Red Flags
- Acute severe asthma — PEFR <50% best, unable to complete sentences, RR ≥25, HR ≥110 — high-flow oxygen, nebulised salbutamol, IV magnesium, oral steroids, ICU consideration[1]
- Life-threatening asthma — silent chest, exhaustion, cyanosis, hypotension, altered consciousness, normal/raised pCO₂ — immediate ICU; consider intubation[1]
- Brittle asthma or near-fatal episode history — referral to specialist; consider biologic therapy[1]
- Asthma with frequent SABA-only use (>3 canisters/year) without controller — high mortality risk; switch to ICS-formoterol[1]
First-line treatment
Interventions
- Inhaler technique check at every visit[1]Single most cost-effective intervention; >50% of patients use inhalers incorrectly. Spacer with pMDI; train and re-check
- Trigger avoidance + asthma action plan[1]Personalised written action plan with self-titration thresholds; avoid known triggers (allergens, occupational, smoke); annual influenza vaccination
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Budesonide-formoterol (low-dose ICS-formoterol)[1] | ICS-LABA combination — MART/SMART | Budesonide-formoterol 200/6 DPI 1 puff BD plus 1 puff PRN as reliever (max 8 puffs/day) — single inhaler for both controller and reliever (MART) | ≥12 years: same as adult; 6–11 years: 200/6 DPI 1 puff BD plus PRN max 6 puffs/day | First-line per GINA 2019+ — replaces SABA monotherapy as both controller and reliever; reduces severe exacerbations vs SABA alone |
| Salbutamol (rescue ONLY if not on MART)[1] | Short-acting beta-agonist (SABA) | 100 mcg pMDI 2 puffs PRN | 100–200 mcg PRN | SABA-only use is no longer endorsed; use only as rescue layered on top of ICS-containing controller |
| ICS-LABA + LAMA (triple therapy)[1] | Triple inhaler | Mometasone-indacaterol-glycopyrronium 160/150/50 mcg DPI once daily; or budesonide-formoterol-glycopyrronium combination | — | Step up from medium-dose ICS-LABA insufficient; before biologic step |
| Mepolizumab, benralizumab, or dupilumab (biologics)[1] | Monoclonal antibody (anti-IL-5 / IL-5R / IL-4R) | Mepolizumab 100 mg SC q4w; benralizumab 30 mg SC q4w × 3 then q8w; dupilumab 200–300 mg SC q2w | Per package | Severe asthma with eosinophilic phenotype despite optimised inhalers; requires specialist referral |
| Prednisolone (acute exacerbation)[1] | Oral glucocorticoid | 30–50 mg PO once daily × 5–7 days; no taper needed at this duration | 1–2 mg/kg/day max 40 mg × 3–5 days | Acute exacerbation; reduces relapse and accelerates recovery |
Budesonide-formoterol (low-dose ICS-formoterol)[1]
ICS-LABA combination — MART/SMART
- Adult
- Budesonide-formoterol 200/6 DPI 1 puff BD plus 1 puff PRN as reliever (max 8 puffs/day) — single inhaler for both controller and reliever (MART)
- Paediatric
- ≥12 years: same as adult; 6–11 years: 200/6 DPI 1 puff BD plus PRN max 6 puffs/day
First-line per GINA 2019+ — replaces SABA monotherapy as both controller and reliever; reduces severe exacerbations vs SABA alone
Salbutamol (rescue ONLY if not on MART)[1]
Short-acting beta-agonist (SABA)
- Adult
- 100 mcg pMDI 2 puffs PRN
- Paediatric
- 100–200 mcg PRN
SABA-only use is no longer endorsed; use only as rescue layered on top of ICS-containing controller
ICS-LABA + LAMA (triple therapy)[1]
Triple inhaler
- Adult
- Mometasone-indacaterol-glycopyrronium 160/150/50 mcg DPI once daily; or budesonide-formoterol-glycopyrronium combination
- Paediatric
- —
Step up from medium-dose ICS-LABA insufficient; before biologic step
Mepolizumab, benralizumab, or dupilumab (biologics)[1]
Monoclonal antibody (anti-IL-5 / IL-5R / IL-4R)
- Adult
- Mepolizumab 100 mg SC q4w; benralizumab 30 mg SC q4w × 3 then q8w; dupilumab 200–300 mg SC q2w
- Paediatric
- Per package
Severe asthma with eosinophilic phenotype despite optimised inhalers; requires specialist referral
Prednisolone (acute exacerbation)[1]
Oral glucocorticoid
- Adult
- 30–50 mg PO once daily × 5–7 days; no taper needed at this duration
- Paediatric
- 1–2 mg/kg/day max 40 mg × 3–5 days
Acute exacerbation; reduces relapse and accelerates recovery
Safety-net
- Use ICS-formoterol every day even when feeling well — it prevents flares; rescue-only use is not enough[1]
- If using SABA-rescue more than 3 times a week or waking at night with symptoms — your asthma is not controlled; review needed[1]
- Severe breathlessness, blue lips, unable to talk in sentences, no response to rescue inhaler — call emergency services immediately[1]
Referral criteria
Clinical summary
Diagnosis and stepped management of asthma — Indian Chest Society perspective with ICS-formoterol MART/SMART approach for moderate-to-severe disease.