Asthma is a chronic inflammatory airway disease that looks different from client to client. Wheeze, breathlessness, chest tightness, and cough come and go and change in severity, and so does the degree of airflow obstruction. Unlike COPD, the obstruction is largely reversible, on its own or with treatment.

Three linked processes narrow the airway

Repeated inflammation can cause airway remodeling (thickened basement membrane, smooth muscle hypertrophy), which makes some limitation persistent. Air is trapped behind narrowed airways, producing hyperinflation and ventilation–perfusion mismatch.

Common triggers

• Viral respiratory infections (the most common trigger of exacerbations, especially in children)
• Allergens: house dust mites, animal dander, cockroaches, pollen, molds
• Tobacco smoke, air pollution, strong odors, occupational exposures
• Exercise and cold, dry air (exercise-induced bronchoconstriction)
• Drugs: aspirin and other NSAIDs in sensitive clients (NSAID-exacerbated respiratory disease), nonselective beta-blockers (including eye drops)
• Gastroesophageal reflux, emotional stress, menstruation, pregnancy

Risk factors for poor outcomes: prior intubation or ICU admission for asthma, frequent SABA use (for example, more than one 200-dose canister per month), no ICS, poor adherence or incorrect inhaler technique, smoking, obesity, and psychosocial problems.

Subjective

• Episodic shortness of breath, chest tightness, cough (often worse at night or early morning)
• Symptoms after exercise, allergen exposure, laughing, or colds
• History of atopy (allergic rhinitis, eczema), family history

Objective during an attack

• Expiratory wheeze on auscultation is the classic finding; the expiratory phase is prolonged
• Tachypnea, tachycardia, use of accessory muscles, tripod positioning
• Speaks in phrases or words rather than sentences as severity increases
• Anxiety, restlessness
• Hyperresonance on percussion

Signs of a life-threatening attack

• "Silent chest" — diminished or absent breath sounds because airflow is too low to produce a wheeze. Disappearance of wheezing in a deteriorating client is not improvement
• Drowsiness, confusion, cyanosis, exhaustion
• SpO₂ below 90%, bradycardia, hypotension
• Normal or rising PaCO₂ during an attack (early attacks cause hyperventilation with low PaCO₂; a "normal" value means the client is tiring)

Symptom control assessment (past 4 weeks)

0 = well controlled; 1–2 = partly controlled; 3–4 = uncontrolled. Clients with a well-controlled pattern have no night waking and no activity limitation — occasional night symptoms do not meet the definition. Control is assessed separately from risk of future exacerbations.

PEF meter technique: move the indicator to zero, stand up, take the deepest breath possible, seal the lips around the mouthpiece, and blow out as hard and fast as possible. Do this 3 times and record the highest value, not the average.

PEF zones (action plan): green ≥ 80% of personal best; yellow 50–79% (use reliever, follow plan, contact provider); red < 50% (use reliever and seek emergency care).

Current treatment principle (GINA): every adult and adolescent with asthma should receive an ICS-containing treatment. SABA-only treatment is no longer recommended for adults and adolescents, because regular or frequent SABA use without ICS increases the risk of severe exacerbations and death. This is a common area where older question banks are outdated.

Two treatment tracks (adults and adolescents)

• Track 1 is preferred because it reduces severe exacerbations compared with a SABA reliever.
• Formoterol is used as reliever because it has a fast onset. Other LABAs (e.g., salmeterol) are not used as relievers.
• A LABA must never be used alone in asthma — always combined with ICS.
• Review control, inhaler technique, and adherence before stepping up; step down after about 3 months of good control.
• Biologics (step 5, severe asthma): anti-IgE (omalizumab), anti-IL-5/5R (mepolizumab, benralizumab, reslizumab), anti-IL-4Rα (dupilumab), anti-TSLP (tezepelumab), and newer long-acting anti-IL-5 agents. Given by injection; watch for injection-site reactions and anaphylaxis (observe after injection as per protocol).

Drug safety

Acute exacerbation

1. Inhaled SABA by pMDI with spacer (or nebulizer), reassessing after each dose and avoiding unnecessarily high cumulative doses; ipratropium added for severe attacks. In mild exacerbations, ICS-formoterol is an alternative reliever.
2. Oxygen if SpO₂ is below 92%, keeping SpO₂ no higher than about 95% in adults and children 6–11 years (children 5 years and younger: target ≥ 92%). Asthma targets differ from the 88–92% COPD target.
3. Systemic corticosteroid early — oral prednisolone about 1 mg/kg/day (maximum 50 mg) for 5–7 days in adults; oral is as effective as IV when the client can swallow.
4. IV magnesium sulfate for severe attacks not responding to initial treatment.
5. If asthma occurs with anaphylaxis, give IM epinephrine first, then bronchodilators.
6. Worsening despite treatment (exhaustion, rising PaCO₂, confusion) → ICU, possible intubation.
7. Before discharge: measure lung function if possible, start or step up ICS-containing treatment, check inhaler technique, give a written action plan, and arrange follow-up within days.

Listed in priority order.

1. Airway and breathing
   • Position upright (high-Fowler's) or leaning forward
   • Assess respiratory rate, effort, ability to speak, breath sounds, SpO₂, mental status
   • Give oxygen and the inhaled bronchodilator together as ordered — oxygen when SpO₂ is below 92%; do not delay the bronchodilator for tests such as chest X-ray or ABG
   • Recognize silent chest, drowsiness, and a rising PaCO₂ as signs of impending respiratory failure and call the rapid response team
2. Monitor response
   • PEF or FEV₁ before and after treatment, heart rate, SpO₂, work of breathing
   • Watch for SABA effects: tachycardia, tremor, hypokalemia (check potassium with repeated doses)
3. Medications
   • Give systemic corticosteroids promptly; monitor glucose and BP
   • When a bronchodilator and an ICS are both scheduled, give the bronchodilator first
   • Avoid sedatives during an acute attack — they depress breathing
   • Avoid aspirin/NSAIDs in sensitive clients and nonselective beta-blockers
4. Secretions and hydration
   • Encourage adequate fluid intake (unless restricted) to thin mucus; controlled coughing
5. Anxiety
   • Stay with the client, speak calmly, and coach slow breathing ("breathe slowly with me; I will stay with you"). Anxiety increases oxygen demand and work of breathing
6. Environment
   • Remove triggers (flowers, strong odors, smoke); keep the room calm
7. Discharge preparation — teach-back of inhaler technique and the written action plan

• Controller vs. reliever
  • ICS-containing treatment treats inflammation and prevents attacks — take as prescribed even when feeling well
  • With Track 1, the same ICS-formoterol inhaler is used for relief; follow the maximum in the written plan (budesonide-formoterol: usually no more than 12 inhalations in one day for adults) and seek care if you need more
  • A SABA relieves bronchospasm quickly but does not treat inflammation; needing it more than twice a week means asthma is not controlled
• Inhaler technique (same device principles as in COPD): pMDI — shake, exhale, slow deep breath while pressing, hold breath up to 10 seconds, use a spacer; DPI — do not shake, fast forceful breath. Rinse mouth and spit after ICS
• PEF monitoring and the written asthma action plan (green/yellow/red zones)
• Trigger control: no smoking or vaping and avoid secondhand smoke; wash bedding in hot water for dust mites; keep pets out of the bedroom if allergic; check air-quality reports
• Exercise: stay active; warm up; use the reliever before exercise as prescribed
• Vaccination: influenza and COVID-19 as recommended; other vaccines per national schedule
• Tell all providers about aspirin/NSAID sensitivity; avoid over-the-counter NSAIDs if reactive
• Montelukast: report mood or sleep changes
• Seek emergency care for: difficulty speaking, blue lips, reliever not helping or needed again within a short time, PEF below 50% of personal best, or drowsiness

Call for help immediately if wheezing disappears while distress continues, the client cannot speak, SpO₂ stays below 90% despite oxygen, or level of consciousness falls.

• Asthma = variable, largely reversible airflow limitation from chronic airway inflammation
• Classic sound: expiratory wheeze; a silent chest is an ominous sign, not improvement
• Normal or rising PaCO₂ during an attack = client is tiring → impending respiratory failure
• SABA-only treatment is no longer recommended in adults and adolescents; all should receive ICS-containing therapy
• Preferred reliever (Track 1): as-needed low-dose ICS-formoterol; never use a LABA without ICS
• Well controlled = daytime symptoms and reliever use ≤ 2 times/week, no night waking, no activity limitation
• Exacerbation: SABA (plus ipratropium if severe) + early systemic corticosteroid (5–7 days); oxygen if SpO₂ < 92%, keeping SpO₂ about ≤ 95%
• PEF: stand, blow hard and fast, 3 tries, record the best; red zone < 50% of personal best
• Rinse mouth and spit after ICS to prevent oral candidiasis
• Bronchodilator before ICS when both are due
• Most common trigger of exacerbations in children: viral respiratory infection
• Montelukast carries a boxed warning for neuropsychiatric effects; oral steroids raise glucose and BP