Asthma: understanding and improving control

Airway inflammation + variable contraction of airway muscles + sometimes excess mucus: the airways temporarily narrow. Symptoms may almost completely disappear between episodes.

In children aged 5 years or younger, not every wheezing episode necessarily represents persistent asthma. Diagnosis is based on recurrent compatible episodes, absence of a more likely cause and clinical response to treatment. If evidence is not yet sufficient, follow-up over time is essential.

From about age 6, typical variable respiratory symptoms are sought together with objective variability in expiratory airflow. Spirometry with a bronchodilator test is the usual examination. A normal result on one day does not necessarily rule out asthma.

These tests may help define the type of inflammation or the role of allergy. None diagnoses asthma on its own. Normal values do not rule it out either.

No. Exercise may trigger bronchoconstriction in some people or reveal insufficiently controlled asthma. The usual goal is to enable physical activity. Very atypical exercise symptoms may prompt a search for another cause, such as inducible laryngeal obstruction.

Asthma may be caused or aggravated by work: improvement during holidays or weekends, or a link with dust, flour, latex, animals or chemicals. In some patients with asthma and nasal polyps, NSAIDs can trigger respiratory reactions. This does not mean every person with asthma is ‘allergic to aspirin’.

• few daytime symptoms;
• few or no night-time awakenings;
• little limitation of activities;
• little need for reliever treatment;
• few exacerbations, ED attendances or courses of corticosteroids.

Rapid relief remains useful when included in your plan, but it does not replace anti-inflammatory protection. If you use your reliever very often, tell your doctor: this may indicate inadequate control.

An effective medicine may work poorly if it does not reach the airways correctly. Technique, device, spacer when indicated and suitability for age should be checked regularly.

When an allergen is genuinely linked to symptoms, realistically reducing exposure may help. A positive test alone does not prove it is responsible for asthma. Active/passive smoking, vaping, pollution and occupational exposures may also worsen symptoms and exacerbations.

This list does not mean that every person with asthma needs all these tests. Assessment is guided by the history, examination and unusual signs.

The process usually follows several steps: confirm asthma → optimise the basics → identify comorbidities and differential diagnoses → characterise inflammation → consider targeted treatment.

• clinically relevant allergy;
• blood eosinophils;
• FeNO when available;
• nasal polyps, atopic dermatitis or other type 2 comorbidities;
• ABPA, AERD/N-ERD, EGPA or hypereosinophilia when suggested by the context.

An exacerbation may involve increased breathlessness, cough or wheeze, night waking, greater need for reliever treatment or a fall in expiratory flow when measured. Follow your written action plan.

A child with well-controlled asthma should be able to run, play and take part in sport. An Individualised healthcare plan (PAI – French school system) may be useful depending on the situation. During adolescence, the goal is gradual independence: knowing treatments, using the inhaler correctly, recognising deterioration and discussing smoking or vaping openly.

It specifies your daily treatment, reliever treatment, signs of worsening, when to contact the doctor and when to call emergency services. Keep it accessible and have it updated with your care team.