1. Frequent SABA use = poor control → step up therapy
2. Always assess inhaler technique before stepping up — it's the most common fixable cause of failure
3. Treat the comorbidities (rhinitis, GERD, anxiety) — they directly perpetuate poor asthma control
4. Issue a written action plan — it's the single most effective self-management tool
5. Consider SMART therapy (single ICS/formoterol inhaler as both maintenance + reliever) — it significantly reduces exacerbations

History of Present Illness (HPI)

Written as a clinical narrative — the way you'd document it in the notes

Paragraph 1 — Onset & Cardinal Symptoms

Paragraph 2 — Timing & Pattern

Paragraph 3 — Triggering & Aggravating Factors

Paragraph 4 — Current Medication Use & Control

Paragraph 5 — Impact on Daily Life & Red Flag Assessment

Clinical summary: Known asthmatic with a [X]-year history, presenting with a multi-week deterioration characterized by daily symptoms, frequent nocturnal awakenings, near-daily SABA overuse, poor preventer adherence, incorrect inhaler technique, and significant functional impairment — consistent with uncontrolled moderate-to-severe persistent asthma requiring immediate clinical review, step-up pharmacotherapy, inhaler technique correction, and a written asthma action plan.

Management of the Overwhelmed Asthmatic Patient

Uncontrolled Moderate-to-Severe Persistent Asthma

STEP 1 — IMMEDIATE IN-CLINIC ASSESSMENT

• SpO₂, RR, HR, ability to speak in full sentences
• Auscultate chest — wheeze vs. silent chest
• PEF % personal best

• Ask the patient to demonstrate their current technique
• Correct errors: shake → exhale → actuate + slow deep inhale simultaneously → hold breath 10 seconds
• Prescribe a spacer device — increases lung deposition by up to 4× compared to MDI alone

• Rule out vocal cord dysfunction, COPD, cardiac failure if any atypical features

STEP 2 — PHARMACOLOGICAL MANAGEMENT

A. Treat Today's Exacerbation First

B. Step Up Long-Term Controller Therapy

SMART = Single Maintenance And Reliever Therapy One inhaler (ICS/formoterol) used as BOTH the daily preventer AND the as-needed reliever. Evidence shows SMART reduces exacerbations and oral steroid courses more effectively than fixed ICS + SABA PRN.

C. When to Consider Biologic Therapy (Step 5–6)

STEP 3 — TREAT COMORBIDITIES

STEP 4 — NON-PHARMACOLOGICAL MEASURES

• Remove or keep cat out of bedroom; use HEPA air purifier
• Allergen-impermeable mattress and pillow covers; wash bedding in hot water (≥60°C) weekly
• Remove carpets where possible
• Pre-exercise: salbutamol 2 puffs 15–30 minutes before activity
• Avoid cold air exposure; use a scarf over mouth in cold weather

• If current smoker → smoking cessation is the single most impactful intervention
• Offer NRT + varenicline + behavioral support
• Household smoking ban even if patient is a non-smoker

STEP 5 — WRITTEN ASTHMA ACTION PLAN

STEP 6 — MONITORING & FOLLOW-UP

1. Symptom frequency (day + night)
2. SABA use (canisters/month)
3. Activity limitation
4. Lung function (FEV₁ or PEF)
5. Inhaler technique (demonstrate each time)
6. Adherence and barriers

STEP 7 — PATIENT EDUCATION (Before Leaving the Clinic)

• Explain the difference between preventer (ICS — reduces inflammation, must be used daily even when well) vs. reliever (SABA — opens airways fast but does NOT treat inflammation)
• Emphasize: "Using your blue inhaler every day means your asthma is not controlled — it is not a solution, it is a warning sign"
• Demonstrate and have the patient demonstrate back the correct inhaler + spacer technique
• Explain the written action plan in the patient's own language
• Book annual flu vaccination today
• Provide emergency contact number and clear instructions on when to go to ER
• Address the patient's anxiety — validate that feeling overwhelmed is common, and that with the right plan, most patients achieve full control

Summary of Today's Management in One View

TODAY:
├── Salbutamol 4–8 puffs via spacer (in clinic)
├── Prednisolone 40 mg OD × 7 days (oral)
├── Fix inhaler technique + issue spacer
└── Step up to ICS/LABA (SMART: budesonide/formoterol)

SHORT-TERM (2–4 weeks):
├── Add montelukast 10 mg ON if rhinitis present
├── Treat GERD / rhinitis / other comorbidities
├── Trigger avoidance plan
└── Written action plan + PEF meter

LONG-TERM (3+ months):
├── Review control → step down if appropriate
├── Reassess for LAMA add-on if uncontrolled
├── Refer if still uncontrolled → consider biologics
└── Annual flu vaccine + spirometry

Key Questions to Ask in an Asthma HoPi

The must-ask checklist — nothing skipped

🔑 1. THE 4 CARDINAL SYMPTOMS

🔑 2. TIMING — THE MOST DIAGNOSTIC QUESTIONS

The pattern tells you more than the symptom itself.

• "Are symptoms worse at night or early morning?" (Nocturnal/early-morning = classic asthma — circadian pattern)
• "Do symptoms come and go, or are they always there?" (Episodic and reversible = asthma; constant = think COPD or other)
• "How many days per week do you get symptoms?" (Classifies severity: ≤2 = intermittent; daily = persistent)
• "How many nights per week do you wake up because of it?" (>1×/week = at least moderate persistent)

🔑 3. TRIGGERS — GO THROUGH THEM ONE BY ONE

🔑 4. INHALER USE — THE CONTROL QUESTIONS

• "What inhalers are you on? Show me how you use them." (Technique is wrong in >70% of patients — the most fixable cause of poor control)
• "How many times a day are you using your blue/reliever inhaler?" (>2 days/week = poor control; daily use = significant red flag)
• "How many canisters of the reliever have you used in the past month?" (>1 canister/month = poorly controlled)
• "Are you taking your preventer inhaler every day, even when you feel well?" (Most patients stop it when symptoms improve — this is a key education gap)
• "Has your inhaler stopped working as well as it used to?" (Reduced effect = worsening inflammation, not tolerance)

🔑 5. IMPACT ON DAILY LIFE

• "How many nights have you woken up because of asthma this week?"
• "Has asthma stopped you from doing normal activities — exercise, work, housework?"
• "How many days of work or school have you missed?"
• "Can you climb a flight of stairs without stopping?"
• "Does asthma affect your sleep?"

🔑 6. PAST ASTHMA HISTORY — THE RISK MARKERS

• "Have you ever been admitted to hospital because of asthma?"
• "Have you ever been in ICU or put on a breathing machine?" ← Near-fatal history — highest risk
• "How many courses of steroid tablets have you had in the past year?" (≥2 = severe/uncontrolled)
• "Have you ever needed a nebulizer in A&E?"
• "When were you last well-controlled?"

🔑 7. COMORBIDITIES THAT DRIVE POOR CONTROL

• "Do you have a blocked or runny nose, or sneeze a lot?" → Allergic rhinitis
• "Do you get heartburn or acid reflux, especially at night?" → GERD
• "Do you have eczema or skin allergies?" → Atopic march
• "Has anyone told you that you stop breathing in your sleep / snore loudly?" → OSA
• "Do you feel anxious or down in mood?" → Anxiety/depression — very common in asthma

🔑 8. SMOKING & ENVIRONMENT

• "Do you smoke — cigarettes, shisha, vaping?" (pack-years; type)
• "Does anyone in your home smoke?"
• "Do you have carpets, soft furnishings, pets at home?"
• "Is there any damp or mold in your home?"
• "What do you do for work? Any chemical or dust exposure?"

🔑 9. DRUGS TO ALWAYS ASK ABOUT

Quick-Fire Memory Aid

"WHAT TRIGGERS MY ASTHMA DOCTOR?"