Asthma in adults

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]

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

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)

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

Acute exacerbation; reduces relapse and accelerates recovery

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]

Acute severe or life-threatening asthmaEmergency department / ICU^[1]
Uncontrolled asthma despite step 4 (medium-dose ICS-LABA-LAMA)Pulmonology specialist for biologic candidacy and phenotyping^[1]
Occupational asthma suspicionPulmonology + occupational medicine for trigger identification^[1]

Diagnosis and stepped management of asthma — Indian Chest Society perspective with ICS-formoterol MART/SMART approach for moderate-to-severe disease.

1.Indian Chest Society Guidelines for Asthma Management; GINA 2024 Strategy Report (2023)