Diagnosis
Asthma is an inflammatory condition characterised by variable airflow limitation accompanied by typical symptoms of wheeze , breathlessness , cough and chest tightness . 2 These features are often episodic and occur in response to triggers , such as inhaled allergens , viral infections , exercise , and certain medications such as beta blockers and NSAIDs .
The diagnosis requires confirmation of variable airflow obstruction by demonstration of spirometry evidence of bronchodilator reversibility , demonstration of peak flow variability or evidence of bronchial reactivity via provocation testing .
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FEV1 after four weeks of ICS treatment can also confirm the diagnosis . 2 If a patient is already established on an ICS , repeat spirometry after cautious withdrawal of preventer therapies should be considered . Bronchial provocation testing represents a definitive test that can also be an effective way to rule out the diagnosis of asthma . 3
The importance of confirming the diagnosis is twofold : to avoid excessive use of preventer therapies and to ensure alternative diagnoses are not being missed .
Many conditions can coexist with or mimic asthma and give the incorrect impression of severe disease . In adults , these may include chronic upper airway
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of salbutamol and ICS or oral corticosteroids
, which is not without risks .
Management
Goals
Once a diagnosis of asthma is established , the goals of care are to control symptoms and mitigate the risk of future adverse events , including asthma exacerbations , airway remodelling and medication side effects . 2 Preventing asthma exacerbations is of particular importance as these events can be associated with future exacerbation risk , lung function decline , significant corticosteroid burdens , social and economic disruption and mortality . 4 Specific
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Persistent symptoms or exacerbations despite high-dose ICS therapy should prompt referral to specialist care , where advanced pharmacological therapy and multidisciplinary care can be facilitated .
traits that are independent risk factors for asthma exacerbations include insufficient ICS therapy ; high SABA use ( ≥3 200- dose canisters a year ); poor adherence to preventers or incorrect inhaler technique ; smoking , including e-cigarettes ; and comorbidities , such as obesity , chronic rhinosinusitis , gastro-oesophageal reflux , food allergy and mood disorders . 5 , 6 A low FEV1 ( less than 60 % predicted ) is also a risk factor for exacerbations , as is elevation of markers of eosinophilic inflammation , such as blood eosinophils and fractional exhaled nitric oxide ( FeNO ). 2 These risk factors are all potential targets for intervention and should be actively screened for and managed where possible .
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General approach As our understanding of asthma evolves , we now appreciate the role of airway inflammation as the primary driver — rather than the mechanical effects of bronchoconstriction . This is reflected in the place of corticosteroids as the cornerstone of asthma management . ICS decrease the risk of asthma exacerbations , improve symptom control and reduce asthma-related death . This therapy is now recommended for all patients with asthma . 7 , 8
Recent society guidelines now discourage the use of SABA therapy alone . Either an ICS – formoterol combination as needed or a regular low-dose ICS plus SABA as needed are the preferred options for mild asthma . 2 This is based on recent evidence demonstrating ICS – formoterol combinations are superior to SABA alone at reducing severe exacerbations . 9
Patients with mild asthma , characterised
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