Who / when
- Adults with cough, difficult breathing, tight chest or wheeze that comes and goes.
- Asthma is likely with: symptoms since childhood or early adulthood; hay fever, eczema or allergies; symptom-free spells; worse at night or early morning; triggered by infections, exercise, weather or stress; relief with salbutamol.
- Smoker or heavy smoke or dust exposure, onset after 40, slowly worsening, daily cough with sputum: think COPD (see the COPD protocol).
Red flags: refer now
Very severe attack (life-threatening):
- Drowsy or confused, exhausted, poor breathing effort, silent chest.
- Cyanosis, low blood pressure or irregular pulse.
- Oxygen saturation below 92%.
Severe attack: cannot finish a sentence in one breath; breathing over 25 per minute; pulse 110 or more; peak flow 33 to 50% of best or predicted.
Treat while you arrange transferStart treatment now (see Treat). A very severe attack, or a severe attack that does not respond, needs transfer to hospital with oxygen and salbutamol continued on the way.
Assess
Make the diagnosis
- Measure peak expiratory flow (PEF). Give two puffs of salbutamol and measure again after 15 minutes.
- Improvement of 20% or more: asthma likely. Less than 20%: COPD more likely.
At every visit: is asthma controlled?
- Daytime symptoms, and salbutamol use, no more than twice a week.
- Night symptoms less than twice a month.
- No or minimal limit on daily activities.
- No severe attack (needing oral steroids or admission) in the last month.
- PEF above 80% of predicted, if you can measure it.
Watch the person use their inhaler at every visit. Poor technique is a common reason for poor control.
Classify
| Picture | Classify as | Action |
|---|
| Drowsy, exhausted, silent chest, cyanosis, SpO2 below 92% | Very severe attack | Treat now and transfer |
| Cannot finish sentences, RR over 25, pulse 110 or more, PEF 33 to 50% | Severe attack | Treat now; transfer if not responding |
| Any control criterion not met | Not well controlled | Check adherence and technique, then step up |
| All control criteria met | Controlled | Keep the same step; consider stepping down after a long stable period |
Treat
Stepwise treatment (WHO PEN)
At each step, check adherence and watch inhaler technique before moving up. Use a spacer with a metered-dose inhaler.| Step | Treatment |
|---|
| 1 | Inhaled salbutamol when needed |
| 2 | Salbutamol when needed plus low-dose inhaled beclometasone, starting at 100 micrograms twice daily |
| 3 | As step 2, with a higher dose of beclometasone: 200 or 400 micrograms twice daily |
| 4 | Add low-dose oral theophylline to step 3 (where long-acting beta agonists and leukotriene antagonists are not available) |
| 5 | Add oral prednisolone at the lowest dose that controls symptoms (nearly always under 10 mg a day), and refer |
Treating an attack
- Prednisolone 30 to 40 mg by mouth daily for 5 days (longer if needed until recovered).
- High-dose salbutamol by metered-dose inhaler and spacer (for example 4 puffs every 20 minutes for 1 hour) or by nebuliser.
- Oxygen, if available, when saturation is below 90%.
Medicines to avoidAvoid NSAIDs and beta-blockers in people with asthma: both can trigger attacks.
Follow-up
- Review control every 3 to 6 months.
- Review sooner after any change of treatment, after an attack, or when control is poor.
- Each visit: control questions, PEF if available, inhaler technique, adherence, triggers, smoking.
Counsel
- Asthma can be controlled, but it may need treatment every day and regular check-ups.
- Inhalers are safe, not habit-forming, and work better than tablets or syrup. A spacer helps more medicine reach the lungs.
- The steroid inhaler takes several days or weeks to work fully. Keep using it when you feel well.
- Know what to do if asthma gets worse, and bring your inhaler to every visit.
- Stop smoking and avoid others' smoke; avoid dusty and smoky rooms and known triggers.
- Reduce dust at home: damp-dust furniture, sprinkle water before sweeping, air bedding in the sun.
- Stay physically active.
Your reliever inhaler (salbutamol) opens your chest quickly when you are wheezy. Your steroid inhaler calms the lungs over weeks, so use it every day, even when you feel well.
When to refer
- Same day: very severe attack, or a severe attack not improving with treatment.
- Asthma that stays poorly controlled despite good adherence and technique.
- The diagnosis is uncertain.
- Regular oral prednisolone is needed to keep control.
Sources
World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020. World Health Organization. Basic emergency care: approach to the acutely ill and injured (WHO and ICRC). 2018. World Health Organization. WHO Model List of Essential Medicines. 2025.