Forum of international respiratory society about asthma

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Forum of International Respiratory Societies asthma 2026

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FIRS Forum International Respiratory Societies asthma statement guidelines

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https://firsnet.org/inhaled-medicines-intervention-statement…

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Here is a comprehensive overview of the Forum of International Respiratory Societies (FIRS) and its work on asthma:

Forum of International Respiratory Societies (FIRS) - Asthma

What is FIRS?

FIRS was established in 2001 and unites the world's leading international professional respiratory societies to promote global equity in the prevention, diagnosis, and treatment of respiratory disease. Its membership includes:

American College of Chest Physicians (CHEST)
American Thoracic Society (ATS)
Asian Pacific Society of Respirology (APSR)
Asociación Latinoamericana de Tórax (ALAT)
European Respiratory Society (ERS)
International Union Against Tuberculosis and Lung Disease (The Union)
Pan African Thoracic Society (PATS)
Global Initiative for Asthma (GINA)
Global Initiative for Chronic Obstructive Lung Disease (GOLD)

With over 70,000 members globally, FIRS works alongside the WHO and other global bodies.

FIRS Position on Asthma

FIRS classifies asthma as one of the five most urgent respiratory conditions globally. Its advocacy focuses on three pillars:

1. Access to Inhaled Medicines

FIRS launched a major campaign on World Asthma Day 2025 to close wide gaps in access to inhaled medicines for asthma and COPD. Their core message: "No child should die because an inhaler is unavailable."

The campaign highlights that 102 million children under 15 have asthma, but life-saving inhalers remain inaccessible in many low- and middle-income countries (LMICs). FIRS is calling for action in five key areas:

Increasing availability of quality, affordable inhalers
Strengthening health system capacity
Supporting guideline implementation in LMICs
Reducing the economic burden of uncontrolled asthma on families
Integrating asthma care within broader lung health systems

2. World Health Assembly Advocacy (2026)

At the 79th World Health Assembly, FIRS and The Union delivered an intervention calling for a draft Resolution to improve availability of quality, affordable, and effective inhalers for COPD and asthma in all LMICs. If adopted, this would push national governments, industry, and global health agencies to invest greater resources to meet this need.

3. Integrated Lung Health

FIRS advocates integrating asthma care with TB, COPD, smoking cessation, post-TB lung disease, and cancer screening at the community and primary care levels - moving away from disease-specific silos toward people-centred, equitable care.

FIRS Lung Health Taskforce (2026)

FIRS recently launched the FIRS Lung Health Taskforce in partnership with the Global Lung Function Initiative. It will:

Develop a Lung Health Spirometry Toolkit
Create a global Lung Health Index
Advance understanding of lung health throughout life (relevant to early asthma detection)

Clinical Guidelines on Asthma (FIRS Member Societies)

While FIRS focuses on global advocacy, its member societies publish clinical guidelines:

GINA (Global Initiative for Asthma) - the primary clinical guideline body for asthma management worldwide
ERS/ATS joint guidelines on severe asthma - address phenotyping, biologic therapies, and refractory disease
The ERS/ATS severe asthma guidelines cover diagnosis, evaluation, and stepwise treatment including biologics (omalizumab, mepolizumab, etc.)

Key Advocacy Themes (2025-2026)

Issue	FIRS Stance
Access to inhalers in LMICs	High-priority campaign; resolution sought at WHA
Asthma in children	102 million children affected; access gap a major concern
Guideline implementation	Health systems in many countries lack capacity to apply existing guidelines
Disease integration	Asthma should be screened/treated within integrated lung health programs
Economic burden	Poorly controlled asthma avoidable with appropriate management

For the latest updates, visit the FIRS official website and GINA for current clinical guidelines.

About asthma is obstruction

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Here is a thorough breakdown of asthma as an obstructive lung disease, drawn from multiple authoritative textbooks:

Asthma: The Obstructive Pattern

Definition and Core Concept

Asthma is a chronic disease characterized by episodic and reversible airflow obstruction due to bronchial smooth muscle hyperreactivity and inflammation that is responsive to bronchodilator and corticosteroid treatments.

Tintinalli's Emergency Medicine

Per the GINA 2019 definition (cited in Murray & Nadel):

"Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is 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."

Mechanisms Causing the Obstruction

Three main factors narrow the airways during an asthma attack:

Mechanism	Description
Bronchospasm	Hyperreactive smooth muscle contracts, narrowing the airway lumen
Mucosal edema	Inflammatory mediators cause vascular leakage, swelling the bronchial wall
Mucus plugging	Hypersecretion of mucus blocks smaller airways

These occur on a background of chronic eosinophilic and T-lymphocyte airway inflammation, triggered by allergens, irritants, infections, exercise, or medications.

Cellular and Molecular Immunology (Abu-Ata)
Miller's Anesthesia

Spirometry: Confirming the Obstructive Pattern

The obstruction in asthma shows up on pulmonary function testing as follows:

FEV1/FVC ratio < 70% - the hallmark of obstruction
FEV1 may be normal between flares, but falls during attacks
Reversibility test: Improvement of FEV1 >12% and >200 mL after bronchodilator = reversible airflow obstruction, strongly suggestive of asthma
A 20% and 200 mL increase in FVC after bronchodilator is also suggestive
In severe asthma, FVC may fall due to air trapping, which can paradoxically increase the FEV1/FVC ratio
FEF25-75% (mid-expiratory flow) may detect small airway obstruction even when FEV1 is normal
Murray & Nadel's Textbook of Respiratory Medicine

Algorithm for diagnosing asthma in adults based on spirometry with reversibility testing

Diagnostic algorithm for asthma - from Murray & Nadel's Textbook of Respiratory Medicine

Airway Hyperresponsiveness (AHR)

AHR to environmental stimuli is a hallmark of asthma. When spirometry is normal but asthma is suspected, a methacholine challenge test is used:

FEV1 falls by >20% at the PC20 (provocative concentration)
PC20 <16 mg/mL = mild AHR
PC20 <4 mg/mL = moderate AHR
PC20 <1 mg/mL = severe AHR
Murray & Nadel's Textbook of Respiratory Medicine

Diffusing Capacity (DLCO): A Key Distinguishing Feature

Unlike COPD/emphysema, in asthma:

DLCO is normal or elevated (due to increased perfusion of upper lung zones)
This is a key way to distinguish asthma from other obstructive diseases
An unexpected increase in DLCO should raise suspicion for undiagnosed asthma
A decreased DLCO in a suspected asthmatic suggests an alternative diagnosis or coexisting condition

Reversibility vs. Fixed Obstruction

Feature	Asthma	COPD
Reversibility	Largely reversible	Largely irreversible
Age of onset	Often younger	Typically older (>40 yrs)
Smoking history	Less common	Common
Atopy	Frequent	Less common
DLCO	Normal or elevated	Decreased
Corticosteroid response	Good	Limited

Chronic/Remodeled Asthma: Long-standing asthma can cause structural changes ("airway remodeling") leading to persistent, fixed obstruction that no longer fully reverses. In such cases, distinguishing from COPD may be impossible. This is termed asthma-COPD overlap (ACO).

Murray & Nadel's Textbook of Respiratory Medicine

Clinical Takeaway

Asthma is classified as an obstructive lung disease because it reduces expiratory airflow (low FEV1/FVC). What distinguishes it from COPD is the reversibility of that obstruction - at least early in the disease course. Over time, without adequate treatment, irreversible remodeling can make the obstruction permanent.

List of all obstructive lung diseases

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Here is a comprehensive, textbook-grounded list of all obstructive lung diseases, organized by location and type:

Obstructive Lung Diseases - Complete Classification

Defining feature: Reduced expiratory airflow (low FEV1/FVC ratio) due to airway narrowing, collapse, or plugging.

A. Upper Airway Obstructive Diseases

(Obstruction of larynx, trachea, large bronchi)

Disease	Key Features
Vocal cord dysfunction / Paradoxical vocal fold motion	Extrathoracic variable obstruction on flow-volume loop; mimics asthma; no bronchodilator response; confirmed on laryngoscopy
Tracheal stenosis (post-intubation/tracheostomy)	Fixed obstruction; plateau on both inspiratory and expiratory flow-volume loop
Epiglottitis	Supraglottic swelling causing acute upper airway obstruction; sore throat, stridor
Laryngotracheal tumors / Neoplasms	Bronchogenic carcinoma, carcinoid, adenoma; unilateral wheeze, confirmed by bronchoscopy
Tracheomalacia	Collapse of tracheal wall; dynamic expiratory obstruction
Anaphylaxis	Acute laryngeal edema; abrupt onset with urticaria, angioedema, hypotension
Retropharyngeal abscess	Posterior pharyngeal swelling; stridor

Goldman-Cecil Medicine (Table 24-1)

B. Lower Airway Obstructive Diseases

(Obstruction of bronchi, bronchioles, alveolar ducts)

1. Asthma

Episodic, reversible airflow obstruction
Caused by bronchospasm + mucosal edema + mucus plugging
FEV1/FVC <70%; reverses >12% + 200 mL with bronchodilator
Hallmark: airway hyperresponsiveness (AHR)

2. Chronic Obstructive Pulmonary Disease (COPD)

COPD is an umbrella term with two main components that commonly coexist:

Subtype	Mechanism
Emphysema	Destruction of alveolar walls; loss of elastic recoil; dynamic airway collapse; low DLCO
Chronic bronchitis	Mucus hypersecretion + airway wall thickening; DLCO normal/near-normal

Obstruction is largely irreversible (fixed)
Typically in smokers >40 years old

3. Asthma-COPD Overlap (ACO)

Persistent airflow limitation + features of both asthma and COPD
Airway remodeling from chronic asthma → fixed obstruction
Murray & Nadel's Textbook of Respiratory Medicine

4. Bronchiectasis

Permanent bronchial dilation with wall thickening
Copious mucopurulent sputum + digital clubbing
Obstructive pattern on PFTs; diagnosis confirmed by high-resolution CT

5. Cystic Fibrosis (CF)

Genetic (CFTR mutation); viscous mucus → progressive obstruction
Features: productive cough, bronchiectasis, Pseudomonas colonization, pancreatic insufficiency, digital clubbing
Progressive obstructive pattern; two sweat chloride values ≥50 mEq/L diagnostic
Goldman-Cecil Medicine

6. Bronchiolitis / Bronchiolitis Obliterans

Inflammation/fibrosis of small airways (<2 mm)
Causes: viral (in children), connective tissue disease, post-transplant (chronic rejection), ulcerative colitis, toxic fume inhalation
Mild obstructive + restrictive pattern on PFTs; hyperinflation
Fine nodular infiltrates on CXR
Bronchiolitis obliterans (constrictive bronchiolitis): submucosal fibrosis → bronchiolar narrowing

7. Small Airway Disease

Isolated disease of airways <2 mm diameter
FEV3 and FEF25-75% abnormally low; FEV1 may be normal
DLCO and lung volumes normal; minimal bronchodilator response
May represent early/pre-clinical obstructive disease
Fishman's Pulmonary Diseases and Disorders

8. Hypersensitivity Pneumonitis (Extrinsic Allergic Alveolitis)

Can produce mixed obstructive + restrictive picture
Caused by repeated inhalation of organic antigens

9. Alpha-1 Antitrypsin Deficiency

Genetic cause of early-onset emphysema in non-smokers
Loss of protease inhibition → alveolar destruction (predominantly lower lobe)
Obstructive pattern; very low DLCO

10. Aspiration-related airway obstruction

Foreign body or recurrent aspiration causing mechanical airway blockage
Can be acute (fixed obstruction) or chronic

Summary Comparison

Disease	Reversibility	DLCO	Smoking link	Age of onset
Asthma	Reversible	Normal/High	No	Any (often young)
Emphysema	Irreversible	Low	Yes	>40 years
Chronic bronchitis	Largely irreversible	Normal	Yes	>40 years
Bronchiectasis	Partially reversible	Normal	No	Any
Cystic fibrosis	Partially reversible	Normal	No	Childhood
Bronchiolitis obliterans	Fixed	Normal	No	Any
Alpha-1 AT deficiency	Irreversible	Low	No (or minor)	Young adult
Small airway disease	Minimal response	Normal	Often	Middle age

The key spirometric criterion for all these conditions is a reduced FEV1/FVC ratio (<70%), with reversibility testing and DLCO helping to differentiate between them.

Fishman's Pulmonary Diseases and Disorders
Murray & Nadel's Textbook of Respiratory Medicine
Goldman-Cecil Medicine

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