FFinalistSouthampton · 2027
Respiratory
AKT · Respiratory/Airways disease

Asthma

Chronic reversible airway inflammation + bronchial hyperresponsiveness (type 2/eosinophilic in most)

Overview

A chronic inflammatory airway disease with reversible airflow obstruction and bronchial hyperresponsiveness. It presents with episodic wheeze, cough and breathlessness with diurnal variation (worse at night/early morning) and triggers. NICE/BTS/SIGN 2024 (NG245) made anti-inflammatory reliever (AIR) and MART the backbone — SABA-only treatment is OUT. Recognising and grading an acute attack (especially life-threatening features) is the high-yield emergency skill.

Recognise

  • Episodic wheeze, cough, chest tightness and breathlessness with diurnal variation (worse at night/early morning) and triggers (cold, exercise, allergens, NSAIDs/beta-blockers)
  • Atopy (eczema, allergic rhinitis), family history; widespread polyphonic expiratory wheeze; reduced PEF with variability
  • Acute severe: PEF 33–50%, RR ≥25, HR ≥110, can't complete sentences. LIFE-THREATENING: PEF <33%, SpO2 <92%, silent chest, cyanosis, exhaustion, bradycardia/hypotension, a NORMAL/rising CO2

Red flags

  • Life-threatening features (silent chest, SpO2 <92%, exhaustion, normal/rising PaCO2) → ITU/anaesthetic involvement — a normalising CO2 in an asthma attack is OMINOUS, not reassuring
  • Near-fatal asthma (raised PaCO2 / needing ventilation) → critical care

Differentials & how to tell them apart

COPDolder smoker, fixed/minimally-reversible obstruction, less diurnal variation, low diffusing capacity
Bronchiectasischronic productive cough/large sputum volumes, recurrent infections, HRCT tramlines
Heart failure ('cardiac asthma')orthopnoea, raised JVP, bibasal crackles, raised BNP
Vocal cord dysfunction / inhaled foreign bodyinspiratory stridor / sudden onset, focal signs

Investigations

Diagnosis (NG245): FeNO + blood eosinophils first; if inconclusive, spirometry with bronchodilator reversibility, then PEF variability/challenge testing. Acute: PEF (% predicted/best), SpO2, ABG (a normal/high CO2 is a red flag), CXR (exclude pneumothorax/infection).

Management

As-needed low-dose ICS/formoterol (AIR) → MART (NG245); acute → O2 + salbutamol + steroid

  1. 1Diagnose with FeNO + eosinophils (then spirometry/reversibility/PEF variability). Start the NG245 ladder: as-needed low-dose ICS/formoterol (AIR), stepping to low- then moderate-dose MART; SABA-only is no longer acceptable (a LABA is never used without an ICS).Gate: Before stepping up, check adherence and inhaler technique; acute attack → grade it (moderate/severe/life-threatening) and treat with oxygen + salbutamol + steroids.
  2. 2Acute severe/life-threatening → nebulised salbutamol + ipratropium, IV magnesium, senior/ITU input. A NORMAL or rising PaCO2 in an acute attack is life-threatening (the patient is tiring) — not reassuring.
NG245 ladder: as-needed low-dose ICS/formoterol (AIR) FIRST → low-dose MART → moderate-dose MART — anti-inflammatory reliever replaces SABA-only; MART = a single ICS/formoterol inhaler as both maintenance and reliever
Add-on for uncontrolled disease: LTRA (montelukast) and/or LAMA; then specialist (biologics) — escalate after checking adherence/inhaler technique; never a LABA without an ICS
Acute attack: oxygen (target 94–98%) + nebulised salbutamol + oral/IV steroid (prednisolone/hydrocortisone) ± ipratropium ± IV magnesium — the OSHITME bundle; steroids in all acute attacks; escalate to ITU if life-threatening
Avoid triggers; beta-blockers and NSAIDs can precipitate attacks — and check inhaler technique/adherence at every review

Key points

Episodic wheeze + diurnal variation + atopy/triggers = asthma → NG245: as-needed low-dose ICS/formoterol (AIR) then MART; SABA-only is OUT, LABA never without ICS. Acute attack: grade it; treat all with steroids; a NORMAL/rising PaCO2 = life-threatening (tiring) → ITU.

Monitor & prognosis

Symptom control/exacerbations, PEF, inhaler technique/adherence, steroid use; FeNO/eosinophils for biologic eligibility.

Most well-controlled on inhaled therapy; poor adherence/technique drives exacerbations and deaths.

Source: NICE/BTS/SIGN NG245 (asthma)