Asthma
Red Flags in Asthma — Features Requiring Immediate Action
| Red flag | Why dangerous | Action |
|---|---|---|
| Cannot complete sentences · SpO2 <92% · Respiratory rate >25/min · HR >110 | Acute severe asthma — PEFR 33–50% predicted. Hypoxia is a late sign. Silent chest = impending respiratory arrest. Agitation or confusion = type 1 respiratory failure. | 999 immediately |
| Silent chest on auscultation in acute attack | No wheeze heard = so little air movement that wheeze has disappeared. Paradoxically worse sign than audible wheeze. Near-fatal attack imminent. | 999 immediately |
| Cyanosis · Bradycardia · Exhaustion · Altered consciousness | Life-threatening asthma — PEFR <33% predicted. Paradoxical breathing, hypercapnia, impending arrest. Requires ICU-level care. | 999 immediately |
| Haemoptysis · Unilateral wheeze · Unexplained weight loss · Stridor · Age >40 new onset | These features are NOT typical of asthma. Unilateral wheeze = foreign body or tumour. Haemoptysis = malignancy, TB, PE. Stridor = upper airway obstruction. Must not be labelled as asthma without excluding these. | Urgent CXR + 2-week wait |
| Previous near-fatal attack (ITU/intubation) or hospital admission for asthma | History of life-threatening attack is the strongest predictor of a future near-fatal attack. These patients need specialist input, written asthma action plan, and low threshold for hospital admission in any acute episode. | Specialist referral + written plan |
| Pneumothorax in acute wheeze: sudden unilateral pleuritic pain + tracheal deviation | Spontaneous pneumothorax can complicate acute asthma. Tracheal deviation to the opposite side = tension pneumothorax = immediate threat to life. Do NOT give pressurised O2 without identifying this first. | 999 — tension PTX |
Safeguarding Considerations — Consider in Every Asthma Consultation
🧒 Children — Neglect and Non-Adherence
- Repeated A&E admissions for asthma in a child = safeguarding concern until proven otherwise
- Prescriptions never collected, inhalers never used, no school inhaler — is the parent able to manage?
- Passive smoke exposure in children: major modifiable risk factor. Document and act on it.
- Mould and damp housing — local authority housing duty; refer to housing officer if needed
- Child unable to self-manage at school despite good parental understanding — IEP/school health referral
🏠 Housing and Environmental Risk
- Mould, damp, overcrowding, cockroaches = major asthma triggers — housing is a health determinant
- Patients who cannot move out of triggering environments (housing insecurity, poverty, domestic entrapment) need social prescribing, not just a prescription
- Domestic abuse: high stress and sympathetic activation worsens asthma control independently of triggers
- Partner who controls housing situation may make trigger avoidance impossible (e.g. partner's smoking, keeping allergen-producing pet)
💊 Mental Health and Self-Harm Risk
- Anxiety and asthma coexist and amplify each other — panic attacks mimic acute asthma and vice versa
- Oral corticosteroid courses: mood change, agitation, hypomania — document and screen
- Patients deliberately over-using or under-using inhalers as self-harm behaviour — rare but documented
- PHQ-9 and GAD-7 at diagnosis and annual review — depression and anxiety independently worsen asthma control and mortality
👩💼 Occupational Risk and Coercion
- Occupational asthma: employer may be reluctant to accommodate workplace adjustments — patient may face job loss
- Document fitness-for-work advice clearly; patients need written evidence for HR/occupational health
- Insecure employment may cause patients to deny symptoms or avoid sick leave — impacts safety at work
- Food industry, healthcare, and cleaning sector workers: highest risk occupational groups; young and migrant workers over-represented
👩🏫 Teaching career
A teacher's voice and breathing are professional tools. Daily wheeze impairs classroom effectiveness and causes anxiety about professional capability. Uncontrolled asthma affects sick days and may trigger occupational health assessment.
"With good asthma control, most people can teach, exercise, and do everything they did before — the goal is to get your breathing to the point where it doesn't hold you back at work."🐱 The cat
The most sensitive trigger conversation in asthma. Rehoming a pet causes genuine distress and relationship conflict. A graduated approach — bedroom exclusion, HEPA filter, regular vacuuming, allergy testing — allows a shared decision rather than a dictated one. Immediate full rehoming advice often leads to total rejection of the consultation.
"I'm not going to tell you the cat has to go today. Let's look at what we can do step by step — there are ways to reduce your exposure significantly while we figure out how much it's contributing."💊 Inhaler myths
"Inhalers make the lungs lazy" is believed by the majority of patients starting preventer therapy. This directly causes non-adherence. The myth must be explicitly named and debunked — not ignored. ICS does not reduce the lungs' ability to breathe; it reduces inflammation that is preventing them from doing so.
"The brown inhaler doesn't do the breathing for you — it reduces the inflammation that's been narrowing your airways. Your lungs don't become dependent on it. They become less inflamed."🧠 Anxiety and asthma
Anxiety and asthma have a bidirectional relationship: anxiety triggers bronchoconstriction and breathlessness triggers panic. Up to 30% of patients with "difficult asthma" have panic disorder or dysfunctional breathing as the primary driver. PHQ-9 and GAD-7 at diagnosis and every review.
"Sometimes anxiety and breathing problems get intertwined and feed each other. How has the breathlessness been affecting your mood and your worry levels?"🏃 Exercise and identity
Asthma patients frequently reduce activity to avoid breathlessness — this worsens fitness, increases obesity risk, and reinforces the belief that they "can't" exercise. Exercise-induced asthma is very well managed with pre-exercise SABA. Restoring activity is a core goal.
"Exercise-induced symptoms are very common in asthma and very treatable — you should not have to give up running. A puff of the blue inhaler 15 minutes before exercise can make a huge difference."👨👩👧 Family influence
Mother with asthma may have given Priya accurate or outdated beliefs about asthma management. Ask what her mother uses and believes. Family modelling affects adherence — if mum never uses a preventer, Priya probably won't either. Explore to correct, not to contradict.
"You mentioned your mum has asthma — what does she use for it? That might tell me what you've grown up thinking is normal for asthma management."- Asking "do you have wheeze?" when it is clearly documented in the notes
- Going straight to prescribing without exploring the cat concern and inhaler myths
- Telling Priya to get rid of the cat without any acknowledgement of the relationship impact
- Not asking about occupation — teacher context shapes the entire management plan
- Missing SABA over-use as the central marker of poor control
Life-Threatening / Near-Fatal
999 now- Silent chest or absent breath soundsNo wheeze = no air movement. Near-fatal attack. ICU required.
- SpO2 <92% / cyanosisHypoxia is a late sign — already significant respiratory failure
- Cannot complete sentences · exhaustionPEFR <33% predicted — life-threatening attack
- Bradycardia · hypotension · altered consciousnessRespiratory arrest imminent — immediate intervention required
- Tension pneumothorax featuresSudden pleuritic pain + tracheal deviation + unilateral absent breath sounds
Acute Severe — Hospital Assessment
Same day- PEFR 33–50% predictedAcute severe attack — nebulised salbutamol + oral prednisolone + O2
- Unable to complete a sentence at restEven if SpO2 acceptable — ongoing severe attack
- HR >110 or RR >25Tachycardia + tachypnoea in acute attack = severe
- Attack not responding after 15–30 min SABAIf no improvement with repeated bronchodilators — hospital
- Previous near-fatal attack with new acute episodeHigh-risk patient — lower admission threshold regardless of PEFR
Stable / Chronic Management
Planned care- New diagnosis of asthmaSpirometry + reversibility ± FeNO · Start AIR (low-dose ICS/formoterol PRN, NG245)
- Annual asthma reviewControl assessment · Inhaler technique · Triggers · Written plan · Step review
- Poor control (reliever >3×/week)Step up the NG245 pathway · Check technique and adherence before stepping up
- Mild acute exacerbation (PEFR >50%)Increase SABA · 40–50 mg prednisolone × 5 days · Review in 48h
- Going straight to treatment plan without assessing current severity
- Missing PEFR or SpO2 in any acute or subacute asthma presentation
- Not considering silent chest as a warning sign (mistaking absence of wheeze for improvement)
- Not measuring PEFR at any asthma presentation — mandatory
- Not explaining why each examination is being done — missed domain 3 opportunity
- Not examining the nose in a patient with likely allergic asthma
- Treating unilateral wheeze as if it were asthma without investigating
- Diagnosing asthma without spirometry or PEFR diary — cannot diagnose on symptoms alone
- Not ordering FeNO when NICE recommends it for uncertain diagnosis
- Not considering allergy testing when a specific allergen (cat) is the likely trigger
- Treating on history alone without objective evidence — especially in medico-legal context
"Asthma is a condition where the airways in your lungs become inflamed and sensitive — a bit like having skin that's prone to reacting. When something irritates them — cold air, exercise, an allergen like cat dander — they tighten up and produce extra mucus, which is what causes the wheeze and tightness. The important thing is: asthma is very treatable. With the right inhalers and trigger management, most people with asthma live completely normal lives — including running, teaching, and keeping active. The goal is to get it so well controlled that you barely notice it."
"Does the cat need to go?"
"The honest answer is: sensitisation to cat dander is one of the more significant allergic triggers for asthma, and removing the exposure is the most effective intervention. But I'm not going to tell you the cat has to go today — I understand how significant that is. What I'd like to do is: first, confirm with an allergy test whether cat dander is the specific trigger for you. Second, while we're waiting, there are practical steps that can significantly reduce your exposure — keeping the cat out of your bedroom, a HEPA air purifier, regular hoovering with an allergen filter. If your symptoms improve significantly with treatment alone, we can reassess. If your asthma remains poorly controlled despite treatment and the cat is confirmed as the trigger, we'll need a more direct conversation — but one that I'm committed to having with you, not at you."
Why this matters: An immediate "get rid of the cat" instruction at a first consultation almost universally leads to disengagement. Shared decision-making with a graduated plan has better outcomes. Document the discussion clearly.
- Diagnosing asthma without objective evidence
- Ordering the cat removed without a graduated, empathic discussion
- Not distinguishing asthma from COPD in an older smoker
- Jargon without explanation — "FEV1," "reversibility," "ICS" without lay translation
- Stopping treatment while waiting for specialist appointment
- Not giving a written asthma action plan to a patient with previous near-fatal attack
- Prescribing biologics (mepolizumab, omalizumab) in primary care without specialist initiation
- Not referring suspected occupational asthma — delay = permanent disease
Validate — name their expectation
Priya has two specific fears: the cat and the inhalers. Both are rational. Acknowledge them explicitly before any management plan — not after.
"Before I go through the plan — can I come back to the two things you mentioned at the start? The cat, and your worry about the inhalers being addictive. Let me address both of those directly."Explain — share your clinical reasoning
Debunk the inhaler myth explicitly. Offer a graduated approach to the cat — not an ultimatum. Frame treatment as enabling her professional and personal life.
"The brown inhaler doesn't create dependence — it reduces inflammation in your airways. Your airways don't become reliant on it; they become less inflamed. As for the cat, I'm not here to tell you it has to go today — let's do an allergy test first and see what practical steps help while we figure that out."Negotiate — offer something today
Name one specific action agreed today. Give her own inhaler, a written asthma action plan, and a specific follow-up date. Use the occupational context to motivate engagement.
"The goal I want for you is that asthma doesn't affect your teaching, your running, or your home life. With the right plan — and we're starting that today — most people get there. Let's agree what we're doing now and when we're checking back."Cat allergen (Fel d 1) is produced in sebaceous glands and saliva, deposited on fur, and becomes airborne as tiny particles that remain suspended for hours. Sensitisation causes mast cell degranulation → histamine + leukotriene release → bronchoconstriction + mucous hypersecretion.
Cat allergen persists in a home for up to 6 months after removal of the cat. Bedroom exclusion reduces nocturnal exposure significantly. HEPA filter reduces airborne allergen by 40–60%. Complete removal is most effective but even partial measures reduce SABA use.
Graduated approach: (1) cat excluded from bedroom — immediate; (2) HEPA air purifier in bedroom; (3) weekly bathing of cat (reduces Fel d 1 by ~80%); (4) allergy testing to confirm sensitisation; (5) revisit rehoming if uncontrolled despite treatment. Document discussion clearly.
HDM (Dermatophagoides pteronyssinus) produces Der p 1 allergen in faeces — deposited in mattresses, pillows, carpets, and soft furnishings. Heat and humidity promote HDM multiplication. Sensitisation in 85% of atopic asthma patients.
Allergen-impermeable mattress covers reduce HDM exposure by 80–90%. Weekly washing of bedding at 60°C kills HDM. Removing carpets from bedroom reduces allergen load by >90%. Evidence for clinical benefit is modest but cumulative with other measures.
Mattress and pillow encasings — widely available, cost-effective. Weekly hot wash of bedding. Dehumidifier to keep bedroom humidity <50%. Minimise soft furnishings. Regular hoovering with HEPA-filter vacuum.
Cigarette smoke causes neutrophilic airway inflammation — steroid-resistant. ICS efficacy is significantly reduced in smokers. Smoking activates histone deacetylase (HDAC2) → corticosteroid insensitivity. Passive smoke exposure in non-smoking asthma patients causes similar effects.
Smoking cessation in asthma: FEV1 improves, exacerbation rate falls, ICS response improves, symptom scores reduce. Even stopping passive exposure (partner, home, workplace) produces measurable improvement. NICE: smoking cessation is the highest-impact intervention in smokers with asthma.
QUIT service referral. Varenicline most effective. NRT as alternative. CO breath test at every review — objective feedback motivates change. Consider the impact of passive smoke in the home — partner smoking indoors should be addressed explicitly.
Exercise-induced bronchoconstriction (EIB): airway cooling + drying → mast cell degranulation → leukotriene-mediated bronchoconstriction occurring 5–15 minutes after exercise. Nasal breathing warms and humidifies air, reducing EIB. Well-controlled asthma should not limit exercise.
Pre-exercise SABA (15 min before): reduces EIB by 80%. 10-minute warm-up protocol: reduces EIB by 50%. LTRA (montelukast): effective for EIB, especially in aspirin-sensitive asthma. Regular exercise actually improves asthma control long-term via improved cardiovascular fitness and reduced obesity.
"You should not give up running. Salbutamol 2 puffs 15 minutes before you run will reduce the bronchoconstriction significantly. Start with a 10-minute warm-up. Breathe through your nose on cold days. If it still limits you on treatment, tell me and we reassess."
Dysfunctional breathing patterns (chronic hyperventilation, mouth breathing) lower CO2 → vasoconstriction + increased airway sensitivity. Buteyko technique teaches nasal breathing, reduced breathing volume, and breath control. Reduces the symptom amplification from anxiety + asthma interaction.
SIGN 2023: breathing exercises recommended for asthma as adjunct to medication. Buteyko and physiotherapy-led breathing retraining reduce SABA use, improve quality of life scores, and reduce symptom scores. Effect is greatest in those with anxiety co-morbidity or dysfunctional breathing pattern.
Refer to physiotherapist or respiratory nurse with breathing retraining expertise. Buteyko apps available (evidence weaker). Especially useful when anxiety and asthma coexist — teaches discrimination between panic attack and asthma attack.
Obesity reduces functional residual capacity (FRC) → airway closure during tidal breathing. Pro-inflammatory adipokines (leptin, IL-6) promote neutrophilic inflammation → ICS-resistant asthma phenotype. Obesity-related GORD further triggers airway inflammation. Metabolic syndrome worsens overall respiratory physiology.
Weight loss 5–10% in obese asthma: FEV1 improves, exacerbation rate falls, OCS courses reduce, quality of life improves. NICE: weight management should be addressed before stepping up ICS in obese patients with apparently uncontrolled asthma.
Structured weight management programme referral. NHS DESMOND equivalent for respiratory patients. Frame as: "Losing weight is one of the most effective things you can do for your breathing — it changes the type of inflammation and makes your inhalers work better."
"This is your reliever — it opens your airways quickly. But if you're needing it more than 3 times a week, that's a sign your asthma isn't controlled and we need to do more, not just use more of this."
Reliever frequency is the central control metric. In SCA: always ask how often they use it and interpret it — daily use = uncontrolled = immediate action. Bonus mark: knowing NG245 replaced SABA-first with AIR→MART, and transitioning legacy SABA-only patients at review.
"This is the most important inhaler — it treats the inflammation causing your asthma. It doesn't work immediately like the blue one, but after a few weeks you should notice fewer symptoms and needing the blue one less. It won't make your lungs lazy — it will make them less inflamed."
Address the "inhalers make lungs lazy" myth every time ICS is prescribed. Check technique and adherence at every review — non-adherence is the most common cause of "poorly controlled" asthma. Rinse mouth after use to prevent candidiasis.
"This inhaler combines the preventer and an additional bronchodilator that lasts 12 hours. It gives better control than doubling the preventer dose alone. Never use the long-acting part without the preventer — they must always be taken together."
MART (Maintenance And Reliever Therapy) with Symbicort reduces severe exacerbations by ~30% vs fixed-dose ICS/LABA + SABA. Ask about MART adherence — patients often use it only as a reliever.
"This tablet reduces a different type of airway inflammation to the inhaler — it is particularly good if you also have hay fever. One important thing: a small number of people notice low mood, vivid dreams, or anxiety — if that happens, let me know straight away and we will stop it."
MHRA 2020 black-box warning for neuropsychiatric effects with montelukast. Must counsel at every prescription. Particularly effective in: allergic asthma + rhinitis, AERD, exercise-induced asthma.
"With this inhaler you take it morning and evening as normal, but if your breathing gets worse you can also use extra puffs as a reliever — up to 8 extra puffs in a day. If you're needing that many extra puffs, that's a sign to contact us urgently or go to hospital."
MART (low-dose → moderate-dose) is the spine of the NG245 adult pathway. The nuance: patients must understand the daily maximum and the 8-puff urgent review threshold. Common SCA deduction: prescribing MART without explaining the relief-use limit.
"This injection works at the root cause — it targets the specific part of your immune system causing the most inflammation in your airways. It is not a cure, but many people find their exacerbations almost disappear. It needs to be given by a specialist team."
In SCA: biologic eligibility should be considered when eosinophil count, FeNO, or multiple OCS courses are present. Referring for assessment is a Tasks domain score — not prescribing biologics yourself.
The cat — relationship vs health
Rehoming a pet can cause genuine relationship conflict. Graduated approach is more effective than ultimatum. Document the discussion. Allergy testing provides objective evidence that helps shared decision-making without seeming like personal judgment.
"I'm not going to tell you the cat has to go today — let's confirm the allergy, try the practical steps, and revisit this with the evidence."Inhaler myths — prevent non-adherence
"Inhalers make lungs lazy" must be explicitly debunked at every new prescription. Non-adherence to ICS is the most common cause of poorly controlled asthma. Technique demonstration and return demonstration at every review.
"The preventer inhaler reduces inflammation — it doesn't do the breathing for you. Your lungs won't become dependent on it."Occupational impact
A teacher's breathlessness is professionally visible. Asthma affecting voice or stamina risks classroom authority and self-confidence. Occupational health referral if school exposures are relevant. Fitness-for-work documentation if needed.
"The goal is that asthma doesn't affect your teaching — that's a realistic target once we get your airways controlled."Anxiety + panic attacks
Anxiety and asthma amplify each other. Panic attack can mimic acute asthma — both cause breathlessness and tachycardia. Breathing retraining helps discriminate. PHQ-9 + GAD-7 at every review. CBT is effective for anxiety component.
"Sometimes when you're anxious your breathing changes in a way that feels like the asthma — would it help to know how to tell the difference?"Exercise and identity
Many patients stop exercising to avoid breathlessness — this worsens asthma long-term. Restoring exercise capacity is a core goal. Pre-exercise SABA should be framed as enabling, not as evidence of severity.
"You should be able to run — let's make that happen. The blue inhaler 15 minutes before you set off makes a huge difference."Family modelling
Mother's approach to asthma management shapes Priya's. If mother never used a preventer, Priya probably thinks they are optional. Ask what her mother does — it reveals the patient's default asthma model and where the educational gap is.
"What does your mum use for her asthma? That helps me understand what you've grown up thinking is normal."Diagnosis / initiation visit — today
Spirometry + FeNO + PEFR diary started · SABA prescribed (own inhaler) · ICS started if SABA >3×/week · Inhaler technique demonstrated · Written asthma action plan · Trigger avoidance advice (cat — graduated) · Allergy testing requested · Asthma self-management education · Annual review appointment booked
4–6 weeks — response assessment
PEFR diary review · Symptom control assessment · Inhaler technique recheck · Side effects (candidiasis?) · SABA use frequency · Adherence to preventer · Cat / trigger changes made? · Step up if not controlled
3 months — control confirmation
Formal control assessment (BTS criteria) · Spirometry repeat if initial abnormal · Allergy test result review · Adjust step if needed · Breathing retraining referral if EIB persists · PHQ-9 and GAD-7
Annual review — mandatory NICE/BTS
Asthma Control Test (ACT) or RCP 3 questions · SABA use in last 3 months · Nocturnal symptoms · Exercise limitation · Inhaler technique · Device concordance · Triggers review · Step up or down · Written action plan updated · Influenza vaccination · Smoking status · Weight · Oral health
Post-exacerbation review (within 48h and 2–4 weeks)
Every acute exacerbation requiring OCS → review within 48h · Trigger identified? · Step up treatment · Written action plan updated · Consider specialist referral if ≥2 OCS courses/year · Assess for biologic eligibility if ≥4 exacerbations/year
| Measure | Timing | Action threshold |
|---|---|---|
| SABA use frequency | Every consultation | >3×/week = poor control → step up. >1 canister/month = risk marker → urgent review. |
| PEFR (personal best) | At home twice daily × 2–4 weeks | <80% personal best = action point. <50% = acute severe → escalate. Variability >20% = confirms diagnosis. |
| Asthma Control Test (ACT) | Every review | Score ≤19 = uncontrolled → step up. Score 20–25 = well controlled → maintain. Score <12 = severe → urgent review. |
| Spirometry (FEV1/FVC) | At diagnosis; repeat if clinical change | FEV1 <70% predicted = moderate–severe → specialist consideration. Declining FEV1 trend = step up + review. |
| FeNO | Annually or when stepping | ≥50 ppb (adults 17+) / ≥35 ppb (ages 12–16) = raised (NG245 diagnostic threshold; at the step-4 gate a raised FeNO means refer rather than blind-escalate). Persistently low with poor control → consider adherence or an alternative diagnosis. |
| Blood eosinophils | Annually in uncontrolled asthma | ≥0.3 × 10⁹/L = eosinophilic phenotype → biologic eligibility screen. Rising eosinophils on OCS = OCS-dependent → refer. |
| OCS courses per year | Every review | ≥2 courses/year → step up + specialist referral. ≥4 courses/year → biologic eligibility assessment. |
| Inhaler technique | Every review | Suboptimal technique → retrain before stepping up. Consider device change (DPI vs MDI + spacer). Up to 80% use inhalers incorrectly. |
Key targets and thresholds
Well controlled: SABA ≤2/week · No nocturnal symptoms · No exercise limitation · PEFR ≥80% predicted
PEFR targets: Personal best (not population predicted). >80% = well controlled. 50–80% = action. <50% = emergency.
Acute severe: PEFR 33–50% or SpO2 <92% → hospital. Life-threatening: PEFR <33% → 999.
Before stepping up: Always check technique + adherence + triggers first. Stepping up without these = wasted step.
⚠ Three scenario-specific phrases — use these verbatim
Why safety-netting is especially critical in asthma
- Silent chest / absent breath sounds
- SpO2 <92% / cyanosis
- Cannot complete sentences
- PEFR <33% predicted
- Bradycardia / exhaustion / confusion
- PEFR 33–50% / SpO2 92–94%
- HR >110 / RR >25
- Not responding to SABA after 30 min
- Previous near-fatal + any acute episode
- 2+ OCS courses this year
- New diagnosis: spirometry + PEFR diary + FeNO
- Annual review: control + technique + triggers
- Reliever >3×/week: step up NG245 pathway
- Mild exacerbation (PEFR >50%): increase SABA + OCS
| Reversibility (bronchodilator) | ≥12% + ≥200mL FEV1 |
| PEFR variability — diagnosis | >20% variability |
| FeNO — eosinophilic inflammation | ≥50 ppb adult (17+) · ≥35 ppb age 12–16 |
| Blood eosinophils — biologic | ≥0.3 × 10⁹/L |
| SABA over-use — mortality risk | >1 canister/month |
| Well controlled | SABA ≤2/wk, no nocturnal, no limitation |
| Step up trigger | SABA >3×/wk or any nocturnal Sx |
| Specialist referral | ≥2 OCS courses/year |
| Biologic eligibility | ≥4 exacerbations/year + eos ≥0.3 |
| MART relief max | 8 extra puffs/day → urgent review |
| Measure | Timing | Action threshold |
|---|---|---|
| SABA use frequency | Every consultation | >3×/week = step up. >1 canister/month = mortality risk marker → urgent review. |
| PEFR (personal best) | 2× daily × 2–4 weeks at diagnosis | <80% → action. <50% → emergency. >20% variability → confirms diagnosis. |
| Asthma Control Test (ACT) | Every review | ≤19 = uncontrolled → step up. <12 = severely uncontrolled → urgent review. |
| Inhaler technique | Every review | Suboptimal → retrain before stepping up. 80% use inhalers incorrectly. |
| FeNO | At diagnosis; when stepping | >40 = high eosinophilic inflammation → ICS increase. <25 = consider adherence/alternative Dx. |
| Blood eosinophils | Annually if uncontrolled | ≥0.3 × 10⁹/L = biologic eligibility screen if ≥4 exacerbations/year. |
| Spirometry | At diagnosis; repeat if clinical change | FEV1 <70% predicted = moderate–severe → specialist consideration. |
| OCS courses/year | Every review | ≥2 → step up + specialist referral. ≥4 → biologic eligibility assessment. |
→ Graduated approach: allergy test + bedroom exclusion + HEPA first. Ultimatum = consultation failure.
→ The myth must be explicitly named and debunked. Prescribing without doing this = ICS never used.
→ Spirometry + reversibility + PEFR diary required. Symptoms alone are insufficient — NICE NG245.
→ PEFR is mandatory. Not measuring = missing severity + missing diagnosis confirmation.
→ No wheeze = no air movement = near-fatal. Absence of wheeze is worse, not better.
→ LABA monotherapy is independently associated with asthma death. Never alone.
→ BTS/SIGN mandatory. Most evidence-based safety tool. Omission = Tasks deduction.
→ This is a BTS/SIGN red flag requiring urgent review and step up. Must be recognised.
→ MHRA 2020 black box warning. Must counsel depression/suicidal ideation risk at every prescription.