotted on the shore. Tourism vanished. But some in the community hung on. One way to define Bombay Beach is through environmental disaster, but another way is as an example of how to live through disaster and how to live in general.

Candace Youngberg, a town council member and a bartender at the Ski Inn, remembers a very different Bombay Beach. When she was growing up in the 1980s, she’d ride bikes with neighborhood children and run from yard to yard in a pack because there were no fences. But over time, the town changed. With each passing year, she watched necessities disappear. Now there’s no gas station, no laundromat, no hardware store. Fresh produce is hard to come by. A trailer that was devoted to medical care shut down. In 2021, 60.9 percent of Bombay Beach residents lived below the poverty line, compared with the national average of 12.6 percent.

As painful as it was to witness the town of her youth disappear and as deep as the problems there go, Ms. Youngberg admits that adversity bonded those who stayed. She wanted to return Bombay Beach to the version of the town she remembered, to recreate a beautiful place to live year-round, not just in winter, not just during the art season, not just for the tourists posing in front of wreckage. She wanted people to see the homes, the town, the community that once thrived thrive again. With the art came attention and the potential for more resources. She got on the Bombay Beach Community Services District, a town council, and started to work toward improvements like fixing the roads and planting trees to improve air quality.

It might just be that Bombay Beach is a small town, but when I visited last winter, there was something that felt more collaborative, as though everybody’s lives and business and projects overlapped. I’m not sure the community that’s there now started out as intentional, but when fragmented groups of people come together as custodians of an enigmatic space, responsible for protecting it and one another, community is inevitable. Plus, there’s only one place to socialize, one place to gossip, one place to dance out anxiety and only about two-thirds of a square mile to wander. Whether you like it or not, your neighbors are your people — a town in its purest form.

When I was there, I walked the streets with Denia Nealy, an artist who goes by Czar, and my friend Brenda Ann Kenneally, a photographer and writer, who would shout names, and people would instantly emerge. A stranger offered a handful of Tater Tots to Czar and me in a gesture that felt emblematic: Of course a complete stranger on an electric unicycle would cruise by and share nourishment. I was given a butterfly on a stick, which I carried around like a magic wand because that seemed appropriate and necessary. I was told that if I saw a screaming woman walking down the street with a shiv in her hand, not to worry and not to make eye contact and she’d leave me alone; it was just Stabby. There was talk of the Alcoholics Anonymous meeting on the beach, the weekly church sermon led by Jack the preacher (who is also a plumber), a potluck lasagna gathering.

Last year Ms. Kenneally created a trash fashion show/photo series for the Biennale in which she created couture designs out of trash collected from the beach, enlisted regulars in town to model the outfits, then photographed them. (She exhibited a similar series at this year’s festival as well.) The work was a way to showcase the people and the place. Jonathan Hart, a fireworks specialist who slept on the beach, posed like a gladiator; a woman who normally rode through town with a stuffed Kermit the Frog toy strapped to her bike was wrapped in a clear tarp and crown, looking like royalty emerging from the Salton Sea. The environment was harsh, the poses striking. Each frame straddled the line between glamour and destruction but also showcased a community’s pride in survival. Residents were undaunted by the armor of refuse; in fact, it made them stronger. The detritus, what outsiders might think of as garbage, became gorgeous. The landscape that is often described as apocalyptic became ethereal and magical. And that’s because it is.

On my second day, we went down to the docks at noon, and I found myself sitting on a floral mustard couch watching half a dozen or so people taking turns riding Jet Skis into the sun. The sun was hot, even though it was the cool season. Time felt elastic. Mr. Hart told me that he and some friends had fixed up the water scooters to give everyone in town the chance to blow off some steam, to smile a little. It had been a rough couple of months in the region. In preparation for Hurricane Hilary, which hit Mexico and the southwestern United States last August, 26 volunteers made 200 sandbags and delivered them door to door. Neighbors helped secure as many structures as possible.

Most media outlets reported that the hurricane was downgraded to a tropical storm because that’s the weather system that hit Los Angeles, but it was close to a hurricane in Bombay Beach, with winds hitting 60 miles per hour, and most properties were surrounded by water. Roofs collapsed or blew away entirely. “When faced with something like that, they were like, ‘Boom, we’re on it,’” Ms. Youngberg told me. They were together in disaster and in celebrating survival.

It reminded me of the writer Rebecca Solnit’s book “A Paradise Built in Hell,” which considers the upside to catastrophe. She finds that people rise to the occasion and oftentimes do it with joy because disaster and survival leave a wake of purposefulness, consequential work and community. Disasters require radical acts of imagination and interaction. It seemed that because Bombay Beach lived hard, surviving climate catastrophes like extreme weather on top of everyday extremes, it celebrated even harder. It seemed that in Bombay Beach there’s enough to celebrate if you just get through the day, gaze at the night sky and do it all again in the morning.

A lot of the residents who live there now arrived with trauma. Living there is its own trauma. But somehow the combination creates a place of care and physical and emotional presence. People experience life intensely, as one. It’s a town that is isolated, but in spite of a loneliness epidemic, it doesn’t seem so lonely to be there. I felt unexpected joy in what, from everything I’d read from afar, was a place that might as well have been sinking into the earth. I felt so safe and so happy that if we had sunk into the earth together, it wouldn’t have felt like such a bad way to go.

On my last night in Bombay Beach, I went to the Ski Inn, a bar that serves as the center of all social activity. I’d been in town for only two days, and yet it felt as if I’d been to the Ski Inn a million times, as if I already knew everyone and they knew me. A band was playing, we danced and drank, and I forgot about the 8 p.m. kitchen cutoff. The chef apologized, but he’d been working since 11:45 a.m. and had already cleaned the grill and fryer. He’d saved one mac and cheese for the bartender, and when she heard I hadn’t eaten, she offered to split it with me, not wanting me to go hungry or leave without having tried the mac and cheese.

Bombay Beach is a weird place. And this was an especially weird feeling. I had been instantly welcomed into the fold of community and cared for, even though I was a stranger in a very strange land.

I realized I didn’t want to leave. There were lessons there — how to live with joy and purpose in the face of certain catastrophe, how to exist in the present without the ever presence of doom. Next time, I thought, I’d stay longer, maybe forever, and actually ride a Jet Ski.

Jaime Lowe is a Knight-Wallace journalism fellow at the University of Michigan and the author of, most recently, “Breathing Fire: Female Inmate Firefighters on the Front Lines of California’s Wildfires.” Nicholas Albrecht is a photographer based in Oakland, Calif. His first monograph, “One, No One and One Hundred Thousand,” was the culmination of a multiyear project made while living on the shores of the Salton Sea.

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