Asthma Management in Adults and Young People
Written by Ruth Morrow, Respiratory Nurse Specialist, Asthma Society of Ireland
Source: Irish Pharmacy News, March 2026, pages 31-33.
Asthma is a heterogeneous disease, usually characterised by chronic airway inflammation defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation (GINA, 2025).
Asthma affects over 450,000 people in Ireland. 7.1% of Irish adults have asthma with 890,000 likely to experience it sometime in their lifetime. In 2024, two people lost their lives from asthma in Ireland every week despite advances in the knowledge of the mechanisms of asthma and pharmacology. In 2019, the Asthma Society of Ireland published Easing the Economic Burden of Asthma – The Impact of a Universal Asthma Self-Management Programme. The report, for the first time, published confirmation of the enormity of the burden of asthma and contains, up-to-date figures on the number of people affected by asthma in Ireland. Previous estimates grossly under-estimated the number of people with asthma in Ireland. The annual economic burden of asthma is a staggering €472 million. 2017 saw 2.4 million GP and 625,000 practice nurse asthma consultations respectively, 421,000 specialist visits, 133,000 emergency department visits and 8,000 hospital admissions. There was one attendance at emergency departments every 4 minutes by a person with asthma.
The exact cause of asthma remains unknown. However, risk factors such as smoking, obesity, family history and atopy all increase the risk of developing asthma (Shamanthi et al, 2025). There are numerous triggers which can cause symptoms and these differ from person to person (Figure 1).
Wintertime can be particularly challenging for people with asthma due to cold air and common viruses being common triggers. As Spring emerges, this can also be a challenging time as various tree pollen levels start to increase. Some people with asthma may need to increase their controller medication over the winter months to help manage their symptoms.
Symptoms
The clinical features of asthma (wheeze, cough, shortness of breath and chest tightness) result from changes in the airways as a result of abnormal sensitivity called bronchial hyper-reactivity. The muscle of the bronchial walls becomes hypertrophied causing occlusion of the airway resulting in contraction of the muscle causing bronchospasm. Secondly, in the mucosal, submucosa and smooth muscle layers of the bronchi and bronchioles inflammatory cells infiltrate. Eosinophils, neutrophils, macrophages, mast cells and plasma cells are found in varying numbers. All of these cells contain chemical mediators that produce the “asthmatic response”. With the increase in secretions, plugging of the smaller airways result. Asthma is a condition where not only bronchospasm occurs but muscle constriction, mucosal swelling and an increase in secretions in the lumen in the airways (Figure 2).
Management of stable asthma
The goals of asthma management are:
- Symptom control: to achieve good control of symptoms and maintain normal activity levels
- Risk reduction: to minimise future risk of exacerbations, fixed airflow limitation and medication side-effects
(GINA 2025)
Assessment of asthma control involves assessing symptoms over the previous 4 weeks using the GINA Assessment of Asthma Control, the Asthma Control Test (ACT) and assessing risk factors for poor outcomes. Treatment issues should also be addressed at every visit and should include:
- Assessment of the patient’s symptoms, medication usage and impact of asthma on daily life
- Review of inhaler technique and adherence
- Asking about side-effects
- Reviewing and updating the patient’s written asthma action plan
- Exploring the patient’s attitudes and goals for their asthma
The treatment and management of asthma should incorporate the following elements:
- Education on the disease process
- Management of trigger factors
- Medication management – mode of action, inhaler technique, adverse events and adherence
- Asthma Action Plan
- Management of acute flare-ups of asthma
The goal of asthma management is for the patient to be optimally controlled on the minimum amount of medication. GINA (2025) provides health care professionals with a management approach based on control using a step wise approach. This assists health professionals with the titration of medications using a step down or step up approach in attempt to achieve this goal.
The cornerstone of asthma treatment is inhaled therapy as medications are directly targeted at the airways and therefore, are more effective. This also limits the amount of systemic absorption and reduces adverse events. Patients should be commenced on the appropriate step of the treatment guidelines which is dependent on the severity of their symptoms (GINA, 2025). Based on the severity of their symptoms at presentation, the patient is assigned to one of five treatment steps. Patients may move up or down the steps depending on symptoms and the amount of reliever therapy being used. Inhaled glucocorticosteroids (ICS) are the cornerstone of asthma treatment and are the most effective controller medications available. However, there are additional oral medications such as leukotriene receptor antagonists which can be added on and are very useful in patients who have an allergic component to their asthma, experience cold air bronchoconstriction and have exercise induced symptoms. These medications are also licensed for use in allergic rhinitis, a condition which 85% of people with asthma also have. House dust mite sublingual immunotherapy is also now recommended at all steps of the guideline depending on the patient’s asthma phenotype.
Anti-inflammatory (AIR) and Maintenance and Reliever Therapy (MART)
In their review of the literature, GINA found no evidence to support a Step 1 SABA-only approach. The lack of evidence for short acting beta-agonist only treatment (SABA) contrasted with the strong evidence for safety, efficacy and effectiveness of inhaled corticosteroid (ICS) and inhaled corticosteroid and long-acting beta agonist ICS/LABA). For safety reasons, GINA no longer recommends SABA-only treatment for Step 1. It is now recommended that all adults and adolescents with asthma should receive symptom-driven or regular low dose combination LABA/ICS-containing controller treatment, to reduce the risk of serious exacerbations (GINA, 2025).
Patients who have symptoms more than twice a month should be prescribed ICS/LABA twice daily (Step 2-5) known as Maintenance and Reliever Therapy (MART therapy) and patients who have symptoms less than twice a month should use ICS/LABA on “an as-needed basis” (Step1) known as Anti-inflammatory Reliever Therapy (AIR therapy). For patients on AIR therapy who use their inhaler more than twice a week indicates uncontrolled asthma and should be titrated up to MART therapy. For patients on MART who are well controlled and have had no exacerbations in the previous 12 months, can be titrated down to AIR therapy. Level 1 scientific evidence of the greater efficacy and safety of ICS/formoterol versus SABA reliever therapy across the range of asthma severity allows Grade A recommendations to be made for its use as the preferred reliever therapy in adults and adolescents (Beasley et al 2024)
The synergistic effect of ICS and LABA has been known for some time (Barnes, 2002). This effect allows for lower doses of ICS to be used with maximum benefit to the patient and reducing the risk of unwanted side effects. Higher doses of ICS/LABA do not improve asthma control and increases the risk of adverse events. Beasley et al (2024) acknowledged the available evidence suggests that medium dose ICS/formoterol MART has a superior efficacy/safety profile than high dose ICS/LABA plus SABA (Beasley et al 2024).
Further support comes from a meta-analysis by Sobieraj et al (2018) that included 22 524 patients aged 12 years or older and 341 children aged 4 to 11 years with persistent asthma. MART was associated with a significantly lower risk of asthma exacerbations compared with a higher dose of inhaled corticosteroids and LABA as controller therapy.
Why this change?
Inhaled SABA (Salbutamol, Terbutaline) have been first-line treatment for asthma for 50 years. Traditionally asthma was thought to be a disease of bronchoconstriction with SABA being the drug of choice. Added to this, rapid relief of symptoms, reliance on, patient satisfaction and their low cost have meant that SABAs were widely used, overused and over-relied upon. The perception by patients that their reliever “gives me control over my asthma”, so much so that they often don’t see the need for other treatment. However, research over the past number of years has shown that regular and frequent use of SABAs decrease bronchoprotection, increase rebound hyperresponsiveness, and decrease bronchodilator response. Patients with apparent mild asthma are at risk of serious adverse events such as near fatal asthma, acute asthma and death from asthma. Patients who get 3 or more canisters of SABA per year (average 1.7 puffs/day) are associated with higher risk of attendance to the emergency department (Stanford, AAAI 2012) and patients who receive 12 or more canisters per year are associated with higher risk of death (Suissa, AJRCCM 1994). A meta-analysis by Crossingham et al (Cochrane 2021) of four RCTs involving 9,565 patients demonstrated the benefits of LABA/ICS combination therapy showing a 55% reduction in severe exacerbations compared with SABA alone. ED visits or hospitalisations were 65% lower than with SABA alone and 37% lower than with daily ICS.
Non-pharmacological management
The non-pharmacological management of asthma include management of trigger factors, smoking cessation, management of obesity and gastroesophageal reflux disease. Influenza vaccination is recommended for those with more severe asthma. Gastroesophageal reflux can worsen asthma symptoms and treatment of reflux may improve asthma symptoms.
Adherence with medication regimes and inhaler technique
One of the biggest challenges in asthma management is adherence to medication as many patients may be asymptomatic and therefore “don’t feel the need to use their medication daily” Exploring the patient’s beliefs and attitudes can be useful in determining a rationale for non-adherence to medication regime. Saving medication until it is needed, fear of becoming addicted or the health professional didn’t listen are amongst reasons given by patients in the INCA study (Sulaiman et al, 2014). In the current climate, cost is a significant factor even for the person who has a medical card and should not be overlooked. Two proven ways to address non-adherence are shared decision-making between the health professional and the patient and motivation interviewing. Using motivational interviewing, the health professional can assess the individual’s likelihood to adhere to their medication or to non-pharmacological interventions.
Inhaler technique should be checked at every opportunity as errors frequently occur even in patients who are taking inhaled medication for years. Care and maintenance of devices should also be addressed. Inhaler technique videos are available on www.asthma.ie.
Risk factors for poor outcomes
Patients who experience uncontrolled asthma symptoms, had one or more exacerbations in the previous year, the start of the patient’s usual ‘flare-up’ season (especially if autumn), has major psychological or socio-economic problems, poor adherence with controller medication and/or incorrect inhaler technique are at risk of an exacerbation in the coming months.
Table 1: Assessment of Acute Exacerbation of Asthma (GINA, 2025)
Altered consciousness: Mild – No; Severe – Agitated, confused or drowsy.
Oximetry on presentation (SaO₂): Mild – >95%; Severe – <92%.
Speech: Mild – Sentences; Severe – Words.
Pulse rate: Mild – 100-120 bpm; Severe – not specified.
Peak flow: Mild – >50% predicted or best; Severe – <50% of predicted or best.
Central cyanosis: Mild – Absent; Severe – Likely to be present.
Wheeze intensity: Mild – Variable; Severe – Chest may be quiet.
Assessment and Management of Acute asthma
Accurate and timely assessment of acute asthma exacerbations should be carried out to ensure a successful outcome. Table 1 differentiates between a mild and severe acute exacerbation.
The management of acute asthma includes:
- Oxygen therapy – 24% delivered by face mask (usually 1L/min) to maintain oxygen saturation 93-95%
- Inhaled short-acting bronchodilator – 4-10 puffs of Salbutamol by spacer, or 5mg by nebulizer, every 20 min for first hour, then reassess severity. If symptoms persist, deteriorate or recur, give an additional 10 puffs per hour and admit to hospital
- Oral corticosteroids – max 50mgs of oral steroids and continue for 5 -7 days
- Additional treatments can include – For moderate/severe exacerbations, Ipratropium bromide 80mcg (or 250mcg by nebulizer) every 20 minutes
Criteria for immediate transfer to secondary care include:
- Features of severe exacerbation at initial or subsequent assessment
- Patient is unable to speak or drink
- Cyanosis
- Subcostal retraction
- Oxygen saturation <92% when breathing room air
- Silent chest on auscultation
- Lack of response to initial bronchodilator treatment
- Persisting tachypnoea despite 3 administrations of inhaled SABA,
- Unable to be managed at home
Follow-up post exacerbation
All patients should be followed up regularly after an exacerbation, until symptoms and lung function return to normal. Patients are at increased risk during recovery from a further exacerbation. This provides an opportunity to review and update the patient’s asthma action plan, review inhaler technique and adherence and to ascertain if there was a cause for this flare-up eg new trigger factors, poor adherence, poor inhaler technique, medication cost. This might be helpful in preventing future flare-ups.
At follow-up visit(s), the asthma review should include:
- The patient’s understanding of the cause of the flare-up
- Modifiable risk factors, e.g., smoking, weight loss if indicated, addressing new triggers
- Adherence with medications, and understanding of their purpose
- Reliever should be being used as-needed rather than routinely
- If controller medication was increased, the increased dose should be maintained for 3 weeks and possibly longer particularly, if flare-up was during the winter or during pollen season
- Inhaler technique skills
- Written asthma action plan
Conclusion
This article has addressed stable and acute asthma management. The rationale for the introduction of ICS/Formoterol combination therapy has been explored following the changes to the GINA guidelines in 2019.
People who have questions about managing their asthma are encouraged to send a WhatsApp message to Asthma WhatsApp service on 086 059 0132 or freephone the Asthma Society’s HSE-funded Asthma Adviceline on 1800 44 54 64. Both services are free and allow users to communicate directly with an asthma nurse specialist (Figure 3).
Patients can self-refer to the Adviceline using the following link: https://www.asthma.ie/book-a-nurse-call/
Healthcare Professionals can refer patients to the Adviceline using the following link: https://www.asthma.ie/health-professionals/patient-referral/
E-referrals can also be made by clicking the e-referral tab on www.asthma.ie
