Asthma (bronchial asthma): Symptoms, step therapy and everyday life
At a glance
Affected
~260 million worldwide; in Germany about 3–5% of adults and up to ~12% of children/adolescents
Other names
Asthma, bronchial asthma
Cause
Chronic inflammatory airway disease with bronchial hyperresponsiveness
Forms
Allergic and non-allergic asthma (often mixed forms)
Medications (selection)
ICS (e.g. budesonide, fluticasone), LABA (e.g. formoterol), SABA (e.g. salbutamol / US: albuterol), biologics
ICD-10
J45
1. What is asthma?
Bronchial asthma is a chronic inflammatory disease of the airways. The bronchi react over-sensitively to various stimuli — this usually leads to three characteristic changes: the bronchial mucosa swells (inflammation), the bronchial muscle tightens (bronchospasm), and thick mucus is produced. The result: the airways narrow, and breathing out becomes especially difficult.¹
Asthma often runs in attacks — phases with symptoms alternate with symptom-free intervals. The intensity of symptoms can change over the course of life and often fluctuates seasonally (e.g. pollen season, infection season).
New treatment goal: remission
The German National Care Guideline for asthma (NVL 2024) goes beyond mere symptom control — the aim is remission: the most complete freedom from symptoms possible with the least possible therapy. With modern medications, this goal is realistic for many of those affected.¹
Form 1
Allergic asthma (extrinsic)
Triggered by allergens (e.g. pollen, house dust mites, animal hair, mould). Often begins in childhood. Frequently combined with hay fever and atopic dermatitis (the atopic triad). Typically a type-2 inflammation with elevated IgE levels and eosinophil granulocytes. In childhood, allergic asthma is the most common form.¹
Form 2
Non-allergic asthma (intrinsic)
No allergic component can be detected. Often begins in adulthood. Typical triggers: respiratory infections (the most common trigger), cold air, physical exertion, environmental pollutants. Often harder to treat.
Form 3
Mixed and special forms
Very common — many patients have both allergic and non-allergic components.¹
- Analgesic asthma (NSAID-exacerbated respiratory disease): triggered by NSAIDs such as ASA (aspirin) or ibuprofen. Often combined with nasal polyps (Samter's triad). For known analgesic asthma, paracetamol (acetaminophen) can be an alternative.
- Exercise-induced asthma: symptoms mainly with physical exertion — especially in cold, dry air. No reason to give up sport.
3. Symptoms — and when it's an emergency
Typical asthma symptoms
- Attacks of shortness of breath — especially when breathing out (expiratory dyspnoea)
- Wheezing breath sounds — often audible during forced exhalation
- Dry, attack-like cough — often at night and in the early morning hours. In some patients, cough is the only symptom ("cough-variant asthma")
- Tightness in the chest or chest pain
- Increased mucus production — often thick, glassy sputum
- Symptoms often worsen with allergen contact, infections, physical exertion, cold air or stress
Typical of asthma: symptoms come and go
There are usually good and bad days or weeks. Seasonal fluctuations are common in allergic asthma.
Acute asthma attack — an emergency!
- Severe, increasing breathlessness — exhalation is greatly prolonged
- Use of the accessory respiratory muscles — bracing the arms, visible drawing-in of the skin between the ribs
- The affected person can no longer speak in longer sentences
- Palpitations, anxiety, restlessness
- Bluish lips or fingernails (cyanosis) — a sign of oxygen deficiency
- No more audible wheezing ("silent chest") — paradoxically a warning sign of a very severe narrowing
What to do in a severe asthma attack?
1) Stay calm. 2) Sit upright, brace your arms (tripod position, leaning forward on your arms). 3) Inhale your reliever spray according to your medical action plan. 4) Pursed-lip breathing: breathe out slowly through pursed lips. 5) If there is no improvement, with cyanosis or a "silent chest", call 112 immediately (in the US: 911).¹
4. Causes and triggers
Why does asthma develop?
- Genetic predisposition — asthma, hay fever and atopic dermatitis often cluster in families¹
- Disturbed immune regulation — an overreaction of the immune system to actually harmless stimuli (often a Th2-dominated inflammation)
- Environmental factors — e.g. air pollution, tobacco smoke (active and passive), fine particulate matter⁴
- Early-childhood factors — e.g. severe respiratory infections in infancy (including RSV)
- Overweight/obesity can increase the risk of asthma and worsen treatment control
What sets off asthma attacks? (triggers)
- Allergens: pollen (seasonal), house dust mites (year-round), animal hair, mould spores
- Respiratory infections — a common trigger in non-allergic asthma and in children
- Physical exertion (exercise-induced asthma) — especially in cold, dry air
- Cold air, fog, sudden changes in weather
- Tobacco smoke, perfume, paints, cleaning agents, other chemicals
- Stress and psychological strain can promote asthma episodes
- NSAID painkillers (e.g. ASA, ibuprofen) in analgesic asthma
- Beta blockers — can trigger a bronchospasm in sensitive patients. More: Drug interactions
5. Diagnosis
- History-taking: Typical symptoms (cough, breathlessness, wheezing)? When, how often, which triggers? Family history? Accompanying allergies?
- Lung function test (spirometry): measures breathing volume and speed (FEV1, FVC). Shows the typical obstructive ventilation disorder. The reversibility test can support the diagnosis.¹
- Peak flow measurement: a simple self-measurement at home. Day-to-day variability can be a sign of asthma. Useful for monitoring and for the asthma action plan (traffic-light scheme).
- FeNO measurement: nitric oxide in the exhaled breath — often elevated in eosinophilic type-2 inflammation. Can help with treatment decisions.¹
- Allergy tests: prick test, specific IgE in the blood — when allergic asthma is suspected.
- Provocation test: e.g. with methacholine — for an unclear diagnosis despite a normal lung function test.
- Differential diagnoses: COPD (especially in smokers), vocal cord dysfunction, heart failure or reflux-related cough should be ruled out.
More: Preparing for a doctor's appointment.
6. Medications: step therapy per NVL 2024
In Germany, asthma therapy follows a 5-step scheme of the National Care Guideline (NVL).¹ Basic principle: "as much as necessary, as little as possible." With good control, therapy can be reduced (step-down); with poor control, it is intensified (step-up). Which step and which medication are used is always decided by the treating physician.
Important change in NVL 2024: SABA monotherapy is outdated
The classic SABA monotherapy (e.g. salbutamol alone as needed) is now considered outdated. It is recommended that every as-needed inhalation also contains an inhaled corticosteroid (ICS) — either as a fixed combination or alongside the ICS controller.¹˒⁴
Reliever medications — for acute symptoms
Reliever 1
SABA (e.g. salbutamol / US: albuterol)
Short-acting bronchodilator — works within a few minutes and is traditionally used as a reliever spray. SABA therapy alone is no longer recommended under NVL 2024.¹
Reliever 2
ICS/formoterol as needed (NVL 2024)
A fixed combination of an inhaled corticosteroid (ICS) and a fast-acting bronchodilator (formoterol) — already possible as an as-needed therapy in the lower steps. Advantage: every as-needed inhalation automatically contains an anti-inflammatory component. In steps 1–2 still formally off-label, but recommended by NVL and GINA.¹˒⁴
Maintenance therapy (controller) — daily anti-inflammatory treatment
Step 1–2
Mild asthma
ICS (low dose, e.g. budesonide, fluticasone, beclometasone) as a spray or powder inhaler are usually the basis. They can suppress the chronic airway inflammation. Alternatively, an ICS/formoterol fixed combination can be used purely as needed — e.g. in patients who only rarely have symptoms.¹
Step 3
Moderate asthma
- ICS + LABA (long-acting bronchodilator) as a fixed combination — e.g. budesonide/formoterol, fluticasone/salmeterol, fluticasone/vilanterol, beclometasone/formoterol
- SMART/MART concept: budesonide/formoterol as the single inhaler for both maintenance and as-needed therapy. Can reduce exacerbations more than the classic combination.¹˒³˒⁴
- Alternative: ICS + LTRA (montelukast as a tablet) — e.g. in exercise-induced asthma or analgesic asthma¹
Step 4
Severe asthma
- ICS (medium to higher dose) + LABA as a fixed combination
- If needed, additionally a LAMA (e.g. tiotropium) as triple therapy (ICS + LABA + LAMA)
- According to NVL 2024, a sufficiently long therapy trial at step 4 should usually precede the use of biologics¹
Step 5
Most severe uncontrolled asthma — biologics
For asthma patients who are not adequately controlled despite maximal inhaled therapy. These antibody medications specifically block inflammatory messengers and are used in specialized centres.¹˒³
- Omalizumab (Xolair): anti-IgE — for severe allergic asthma with elevated IgE
- Mepolizumab (Nucala): anti-IL-5 — for severe eosinophilic asthma
- Benralizumab (Fasenra): anti-IL-5 receptor — works similarly to mepolizumab
- Dupilumab (Dupixent): anti-IL-4/IL-13 — for type-2 inflammation, often also effective with concurrent atopic dermatitis
- Tezepelumab (Tezspire): anti-TSLP — newly added in NVL 2024, works independently of the inflammation type¹
Systemic corticosteroids (e.g. prednisolone)
Recommended only as a short-term burst therapy for severe exacerbations. According to NVL 2024, ongoing oral corticosteroid therapy should be avoided where possible — the available biologic options should be checked beforehand. More:
Stopping corticosteroids.
¹
No fear of inhaled corticosteroids
ICS at the recommended dose is generally considered safe — including for children. It acts locally in the airways with usually minor systemic effects. Weight gain, osteoporosis or diabetes primarily concern systemic corticosteroid use. Tip: rinse your mouth after inhaling — this clearly reduces the risk of oral thrush.
