Asthma: Symptoms, Inhalers and How to Stay in Control
Asthma is a long-term condition in which the airways are inflamed and over-sensitive, so they narrow and fill with mucus when something irritates them. That produces wheezing, coughing (often worst at night or in the early morning), chest tightness and breathlessness, in episodes rather than constantly. Dust, smoke, smog, cold air, viral colds, exercise, strong smells and some medicines are common triggers. It is diagnosed from the pattern of symptoms plus a breathing test showing airway narrowing that improves with a reliever inhaler. Treatment has two halves: a preventer inhaler containing a low dose of steroid, which calms the inflammation and is what actually keeps you well, and a reliever inhaler for symptoms. Current international guidance no longer recommends using a reliever alone, because relying on it leaves the underlying inflammation untreated and raises the risk of a severe attack. Most people with asthma can work, study, exercise and sleep normally once the preventer is taken every day and the inhaler technique is correct. Asthma is not curable, but it is very controllable. An attack in which you cannot speak a full sentence, the reliever is not lasting, or the lips look blue is a medical emergency.
Health writers · Aslam Clinic
What asthma is
Air reaches the lungs through branching tubes called airways. In asthma the lining of those tubes is permanently a little inflamed and irritable, even on a good day. When something provokes it — dust, smoke, a cold virus, cold air — three things happen quickly: the muscle wrapped around the airway squeezes, the lining swells, and it produces sticky mucus. The tube narrows. Breathing out through a narrowed tube is what makes the whistling sound called a wheeze.
Two features separate asthma from most other chest problems. It is variable — worse at night, worse after a trigger, better in between — and it is reversible, meaning the narrowing opens up again with a or on its own. A cough that is present identically all day every day for months is usually something else, and the other article in this section covers that.
Asthma often runs alongside and hay fever, and often in families. That does not make it an allergy in every person: plenty of adults develop asthma in their thirties or forties with no allergic history at all, sometimes after a chest infection or a job with dust or fumes in it.
What sets it off here
Triggers are personal, and the single most useful thing you can do in the first month is work out which ones are yours. The list below is what a clinic in Pakistan sees most.
- Winter smog. From roughly November to February the air over Punjab and parts of Sindh traps particulate matter close to the ground, and asthma admissions rise with it. Early morning is usually the worst hour, not the best one for a walk.
- Household smoke. Wood, dung and coal stoves, mosquito coils, agarbatti and burning rubbish are all strong airway irritants. So is a gas heater in a sealed room.
- Tobacco, in any form. Cigarettes, sheesha, and smoke breathed in from someone else in the house. Sheesha is not gentler than a cigarette.
- House dust mite. Bedding, mattresses, carpets, soft toys and stored clothes. Hot, humid coastal cities are worse for it than dry ones.
- Colds and flu. A viral infection is the commonest reason a stable asthmatic suddenly needs the hospital.
- Cold air, dust storms and exercise, especially outdoors in winter or during a loo wind.
- Medicines. such as ibuprofen, diclofenac and aspirin can worsen asthma in a minority of adults; so can beta-blocker tablets and eye drops. Tell every prescriber that you have asthma.
- Strong smells — paint, agarbatti, perfume, phenyl, insect spray.
How it is diagnosed
There is no single blood test for asthma. The diagnosis is made from the story — variable wheeze, cough and breathlessness with a trigger pattern — and then confirmed with a breathing test wherever possible, because treating someone for asthma who does not have it is a common and unhelpful mistake.
is the main test: you blow hard into a machine, then repeat it fifteen minutes after a reliever inhaler. A meaningful improvement afterwards is the reversibility that defines asthma. A peak flow meter is the cheap alternative and is widely available here; blowing into it morning and evening for two weeks and writing down the best of three readings each time will often show the day-to-night swing that clinches the diagnosis. A does not diagnose asthma but is often done once, to rule out the things that imitate it.
The two inhalers, and why the order matters
This is the part that is most often misunderstood, and getting it wrong is the commonest reason someone ends up in an emergency room.
| Reliever | Preventer | |
|---|---|---|
| What it contains | A short-acting , usually salbutamol | An inhaled , sometimes combined with a long-acting bronchodilator |
| What it does | Relaxes the muscle around the airway | Settles the in the airway lining |
| How fast | Minutes | Days to weeks, building up |
| When taken | For symptoms, and before exercise if advised | Every day, including on days you feel well |
| What happens if you skip it | You are breathless until you take it | Nothing today. An attack in a few weeks |
| Common colour of the device | Usually blue in Pakistan, but do not rely on colour | Brown, orange, purple, red and others — read the label |
Since 2019 the Global Initiative for Asthma has recommended that adults and adolescents should not be treated with a reliever alone, at any severity. Every such person should be on an inhaled corticosteroid in some form — either taken daily, or as a combined steroid-and-formoterol inhaler used both as the regular preventer and as the reliever. The reasoning is blunt: reliever-only treatment leaves the inflammation untouched, and people who use large amounts of reliever have more severe attacks and more deaths. If you are using more than one reliever canister every two to three months, that is a signal to be reassessed, not to buy more.
Getting the inhaler to actually work
Studies repeatedly find that most people use a metered-dose inhaler incorrectly, which means most of the dose lands on the tongue and the back of the throat rather than in the lung. Before anyone concludes that a medicine has failed, the technique should be watched.
- Shake the inhaler and take the cap off. Check the counter if it has one; a canister that floats in water is not a reliable test and never was.
- Breathe all the way out, away from the device.
- Seal your lips around the mouthpiece, start to breathe in slowly, and press once as you begin the breath.
- Keep breathing in slowly and deeply for four to five seconds.
- Hold your breath for about ten seconds, then breathe out gently.
- Wait about thirty seconds before a second puff, and shake again.
- Rinse your mouth and spit after a steroid-containing inhaler. That prevents hoarseness and oral thrush.
Things sold for asthma that are not asthma treatment
- Salbutamol syrup and tablets. Taken by mouth the drug reaches the whole body, so it causes far more tremor and while working less well in the airway than a puff of the same drug. Inhaled is better in every respect, including for small children with a spacer and mask.
- Long-acting steroid injections. Depot steroid given every few weeks or months for asthma is still offered in some places. It exposes the whole body to steroid for weeks, with real risks to bone, blood sugar and infection, and it has no place in routine care.
- for every attack. Most attacks are triggered by a , not . Antibiotics do not open an airway and their overuse is the reason resistant infections are now hard to treat here.
- Nebuliser dependence. A nebuliser is not stronger than an inhaler with a spacer for the same drug; several trials show they are equivalent for most attacks. Keeping one at home can delay the decision to go to hospital, which is the actual danger.
- Steroid-phobia. The reverse error is just as damaging. Refusing a preventer because of what steroid tablets do over years leaves the disease untreated. Inhaled doses are micrograms, delivered to the airway lining.
What you can do yourself
- Take the preventer every day at a fixed time, tied to an existing habit. Asthma control is built over weeks, not on the bad day.
- Ask your doctor for a written action plan: what your normal treatment is, what to do when symptoms worsen, and the point at which you go to hospital. Keep it on your phone.
- Wash bedding weekly in hot water, keep the sleeping area free of carpet and stored clothes, and air the room in the afternoon rather than at dawn in the smog months.
- Check the air quality index in winter. On bad days, exercise indoors, keep windows shut in the early morning, and wear a well-fitted N95 mask outdoors — a surgical or cloth mask does not filter particulate matter.
- Stop smoking and get smoking out of the house. This is the single largest gain available, and there is help in our guide to quitting tobacco.
- Have the influenza each year before winter, and ask whether the pneumococcal applies to you.
- If you are overweight, losing even five to ten per cent of body weight measurably improves asthma control.
- Never stop a preventer because you feel well. Feeling well is what it is for.
Is your asthma actually controlled?
Ask yourself these four questions about the last four weeks. Any yes means the asthma is not controlled and the treatment should be reviewed.
- Have you had daytime symptoms more than twice a week?
- Have you woken at night because of your asthma, even once?
- Have you needed the reliever inhaler more than twice a week, other than before exercise?
- Has asthma limited anything you wanted to do — stairs, work, prayer, play, walking to the shop?
When to see a doctor
Book an appointment if you have a wheeze, a night cough or breathlessness that keeps returning, if you are using a reliever more than twice a week, if a preventer does not seem to be helping after four to six weeks of correct daily use, or if you have never had the diagnosis confirmed with a breathing test. Anyone who has had an attack needing steroid tablets or a hospital visit should be reviewed within a week of it, and everyone with asthma benefits from a check at least once a year, with the inhaler technique watched each time. Speak to a doctor before starting an anti-inflammatory painkiller or a beta-blocker if you have asthma.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
